Top Standards Compliance Data Announced for 2015

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1 The Official Newsletter of The Joint Commission April 2016 Volume 36 Number 4 l l Top Standards Compliance Data Announced for 2015 The Joint Commission regularly aggregates standards compliance data to pinpoint areas that present the greatest challenges to accredited organizations and certified programs. These data help The Joint Commission recognize trends and tailor education around challenging standards; National Patient Safety Goals (NPSGs); the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery TM ; and Accreditation or Certification Participation Requirements (APRs or CPRs). The graphs on pages 3 to 8 identify the Joint Commission standards cited most frequently as not compliant during surveys and reviews from January 1, 2015, through December 31, (Data from for-cause surveys and for-cause reviews are not included.) While the principal text of the standards also appears in the graphs, the full content of each (including rationales, notes, and elements of performance) is included in the accreditation and certification manuals on E-dition and in print. The graphs display the 10 most frequently cited requirements per program. Percentages indicate the number of organizations that received Requirements for Improvement (RFIs) for the standards shown. Please note that the graphs for health care staffing services and nursing care centers display more than 10 standards because several were tied in their percentage of RFIs. In addition, the graph for palliative care displays fewer than 10 standards because organizations achieved full compliance with the remaining standards. As a reminder, surveyors and reviewers evaluate compliance with all of the standards in the manuals. These bar graphs are provided only to help organizations recognize potential trouble spots. If you have questions about Joint Commission requirements, you may find that they have already been answered in the Standards Interpretation FAQs at / Standards/FAQs. Questions not addressed on the site may be directed to the Standards Interpretation Group via the online question form at jointcommission.org/sigsubmission/ sigsubmissionform.aspx. P Contents 1 Top Standards Compliance Data Announced for In Sight 2 Clarifications and Expectations Column on Hiatus 9 Two Changes Announced for Comprehensive Stroke Measure Set 9 Reminder: Organizations Denied Accreditation Also Lose All Certifications 10 Sentinel Event Statistics Released for Revision to Requirement for Psychiatric Hospitals That Use Joint Commission Accreditation for Deemed-Status Purposes 11 Joint Commission Names Ronald Wyatt First Patient Safety Officer 12 Sentinel Event Alert: New Alert Focuses on Suicide Ideation 18 On-Site Intracycle Monitoring a Key Resource in Continuous Improvement Process 19 Pioneers in Quality Program Provides Support During Top Performer Hiatus 19 Federal Occupational Health Receives Joint Commission Accreditation Continued on page 3

2 In Sight Executive Editor Katie Byrne Senior Project Manager Allison Reese Associate Director, Publications Helen M. Fry, MA Executive Director, Publications and Education Catherine Chopp Hinckley, MA, PhD Subscription Information: The Joint Commission Perspectives (ISSN ) is published monthly (12 issues per year) by Joint Commission Resources, 1515 West 22nd Street, Suite 1300W, Oak Brook, IL Send address corrections to Joint Commission Perspectives, or Annual subscription rates for 2016: United States, Canada, and Mexico $319 for print and online, $299 for online only. Rest of the world $410 for print and online, $299 for online only. For airmail add $25. Back issues are $25 each (postage paid). Orders for single/ back copies receive a 20% discount. Site licenses and multiyear subscriptions are also available. To begin your subscription, call , or mail orders to Joint Commission Resources, Collections Center Drive, Chicago, IL Direct all inquiries to or Copyright 2016 The Joint Commission No part of this publication may be reproduced or transmitted in any form or by any means without written permission. Contact for inquiries. Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes the materials under license from The Joint Commission. The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Visit us on the Web at This column informs you of developments and potential revisions that can affect your accreditation and certification and tracks proposed changes before they are implemented. Items may drop off this list before the approval stage if they are rejected at some point in the process. ACCEPTED STANDARDS l Revision to Provision of Care, Treatment, and Services (PC) Standard PC for psychiatric hospitals to maintain alignment with a Centers for Medicare & Medicaid Services (CMS) Condition of Participation (CoP) regarding patient treatment plans (see article on page 11) CURRENTLY IN FIELD REVIEW l Proposed new National Patient Safety Goal NPSG on pediatric computed tomography (CT) imaging for ambulatory care organizations, hospitals, and critical access hospitals (field review ends March 31, 2016) l Proposed expansion of the Integrated Care Certification program option for ambulatory care organizations, hospitals, and critical access hospitals to include home care organizations and nursing care centers as partners along the post-acute care continuum (field review ends April 8, 2016) Note: Please note that field review dates are tentative and subject to change. To participate in or read more about field reviews, please visit The Joint Commission website at mission.org/standards_information/field_reviews.aspx. CURRENTLY IN DEVELOPMENT STANDARDS l Proposed new Comprehensive Cardiac Center advanced certification option for accredited hospitals l Proposed new and revised requirements for Advanced Certification for Heart Failure in the disease-specific care program l Proposed new Medication Management (MM) Standard , EPs 1 8, regarding antimicrobial stewardship for critical access hospitals, hospitals, and nursing care centers l Proposed addition of National Patient Safety Goal NPSG for nursing care centers and proposed modification of NPSG for hospitals and critical access hospitals Clarifications and Expectations Column on Hiatus The column Clarifications and Expectations, authored by George Mills, MBA, FASHE, CEM, CHFM, CHSP, director, Department of Engineering, The Joint Commission, is on hiatus. It is scheduled to return, with the 38th installment of the series, in the June 2016 issue of Perspectives. P 2 The Joint Commission Perspectives April 2016

3 Top Standards Compliance Data for 2015 Ambulatory Care 48% HR The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 46% IC The organization reduces the risk of infections associated with medical equipment, devices, and supplies. 36% EC The organization maintains fire safety equipment and fire safety building features. 31% MM The organization safely stores medications. 28% MM The organization safely manages high-alert and hazardous medications. 27% EC The organization manages risks associated with its utility systems. 26% IC The organization identifies risks for acquiring and transmitting infections. 26% EC The organization inspects, tests, and maintains emergency power systems. 26% EC The organization manages risks related to hazardous materials and waste. 24% EC The organization inspects, tests, and maintains medical equipment. Note: The data determined for the ambulatory care program were derived from an average of 650 applicable surveys. Top Standards Compliance Data for 2015 Behavioral Health Care 36% CTS The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served. 27% HRM The organization verifies and evaluates staff qualifications. 27% NPSG Identify individuals at risk for suicide. 20% IC The organization facilitates staff receiving the influenza vaccination. 20% HRM Staff are competent to perform their job duties and responsibilities. 19% CTS The organization screens all individuals served for their nutritional status. 16% CTS The organization screens all individuals served for physical pain. 16% EC The organization maintains fire safety equipment and fire safety building features. 16% EC The organization establishes and maintains a safe, functional environment. 16% CTS For organizations providing care, treatment, or services in non 24-hour settings: The organization implements a written process requiring a physical health screening to determine the individual s need for a medical history and physical examination. Note: The data determined for the behavioral health care program were derived from an average of 804 applicable surveys. April 2016 The Joint Commission Perspectives 3

