Improving Joint Commission Standards Compliance Around Patient Suicide Risks

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patient suicide risks

As a behavioral health compliance business partner, Circa Behavioral Healthcare Solutions is dedicated to ensuring that our partners stay updated on all regulatory updates. The Joint Commission, as an accrediting body utilized by many licensed in the mental health and addiction field, provides these updates regularly. On an annual basis, the Joint Commission compiles data on healthcare organizations’ standards compliance and then publishes a list of the most commonly cited standards violations. These are typically the most challenging standards for organizations to meet.

When reviewing behavioral health accredited organizations in 2023, the most challenging standards were related to patient safety, and in particular the National Patient Safety Goals that require efforts to prevent, identify, and fix any areas around patient suicide risks.

Patient suicide attempts or incidents are extremely common, so Circa Behavioral believes it is a critical area to address within our compliance plan and program. We don’t always talk openly about such incidents, so having tough conversations along with transparency can go a long way in making sure this risk area is effectively managed as part of our leadership, environmental, social, and governance goals of our strategic plans.

Joint Commission Required Standards

What are The Joint Commission recommendations for suicide screening? Here is a quick checklist to ensure your behavioral health program has covered all these elements and has met all required standards. These include the seven elements required by the Office of Inspector General (OIG) to meet effective compliance program requirements. As we know, such patient incidents can also result in lawsuits and grievances that negatively impact treatment organizations, so attention to each of these twelve points is critical:

  1. Have you conducted an annual risk assessment of all areas in the physical environment, clinical services, and operational plans?
  2. Do you have the risk areas addressed in your annual compliance work plan to ensure that all efforts are taken to minimize and mitigate patient suicide risks?
  3. Is your compliance officer or other executive leader assigned to administer and oversee the efforts to address the risks?
  4. Are your policies and procedures updated to meet Joint Commission standards and to guide staff as needed in each area?
  5. Do your education and training efforts align with both the updated standards and your policies so staff members are competent in all areas?
  6. Is your compliance hotline prepared to receive calls that report quality and safety issues related to suicide in the event quick actions are needed?
  7. Do your quarterly mock surveys, ideally administered by external experts who are not involved in daily operations, identify any gaps in safety that need to be addressed?
  8. Are any safety issues being addressed in a timely manner to reinforce the importance of these areas?
  9. If any corrective actions related to suicide prevention are needed, is there adequate focus on response and prevention across all areas?
  10. Have you addressed your staff’s well-being to ensure they are prepared to assist the suicidal risks with the patients you serve?
  11. Have you addressed any team workforce issues, such as communication or conflicts, to ensure all team members are on the same page regarding these patient suicide risks areas?
  12. Have you addressed all workplace issues like leadership gaps, culture issues, or other potential risks that might possibly impact suicide prevention?

Benefits of Joint Commission Compliance Plans

When behavioral health organizations take the time, invest the resources, and confirm that all elements are properly addressed in compliance plans and programs, these annual evaluations offer an opportunity to review data and identify needs in each area. If a program experiences a tragic patient suicide, it provides an opportunity to review such incidents and identify operational vulnerabilities and areas needing improvement.

This may feel like a lot of extra effort and work, but when these efforts can prevent suicide, it is obviously worth it. Any patient suicide gesture, attempt, or completed incident impacts overall patient care as well as staff wellbeing, which then negatively affects the success of the treatment program.

Learn About Compliance Options

Circa Behavioral Healthcare Solutions would love to serve as your compliance business partner to ensure you are prepared in this critical area! Together we make sure that all organizational efforts are being taken to prevent patient suicide. Please contact Maeve O’Neill, National Compliance Director, at (888) 458-6619.