Focus Ligature Risk Management on Preventive Measures—and CMS/TJC Standards

5 steps to assess patient mental health proactively and consistently

Approximately 105 Americans die by suicide every day, according to the Centers for Disease Control and Prevention (CDC), with close to 6% of these deaths occurring in a hospital setting. Understandably, inpatient suicide is a growing concern for the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission (TJC), which has led to heightened scrutiny of patient safety rules.

That’s why it’s vital to correctly gauge patients’ suicide risk and understand your obligations under CMS & TJC standards, hospital compliance consultant Sue Dill Calloway explains in her webinar “Ligature Risks: Master Compliance with CMS Hospital CoPs & TJC Requirements.” Without this knowledge, your hospital team could be overlooking suicide warnings in high-risk patients—and putting them in unsafe environments.

Here are five strategies to assess patient mental health and integrate preventive measures in your healthcare environment:

Cultivate A Suicide-Prevention Culture

1. Establish a lead team: Without execution, an idea, no matter how well-intentioned, is useless. The ZeroSuicide in health and behavioral health campaign believes “anything short of zero suicides in health care is unacceptable.” Select key team members to embrace a thorough understanding of compliance regulations and establish philosophy guidelines that set the tone toward suicide on a cultural level.

2. But train everybody: Even with a team leading your suicide-prevention initiatives, your entire healthcare workforce needs to be equipped with the skills to support high-risk patients. This includes understanding the warning signs of suicidal intent and creating safe environments for high-risk patients. Expert panelists for the Joint Commission agreed: “well-trained, vigilant, compassionate staff who rigorously follow procedures for protecting patients” are critical to ensure the safety of high-risk patients.

Customize Services (and Environments) for the Highest-Risk Patients

3. Consistently screen patients’ mental health: An article by the Joint Commission Journal reports “more than 80% of suicide decedents had contact with a health care provider in the year prior to their death.” This means healthcare providers are at the front lines in suicide prevention and identifying at-risk individuals. Suicide risk screening can be as simple as a short mental health survey provided to patients at every appointment.

4. Go above and beyond for high-risk individuals: High-risk patients have specific needs. Equip your staff to offer preventative services such as counseling and/or one-on-one observers.

5. Make safe rooms ligature-resistant: “If a patient requiring admission to a general acute inpatient setting has serious suicidal ideation, all objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care should be removed,” states the Joint Commission. Precautions include installing encased bathroom fixtures, plated safety bars, and risk-mitigation door devices.

 Equip Your Healthcare Team With Suicide Prevention Training

Anyone responsible for compliance with CMS hospital CoPs and TJC standards, as well as professionals working with suicidal patients, needs to know how to assess patient mental health and provide safe, responsive care for high-risk patients. In her live audio event, Calloway outlines the best tools for that assessment. After all, successful ligature risk reduction begins with good mental health assessment practices.

To join the conference or see a replay, order a DVD or transcript, or read more

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