4 Top Standards Compliance Data for 2015 Critical Access Hospitals 67% EC The critical access hospital manages risks associated with its utility systems. 60% IC The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 55% EC The critical access establishes and maintains a safe, functional environment. 52% EC The critical access hospital maintains fire safety equipment and fire safety building features. 43% LS % LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. The critical access hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 36% EC The critical access hospital manages risks related to hazardous materials and waste. 36% LS The critical access hospital provides and maintains systems for extinguishing fires. 34% LS The critical access hospital maintains the integrity of the means of egress. 31% EC The critical access hospital inspects, tests, and maintains emergency power systems. Note: The data determined for the critical access hospital program were derived from 162 applicable surveys. Top Standards Compliance Data for 2015 Disease-Specific Care Certification 32% DSDF.3 The program is implemented through the use of clinical practice guidelines selected to meet the patient s needs. 17% DSDF.1 Practitioners are qualified and competent. 16% DSDF.2 The program develops a standardized process originating in clinical practice guidelines (CPGs) or evidence-based practice to deliver or facilitate the delivery of clinical care. 12% DSCT.5 The program initiates, maintains, and makes accessible a medical record for every patient. 12% DSDF.4 The program develops a plan of care that is based on the patient s assessed needs. 11% DSSE.3 The program addresses the patient s education needs. 8% DSPM.5 The program evaluates patient satisfaction with the quality of care. 8% DSPR.1 The program defines its leadership roles. 6% DSPR.5 The program determines the care, treatment, and services it provides. 5% DSSE.1 The program involves patients in making decisions about managing their disease or condition. Note: The data determined for the disease-specific care program were derived from 1,433 applicable surveys (not including those for Advanced Certification for Lung Volume Reduction Surgery or Advanced Certification for Ventricular Assist Device Destination Therapy). 4 The Joint Commission Perspectives April 2016

5 Top Standards Compliance Data for 2015 Health Care Staffing Services Certification 10% HSHR.1 The HCSS firm confirms that a person s qualifications are consistent with his or her assignment(s). 7% HSHR.6 The HCSS firm evaluates the performance of clinical staff. 6% HSLD.5 The services contracted for by the HCSS firm are provided to customers. 4% HSPM.4 The HCSS firm analyzes its data. 3% CPR 5 The staffing firm submits performance measurement data to The Joint Commission on a routine basis. 3% HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors. 3% HSLD.9 The HCSS firm addresses emergency management. 2% HSHR.2 As part of the hiring process, the HCSS firm determines that a person s qualifications and competencies are consistent with his or her job responsibilities. 2% HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information. 1% CPR 6 1% CPR 11 The staffing firm notifies the public it serves about how to contact the firm s management and The Joint Commission to report concerns about the quality and safety of patient care provided by the staffing firm s employees or independent contractors. Any staffing firm employee or independent contractor who has concerns about the quality and safety of patient care provided by the staffing firm s employees or independent contractors can report these concerns to The Joint Commission without retaliatory action from the staffing firm. 1% HSLD.1 The health care staffing services (HCSS) firm clearly defines its leadership roles. Note: The data determined for the health care staffing services program were derived from 190 applicable surveys. Top Standards Compliance Data for 2015 Home Care 41% PC The organization provides care, treatment, or services in accordance with orders or prescriptions, as required by law and regulation. 32% PC The organization plans the patient s care. 31% IC The organization offers vaccination against influenza to licensed independent practitioners and staff. 26% RC The patient record contains information that reflects the patient s care, treatment, or services. 25% IC The organization implements the infection prevention and control activities it has planned. 25% HR Staff are competent to perform their responsibilities. 24% HR The organization verifies staff qualifications. 23% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 20% EM The organization evaluates the effectiveness of its Emergency Operations Plan. 17% PI The organization compiles and analyzes data. Note: The data determined for the home care program were derived from an average of 2,094 applicable surveys. April 2016 The Joint Commission Perspectives 5

6 Top Standards Compliance Data for 2015 Hospitals 62% EC The hospital establishes and maintains a safe, functional environment. 59% IC The hospital reduces the risk of infections associated with medical equipment, devices, and supplies. 58% EC The hospital manages risks associated with its utility systems. 51% LS The hospital maintains the integrity of the means of egress. 50% LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. 47% RC The hospital maintains complete and accurate medical records for each individual patient. 46% LS The hospital provides and maintains systems for extinguishing fires. 45% LS % PC Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation. 39% EC The hospital manages risks related to hazardous materials and waste. Note: The data determined for the hospital program were derived from an average of 1,447 applicable surveys. Top Standards Compliance Data for 2015 Laboratory and Point-of-Care Testing 77% QSA The laboratory participates in Centers for Medicare & Medicaid Services (CMS) approved proficiency testing programs for all regulated analytes. 44% HR Staff are competent to perform their responsibilities. 35% QSA The laboratory has a process for handling and testing proficiency testing samples. 32% DC The laboratory report is complete and is in the patient s clinical record. 31% QSA The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. 29% QSA The laboratory performs calibration verification. 28% QSA The laboratory maintains records of its participation in a proficiency testing program. 27% EC The laboratory inspects, tests, and maintains laboratory equipment. 19% QSA The laboratory conducts surveillance of patient results and related records as part of its quality control program. 15% HR The laboratory verifies staff qualifications. Note: The data determined for the laboratory program were derived from an average of 785 applicable surveys. 6 The Joint Commission Perspectives April 2016

7 Top Standards Compliance Data for 2015 Nursing Care Centers 36% HR The organization permits licensed independent practitioners to provide care, treatment, and services. 20% PC The organization assesses and manages the patient s or resident s pain. 18% MM The organization safely stores medications. 14% HR The organization verifies staff qualifications. 14% PC The organization plans the patient s or resident s care. 12% NPSG % PC Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. The organization provides patient and resident education and training based on each patient s or resident s needs and abilities. 12% WT Staff and licensed independent practitioners performing waived tests are competent. 11% PC The organization assesses and reassesses the patient or resident and his or her condition according to defined time frames. 11% IC The organization offers identifies risks for acquiring and spreading infections. 11% EC The organization manages safety and security risks. Note: The data determined for the nursing care centers program were derived from 314 applicable surveys. Top Standards Compliance Data for 2015 Office-Based Surgery Practices 50% IC The practice reduces the risk of infections associated with medical equipment, devices, and supplies. 50% HR The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently. 26% MM The practice safely stores medications. 24% IC The practice identifies risks for acquiring and transmitting infections. 20% MM The practice safely manages high-alert and hazardous medications. 19% NPSG Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. 18% EC The practice inspects, tests, and maintains medical equipment. 17% IC The practice offers vaccination against influenza to licensed independent practitioners and staff. 17% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 16% MM The practice addresses the safe use of look-alike/sound-alike medications. Note: The data determined for the office-based surgery practices program were derived from 146 applicable surveys. April 2016 The Joint Commission Perspectives 7

8 Top Standards Compliance Data for 2015 Palliative Care Certification 32% PCPC.4 The interdisciplinary program team assesses and reassesses the patient s needs. 26% PCPC.3 The program tailors care, treatment, and services to meet the patient s lifestyle, needs, and values 18% PCPI.2 The program collects data to monitor its performance. 18% PCPI.3 The program analyzes and uses its data to identify opportunities for performance improvement. 18% PCPM.7 The program has an interdisciplinary team that includes health care professionals with the education and experience to provide the program s specialized care, treatment, and services that meet the needs of the patient and family. 8% PCIM.2 The program maintains complete and accurate medical records. 8% PCPM.6 Program leaders are responsible for selecting, orienting, educating, and retaining staff. 3% PCPC.5 The program provides care, treatment, and services according to the plan of care. Note: The data determined for the palliative care program were derived from 38 applicable surveys. Top Standards Compliance Data for 2015 Perinatal Care Certification 17% PNIM.2 The program maintains complete and accurate medical records. 17% PNPM.1 The program s leaders secure support from the organization. 8% PNPC.2 The program communicates with and involves mothers and, as appropriate, families in decision-making. 8% PNPC.3 The program tailors care, treatment, and services to meet the lifestyle, needs, and values of the mother and, as appropriate, family. 8% PNPC.4 The interdisciplinary program team assesses and reassesses the mother s and newborn s needs. 8% PNPC.5 The program provides care, treatment, and services according to the plan of care. 8% PNPM.2 The program defines its leadership roles. 8% PNPM.3 The program provides services that meet patient needs. 8% PNPM.7 8% PNPM.9 The program has an interdisciplinary team that includes individuals with expertise in and/or knowledge about the program s specialized care, treatment, and services. The program has essential obstetric and newborn emergency equipment, supplies, and medications stocked and readily available. Note: The data determined for the perinatal care program were derived from 12 applicable surveys. 8 The Joint Commission Perspectives April 2016

9 Two Changes Announced for Comprehensive Stroke Measure Set Effective January 1, 2016, and until further notice, The Joint Commission has suspended data collection for Comprehensive Stroke (CSTK) measure CSTK-07: Median Time to Revascularization. CSTK-07 is one of eight comprehensive stroke measures required (in addition to the eight stroke [STK] measures) to meet performance measure requirements for Comprehensive Stroke Center Certification (see sidebar at right for the CSTK measure set). The Joint Commission decided to suspend CSTK-07 due to reports from comprehensive stroke centers of data collection issues involving the following data elements: l First Pass Date The date associated with the time of the first pass (that is, mechanical deployment) of a clot retrieval device l First Pass Time The time (military time) of the first pass (that is, mechanical deployment) of a clot retrieval device l First Pass of a Mechanical Reperfusion Device First pass (that is, deployment) of a mechanical reperfusion device to remove a clot occluding a cerebral artery CSTK-07 may be reinstated in the future pending stakeholder feedback on the above data elements. In addition, The Joint Commission expects to add a new measure, CSTK-09: Arrival Time to Skin Puncture, to the set for implementation January 1, The measure specifications for CSTK-09 will be detailed in the Specifications Manual for Joint Commission National Quality Measures at /specifications_manual_ joint_commission_national_quality_core_measures.aspx when they become available. The CSTK measures were developed for the management of both ischemic and hemorrhagic stroke patients in hospitals equipped with the clinical expertise, infrastructure, and specialized neurointerventional and imaging services needed to provide the next level of stroke care. Questions may be directed to Karen Kolbusz, RN, BSN, MBA, associate project director, Department of Quality Measurement, The Joint Commission, at mission.org. P Comprehensive Stroke (CSTK) Measure Set CSTK-01 CSTK-02 CSTK-03 CSTK-04 CSTK-05 CSTK-06 CSTK-07 CSTK-08 CSTK-9 National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients) Modified Rankin Score (mrs at 90 days) Severity Measurement Performed for Subarachnoid Hemorrhage (SAH) and Intracerebral Hemorrhage (ICH) Patients (Overall Rate) Procoagulant Reversal Agent Initiation for ICH Hemorrhagic Transformation (Overall Rate) Nimodipine Treatment Administered Median Time to Revascularization SUSPENDED 1/1/16 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade) Arrival Time to Skin Puncture EXPECTED IMPLEMENTATION 1/1/17 REMINDER: Organizations Denied Accreditation Also Lose All Certifications According to the Joint Commission s accreditation and certification structure, an organization seeking Joint Commission certification must first be accredited under one of the Joint Commission s accreditation programs. This stipulation applies in the other direction as well that is, if an organization is denied accreditation for any reason, the organization will also lose any Joint Commission certifications it has achieved. On a related note: Although the results of a certification program s decision have no effect on an organization s accreditation status, a potential Immediate Threat to Health or Safety situation discovered during a certification review may trigger a for-cause accreditation survey of the larger organization that could affect its accreditation status. Questions may be directed to Gail Weinberger, MA, director, Accreditation and Certification Policy and Administration, The Joint Commission, at org. P April 2016 The Joint Commission Perspectives 9

10 Sentinel Event Statistics Released for 2015 From the January 1995 implementation of The Joint Commission s Sentinel Event Database through December 31, 2015, The Joint Commission has reviewed 12,122 reports of sentinel events and included de-identified information about them in the Sentinel Event Database. Database content includes data collected and analyzed from the review of sentinel events and comprehensive systematic analyses, as tracking this information may help guide local efforts to enhance patient safety by mitigating future risk. The Joint Commission recently updated its summary data of sentinel events statistics for Data from the 9,581 incidents reviewed from 2004 through 2015 show that these events have affected a total of 9,884 patients as follows: l Death: 5,540 (56.1%) patients l Unexpected additional care: 2,585 (26.2%) patients l Permanent loss of function: 863 (8.7%) patients l Psychological impact: 324 (3.3%) patients l Severe temporary harm: 222 (2.2%) patients l Permanent harm: 66 (0.7%) patients In addition, 277 (2.8%) patients were affected by other outcomes; for 7 (0.1%) patients, the outcome was unknown. All sentinel events must be reviewed by the organization and are subject to review by The Joint Commission. The Joint Commission reviewed a total of 936 sentinel events during 2015; of these, 698 were voluntarily self-reported by an accredited or certified entity, and 238 were non self-reported via the complaint process or the media. The box below shows the 10 most frequently reported types of sentinel events. The Joint Commission Office of Quality and Patient Safety (OQPS) collaborates with organizations on the completion of a comprehensive systematic analysis for identifying the causal and contributory factors to a sentinel event. Root cause analyses, which focus on systems and processes, are the most Most Frequently Reported Sentinel Events, January 1 December 31, Unintended retention of a foreign object Wrong patient, wrong site, or wrong procedure Falls* Suicide Delay in treatment* Operative/postoperative complication* Other unanticipated events Criminal event Perinatal death/injury* Medication error* 41 * Resulting in death or permanent loss of function Includes asphyxiation, burns, choking on food, drowning, and being found unresponsive common form of the comprehensive systematic analyses used to identify factors that contributed to a sentinel event. The majority of sentinel events are a result of multiple root causes; the 10 most frequently identified root causes (spanning several types of events) for 2015 are shown in the box below. The contribution of human factors to safety must be viewed as an institutional emergent property not an individual failure, says Ronald Wyatt, MD, MHA, patient safety officer (see the following page for the announcement of this new role) and medical director, The Joint Commission. High-reliability organizations must consider cognitive ergonomics, which includes modifying equipment and continuously evaluating the workflow and task environments. Applying human factors engineering to improve a system helps establish and sustain a resilient health care organization that is sensitive to operations one that can learn from, adapt to, and address active failures and latent conditions contributing to sentinel events, Wyatt adds. The safety search requires a deep understanding of the impact of sociotechnical and cultural factors that can interfere with human awareness and the ability to respond to the unexpected. An estimated fewer than 2% of all sentinel events are reported to The Joint Commission; as this is not an epidemiologic data set, no conclusions should be drawn about the frequency of events. For more information, call the Office of Quality and Patient Safety at or visit P Most Frequently Identified Root Causes for Sentinel Events, January 1 December 31, Human factors (such as competency assessment and staff supervision) Leadership (related to issues such as priority setting and complaint resolution) Communication (among staff, administration, and/or patients and families) Assessment (includes patient observations and care decisions) Physical environment (such as emergency management and fire safety) Health information technology related 125 (refers to issues such as incompatibility between devices and hardware failure) 7. Care planning (planning and/or collaboration issues) Operative care (includes blood use and/or patient monitoring Medication use (includes labeling and preparing medications) Information management (having to do with, for example, the aggregation of data) The Joint Commission Perspectives April 2016

