January 2019
Welcome to the first edition of 2019. As we stated last year,  we will have
a new version of the C&A newsletter. Each month we will select a topic and provide TJC and CMS guidance as well as, ways to be compliant.

This first edition will discuss the new requirements for National Patient Safety Goal 15 - suicide.  

Let's get started!
The Background: The statistics on suicide are staggering and continue to increase and increase across all age groups. In the article entitled, "High rate of healthcare visits before suicide attempts" (2015) an estimated 38% sought healthcare assistance within a week before attempting suicide. USA Today (May 2017) reported that admission rates for ages 5 - 17 doubled from 2008 - 2015 for suicide. The loss is measured in both lives and money. The American Foundation for Suicide Prevention (AFSP), estimated that almost $69 billion dollars is spent on suicide, self-injurious behavior and recovery. This is a topic that has been a focus for behavioral health for many years and now is in the eye of the population at large as attempts and rates of suicide rise.
The Requirements
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:
  1. 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.
  1. 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.
  2. Use an evidence-based process to conduct a suicide assessment of patients who have screened positive for suicidal ideation.
  3. Document the patient's risk of suicide and the mitigation plan.
  4. Follow written policies and procedures which include training, reassessment and monitoring.
  5. Follow written policies and procedures for discharge processes.
  6. 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

Reduction Strategies:
  • Select an evidence-based tool that will truly assist your staff in identifying patients at higher risk for suicide. The most commonly chosen, although not required, is the Columbia Suicide Severity Rating Scale (C-SSRS). This is an in-depth review of the entire person's presentation.
  • Consider using the C-SSRS screen which is a six-question tool that if positive encourages patients to be evaluated by someone with additional credentials to determine lethality, intentionality and access to plan.
  • Assure that appropriate education is provided to all staff, not just clinical. Don't assume that clinical staff know all they should about suicide! Non-clinical an ancillary staff should receive basic information about what to do if a patient expresses suicide or thoughts of harming them self.
  • Ask about access to fire arms - this is not required. Research shows that more than 50% of suicides are committed with a firearm. The next frequent causes of suicide are hanging and poisoning (AFSP, 2017).
  • Determine at what age the organization will begin to assess for suicide intent. One question that may lead pre-teens and teens to talk is to ask about bullying. This one question can provide a plethora of information.
  • Confirm staff have access to up-to-date policies - review to determine if different policies exist for different departments
  • Provide education, at the appropriate level, competencies and support to staff, including Medical Staff
  • Utilize resources within the organization - psychiatric units - consider the use of telepsychiatry
  • Take all comments about suicide as real until an assessment has been thoroughly completed
American Foundation for Suicide Prevention (2018). Retrieved from https://afsp.org/about-suicide/suicide-statistics/.
CMS QSOG18 (2018). CMS Clarification of Psychiatric Environmental Risks.
TJC Hospital Standards (2019).
USA Today (May 2017). Youth suicide rates are rising. School and internet may be to blame. 



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