Goal 15

The organization identifies safety risks inherent in the population of the individuals it serves.

NPSG.15.01.01

–Rationale for NPSG.15.01.01–

Suicide of an individual served while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals.

Element(s) of Performance for NPSG.15.01.01

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). Note: Noninpatient behavioral health care and human services settings and unlocked inpatient units do not need to be ligature resistant. The expectation for these settings is to conduct a risk assessment to identify potential environmental hazards to individuals served, identify individuals who are at high risk for suicide, and take action to safeguard these individuals from the environmental risks (for example, continuous monitoring in a safe location while awaiting transfer to higher level of care and removing objects from the room that can be used for self-harm).
2. Screen all individuals served for suicidal ideation using a validated screening tool. Note: The Joint Commission requires screening for suicidal ideation using a validated tool starting at age 12 and above.
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. Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens individuals served for suicidal ideation and assesses the severity of suicidal ideation.
4. Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.
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.
6. Follow written policies and procedures for counseling and follow-up care at discharge for individuals served identified as at risk for suicide.
7. Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide and take action as needed to improve compliance.