11 Revision to Requirement for Psychiatric Hospitals That Use Joint Commission Accreditation for Deemed-Status Purposes Effective April 4, 2016, The Joint Commission has revised Provision of Care, Treatment, and Services (PC) Standard PC , Element of Performance (EP) 6, for psychiatric hospitals that use Joint Commission accreditation for deemed-status purposes. This revision is intended to more clearly address the Centers for Medicare & Medicaid Services (CMS) Condition of Participation (CoP) for psychiatric hospitals related to the inclusion of treatment modalities in patient treatment plans ( (c)(1)(iii)). The revision, which is the new language underlined in the box below, is currently available at org/standards_information/prepublication_standards.aspx. It will be posted in the spring E-dition update and published in the 2016 Update 1 to the Comprehensive Accreditation Manual for Hospitals. For more information, contact Laura Smith, project director, Department of Standards and Survey Methods, The Joint Commission, at P Official Publication of Joint Commission Requirements Revision to Requirement for Deemed-Status Psychiatric Hospitals Applicable to Deemed-Status Psychiatric Hospitals Effective April 4, 2016 Provision of Care, Treatment, and Services (PC) Standard PC The hospital plans the patient s care. Element of Performance for PC C 6. For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The written plan of care includes the following: M A substantiated diagnosis (The substantiated diagnosis is the diagnosis identified by the treatment team to be the primary focus upon which treatment planning will be based. It evolves from the synthesis of data from various disciplines. The substantiated diagnosis may be the same as the initial diagnosis or it may differ, based on new information and assessment.) Documentation to justify the diagnosis and the treatment and rehabilitation activities carried out Documentation that demonstrates all active therapeutic efforts are included The specific treatment modalities used to treat the patient Joint Commission Names Ronald Wyatt First Patient Safety Officer The Joint Commission recently appointed Ronald M. Wyatt, MD, MHA, to the newly created position of patient safety officer. Wyatt also will continue to serve as The Joint Commission s medical director in the Division of Healthcare Improvement, a position he has held since he joined the organization in In his new role, Wyatt is focusing on health care quality and patient safety at the organizational level including patients, practitioners, staff, and leadership and the health care system level. In addition, he is responsible for promoting quality improvement and patient safety to internal and external stakeholders and expanding The Joint Commission s role as an influencer in public policy and legislation. During his time at The Joint Commission, Wyatt has led several important patient safety initiatives. He was instrumental in renaming the former Office of Quality Monitoring as the Office of Quality and Patient Safety to better reflect the primary focus on patient Ronald M. Wyatt, MD, MHA Continued on page 18 April 2016 The Joint Commission Perspectives 11

12 New Alert Focuses on Suicide Ideation The recently released Joint Commission Sentinel Event Alert Issue 56 focuses on preventing suicide in health care settings. The new Alert is designed to assist health care providers, including primary, emergency, and behavioral health clinicians, in better identifying and treating individuals with suicide ideation. The Alert also provides screening, risk assessment, safety, treatment, discharge, and follow-up care recommendations for at-risk individuals. The Joint Commission is bringing attention to this issue because its Sentinel Event Database received 1,089 reports of suicides occurring from 2010 to The most common root causes documented were shortcomings in assessment (most commonly psychiatric assessment). In addition, 21.4% of Joint Commission accredited behavioral health care organizations and 5.14% of Joint Commission accredited hospitals, for which a related National Patient Safety Goal was applicable, were noncompliant in 2014 with conducting a risk assessment that identifies specific patient characteristics and environmental features related to suicide risk. Sentinel Event Alert Issue 56, published here in its entirety, is part of a series issued by The Joint Commission. Previous Alerts have addressed issues such as patient falls, health information technology, tubing misconnections, misuse of vials, unintended retention of foreign objects, medical device alarm safety, risks associated with opioid use, health care worker fatigue, diagnostic imaging risks, violence in health care facilities, maternal death, anticoagulants, medication reconciliation, surgical fires, and health care associated infections. Sentinel Event Alerts can be found on the Joint Commission website at org/sentinel_event.aspx. Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings The rate of suicide is increasing in America. 1 Now the 10 th leading cause of death, 2 suicide claims more lives than traffic accidents 3 and more than twice as many as homicides. 4 At the point of care, providers often do not detect the suicidal thoughts (also known as suicide ideation) of individuals (including children and adolescents) who eventually die by suicide, even though most of them receive health care services in the year prior to death, 5 usually for reasons unrelated to suicide or mental health. 5 7 Timely, supportive continuity of care for those identified as at risk for suicide is crucial, as well. 8 Through this Alert, The Joint Commission aims to assist all health care organizations providing both inpatient and outpatient care to better identify and treat individuals with suicide ideation. Clinicians in emergency, primary, and behavioral health care settings particularly have a crucial role in detecting suicide ideation and assuring appropriate evaluation. Behavioral health professionals play an additional important role in providing evidence-based treatment and follow-up care. For all clinicians working with patients with suicide ideation, care transitions are very important. Many patients at risk for suicide do not receive outpatient behavioral treatment in a timely fashion following discharge from emergency departments and inpatient psychiatric settings. 6 The risk of suicide is three times as likely (200% higher) the first week after discharge from a psychiatric facility 9 and continues to be high especially within the first year 6,10 and through the first four years 11 after discharge. This Alert replaces two previous alerts on suicide (issues 46 and 7). The suggested actions in this Alert cover suicide ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow-up care of at-risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care. Some organizations are making significant progress in suicide prevention. 12 The Perfect Depression Care Initiative of the Behavioral Health Services Division of the Henry Ford Health System achieved 10 consecutive calendar quarters without an instance of suicide among patients participating in the program. The US Air Force s suicide prevention initiative reduced suicides by one-third over a six-year period. Over a period of 12 years, Asker and Bærum Hospital near Oslo, Norway, implemented continuity-of-care strategies and achieved a 54% decline in suicide attempts in a high-risk population with a history of poor compliance with follow-up. Additionally, the hospital s multidisciplinary suicide prevention team accomplished an 88% success rate for getting patients to the aftercare program to which they were referred. 8 Dallas Parkland Memorial Hospital became the first US hospital to implement universal screenings to assess whether patients are at risk for suicide. Through preliminary screenings of 100,000 patients from its hospital and emergency department, and of more than 50,000 outpatient clinic patients, the hospital has found 1.8% of patients there to be at high suicide risk and up to 4.5% to be at moderate risk The Joint Commission Perspectives April 2016

