TJC Clarifies Suicide Risk NPSG Requirements

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By Jay Kumar

The Joint Commission (TJC) this week released some clarifying information on its National Patient Safety Goal about suicide risk reduction, NPSG.15.01.01, which is effective July 1, 2019. Element of performance (EP) 3 requires that the suicide risk assessment include risk factors, which TJC describes as “a combination of individual, biological, psychological, familial, community, cultural, and/or societal characteristics or factors that may contribute to the risk of suicide.”

According to a new FAQ, examples of risk factors include:

  • Family history of suicide
  • Family history of child maltreatment
  • Previous suicide attempt(s)
  • History of mental disorders, particularly clinical depression
  • History of alcohol and substance abuse
  • Feelings of hopelessness
  • Impulsive or aggressive tendencies
  • Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma)
  • Local epidemics of suicide
  • Isolation, a feeling of being cut off from other people
  • Barriers to accessing mental health treatment
  • Loss (relational, social, work, or financial)
  • Physical illness
  • Easy access to lethal methods
  • Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts

TJC also posted an FAQ about assessing protective factors, which EP 3 requires the suicide risk assessment to include. Protective factors are “characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact. Protective factors may buffer individuals from suicidal thoughts and behaviors,” according to the FAQ.

Examples of protective factors include, but are not limited to:

  • Safe, secure, monitored environment (e.g., inpatient hospitalization)
  • Receiving clinical care for mental, physical, and substance abuse disorders
  • Easy access to a variety of clinical interventions and support for help seeking
  • Family and community support (connectedness)
  • Support from ongoing medical and mental healthcare relationships
  • Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
  • Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Another new FAQ clarified that suicide screening is not required for all patients. The NPSG “does not require organizations to universally screen all patients for suicidal ideation,” according to the FAQ. “Screening patients for suicide risk with secondary diagnoses or secondary complaints of emotional or behavioral disorders is encouraged but not required.”

Clinicians treating patients for medical conditions should be aware that the patients “may also have behavioral tendencies that, if triggered, may lead to self-harm. For example, changes in health status resulting in a poor prognosis, chronic pain resulting from injury or illness, etc.,” the FAQ said. “Psychosocial changes, such as sudden loss of a loved one, broken relationships, financial hardship, etc., can also trigger self-harm behaviors. These patients may also be at risk for suicide, therefore, it is important for clinicians to properly assess these individuals for suicidal ideation as part of their overall clinical evaluation, when indicated.”

New FAQs were also posted providing additional information about using an evidence-based process to conduct suicide assessments and using validated screening tools for patients being evaluated or treated for behavioral health conditions as their primary reason for care.