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Evaluating the Prevalence of Leading Practices in Suicide Prevention


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By Salome Chitavi, PhD, Research Scientist II, Department of Research


In some populations, suicide is on the rise. Suicide is the 12th leading cause of death overall in the United States, and the second among the age groups of 10-14 and 25-34.

The Joint Commission considers suicide within an inpatient setting or immediately following discharge as a sentinel event. A 2018 study in The Joint Commission Journal on Quality and Patient Safety estimated that approximately 49 to 65 inpatient suicides occur in the United States every year, and The Joint Commission’s sentinel event data suggests that the majority of sentinel event suicides occur post-discharge.

Suicide Prevention Awareness Month, held each September, recognizes that anyone can have an impact in preventing suicide. At The Joint Commission, we take our role in helping prevent inpatient suicide at accredited healthcare organizations seriously.

National Study on Leading Practices

As part of this commitment, The Joint Commission’s Department of Research is conducting a new national study evaluating the prevalence of leading practices in suicide prevention in accredited hospitals. The study, which is supported by The Pew Charitable Trusts, seeks to understand the extent to which several leading practices related to suicide prevention are currently used in Joint Commission accredited hospitals and emergency departments.

A sample of hospitals and emergency departments that were invited to participate are currently responding to the questionnaire, and we look forward to the results to learn more about suicide prevention in healthcare settings and to improve the current standards impacting approximately 80% of the nation’s hospitals.

The Joint Commission already provides organizations with many resources to support their compliance with standards, requirements and National Patient Safety Goals® (NPSGs) related to suicide prevention in hospitals and behavioral healthcare and human services (BHC) organizations. These include:

  • Information about NPSGs
  • Suicide prevention recommendations from past issues of The Joint Commission Perspectives®
  • An R3 Report explaining the requirement, rationale and reference for The Joint Commission’s 2019 suicide prevention standards
  • Links to suicide reduction tools, resource compendium and webinars

It is our hope that the results of the study help The Joint Commission assess its standards, NPSGs and other recommendations to ensure they are sustainable for organizations and effective in preventing suicide.

Suicide Prevention Requirements

While The Joint Commission’s NPSG has seven specific requirements related to suicide prevention, the current research study is focused on two of these requirements. Accredited hospitals and BHC organizations are expected to:

  • Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool (, EP2).
  • Follow written policies and procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide (, EP6).

In the last 18 months, 89% of accredited hospitals were compliant with the suicide screening requirements, and nearly 97% of organizations were compliant with following their written policies and procedures for counseling and follow-up care at discharge. While this is encouraging, the compliance rates don’t tell us anything about the degree to which hospitals might routinely screen other types of patients, or how many hospitals have decided to adopt universal screening practices. We also know that there are a growing number of well-researched safety practices that are associated with discharge planning, and we would like to know how many hospitals are implementing discharge planning activities that might be considered leading practices (such as formal safety planning, lethal means safety assessments and the use of caring contacts).

The study aims to understand how frequently these types of practices are being implemented in hospitals, along with challenges and barriers that may be associated with implementation. Hopefully, the study results will help to inform efforts that The Joint Commission may take in the future to help healthcare organizations in their efforts to prevent suicide. We hope to release the results in 2023.

Hospital participation is limited to completion of an online questionnaire which takes 30 to 45 minutes to complete. If your hospital was invited to participate but has not yet responded to the online questionnaire, we encourage you to complete the questionnaire using the link provided to your primary accreditation contact via email on August 29. For additional information, please contact Salome Chitavi, PhD, at or 630-792-5977.


Salome Chitavi, PhD is a Research Scientist II in the Department of Research at The Joint Commission. She is the principal investigator for the study Evaluating the Prevalence of Leading Practices in Suicide Prevention in Joint Commission-accredited Hospitals in the United States. Dr Chitavi has experience in organizational research, development of guidance and educational resources for hospital leadership and staff, and dissemination of research products to healthcare organizations. She led the review and compilation of the Suicide Prevention Resources Compendium to support Joint Commission accredited organizations’ implementation of NPSG 15.01.01.