13 Who Is At Risk for Suicide? Much of what we know about the profile of individuals who have died by suicide and those who have attempted suicide comes from looking in the rearview mirror at data compiled about suicide victims and attempts. Suicide may affect certain demographics such as military veterans 14 and men over age 45 more than others. It s important to identify the risk factors, rather than membership in a group, when considering suicide risk. Paying attention to risk factors matters because patients may not disclose suicide ideation voluntarily. Risk factors for suicide include the following: l Mental or emotional disorders, particularly depression and bipolar disorder. 15 Up to 90% of suicide victims suffer from a mental or emotional disorder at the time of death. 16 l Previous suicide attempts or self-inflicted injury; the risk of suicide is twice as high (100% higher) than general suicide rates for one year following a suicide attempt 6,15 and the higher risk continues beyond that. 6,11 The risk is even higher the first few weeks immediately following a suicide attempt. 8 l History of trauma or loss, such as abuse as a child, 17 a family history of suicide, 17 bereavement, 18 or economic loss 18 l Serious illness, 18 or physical or chronic pain or impairment 18 l Alcohol and drug abuse 15 l Social isolation 19 or a pattern/history of aggressive or antisocial behavior 20 l Discharge from inpatient psychiatric care, 21,22 within the first year after 10 and particularly within the first weeks and months after discharge. 23 While some depressed patients who attempt or die by suicide after inpatient psychiatric hospitalization express suicide ideation before or during hospitalization, other depressed patients who have received inpatient psychiatric treatment develop suicide ideation after discharge. 24 l Access to lethal means coupled with suicidal thoughts 18 Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alerts identify specific types of sentinel and adverse events and high-risk conditions, describe their common underlying causes, and recommend steps to reduce risk and prevent future occurrences. Accredited organizations should consider information in an Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the Alert or reasonable alternatives. Please route this issue to appropriate staff within your organization. Sentinel Event Alerts may only be reproduced in their entirety and credited to The Joint Commission. To receive by or to view past issues, visit jointcommission.org. However, there is no typical suicide victim. Most individuals having these risk factors do not attempt suicide, and others without these conditions sometimes do. Therefore, there is a danger in considering only individuals with certain conditions or experiences in certain health care settings as being at risk for suicide. It s imperative for health care providers in all settings to better detect suicide ideation in patients, and to take appropriate steps for their safety and/or refer these patients to an appropriate provider for screening, risk assessment, and treatment. Assessing Suicide Risk Remains a Challenge The Joint Commission s Sentinel Event database* has reports of 1,089 suicides occurring from 2010 to 2014 among patients receiving care, treatment, and services in a staffed, around-the clock care setting or within 72 hours of discharge, including from a hospital s emergency department. The most common root cause documented during this time period was shortcomings in assessment, most commonly psychiatric assessment. In addition, 21.4% (165) of Joint Commission accredited behavioral health organizations and 5.14% (65) of Joint Commission accredited hospitals (for which the requirement was applicable) were rated noncompliant in 2014 with National Patient Safety Goal NPSG , Element of Performance (EP) 1 Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide. Actions Suggested by The Joint Commission To accomplish the following suggested actions, The Joint Commission urges all health care organizations to develop clinical environment readiness by identifying, developing, and integrating comprehensive behavioral health, primary care, and community resources to assure continuity of care for individuals at risk for suicide. 12,25 Many communities and health care organizations presently do not have adequate suicide prevention resources, leading to the low detection and treatment rate of those at risk. As a result, providers who do identify patients at risk for suicide often must interrupt their workflow and disrupt their schedule for the day to find treatment and assure safety for these patients. * The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. Continued on page 14 April 2016 The Joint Commission Perspectives 13

14 SENTINEL EVENT ALERT: New Alert Focuses on Suicide Ideation (continued) Continued from page 13 Detecting Suicide Ideation in Nonacute or Acute Care Settings Primary, emergency, and behavioral health clinicians all play crucial roles in detecting suicide ideation through the following three steps, which can be taken in nonacute or acute care settings: 1. Review each patient s personal and family medical history for suicide risk factors. These are listed in the Who is at risk for suicide? section of this Alert. 2. Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. A waiting room questionnaire including a question specifically asking if the patient has had thoughts about killing him or herself may help identify individuals at risk for suicide who otherwise may not have been identified. Research shows that a brief screening tool can identify individuals at risk for suicide 11,26 32 more reliably than leaving the identification up to a clinician s personal judgment or by asking about suicidal thoughts using vague or softened language. For example, a study using the Patient Health Questionnaire (PHQ-9) 33 found that those who expressed thoughts of death or self-harm were 10 times more likely to attempt suicide than those who did not report those thoughts. 26,31 Some practices use a shorter version called the PHQ-2, 34 which asks two questions about depression symptoms, and some add an additional question about suicidal thoughts and feelings. If a patient answers yes to any of these questions, the PHQ-9 is administered. 35 Other brief screening tools include the Emergency Medicine Network s ED- SAFE Patient Safety Screener 36 for emergency departments and the Suicide Behaviors Questionnaire-Revised (SBQ- R) Review screening questionnaires before the patient leaves the appointment or is discharged. To determine the proper immediate course of treatment, conduct or refer for secondary screening and assessment patients determined to be at risk for suicide. Useful secondary screeners include the Suicide Prevention Resources Center s Decision Support Tool 38 and the Emergency Medicine Network s ED-SAFE Patient Safety Secondary Screener 39 for emergency departments. The SAFE-T 20 Pocket Card and the Columbia-Suicide Severity Rating Scale (C-SSRS) 40 can be used for in-depth screening and assessment. For patients who screen positive for suicide ideation and deny or minimize suicide risk or decline treatment, obtain corroborating information by requesting the patient s permission to contact friends, family, or outpatient treatment providers. If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient s permission when the clinician believes the patient may be a danger to self or others. 38 Taking Immediate Action and Safety Planning During the following two steps, behavioral health clinicians are generally added to the care team via consultation or referral. The care team should do the following: 4. Take the following actions, using assessment results to inform the level of safety measures needed. l Keep patients in acute suicidal crisis in a safe health care environment under one-to-one observation. Do not leave these patients by themselves. Provide immediate access to care through an emergency department, inpatient psychiatric unit, respite center, or crisis resources. Check these patients and their visitors for items that could be used to make a suicide attempt or harm others. Keep these patients away from anchor points for hanging and material that can be used for self-injury. 41 Some specific lethal means that are easily available in general hospitals and that have been used in suicides include bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing. 42,43 l For patients at lower risk of suicide, make personal and direct referrals and linkages to outpatient behavioral health and other providers for follow-up care within one week of initial assessment, 8 rather than leaving it up to the patient to make the appointment. l For all patients with suicide ideation: Give every patient and his or her family members the number to the National Suicide Prevention Lifeline, TALK (8255), as well as to local crisis and peer support contacts. 44 Conduct safety planning 45 by collaboratively identifying possible coping strategies with the patient and by providing resources for reducing risks. 12,44 A safety plan is not a no-suicide contract (or contract for safety ), which is not recommended by experts in the field of suicide prevention. 44 Review and reiterate the patient s safety plan at every interaction until the patient is no longer at risk for suicide. 38 Restrict access to lethal means. Assess whether the patient has access to firearms or other lethal means, such as prescription medications and chemicals, and discuss ways of removing or locking up firearms and other weapons during crisis periods. Restricting access is important because many suicides occur with little planning during a short-term crisis, and both intent and means are required to attempt suicide. 46 The 14 The Joint Commission Perspectives April 2016

