Standards FAQ Details | Joint Commission
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Thursday 12:35 CST, February 22, 2018

Standards FAQ Details


Environment of Care (EC) (Hospital and Hospital Clinics / Hospitals)

Ligature Risks - Assessing and Mitigating Risk For Suicide and Self-Harm
Modify | April 24, 2017
What are the Joint Commission expectations for identifying and managing ligature risks in the hospital setting?

For inpatient psychiatric hospitals, inpatient psychiatric units in general acute care hospitals, and non-behavioral health units DESIGNATED for the treatment of psychiatric patients (i.e. special rooms/safe rooms in Emergency Departments or Medical Units):
The requirements found in the Environment of Care (EC) chapter of the accreditation manual at EC.02.06.01 require hospitals to establish and maintain a safe, functional environment. Element of Performance # 1 states “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided”. Therefore, ligature and self-harm risks must be identified and eliminated.  While risks are in the process of being eliminated, policies and procedures must be developed and implemented to mitigate the harm posed by such risks.  Mitigation plans must include, at a minimum the following: :
•  Ensuring that leadership and staff are aware of the current environmental risks
•  Identifying patients’ risk for suicide or self-harm, then implement appropriate interventions based upon risk. 
•  Ongoing assessments and reassessments of at-risk behavior  as defined by the organization.
•  Ensuring the proper training of staff to properly identify patients’ level of risk and implement appropriate interventions
•  Incorporating suicide risk and self-harm reduction strategies into the overall Quality Assessment/Performance Improvement (QAPI)  program - see LD.01.03.01 EP 21.
•  If equipment poses a risk but is necessary for the safe treatment of psychiatric patients (i.e. medical beds with side rails on a geriatric unit), the 
   organization must consider these risks in patients’ overall suicide/self-harm risk assessments, then  implement appropriate interventions to
   diminish those risks
In non-behavioral health units (i.e. Emergency Rooms or Medical Inpatient Units) that are NOT DESIGNATED specifically for the treatment of psychiatric patients; however, where psychiatric patients may temporarily reside, ligature/self-harm environmental risks must also be identified.

All physical risks not required for the treatment of the patient that can be removed, must be removed. Furthermore, an appropriate level of effective surveillance must be implemented if self-harm risks remain in the environment.  Organizational policies and procedures must adequately guide staff in the assessment of patients’ risk for suicide/self-harm and the implementation of interventions based upon the patients’ individual needs.

For non-inpatient programs surveyed under the Hospital Accreditation manual, an environmental risk assessment should be completed.  Based upon the results of that assessment, taking into account the individuals they serve, the organization determines if any modifications to the environment should be made.  Policies and procedures should also be developed and implemented to address the immediate action to be taken by staff when a patient is assessed to be at risk for suicide.

Additional Resources for assessing suicide risk:
 Sentinel Event Alert # 56
 Facility Guidelines Institute: Design Guide for the Built Environment of Behavioral Health Facilities
Suicide Risk Booster - available to accredited organizations via their Secure Extranet Site


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