March 27, 2017 | | Comments 0
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Joint Commission: More details on self-harm assessments

The Joint Commission announced that as of March 1, its surveyors will place special focus on suicide, self-harm, and ligature observations in psychiatric hospitals and units. Now, surveyors will document any and all observations of ligature or self-harm risks in the environment during the survey. The six major areas of assessment will be:

  • Plans and policies on harm mitigation
  • Effective coordination of staffing to deal with mitigation plans
  • Patient suicide risk-assessment processes
  • Policies and practices on what to do for at-risk patients
  • Staff awareness of a patient’s level of risk
  • Facilities’ improvement processes for things like:
    • Tracking patients’ histories
    • Root-cause analyses of safety events
    • Compliance monitoring
    • Response to non-compliance

Each observation will be documented, classified as a requirement for improvement, scored at EC.02.06.01, element of performance 1, and placed on the facility’s SAFER Matrix.

See our previous Accreditation Insider and Briefings on Accreditation and Quality coverage on suicide risks.

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Filed Under: Accreditation

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About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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