15 Harvard T.H. Chan School of Public Health s Means Matter website provides helpful advice on means restriction. 46 Behavioral Health Treatment and Discharge Behavioral health clinicians manage the patient s evidencebased treatments and discharge plans, as well as coordinate care transitions and follow-up care with the patient s other providers. 5. Establish a collaborative, ongoing, and systematic assessment and treatment process with the patient involving the patient s other providers, family, and friends as appropriate. Suicide risk, by nature, is very dynamic changing according to personal events, a person s level of desperation, and available interventional resources. 47 Treatment of individuals at risk for suicide requires a collaborative approach that acknowledges the ambivalence the desire to find a solution to their pain versus the innate desire to live that these patients often feel. 48 A valuable support to traditional risk assessment is to use a risk formulation model drawn from prevention research 49 and violence assessment 50 that can help providers to understand a patient s current thoughts, plans, access to lethal means, and acute risk factors. This understanding can be used to develop personalized care and both short- and long-term safety plans for patients struggling with thoughts of suicide. 6. To improve outcomes for at-risk patients, develop treatment and discharge plans that directly target suicidality. 12 Traditionally, behavioral health clinicians often have treated the underlying depression or other mental health disorders in patients but have not directly addressed suicide risk. Providing direct treatment of suicide risk using evidence-based interventions is vital. Hospitalization is often necessary for a patient s immediate safety, but hospitalization used solely as a containment strategy may be ineffective or counterproductive and considered by the patient as a disincentive or penalty for expressing suicidal thoughts. 54 Evidence-based clinical approaches that help to reduce suicidal thoughts and behaviors include 1) Cognitive Therapy for Suicide Prevention (CBT-SP), 55,56 2) the Collaborative Assessment and Management of Suicide (CAMS), 19,57 and 3) Dialectical Behavior Therapy (DBT). 58 In addition, Caring Contacts has a growing body of evidence as a post-discharge suicide prevention strategy. See an overview of these and other evidence-based interventions, which emphasize patient engagement, collaborative assessment and treatment planning, problem-focused clinical intervention to target suicidal drivers, skills training, shared service responsibility, 12 and proactive and personal clinician involvement in care transitions and follow-up care, such as the following: l Engaging the patient and family members/significant others in collaborative discharge planning to promote effective coping strategies l Discussing the treatment and discharge plan with the patient and sharing the plan with other providers having responsibility for the patient s well-being l Determining how often patients will be called and seen l Establishing real-time telephone or live contact with at-risk patients who don t stay in touch or show up for an appointment, rather than having staff or resources just leave reminder messages or s l Directly addressing patients thoughts about suicide at every interaction 62 l Using motivational enhancement to increase the likelihood of engagement in further treatment 44 Education and Documentation These recommendations are relevant to all care providers and settings. 7. Educate all staff in patient care settings about how to identify and respond to patients with suicide ideation. Develop a process for how staff can sensitively respond to a patient with suicidal thoughts and feelings in a way that is appropriate to their role and professional training. 63 Education for staff should cover environmental risk factors; finding help in emergencies; and policies for screening, assessment, referral, treatment, safety, and support of patients at risk for suicide. The Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention developed Suicide Prevention and the Clinical Workforce: Guidelines for Training. 64 Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments, 38 The Joint Commission s Standards BoosterPak Suicide Risk for NPSG , the QPR Institute, and the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (2013) 14 also are good resources. 8. Document decisions regarding the care and referral of patients with suicide risk. Thoroughly document every step in the decision-making process and all communication with the patient, his or her family members and significant others, and other caregivers. Document why the patient is at risk for suicide and the care provided to patients with suicide risk in as much detail as possible, including the content of the safety plan and the patient s reaction to and use of it; discussions and approaches to means reduction; and any follow-up activities taken for missed appointments, including texts, postcards, and calls from crisis centers. Be generous in documentation, as it becomes the main method Continued on page 16 April 2016 The Joint Commission Perspectives 15

16 SENTINEL EVENT ALERT: New Alert Focuses on Suicide Ideation (continued) Continued from page 15 of communication among providers. For a documentation checklist, see page 21 of Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments. 38 Related Joint Commission Requirements The advice provided in this Alert applies universally to all patients in all settings. In addition, since the risk of suicide increases after discharge from emergency departments and inpatient settings, it s important for health care organizations to incorporate appropriate transition and follow-up actions in accordance with Provision of Care, Treatment, and Services accreditation requirement PC The organization has a process that addresses the patient s need for continuing care, treatment, and services after discharge or transfer. Joint Commission Requirements Related to Detecting and Treating Patients with Suicide Ideation Care, Treatment, and Services CTS Environment of Care EC EC National Patient Safety Goal NPSG , EPs 1 3 Performance Improvement PI Provision of Care, Treatment, and Services PC , EP 24 PC PC PC See the content of these standards on The Joint Commission website, posted with this Alert. Hospital Ambulatory Behavioral Health Home Care Nursing Care Center Resources Zero Suicide Toolkit, from the Suicide Prevention Resource Center and the National Action Alliance for Suicide Prevention Office-Based Surgery ED-SAFE Materials, from the Emergency Medicine Network Caring for Adult Patients with Suicide Risk A Consensus Guide for Emergency Departments, and Quick Guide for Clinicians, from the Suicide Prevention Resource Center Means Matter website, from the Harvard T.H. Chan School of Public Health Mental Health Environment of Care Checklist For reviewing inpatient mental health units for environmental hazards, from the VA National Center for Patient Safety QPR Institute Suicide prevention courses and training for professionals, institutions, and the public, on site or through a self-study program SAFE-T Pocket Card for Clinicians Five-step evaluation and triage for suicide assessment Suicide Prevention and the Clinical Workforce: Guidelines for Training, from the Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, from the Department of Veterans Affairs, Department of Defense, June 2013 P References 1. Centers for Disease Control and Prevention. Data & Statistics Fatal Injury Report for (Accessed May 18, 2015). 2. Centers for Disease Control and Prevention. FastStats Death and mortality. (Accessed May 18, 2015). 3. Centers for Disease Control and Prevention. FastStats Mortality Motor vehicle traffic deaths. (Accessed May 18, 2015). 4. Centers for Disease Control and Prevention. FastStats Mortality All homicides. (Accessed May 18, 2015). 5. Ahmedani BK, et al: Health care contacts in the year before suicide death. Journal of General Internal Medicine, DOI: / s Suicide Prevention Resource Center. Continuity of care for suicide prevention: The role of emergency departments. Waltham, MA: Education Development Center, Inc., Stone DM and Crosby AE. Suicide prevention. American Journal of Lifestyle Medicine, Oct. 16, 2014 (accessed July 24, 2015). 8. Knesper, DJ. American Association of Suicidology & Suicide Prevention Resource Center. Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, Massachusetts: Education Development Center, Inc., Siegfried N & Bartlett M. Navigating suicide assessment: A roadmap for providers. A presentation at The Joint Commission s 2014 Annual Behavioral Health Care Conference, Oct , Goldacre M, et al. Suicide after discharge from psychiatric inpatient care. Lancet, 1993;342: Allen MH et al: Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. Suicide and Life-Threatening Behavior, June 2013;43(3): Covington D, et al. Suicide Care in Systems Framework. National Action Alliance: Clinical Care & Intervention Task Force; Jacobson S. Parkland s suicide-risk screening finds more patients need preventive care. The Dallas Morning News. The Scoop Blog. Sept. 8, 2015 (accessed Nov. 6, 2015). 14. VA/DoD Clinical Practice Guideline for Assessment and Management 16 The Joint Commission Perspectives April 2016

