Noting little improvement in the number of in-hospital suicides reported as sentinel events over the past seven years, The Joint Commission (TJC) has revised its National Patient Safety Goal (NPSG) regarding suicide prevention.

The move follows a re-evaluation of the NPSG covering this issue that began in 2016, and included research, public field review, and analysis with experts in suicide prevention as well as representatives from healthcare organizations and other key stakeholders.

TJC notes that suicide remains the 10th leading cause of death in the United States, making this issue a significant concern to healthcare organizations.

The revised NPSG 15.01.01 (reduce the risk of suicide) includes seven elements of performance on which TJC will review hospitals and behavioral healthcare organizations during accreditation surveys, an increase from three such elements in the current NPSG, called “identify individuals at risk for suicide.”

The revised requirements, which will go into effect on July 1, 2019, direct hospital surveyors to assess:

  • environmental risk assessment and steps to minimize suicide risk;
  • use of a validated screening tool to assess patients who may be at risk for suicide;
  • use of an evidence-based process for assessing patients who screen positive for suicidal ideation;
  • documentation on patients found to be at risk as well as plans for risk mitigation;
  • documented policies and procedures that address the care of at-risk patients as well as evidence that these policies and procedures are followed;
  • consistent monitoring of the implementation and effectiveness of suicide prevention procedures and actions taken to boost compliance.

TJC notes that the revised NPSG is designed to be more specific and instructional to healthcare organizations and that it is more in keeping with the latest research and expert panel recommendations. The goal is to improve the quality and safety of care for patients who are treated for behavioral health conditions as well as those found to be at risk for suicide.

More details about the revised NPSG are available in an R3 (requirement, rationale, reference) report published by TJC online at: