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Suicide Risk Screening in Healthcare Organizations

03/23/2022

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

The Joint Commission has been focused on rates of suicide within the United States, particularly those that occur within healthcare organizations, well before the COVID-19 pandemic. 

The Joint Commission revised National Patient Safety Goal (NPSG) 15.01.01 to reduce the risk for suicide. This NPSG went into effect on July 1, 2019 for hospitals and behavioral healthcare and human services (BHC) organizations and on July 1, 2020 for critical access hospitals. The revised goal is more specific, instructional, and aligns with current research and recommendations from The Joint Commission’s Technical Advisory Panel . 

Now that more than two years have passed since implementation of the revised goal, we are able to see how accredited organizations are adapting to the requirements. In this blog series, we’ll be discussing what our surveyors are identifying in the field in terms of compliance and interpretation of the various elements of performance (EPs) related to suicide prevention.  

Today, we’re focusing on EP2 for hospitals and critical access hospitals: Screen all patients for suicidal ideation who are being evaluated and treated for a behavioral health condition as a primary reason for care using a validated screening tool. BHC: Screen all individuals served for suicidal ideation using a validated screening tool.

In 2020, the noncompliance percentage for this EP was 9.77%—that is, 55 of 563 hospitals surveyed did not comply with this requirement.

Use of Validated Screening Tools
One of the key issues surveyors reported is organizations  not using validated tools to screen patients for suicide risk. There are examples of validated screening tools featured on The Joint Commission’s suicide prevention portal, which can be accessed on our website.

Some organizations are using “home-grown” screening tools or those of which the origin is unknown to screen for suicide risk. These may not have been tested for reliability, validity, sensitivity and specificity in research studies designed for the purpose of tool validation.

In some cases, when using a validated tool, healthcare providers omitted questions. Doing this compromises the validity of the tool. Validated screening tools should not be modified/changed unless the organization can show evidence of written approval from the developer/creator of the tool indicating that such modifications do not compromise the validity of the tool.

Position on Universal Screening
Patients who are determined to need evaluation or treatment for behavioral health conditions in hospitals and all patients receiving care, treatment, or services in BHC organizations need to be screened for suicide risk. Universal screening is not required per the NPSG.

If an organization adopts a universal screening approach, they will be surveyed to its policies and procedures. 

Patients’ Refusal to Answer Questions
Surveyors also noted that an individual may refuse to answer some or all the questions on the validated screening tools. 

In cases where an individual refuses to answer a question or a screening is not able to be completed, organizations should err on the side of caution and implement appropriate mitigation strategies until further screening and assessment, when needed, can be completed. 

Patient Screening Criteria - Age
The requirement for screening using a validated tool applies to patients 12 and over. Organizations can determine when and how to screen patients younger than 12. Evidence-based processes should be followed when possible. 

Patients in long-term care and/or rehabilitation settings (without an emergency department or psychiatric services) do not need to be screened unless a behavioral condition is the primary reason for care. It’s important to note that NPSG.15.01.01, EPs 3-7 would still apply. 

Screening Vs. Full Assessment
Lastly, there are very specific circumstances when a patient should undergo a full suicide assessment, rather than a screening.

Anyone who has attempted suicide is considered a presumptive positive and should undergo an evidenced-based suicide risk assessment to determine level of risk. A challenging area can be screening certain patient populations, such as those who have:

  • developmental delays
  • intellectual disabilities
  • autism spectrum disorder
  • or are nonverbal

Since suicide screening tools have not been widely studied with these populations, a full assessment may be more appropriate. The assessment may still be challenging and require parent/guardian involvement and additional collateral information. If able, a screening using a validated tool would still be acceptable. 
We hope this blog post helps you understand the expectations of screening for suicide risk and applying them at your organization. Stay tuned for our next blog installment on assessing individuals who have screened positive for suicide risk and mitigating that risk. 

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 has worked for Lurie Children’s Hospital, Children’s Home and Aid, and Mount Sinai Hospital.  Most recently, she has 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 Hospital Psychiatric Programs at The Joint Commission. Certified in psychiatric-mental health nursing by the 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.