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Implementation and Effectiveness of Suicide Prevention Policies


Doctor holding a yellow ribbon.

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

Editor’s Note: This is the final installment in our blog series on National Patient Safety Goal (NPSG) 15.01.01: Reduce the Risk of Suicide. Throughout this series, we have highlighted surveyors’ observations on various elements of performance (EPs)  at accredited organizations. Earlier posts have discussed written policies and procedures for follow up care of individuals at risk of suicide and suicide risk screening and assessment.

This installment features conversation on EP 7: Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of patients at risk for suicide and take action as needed to improve compliance. 

The rate of non-compliance with this EP was 6.75% of hospitals surveyed in 2021, however, more focus has been on screening, assessment, mitigation, and policies and procedures since then . Monitoring the success of an overall suicide prevention program is imperative to reduce the risk for suicide in healthcare.

For instance, there have been situations where a staff member’s failure to adhere to policies and procedures was identified as a root cause after a patient death by suicide. Stories like this are devastating and emphasize why The Joint Commission supports organizations in implementing successful suicide prevention programs.  

Moving Beyond Auditing
Surveyors observed that leadership is generally auditing completed screenings and assessments.

Auditing is a start but it's not always enough. Opportunities to identify weak points in processes cannot always be identified through auditing alone. For example, implementation and sustainment of mitigation strategies may require actual observations of such interventions to ensure compliance with policies and procedures. 

There must be evidence of monitoring for ALL aspects of suicide prevention, including, but not limited to:

  • screening
  • assessment
  • implementation of mitigation strategies
  • suicide and/or self-harm events  
  • adherence to policies and procedures 

Staff Accountability
Monitoring all aspects of suicide prevention is important, but more so, leadership must take action when compliance issues are identified. At times, surveyors noted issues with staff accountability and failure of leadership to act when deficiencies had been identified. 

Some examples include: 

  • Multiple blanks on documentation may indicate that staff are not performing 15-minute observations as required by policies/procedures.
  • One-on-one observations not performed as required. For example, staff assigned to observe a patient at high-risk for suicide seen reading books and performing other activities in lieu of maintaining continuous observation.
  • Suicide risk screenings not completed as required.
  • Suicide risk assessments are incomplete or do not include all required components.

Data Tracking

 Surveyors identified that many organizations can improve upon tracking the overall successes and opportunities for improvement of their suicide prevention strategies. Organizations must have a process in place to collect data on self-harm/suicide events and analyze such events for opportunities. If opportunities are identified, it’s imperative that sustainable actions are put into place and monitored for compliance. 

As the saying goes, “what gets measured, matters” and it holds true with organizational suicide prevention planning. When it comes to working with patients at risk of suicide, it is essential to help our colleagues take every possible preventive measure to keep patients safe.

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 a Team Lead in the Standards Interpretation Group for the Behavioral Healthcare and Human Services, Hospital Psychiatric and Lab Programs at The Joint Commission. Certified in psychiatric-mental health nursing by the American Nurses Credentialing Center (ANCC), Ms. Malfeo-Martin has over 17 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.