Revised Joint Commission National Patient Safety Goal on Suicide Prevention Effective Today

PUBLISHED: Jul 1, 2019
Relevant to: Behavioral Health, Hospitals

StayAlert! is reminding customers that July 1, 2019 is the effective date for the revised Joint Commission (TJC) National Patient Safety Goal (NPSG) addressing suicide prevention, applicable to Joint Commission-accredited hospitals and behavioral health care organizations.

NPSG 15.01.01 is intended to improve safety and quality of care for patients identified as high risk for suicide and includes seven new and revised elements of performance addressing the following:

  • A requirement that behavioral health care organizations, psychiatric hospitals and psychiatric units in general hospitals conduct environmental risk assessments to ensure environments are ligature resistant.
  • A requirement that non-psychiatric units in general hospitals minimize environmental risks for patients at risk for suicide. Note that these units are not expected to be ligature resistant.
  • Implementation of a validated suicide risk assessment tool for screening individuals being treated or evaluated for behavioral health conditions as their primary reason for care. Note, the NPSG does not require universal screening.
  • Implementation of a mitigation plan that is developed based on each individual patient’s overall identified suicide risk.
  • Development and implementation of written policies and procedures for counseling and follow-up care for individuals identified as at risk for suicide.

Over the last year, in anticipation of the effective date, StayAlert! has covered many aspects of these new and revised requirements. Included with today’s notice is a compilation of example policies addressing the requirements.

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