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
- 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.