Joint Commission Online - Dec. 13, 2023

December 13, 2023

The Joint Commission revised its definition of suicide in the Sentinel Event Policy, effective Jan. 1, 2024. The original definition, developed more than 10 years ago, focused on inpatient and “staffed around-the-clock” care settings or suicides within 72 hours of discharge. Data and evidence-based literature support extending the time frame and services in which a patient receives care when considering suicide as a sentinel event.

Additional revisions to the Sentinel Event Policy clarify expectations regarding a health care organization’s partnership and collaboration with The Joint Commission’s Office of Quality and Patient Safety (OQPS). Organizations are strongly encouraged to report sentinel events to The Joint Commission. This gives organizations the opportunity to use the expertise and experience of Joint Commission patient safety specialists to analyze root causes, redesign processes, and monitor performance improvement practices and other aspects of the sentinel event process.

The revisions apply to all Joint Commission accreditation and certification programs, except the Health Care Staffing Services Certification, Integrated Care Certification, Sustainable Healthcare Certification, and Maternal Levels of Care Verification programs.

The following is the current definition of suicide in the Sentinel Event Policy: Suicide of any patient receiving care, treatment, and services in a staffed around-the clock care setting or within 72 hours of discharge, including from the health care organization’s emergency department (ED).

The following is the revised definition of suicide in the Sentinel Event Policy: Death caused by self-inflicted injurious behavior if any of the following apply:

• While in a health care setting
• Within 7 days of discharge from inpatient services
• Within 7 days of discharge from emergency department (ED)
• While receiving or within 7 days of discharge from the following behavioral health care services:
  • Day Treatment/Partial Hospitalization Program (PHP)/Intensive Outpatient Program (IOP)
  • Residential
  • Group Home
  • Transitional Supportive Living

The Joint Commission extensively reviewed current evidence-based literature to evaluate the time of highest risk for self-injurious behavior while receiving health care services or post discharge from a health care facility. As a result, the following reflects how the definition of suicide was revised:

• Aligns criteria with times of highest risk for suicide.
• Fosters a shared mental model among stakeholders through phases of treatment.
• Highlights the health care organization’s continued responsibility of ongoing assessment as the patient, resident, or individual served progresses through their treatment plan.

Both the current and revised Sentinel Event Policies are available on The Joint Commission’s Sentinel Event Policy and Procedures webpage. For further clarification, contact The Joint Commission via the ASKOQPS tab on your organization’s Joint Commission Connect^® extranet site.