NPSG #15A: Crafting a suicide risk assessment policy

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After reading this article, you will be able to:

1. Discuss who should be involved in crafting a suicide risk assessment policy

2. Identify ways to soften material regarding suicide risk when distributing materials to all patients

Creation of a policy to meet the requirements of National Patient Safety Goal (NPSG) #15A-suicide risk assessment-has proven trickier than expected for many hospitals. This has to do in part with prescriptive versus nonprescriptive components of the goal and finding a way to gently handle a sensitive, volatile topic.

"When this first arrived on my desk, we took immediate notice. Initially, it had looked fairly simple to accomplish, but that turned out to not be the case," says Maureen Kolomeir, MBA, MSN, RN, education resource coordinator for quality, performance improvement, safety, and regulatory compliance for Presbyterian Kaseman Behavioral Health (PKBH) in Albuquerque, NM. "It really is a three-pronged patient safety goal," she says.

Hospitals are expected under this NPSG to identify patients at risk, provide for the safety needs of those patients, and have a method of prevention.

"It's interesting that The Joint Commission [formerly JCAHO] does not prescribe how to do elements of performance 1 and 2," says Kolomeir. "Element 3 is prescriptive in that you have to provide specific information, such as crisis hotline numbers to individuals and their family members for crisis prevention."

When PKBH set about addressing this patient safety goal, it ran into challenges precisely where it expected the fewest.

"EP 3 was probably the one that appeared easiest to do at first glance," she says. "It turns out that was the one we had problems with."

The organization gathered a team involving the director of behavioral health, a research expert (in this case, Kolomeir), a member of the quality department, the medical director of behavioral health, the executive medical director, a psychiatrist dedicated to medical floors, and an emergency department (ED) psychiatrist. A librarian from the medical library was also on hand to lend support.

"Someone we should have had at the table from the very beginning was someone from the legal department," says Kolomeir. "If I could do it over again, I'd put a legal representative in the room."

In crafting the policy, the group aimed to create a central delivery system. "You craft the heart, the core of the system, the template," she says. PKBH then distributed that template to its regional facilities to tweak to the specifics of each individual facility.

Identifying what to look for

Kolomeir's research involved several broad areas and a number of narrower ones, including the following:

Demographics. Who is at risk for suicide? What are the national demographics? What about state demographics?

"You want to show The Joint Commission that you're using data in crafting your policy," says Kolomeir.

For example, young males aged 18-24 are a known high-risk group. Also, in New Mexico, young males of Native American descent are an at-risk group. And widowers over the age of 60 trigger additional questions for suicide risk assessment.

"The Joint Commission wants to know you're taking your community into account, looking for people who meet a risk profile," she says.

Definitions. "Assumptions about definitions will get you into trouble if you don't look at these," says Kolomeir.

For example, what is a "sitter"? Every organization defines a sitter differently: one-on-ones, putting someone on precautions, "arm's length," or observation status. All of these terms can vary from facility to facility and need to be defined in terms of your own organization.

"Look at your organization; do you use each term consistently?" she says. "How has a sitter been trained to sit with someone on suicide precautions? What are the expectations of that person?"

Tip: When crafting definitions for your suicide risk assessment policies, seek out frontline staff members for input. It may be a case in which policies are rewritten to reflect best practices.

Narrow areas of research included:

Exploring the nurses' view about how to interact with patients at risk


The customer's view

Safety is a challenge, says Kolomeir, because facilities must look at two areas: risk to the patient and risk inherent in the physical plant. Every facility is built differently, and the way the physical plant is reviewed must be individualized. Some identify one room on each floor as the designated safe room and alter it appropriately.

Delivering handouts

Presbyterian's Albuquerque facilities are hardwired to deliver handouts with crisis information to every patient in order to avoid the need for an audit.

"Everyone gets one so we don't have to think about who receives the information," says Kolomeir. "Whether they arrive for a behavioral reason or for the flu, everyone receives a card with information about the possibility of suicide."

This can be interpreted negatively, Kolomeir notes, and during the initial rollout, feedback was collected from patients about the method and it indicated that some were troubled by the handout.

In response, PKBH altered the presentation of the handout.

"This is where demographics are important. Instead of a stark handout, we prefaced it as a public service; it is our suicide prevention initiative," she says. "We state the rate of suicide in the state, that it is the third leading cause of death in a certain age group, and that our concern is for every person in the state of New Mexico."

Note: This new format was only recently rolled out, so hard numbers for the results are not yet available.

Writing the policy

The suicide risk assessment policy identifies the scope of patients assessed; those diagnosed or presenting emotional or behavioral disorders-even as a secondary condition-in all departments. One of the first components PKBH looked into during the policy-writing stage was recommended screening tools. The Joint Commission does not recommend a specific tool. One of the more common tools, and the one the organization chose to recommend, is the SAD Persons screening tool.

"We recommend Sad Persons for assessment and tell physicians they can use another assessment tool they're more comfortable with; it's recommended, not prescribed," says Kolomeir.

When a patient is identified, the policy moves into safety risk assessment and details paraphernalia with self-harm potential. The hospitalwide policy does not determine whether line of sight or arm's length is needed.

The assessment stage begins after a safe environment has been established. This varies from campus to campus based on the resources of the facility. The assessment may be done by the medical-surgical floor psychiatrist or a behavioral health consult liaison. PKBH has an ED-based psychiatrist as well.

After the patient is assessed and admitted, risk of suicide is incorporated into the plan of care and continually assessed. Finally, the policy addresses discharge planning.

"The policy addresses in detail how to deal with a crisis situation," says Kolomeir. "The patient [or caregiver] is given hotline numbers, both national and local, and additional resources."

Editor's note: Find a sample policy for suicide risk assessment online at BOJExtra!,

Who is assessed?

The Joint Commission (formerly JCAHO) issued a clarification just after the release of the 2007 patient safety goals due to a number of questions. This applies to all patients in organizations surveyed under the Behavioral Health Care standards, all patients in psychiatric hospitals, and to any patient in a general hospital with a primary diagnosis or primary complaint of an emotional or behavior disorder. The Joint Commission encourages but does not require a suicide risk assessment on patients with secondary diagnoses or secondary complaints of emotional or behavioral disorders. This is not just an inpatient requirement; it pertains to general hospital ERs, hospital-based ambulatory care facilities, or even hospital-based office practices if they are part of the hospital survey.

Source: Lori Hagen, RN, CPHQ, patient safety manager, and James H. Quillen, VAMC, Johnston City, TN.