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Joint Commission focuses on suicide prevention rules during surveys


April 6, 2017

A new focus on preventing patient deaths results in high scrutiny. Here’s what to expect and what to do

Patient injuries caused by self-harm and suicides have long been a problem with hospitals. With behavioral health patients becoming a more prevalent population in healthcare facilities, preventing suicides through thoughtful design has become a priority in most facilities.

It also is about to become more of a concern when it comes to meeting accreditation requirements, and you can expect Joint Commission surveyors to pay more attention to the way your facility helps to prevent suicides.

What will change?

Effective as of March 1, The Joint Commission has ordered its surveyors to immediately start placing more emphasis on the prevention of suicides in hospitals, and will start paying close attention especially to the assessment of potential ligature (hanging) injuries, suicide, and self-harm monitoring, especially in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.

According to Joint Commission literature, the added emphasis on suicide comes at a time of national concern about suicides in the nation’s hospitals, and is meant to be in coordination with the “Zero Suicide” campaign, an effort by several national outreach groups trying to eliminate suicide in healthcare facilities nationwide.

Suicide prevention is also second on the list of The Joint Commission’s Sentinel Event Alerts (SEA), and was the basis for SEA #56, which was issued in February 2016 as a way of bringing attention to the problem. According to that alert, suicide is the 10th leading cause of death, and claims more lives than traffic accidents and more than twice as many as homicides.

Furthermore, The Joint Commission says that care providers often do not detect the suicidal thoughts (i.e., suicide ideation) of individuals (including children and adolescents) who eventually die by suicide, even though most of them received healthcare services in the year prior to death, usually for reasons unrelated to suicide or mental health.

What can you expect?

Hospitals will, of course, have to adhere to the usual Environment of Care (EC) and Life Safety (LS) standards that they’ve always had to when it comes to preparing for surveys, but you can also expect increased scrutiny on standards that were introduced from last February’s Sentinel Alert, including the following:

  • EC.02.06.01, which requires facilities to establish and maintain a safe, functional environment.
  • National Patient Safety Goals (NPSG) NPSG.15.01.01, element of performance (EP) 1, which requires a risk assessment be conducted that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
  • EP 2: Addressing immediate safety needs for patients and determining the most appropriate setting for treatment.
  • EP 3: When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family.
  • Provision of Care, Treatment, and Services (PC) PC.01.01.01, EP 24, which requires that if a patient is boarded while awaiting care for emotional illness and/or the effects of alcoholism or substance abuse (think about where you house patients that come in under the influence to sleep it off), the hospital does the following:
    • Provides a location for the patient that is safe, monitored, and clear of items that the patient could use to harm himself or herself or others.
    • Provides orientation and training to any clinical and nonclinical staff caring for such patients in effective and safe care, treatment, and services (e.g., medication protocols, de-escalation techniques).
    • Conducts assessments and reassessments, and provides care consistent with the patient’s identified needs.
  • PC.01.02.0, which requires hospitals to assess and reassess patients.
  • PC.01.02.13, which requires hospitals to assess the need of patients who receive treatment for emotional and behavioral disorders.
  • PC.04.01.01, which addresses patient needs for continuing care, treatment, and services after discharge or transfer.
  • Provision of Care, Treatment, and Services (PC) PC.04.01.01, which governs the hospital’s process that addresses the patient needs for continuing care, treatment, or services after discharge or transfer.
  • Care, Treatment, and Services (CTS) CTS.02.01.01, which addresses screening procedures for the early detection of risk of imminent harm to self or others.
  • Environment of Care (EC) EC.02.01.01, which addresses the organization’s management of general safety and security risks.

In addition, The Joint Commission has indicated in written literature that during surveys, observations of ligature or self-harm risks will be documented, and may issue an Immediate Threat to Life citation in the worst-case scenarios while on-site (Hospital leadership would be notified immediately). Any violations would be written up by surveyors as a Requirement for Improvement (RFI). You and your staff should be able to show evidence or proof of the following to a surveyor that can answer the following questions:

  • Has your facility previously identified these risks?
  • What is your facility’s plans for removing these risks?
  • What’s your organization’s environmental risk assessment process?

In addition, you can expect that surveyors will assess and scrutinize the following situations in your hospital:

  • Any plans or policies on mitigation of harm posed by risks while removal of any violations found takes place
  • Adequate staffing to support these mitigation plans
  • Patient suicide risk assessment processes
  • Action plans, as well as policies and practices related to patients identified at risk
  • Ensuring staff awareness of a patient’s level of risk
  • The organization’s internal processes for improvement, including:
    • History of patient safety events and the process for root cause analysis of these events
    • Process for monitoring compliance with its policies
    • Actions taken when noncompliance was identified

What can you do?

You’re probably asking yourself, “What can I do to make my facility safer?” and you wouldn’t be alone. While many newer facilities are being built with patient treatment areas outfitted to handle the intricate needs of behavioral health patients and other at-risk patients considered high suicide risks, older facilities are struggling to retrofit their existing buildings at lower cost, while trying to remain in compliance with accreditation standards.

