Effective July 2019, TJC has revised and added new standards related to the National Patient Safety Goal 15. Previously the requirements were:
- Screen patients in Psychiatric Hospitals and those patients presenting with behavioral or emotional issues
- Conduct a risk assessment
- Provide safety information
After creating several expert panels, performing additional research, input from organizations and meeting with CMS, the TJC has revised expectations for NPSG 15. To some extent expectations for Psychiatric versus non-Psychiatric units/hospitals have been more clearly established. The new elements of performance are as follows:
- Psychiatric Hospitals and Psychiatric Units in general hospitals: conduct an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and act to minimize the risk(s)
For non-psychiatric units in general hospitals: implement procedures to mitigate the risk of suicide for patients at high risk for suicide
Note: Non-psychiatric units in general hospitals are not expected to be ligature resistant.
- Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool.
- Use an evidence-based process to conduct a suicide assessment of patients who have screened positive for suicidal ideation.
- Document the patient's risk of suicide and the mitigation plan.
- Follow written policies and procedures which include training, reassessment and monitoring.
- Follow written policies and procedures for discharge processes.
- Monitor effectiveness and implementation of policies and procedures.
To read the entire list of requirements refer to the TJC prepublication standards published on November 2018.
In December 2017, CMS published a Survey & Certification Memo (now referred to Quality, Safety and Oversight Group (QSO) regarding Ligature. The intent of the memo was to provide definitions, guidance and recommendations related to patients at risk for suicide. Additionally, the memo clearly stated that there would be no life safety code waivers for ligature issues.
In 2017, CMS also stated, as did TJC, that deficiencies related to ligature issues would be cited at condition of participation (CoP) 482.13. This CoP states that patients have the right to receive care in a safe setting.
Since 2017, CMS has been working with TJC, conducting additional research and seeking input from the public related to this epidemic. In July 2018, CMS published QSO 18, which continued to clarify expectations and requirements. In the QSO, CMS stated the following:
- Provide interim guidance about ligature: State Agencies (SAs) and Accrediting Organizations (AOs) may use their judgment as to the identification of ligature and other
- Accept the information from TJC's expert panels and research
- Continue to review and make revisions to the Interpretive Guidelines for Hospitals and Psychiatric Hospitals