TJC Requirements for Using Evidence-based Process to Assess Suicide Risk

PUBLISHED: Jun 18, 2019
Relevant to: Behavioral Health, Hospitals

The Joint Commission recently issued a Frequently Asked Questions (FAQ) about their requirement under National Patient Safety Goal.15.01.02, Element of Performance 2 that requires organizations (Hospitals, Behavioral Health) to use evidence-based processes to perform suicide risk assessments on patients that have screened positive for suicidal ideation. This requirement is effective July 1, 2019.

According to TJC, “The use of validated tools is strongly encouraged…” however, TJC understands that organizations may need to adjust language / wording for their patient population. The key is that organizations ensure that questions are aligned with the intent of the original evidence-based tool.

Should an organization opt not to use an evidence-based tool, TJC requires the following criteria to be met:

  • Organization can demonstrate the evidenced based resource(s) used to develop their assessment
  • The assessment must directly ask about:
  • Suicidal ideation
  • Plan, intent
  • Suicidal or self-harm behaviors
  • Risk factors
  • Protective factors
  • Organization must show in their assessment how level of patient risk (high, moderate, low) is determined.
  • Organizations must document the level of risk, clinical justification for that determination and the plan for suicide risk mitigation

TJC offers the follow examples of evidence-based assessment tools in their FAQ:

  • Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Assessment Version
  • Scale for Suicide Ideation - Worst (SSI-W)
  • Beck Scale for Suicide Ideation (BSI)

Included with today’s notice are example policies related to assessment for suicide risk.

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