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March 01, 2017

Now effective: Surveying, scoring of ligature, suicide, self-harm in inpatient psychiatric setting

JCO_Oct_12Effective immediately, The Joint Commission will place added emphasis on the assessment of ligature, suicide and self-harm observations in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals. This comes at a time when there is national concern about the number of suicides in hospitals. Also, the “Zero Suicide” campaign has set a new bar to eliminate suicides in health care facilities. Suicide is among the Top 5 sentinel events in The Joint Commission’s database.

Research has shown that many suicide attempts are impulsive. There is little disagreement that a facility that can eliminate environmental risks is reducing the means and opportunities for patients to commit suicide and/or harm themselves. 

During the on-site survey – Joint Commission surveyors will document all observations of ligature or self-harm risks in the environment and will:

  • Determine if the facility has previously identified these risks
  • Evaluate existing plans the facility has for removing these risks
  • Evaluate the organization’s environmental risk assessment process

Surveyors will assess and/or evaluate:  

  • Plans and policies on mitigation of harm posed by risks while removal occurs
  • Adequacy of staffing patterns to support these mitigation plans
  • The patient suicide risk assessment process
  • Organization policies and practices related to actions needed for patients identified at risk
  • Policies and processes of ensuring staff awareness of a patient’s level of risk
  • The organization’s internal processes for improvement, including:
    • The history of patient safety events and the process for root cause analysis of these events
    • The organization’s process for monitoring its compliance with its policies
    • Actions taken when noncompliance was identified

Documentation of findings and follow-up – Each observation of a ligature or self-harm risk in the inpatient psychiatric patient area will be:

  • Considered a requirement for improvement (RFI)
  • Documented, according to standard procedure, using quantification, precise description and all required elements of documentation 
  • Scored at Environment of Care (EC) 02.06.01, element of performance (EP) 1
  • Rated on the Survey Analysis for Evaluating Risk (SAFER) Matrix™, in terms of Likelihood to Harm a Patient/Staff/Visitor (low, medium, high) and the number of occurrences (limited, pattern, widespread)

In addition, the findings will be cited at the appropriate Condition of Participation (CoP) 482.41 — and, if in the highest risk areas, will be cited at the Condition level and noted as high risk on the SAFER Matrix™. In multi-purpose hospital areas — such as common rooms where there are always staff, emergency rooms or medical inpatient units where psychiatric patients may temporarily reside — the survey team will assess the organization’s awareness of risks, efforts to mitigate, reliability of mitigation efforts, and the surveyor(s) will routinely engage the Standards Interpretation Group in the discussion. The decision on the SAFER Matrix™, as well as the consideration of Standard versus Condition level, will take all of this information into account. The post-survey process for these observations will follow standard procedure in which the organization has a 60-day timeframe to correct the physical environmental risks or have the option of applying for a survey-related waiver.

Survey findings at the highest level of risk may trigger consideration of whether an Immediate Threat to Life (ITL) exists while the surveyors are on-site. Determination of an ITL is only done by the senior leadership at The Joint Commission, who review all the data presented by the survey team. Hospital leadership would be notified immediately if an ITL was under consideration. 

Joint Commission-accredited hospitals that treat psychiatric patients are encouraged to become familiar with the “Design Guide for the Built Environment of Behavioral Health Facilities,” as it includes solutions for environmental hazards to patients. 

For more information on suicide risk, prevention and resources, see the Sentinel Event Alert published by The Joint Commission.

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