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Required Policies and Procedures in Suicide Prevention Programs

05/09/2022

By Gina Malfeo-Martin, MSN, PMH-BC, Team Lead, Standards Interpretation Group and Stacey Paul, MSN, PMHNP-BC, Project Director, Healthcare Standards Development 

This latest post in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the risk for suicide will discuss the element of performance (EP) focused on written policies and procedures addressing the care and follow-up for individuals at risk for suicide.

Specifically, NPSG.15.01.01, EP 5 requires organizations to follow written policies and procedures addressing the care of individuals identified at risk for suicide. At a minimum, these should include the following:

  • training and competence assessment of staff who care for individuals at risk for suicide
  • guidelines for reassessment
  • monitoring requirements for individuals who are at high risk for suicide

Suicide Risk Reassessments
Suicide risk can change throughout the course of treatment; thus, reassessments are imperative. An organization’s reassessment guidelines should address:

  • who is responsible for a reassessment
  • when and/or how often to conduct a reassessment
  • the evidence-based reassessment process to be followed

Surveyors have noted that some organizations are not following their own policy related to the frequency of suicide risk reassessments. They have found some reassessments are not occurring after an individual expresses suicidal ideation or makes a suicidal gesture.

It’s up to the individual organization to determine reassessment timelines and what actions or behaviors need to trigger a reassessment. Organizations must be able to follow their own policy. Reassessment for risk of suicide needs to at least occur when there are changes in the patient condition including, but not limited to:

  • expressing suicidal ideation
  • making suicidal or self-harm gestures

Staff Competency in Caring for Individuals at Risk for Suicide
Surveyors have also observed a gap in training and competence assessment of the staff who care for individuals at risk for suicide, particularly those who perform 1:1 observation of individuals. 

The Joint Commission’s policy on staff training and competency assessment operates under the expectation that staff caring for and monitoring individuals at risk for suicide have training and assessment of competence, as applicable, in the areas for which they are providing care, such as screening, assessment, and monitoring.  Surveyors have found that staff caring for those at risk for suicide have not been trained or demonstrate a lack of competence in caring for individuals at risk of suicide.   

Post-Discharge Follow Up
Surveyors have also noted a disconnect in the post-discharge/follow-up process. This is a critical time as studies have shown that an individual’s risk for suicide is high after discharge from the psychiatric inpatient or emergency department settings. Developing a safety plan with the patient, providing phone numbers of who to reach out to incase of crisis, and facilitating follow-up appointments are examples of ways to mitigate this risk.

This EP  asks organizations to have a policy that defines counseling and follow-up care at discharge for individuals identified as at risk for suicide but does NOT dictate what is required. 

Requirements for Improvement (RFIs) may be written if the organization does not have or does not follow policies and procedures specific to counseling and follow-up care at discharge.

Stay tuned next month for our discussion on more practicalities of preventing suicides in healthcare settings.


Stacey Paul, MSN, RN, APN, PMHNP-BC, is a Project Director, Clinical in the Department of Standards and Survey Methods at The Joint Commission. She has experience in inpatient, partial hospitalization, residential, and outpatient settings in psychiatry. Prior to this position, she worked for Lurie Children’s Hospital, Children’s Home and Aid, and Mount Sinai Hospital. Most recently, she worked as a nurse practitioner in psychiatry at Alexian Brothers Behavioral Health Hospital.

Gina Malfeo-Martin, MSN, RN, is currently an Associate Director in the Standards Interpretation Group for the Behavioral Health Care  and Human Services and Hospital Psychiatric Programs at The Joint Commission. Certified in psychiatric-mental health nursing by the American Nurses Credentialing Center (ANCC), Ms. Malfeo-Martin has over 15 years of psychiatric-mental health nursing experience. She has dedicated her nursing career to psychiatric-mental health and has had a variety of nursing roles within behavioral health. Prior to joining The Joint Commission, she served as a Clinical Nurse Educator and, subsequently, a Manager of Inpatient Behavioral Health where she was responsible for clinical, operational, and financial oversight.