Joint Commission proposes changes to patient suicide risk policies

The Joint Commission has begun accepting comments on proposed revisions to National Patient Safety Goal (NPSG) requirements to “better identify and care” for patients who may be at risk of attempting suicide.

The changes would affect three Joint Commission accreditation programs covering hospitals, critical access hospitals and behavioral healthcare.

In all three care settings, the revised standards say facilities should be able to recognize risk factors in patients, because not all patients will voluntarily disclose suicide ideation. A simple screening tool should be used, along with a more in-depth assessment to identify imminent risks, and all facilities should have plans on what to do with at-risk patients.

“Depending on the acuity of the suicide risk, it could involve taking care of the patient within the organization, transferring the individual to another healthcare setting, referring the patient to another provider of care or other external resources,” the proposed guidelines said.

The elements of performance will be the same across all three care settings:

1. Use an evidence-based tool to screen patients being treated for behavioral or emotional disorders. Examples of tools include Emergency Medicine Network’s ED-SAFE Patient Safety Screener for emergency departments and the Suicide Behaviors Questionnaire-Revised (SBQ-R).
2. When a patient has been positively screened for suicide risk, conduct an assessment using evidence-based tools or refer the patient to another provider for such an assessment.
3. Implement policies and procedures addressing the care of individuals identified as at risk for suicide. The proposed changes note that policies and procedure should be consistent with the needs of patients and organizational resources, and may include “a safe environment, notifying family members or friends as appropriate, transferring the individual to another provider (including logistics), providing referrals to resources such as crisis hot lines and counseling, and developing individual safety plans."
4. Monitor implementation of policies and procedures on the care of individuals identified as suicidal or at risk for suicide and take action as needed to improve compliance.

Comments on the requirements for all three accreditation programs will be accepted through May 1.