17 of Patients at Risk for Suicide. Department of Veterans Affairs, Department of Defense, June 2013 (accessed Jan. 10, 2016). 15. Mental Health America. Suicide. (Accessed May 18, 2015). 16. American Foundation for Suicide Prevention. Key research findings. (Accessed May 31, 2015). 17. Krysinska K, et al: Suicide behavior after a traumatic event. Journal of Trauma Nursing, April June 2009;16(2): U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: recommendation statement. American Family Physician, February 1, 2105;91(3):190F 190I. 19. Jobes DA. The CAMS approach to suicide risk: philosophy and clinical procedures. Suicidology. 2009;14(1): SAFE-T: Suicide Assessment Five-step Evaluation and Triage for Mental Health Professionals. Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center (accessed Aug. 17, 2015). 21. Bickley H, et al: Suicide within two weeks of discharge from psychiatric inpatient care: a case-control study. Psychiatric Services, July 2013;64(7): (accessed June 18, 2015). 22. King EA, et al: The Wessex Recent In-Patient Suicide Study: 1. casecontrol study of 234 recently discharged psychiatric patient suicides. British Journal of Psychiatry, 2001;178: Ho TP. The suicide risk of discharged psychiatric patients. Journal of Clinical Psychiatry, 2003;64: Gaudiano BA, et al: The emergence of suicidal ideation during the posthospital treatment of depressed patients. Suicide and Life Threatening Behavior, October 2008;38(5): Sugimoto-Matsuda J. Suicide prevention in diverse populations: A systems and readiness approach for emergency settings. Psychiatric Times, Nov. 3, 2014 (accessed Aug. 17, 2015). 26. Simon GE, et al: Do PHQ depression questionnaires completed during outpatient visits predict subsequent suicide attempt or suicide death? Psychiatric Services, December 1, 2013;64(12): Shaffer D, et al. The Columbia Suicide Screen: Validity and reliability of a screen for youth suicide and depression. Journal of the American Academy of Child and Adolescent Psychiatry, 2004;43: Cauffman E. A statewide screening of mental health symptoms among juvenile offenders in detention. Journal of the American Academy of Child and Adolescent Psychiatry, 2004;43: Joiner TE Jr, et al. A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: Reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project. Behaviour Research and Therapy, 2002;40: Scott M, et al. The Columbia suicide screen: Does screening identify new teens at risk? Presented at the American Academy of Child and Adolescent Psychiatry; October 21, 2004; Washington, DC. 31. Simon GE, et al: Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services, December 2013;64(12): Boudreaux ED, et al: The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): method and design considerations. Contemporary Clinical Trials, September 2013;36(1): Patient Health Questionnaire-9 (PHQ-9). Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues (accessed Aug. 17, 2015). 34. Kroenke K, et al. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care 2003, (41) (accessed Aug. 17, 2015). 35. Zero Suicide in Health and Behavioral Health Care. Screening for and assessing suicide risk. (Accessed July 27, 2015). 36. Emergency Medicine Network. ED-SAFE materials, Patient Safety Screener. (Accessed Aug. 17, 2015). 37. Osman A, et al. The Suicide Behaviors Questionnaire-Revised (SBQ- R): Validation with clinical and nonclinical samples, Assessment, 2001(5); (accessed Aug. 17, 2015). 38. Caring for Adult Patients with Suicide Risk. A consensus guide for emergency departments. Suicide Prevention Resource Center Education Development Center, Inc. All rights reserved. 39. Emergency Medicine Network. ED-SAFE materials, Patient Safety Secondary Screener (accessed Aug. 17, 2015). 40. Columbia University Medical Center. Columbia-Suicide Severity Rating Scale (C-SSRS) (accessed Aug. 17, 2015). 41. Mills PD, et al: A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. The Joint Commission Journal on Quality and Patient Safety, February 2010;31(2): VA National Center for Patient Safety. Mental Health Environment of Care Checklist (accessed Nov. 6, 2015). 43. Bostwick JM and Rackley SJ: Completed suicide in medical/ surgical patients: Who is at risk? Current Psychiatry Reports, 2007;9: Treating Suicide Directly. A webinar presented by David Jobes, (accessed May 31, 2015). 45. Research Foundation for Mental Hygiene. Safety Planning Intervention for Suicidal Individuals. Copyright 2013 (accessed July 24, 2015). 46. Harvard T.H. Chan School of Public Health. Means Matter. (Accessed May 31, 2015). 47. Healthcare Business Insights. Implementing a contextually-anchored suicide risk assessment to reduce sentinel events. Compliance & Value- Based Care, November 2014; Zero Suicide in Health and Behavioral Health Care. Interventions for Suicide Risk. (Accessed May 31, 2015). 49. Pisani AR, et al. Assessing and managing suicide risk: Core competencies for behavioral health professionals. University of Rochester, Copyright Douglas KS and Skeem JL. Violence risk assessment: Getting specific about being dynamic. Psychology, Public Policy, and Law, September 2005;11(3): Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatric Services, June 2002;(53)6: Muralidharan S and Fenton M. Containment strategies for people with serious mental illness. Cochrane Database of Systematic Reviews, July 19, Huey SJ, et al: Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the American Academy of Child and Adolescent Psychiatry, February 2004;43(2): Freedenthal S. Will I be committed to a mental hospital if I tell a therapist about my suicidal thoughts? Speaking of Suicide website (accessed July 28, 2015). 55. Brown GK, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. Journal of the American Medical Association, 2005;294(5): Stanley B, et al. Cognitive behavior therapy for suicide prevention (CBT-SP): Treatment model, feasibility and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, October 2009;48(10): Comtois KA, et al. Collaborative assessment and management of suicidality (CAMS): Feasibility trial for next-day appointment services. Depression and Anxiety, November 2011;28(11): Linehan MM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, July 2006;63(7): Luxton DD, et al. Can post-discharge follow-up contacts prevent suicide and suicide behavior? A review of the evidence. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 2013;34, Berrouiguet S, et al: Post-acute crisis text messaging outreach for suicide prevention: A pilot study. Psychiatry Research, July 30, 2014;217(3): Carter GL, et al. Postcards from the EDge project: Randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. British Medical Journal, October 8, 2005;331(7520): Zero Suicide in Health and Behavioral Health Care. Transition. (Accessed May 31, 2015). 63. Tischler CL and Reiss NS: Inpatient suicide: preventing a common sentinel event. General Hospital Psychiatry, 2009;31: National Action Alliance for Suicide Prevention: Clinical Workforce Preparedness Task Force. Suicide prevention and the clinical workforce: Guidelines for training Washington, DC. April 2016 The Joint Commission Perspectives 17

