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Joint Commission Behavioral Health Update

July 2011       
In This Issue
TJC Releases New BoosterPak on Suicide Risk Assessment
2011 Behavioral Health Standards on Physical Holding of Children and Youth
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Barrins
Behavioral Healthcare! 

We hope you are enjoying summer in your part of the country! To support your survey readiness efforts, even during this more leisurely season, we are providing information on two topics of interest.


Our first article highlights The Joint Commission's recently released BoosterPak for Suicide Risk. We point out some of the key points contained in the BoosterPak. They are important to be aware of as you refine your suicide risk assessment process.


Our second article covers some of the new requirements in the 2011 Behavioral Health Standards for the physical holding of children and youth. TJC sees this as a high risk intervention and there are several new requirements in the 2011 standards that may impact your organization.


We value your feedback on the newsletter. Please email us your comments and tell us what topics you would like to see in future issues. We look forward to hearing from you! Also, feel free to forward this newsletter to your colleagues. 



Anne Barrins
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  TJC Releases New BoosterPak on Suicide Risk Assessment

Suicide risk assessment as required by National Patient Safety Goal.15.01.01 is being closely scrutinized during surveys. In 2010, 18% of behavioral health organizations surveyed were found non-compliant with this NPSG. Frequently, the issue cited is that the suicide risk assessment lacks detail regarding specific patient characteristics and environmental features that increase or decrease the risk for suicide.


As a resource, TJC has issued a new Standards BoosterPak for Suicide Risk. It is available to all accredited organizations on your TJC Connect extranet site. (Look under
"Accreditation Tools" and scroll down to "What's New.")


The following are some noteworthy points in the BoosterPak and our tips for compliance:


TJC recommends that organizations consider adopting a standardized tool for suicide risk assessment.

Tip: When you make a decision about which tool to use, be sure to research the standardized tools available and carefully review the American Psychiatric Association Guideline on Suicide Risk Assessment .



TJC recommends that the tool include a rating of the suicide risk.

Tip: This topic is sometimes controversial. A rating of the suicide risk does not necessarily mean a numerical rating but rather an estimation of the level of risk such as low, medium, high. The APA Guideline addresses this issue as follows: "The goal of the suicide risk assessment is to identify factors that may increase or decrease a patient's level of suicide risk, to estimate an overall level of suicide risk, and to develop a treatment plan that addresses patient safety and modifiable contributors to suicide risk. The assessment is comprehensive in scope, integrating knowledge of the patient's specific risk factors, clinical history, including psychopathological development; and interaction with the clinician. The estimation of suicide risk, at the culmination of the suicide assessment, is the quintessential clinical judgment, since no study has identified one specific risk factor or set of risk factors as specifically predictive of suicide or other suicidal behavior."


TJC emphasizes staff training and monitoring of your suicide risk assessment process.

Tip:Conduct your own tracers to evaluate the quality of your suicide risk assessment process. Check for the following:

  • Was the suicide risk assessment thoroughly completed?
  • Did it estimate the patient's level of suicide risk?
  • Were appropriate interventions carried out based on this level of risk including: 
    • Level of observation
    • Room assignment
    • Medications
    • Nursing interventions
    • Psychosocial interventions
  • Was the level of risk reassessed at appropriate points? The APA Guideline recommends the following:
    • With occurrence of any suicidal behavior or ideation.
    • Whenever there is any noteworthy clinical change.
    • For inpatients: before increasing privileges/giving passes and before discharge

The BoosterPak also indicates (page 10) that the surveyor will  review the organization's policy and procedure on suicide risk assessment (although NPSG.15.01.01 does not include a requirement for a policy/procedure.)

Tip:Designing and implementing a comprehensive suicide risk assessment process is an important clinical imitative for an organization.  Thus, we recommend that organizations commit their process to writing and develop a written policy/procedure that describes the following: 

  • The tool that will be used
  • Who will conduct the assessment
  • Timeframes for initial assessment and reassessment
  • Documentation requirements
  • Competency requirements

Lastly, the BoosterPak has a comprehensive bibliography and resource list (page 17) that will be very useful to any organization working on refining its suicide risk assessment process.      

  2011 Behavioral Health Standards on Physical Holding of Children and Youth


If you are surveyed under The Joint Commission's Behavioral Health standards, you know that the 2011 BH standards include new requirements for the physical holding of children and youth. These standards are in the Care, Treatment, and Services chapter and are CTS.05.05.01 - CTS.05.05.21. Many of our clients have now been surveyed under these new standards. Based on these surveys, there are a few important details you need to be aware of as you implement these standards:




These standards on the physical holding of children and youth apply ONLY to the physical holding of children or youth. If physical holding is used for an adult, the BH restraint standards apply (CTS.05.06.01 - CTS.05.06.35.)




If you use physical holds for children and youth, you must have policies and procedures specific to physical holds. Standard CTS.05.05.21 EP 1 - 12 lists the elements that must be contained in your policies/procedures.


No More "30 Minute Exception"


Prior to these 2011 standards, the physical holding of children and youth was governed by the restraint standards. There was an exception which allowed that the physical holding of children and youth for less than 30 minutes was not a restraint. If the hold lasted 30 minutes or more, the restraint standards applied. In the 2011 standards, the 30 minute exception does not exist. The new standards apply to all instances of physical holding for children and youth, regardless of the length of time of the hold.


No LIP Order


The new 2011 standards on the physical holding of children and youth do not require an order from an LIP (licensed independent practitioner) for the hold. Any requirements regarding who can authorize a hold are left to the applicable state or federal regulations and organization policy.


Data is Required


You are required to collect data on the use of physical holds, aggregate the data, and report it to leadership. Standard CTS.05.05.19 EP 3 is very specific regarding the data elements that must be collected.


Notification to Leadership


Administrative and clinical leaders must be notified of the following circumstances:

  • When a psychical hold lasts longer than 30 minutes
  • When there are "multiple episodes of holding within a 12 hour period".

So, if you are surveyed under the BH standards and use physical holds for children and youth, be sure to carefully review the new standards and make sure your process is compliant with the new requirements. 

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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.