Top 5 most challenging requirements for BHC organizations in 2021
The Joint Commission collects data on organizations’ compliance with standards, National Patient Safety Goals (NPSGs), and Accreditation and Certification Participation Requirements to identify trends and focus education on challenging requirements.
The Top 5 Behavioral Health Care and Human Services (BHC) requirements identified most frequently as “not compliant” during surveys and reviews from Jan. 1 through Dec. 31, 2021, were under NPSG.15.01.01: Reduce the risk for suicide. In order of greatest to least percentage of noncompliance, they were:
- Element of Performance (EP) 2: Screen all individuals served for suicidal ideation using a validated screening tool.
- EP 1: The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
- EP 5: Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
- Training and competence assessment of staff who care for individuals served at risk for suicide.
- Guidelines for reassessment.
- Monitoring individuals served who are at high risk for suicide.
- EP 3: Use an evidence-based process to conduct a suicide assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
- EP 4: Document individuals’ overall risk for suicide and the plan to mitigate the risk for suicide.
For more information, see the April 2022 issue of Perspectives or the Standards Frequently Asked Questions. The Joint Commission also has a Suicide Prevention Portal with resources for organizations seeking to be in compliance with NPSG.15.01.01.