18 Joint Commission Names Ronald Wyatt First Patient Safety Officer (continued) Continued from page 11 safety. He has collaborated on the development of National Patient Safety Goals, Sentinel Event Alerts (such as New Alert Focuses on Suicide Ideation on page 12), and Quick Safety publications. He also oversees data management and analyses in his division (see Sentinel Event Statistics Released for 2015 on page 10), and he has a particular interest in disparity, equity, and professionalism in health care. I am deeply honored to be named The Joint Commission s first patient safety officer, Wyatt says. This is an outward sign of our steadfast commitment to the goal of zero harm for all patients, and I look forward to working side-byside with our accredited organizations to make that goal a reality. Wyatt, a board-certified internist licensed in Alabama, came to The Joint Commission with a wealth of patient safety experience. He served on the Food and Drug Administration Drug Safety Oversight Board and as a mentor to the Center for Medicare & Medicaid Innovation Advisors program at the Centers for Medicare & Medicaid Services. Wyatt also served as director of the Patient Safety Analysis Center for the Department of Defense Military Health System. Wyatt continues to serve as The Joint Commission representative on the National Coordinating Council for Medication Error Reporting and Prevention. In addition, he was named one of Becker s Hospital Review Top 50 Patient Safety Experts in the United States in 2013 and Wyatt earned his medical degree at the University of Alabama at Birmingham and completed his residency at St. Louis University Hospital, where he served as chief resident in the Department of Internal Medicine. Wyatt earned the Executive Master of Science in Health Administration (MSHA) from the University of Alabama at Birmingham. In 2000, the Morehouse School of Medicine awarded Wyatt an honorary Doctor of Medical Sciences degree. He was a George W. Merck Fellow with the Institute for Healthcare Improvement from 2009 to He also completed a Harvard School of Public Health program in Clinical Effectiveness. P On-Site Intracycle Monitoring a Key Resource in Continuous Improvement Process Based upon customer feedback, The Joint Commission has improved the approach to continuous improvement and readiness for accreditation in the past several years. Although the Joint Commission s on-site accreditation survey is typically every three years (the accreditation cycle for laboratories is every two years), there are a number of interactions between The Joint Commission and its accredited organizations that foster continuous improvement and help organizations deliver high-quality, safe care every day. One such interaction organizations choose is the on-site option available for meeting Intracycle Monitoring (ICM) requirements. Several years ago, the ICM process was streamlined into the Focused Standards Assessment (FSA). After studying which Joint Commission requirements and Centers for Medicare & Medicaid Services Conditions of Participation indicated higher risks for patient safety and quality, intracycle assessment requirements were changed. The FSA can be performed (as in prior years) through an electronic selfassessment and optional conference call with the Standards Interpretation Group; an attestation that the self-assessment has been completed; or two different options for Joint Commission surveyors to perform a focused, on-site collaborative survey at about one and two years in the accreditation cycle. The on-site options (which carry a fee) can be highly customized to meet the individual customer s needs. A written or verbal report is available to focus improvement efforts and identify areas of risk. The results of this customized, focused survey will provide the organization with an assessment of its current compliance without affecting its accreditation status.* Our experiences with TJC s on-site ICM survey process have been consistently positive, shares Jill Fainter, HCA vice-president-quality standards. The on-site survey provides education and consultation, and the timing of the on-site survey supports our continuous commitment to accreditation as foundational to our clinical improvement and patient safety strategies and complements our patient-focused culture. For more information about how choosing the on-site options for the ICM process can help your organization, please contact Ann Blouin, executive vice president, Customer Relations, The Joint Commission, at jointcommission.org. P * The only time that the results of the survey can affect an organization s accreditation status is if an Immediate Threat to Health or Safety situation is identified. 18 The Joint Commission Perspectives April 2016

19 Pioneers in Quality Program Provides Support During Top Performer Hiatus Launched in September 2011, the Top Performer on Key Quality Measures program recognizes Joint Commission accredited hospitals that attain and sustain excellence in accountability measure performance. Top Performer hospitals are identified annually by aggregating the results of a fixed set of designated accountability chart-based performance measures reported through the ORYX program during the previous calendar year. The recent retirement of some accountability measures and the heterogeneity of measure sets reported by hospitals, however, make it difficult to compare hospitals and identify top performers. Also presenting a challenge is the fact that performance rates for electronic clinical quality measures (ecqms) are not necessarily equivalent to performance rates on chart-based measures. Therefore, The Joint Commission put the Top Performer program on hiatus and is reevaluating the national measurement environment (see December 2015 Perspectives, page 3). In the interim, the new Joint Commission Pioneers in Quality program is providing continued support for accredited hospitals on their journey towards using ecqms. Key components of the Pioneers in Quality program include the following: l Webinars providing education about ecqms l Comprehensive ecqm resource portal l Recognition categories for ecqm pioneers l Pioneers in Quality advisory panel l Modified annual report focusing on the evolution of ecqm measurement l Outreach through The Joint Commission Speakers Bureau l Modified Core Measure Solution Exchange including ecqms l Strong focus on partnering with hospitals to provide the highest level of quality care for patients and their families ORYX flexible reporting options remain in place during the hiatus. For additional information, please visit or send an to P Federal Occupational Health Receives Joint Commission Accreditation The Joint Commission recently announced it has awarded Ambulatory Care Accreditation to Federal Occupational Health, the largest provider of occupational health services within the federal government. A component of the Program Support Center within the US Department of Health and Human Services, Federal Occupational Health works in partnership with agencies to design and deliver comprehensive occupational health solutions exclusively to federal employees. Federal Occupational Health serves nearly 400 federal agencies and provides occupational health services to 1.8 million federal employees. Receiving accreditation through The Joint Commission is a great achievement for Federal Occupational Health, says Michelle Smith-Jefferies, MD, MPH, acting director, Federal Occupational Health, Program Support Center. It recognizes our commitment to quality, safety, and excellence in health care. That s something that will provide a strong foundation for us to grow and provide excellent services to our customers. The Joint Commission s accreditation for occupational/ worksite health services aims to help ambulatory organizations with issues regarding work-related injuries and illness, work-related preventive medicine, illness prevention services, Occupational Safety and Health Administration (OSHA), and departmentally mandated medical surveillance programs. The Joint Commission is a member of the National Association of Worksite Health Centers. On behalf of The Joint Commission, I congratulate Federal Occupational Health on earning accreditation, says Michael Kulczycki, executive director, Ambulatory Health Care Accreditation, The Joint Commission. We re very proud to accredit an organization of this caliber, and we commend FOH for its commitment to providing safe, highquality occupational health services. For more information about Ambulatory Health Care Accreditation, please call or Further information about accreditation services for occupational/worksite health services can be found at / occhealth. P April 2016 The Joint Commission Perspectives 19

20 The Official Newsletter of The Joint Commission Volume 36, Number 4, April 2016 Send address corrections to: The Joint Commission Perspectives or Tracers with AMP NOW AVAILABLE FOR ALL JOINT COMMISSION ACCREDITATION PROGRAMS! Tracers with AMP helps you score standards, conduct tracers, and generate robust reports on compliance with Joint Commission standards. Plus, the enterprise reporting function can provide you with a high-level view of your system and a deep dive into specifi c departments or locations. For more information, visit jcrinc.com/tracers-with-amp/. /. Joint Commission Resources, Inc. (JCR), a wholly controlled, not-for-profi t affiliate of The Joint Commission, is the offi cial publisher and educator of The Joint Commission. JCR is an expert resource for health care organizations, providing consulting services, educational services, publications and software to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR provides consulting services independently from The Joint Commission and in a fully confi dential manner. Please visit for more information. TAHN0316 JCP04

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