If there is a hot button (other than Corona Virus) in healthcare regulatory compliance these days, it would have to be the issue of increased patient suicide. Roughly half of the facilities being surveyed at this time will receive one or more findings related to suicide and specifically ligature issues. Oftentimes this finding in and of itself is leads to conditional accreditation and/or a follow-up visit. Surveyors are being very specific about what they won’t accept and quite non-specific about what they will accept. Quite literally they are often taking the position “we will know it when we see it” as far as non-compliance in behavioral health is concerned.
There was a time in healthcare when the concern for suicide and suicide attempts was mostly limited to patients in Psychiatric Hospitals or Psychiatric Units in Acute Care Hospitals. Throughout the 1970’s and going forward there were about 1500 Psychiatric Hospitals and about 6,500 Acute Care (Medical/Surgical) Hospitals throughout the United States, a number which has steadily declined over the past 40 plus years. Within those organizations we generally accepted that we had high rates of suicide attempts and suicides in Psychiatric facilities and relatively low rates in Acute Care Hospitals, except on defined, locked Psychiatric unites which could logically experience the same mortality and morbidity rates as the standalone Psychiatric Hospitals did.
More recently, perhaps in the last 10 to 15 years, regulators and healthcare organizations have become aware of an alarming incidence of suicides in all types of facilities, including Psychiatric Hospitals, Behavioral Units in Acute Care Hospitals, and patient care units in Acute Care Hospitals, including Emergency Rooms, Medical/Surgical Units, Oncology Units, and many others. In retrospect, none of this seems terribly surprising as healthcare moved away, through the insistence of Medicare/Medicaid (CMS), The Joint Commission (TJC) and others, from the frequent use of seclusion rooms, hard restraints, soft restraints, and chemical restraints, all of which were perceived by regulators as too restrictive an environment for most situations and all of which were being used largely for the purpose of preventing patients from attempting to cause self-harm.
What appears to have changed the most in the past 10 to 15 years is the regulators focus on other than behavioral units and specifically the Emergency Department, ICU and other Medical/Surgical Units. The Joint Commission for example, has published multiple sentinel event alerts and nearly a dozen FAQ’s regarding suicide and ligature issues. Many of these address issues away from the behavioral units.
Perhaps the most difficult part of this issue is the general lack of clear and specific regulations in the industry related to facilities design, equipment, and practices related to the potentially suicidal patient. For those who are unfamiliar with the Behavioral Health setting, it is important to know that there are virtually no “Standards” identifying the design/build aspects of features or products that would present a danger to patients. The standards nearly always lead you in the direction of “do a risk assessment”, when approaching a decision about whether a medical bed could be put in a behavioral room or whether you can use an architectural lay-in ceiling, or need a hard ceiling in a specific situation or type of room. The two primary documents that are widely published and used, as well as referred to in The Joint Commission standards are the Facility Design Guidelines and the OMH guidelines.
When assessing risk for suicide and determining measures that should be taken, be it on a behavioral unit or not, it is important to consider:
- Inherent patient risks based on both the patients emotional state and the facility design
- Presence of and adherence to organizational policies and procedures
- Staff training and knowledge
- Adequacy of staffing
- Patient supervision
- Facility and equipment design and condition
- Monitoring and surveillance of facility and equipment condition
As it stands today, the facilities that seem to fare the best during survey outcome are the ones that have done frequent and comprehensive documented risk assessments and have incorporated FDC and OMH guidelines into the design and equipment selection for their facilities.
The COMPQUAIL Compliance Solution provides a preliminary risk assessment form which is not all inclusive and should be modified and added to by facilities in order to make it fully relevant to their facility and their facilities needs.