Fortunately, there is plenty of advice out there. The Joint Commission recommends the Design Guide for the Built Environment of Behavioral Health Facilities, published by the Facilities Guidelines Institute (FGI), and there are also the design guidelines, published by the International Association of Healthcare Safety and Security (IAHSS), that has lots of information regarding helping prevent patient suicides and harm.

In the meantime, there are things you can do now to assess your facility, and take measure with your staff to help cut down on the risk. Experts say you should consider the following:

Decrease boarding times. Many safety experts say that long waits are major precursors to violence and anxiety among patients, especially to behavioral health patients, forensic patients, or any others prone to harming themselves or others. Anything you can do to cut current waiting times and keep boarding times down will help to decrease the risk of violence or suicidal behaviors.

“Sometimes at least half our ED psychiatric patients are being boarded, often for eight hours or more or even several days,” says Peter Charvat, MD, an ED physician at St. Cloud (Minnesota) Hospital. “We often get these patients transferred to us from outlying cities, psychiatrists in the community, and law enforcement. Many of the hospitals in our area don’t have the resources to handle these patients, so they are sent here.”

Make the environment friendly. Many hospitals are creating behavioral health units—and more patient treatment areas in general—that boast high ceilings, open areas, and large windows that allow more natural light to come in. The result? Friendly, therapeutic places that calm patients and give a greater overall feeling.

What you do will depend on your space and budget, but picture behavioral health units with “wander space,” to a group area to hang out and walk off their energy as opposed to sitting around. Some hospital waiting rooms are being designed with a living room feel, with even comfy furniture and fireplaces in some cases, as well as showers and video game areas to create a less-threatening environment for those who may be subjected to longer stays.

Design through the eyes of the suicidal. In 2013, Minnesota hospitals began redesigning patient rooms, when it was found that facilities there were seeing some of the highest national rates of suicides since the 1990s. As a result, facilities began floor-to-ceiling reviews of room designs, eliminating any features that patients could use to potentially harm themselves.

“Patients who are determined to harm themselves can do so by self-strangulation or by banging their heads on the floor or on a wall,’’ said Kathy Knight, vice president of behavioral services at University of Minnesota Medical Center-Fairview, in a report in the Star-Tribune of Minneapolis. “It’s very challenging to prevent suicide when there is a deep determination to die.”

In its psychiatric units, the hospital concentrated on patient bathrooms, which is where many suicide attempts take place (here’s your documentation as to your plan of attack, for the surveyors).

“There are no pinch points in the doors anymore,” Knight said in the Star-Tribune report. “We have breakaway shower heads. The handles on the faucets are modified. We don’t have door knobs. There really isn’t anything that we don’t constantly look at.”

Think about flexibility. If you have a behavioral health patient who needs a special room—and all your rooms are filled with equipment that they could potentially harm themselves with—they’ll have to wait until you can accommodate them, and that can lead to other problems. Why not redesign your rooms so that they can accommodate anyone?

To cut down on hazards, some facilities have begun designing “multi-modal rooms” that can be transformed depending on the needs of the patient being treated. Need a safe room for a behavioral health patient? Regular rooms are designed with medical equipment, oxygen tanks, IV pole, and other potentially harmful items behind a sliding “garage door” that can be pulled down and secured.

Lower surfaces. Although it can be pricey and difficult for older hospitals to renovate current spaces, newer construction is focusing on design elements that provide fewer opportunities for patients to harm themselves. "You want to design it in such a way that it makes it difficult to jump off higher areas," says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, N.C. Smith has served on a task force for construction and renovation for the IAHSS, which focuses on recommendations ranging from avoiding high parking decks to rooftop play areas (a hospital in North Carolina tried it).

“The people that create these spaces create what's called an attractive nuisance,” he says. “Just by the nature [of] how it’s designed, it has safety issues or people could easily commit suicide.”

Search everyone. Especially in a busy emergency room environment, it can be difficult to assess who will be a violence or a suicide risk, so many hospitals have developed procedures for screening patients as they are admitted. Clothes are removed; sharps, belts, and jewelry are inventoried; and purses and other belongings are placed somewhere safe. In the meantime, a nurse or other staff member asks some basic questions to ascertain each patient’s baseline mental status. Finally, a patient may be given a color-coded set of scrubs to dress in. “Does this mean you strip search everyone? Maybe not, but in some places a purple gown can ID someone as high risk,” Smith says.

Use checklists. Many physicians and hospitals swear by checklists to minimize mistakes in the surgical suite; now, some hospitals are adapting checklists to other areas, such as the behavioral care unit.

St. Cloud Hospital uses a checklist that gives staff a list of things to do when preparing a room for a new patient arrival. Tasks on the checklist include things like moving extra garbage cans into the bathroom, removing excess furniture and cords, taking down decorative crucifixes, and folding a room’s computer up into a wall when it’s not being used.

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