Assessing the Risk: Suicidal Behavior in the Hospital Environment of Care

Sharon Chaput, RN, CSHA; Kirk Woodring, LICSW, CGP

Suicide of a care recipient while in a staffed, round-the-clock care setting or within 72 hours of discharge has remained in the top five most frequently reported sentinel events to The Joint Commission since 1995. Perform thorough suicide risk assessments and comply with the Joint Commission’s Sentinel Event Alert through strategies provided in the HCPro book Assessing the Risk: Suicidal Behavior in the Hospital Environment of Care. Authors Sharon Chaput, RN, CSHA, and Kirk Woodring, LICSW, CGP, provide efficient and effective ways to address environment of care issues, improve documentation and patient handoffs, and utilize rapid assessment to reduce suicide risk at your facility.

• Gain a better understanding of NPSG 15.01.01 and implement the necessary processes to ensure compliance with this goal
• Help your staff identify and assess at-risk patients quicker and more effectively by using the ready-made screening and assessment tools
• Ensure proper documentation of suicide risk assessments by staff in high-risk units such as the emergency room
• Learn from your peers through several case studies and results of recent CMS and Joint Commission surveys
• View sample interviews with high-risk patients to understand motives and recognize components of the interview that elucidate risk

• Environment of care risk assessment
• Individual crisis prevention plan for adults
• RN assessment of patient safety progress note
• Shift progress/ reassessment note
• Therapeutic intervention survey
• Sample safety tool for kids
• SAD PERSONS scale

• Introduction
• Overview and rationale for NPSG 15.01.01
  • Elements of Performance
  • Sentinel Event statistics
  • What other hospital settings besides psychiatric or behavioral health should do to comply with this goal
• Suicide risk factors
  • Various risk factors
  • Protective factors
• Parasuicidal behavior
  • Self mutilation: Cutting in teens and adults
  • Assessment and risk factors
  • Treatment
  • Post Traumatic Stress Disorder
• Components of a suicide risk assessment
• Documentation of suicide risk assessments
  • What and when to document
  • Suicide risk scales and sample tools/forms for emergency departments and other settings
• Environment of Care (EC): What to assess for compliance
  • Annual EC risk assessments
  • Determine EC needs based on settings
  • Recent CMS and Joint Commission surveys
• Case studies
  • Emergency department
  • Outpatient therapy
  • Labor/delivery unit: Postpartum depression
  • Post Traumatic Stress Disorder

National Association for Healthcare Quality (NAHQ)
This activity will be submitted to the National Association for Healthcare Quality for CPHQ CE credit.

Sharon Chaput, RN, CSHA, is the Director of Standards and Quality Management at the Brattleboro Retreat. Ms. Chaput has 24 years of experience as an RN with 20 years working in behavioral health in various positions, including charge nurse, nurse manager, and program director.Ms. Chaput is considered to be a national field expert in healthcare accreditation. She assisted in developing the national Certification for Accreditation Health Professionals (CSHA) examination. She has also spoken at national accreditation professionals conferences on suicide risk assessment and has provided consultative services for hospitals on Joint Commission survey readiness.

Kirk Woodring, LICSW, CGP, is a licensed independent clinical social worker and the Director of Access, Evaluation and Ambulatory Services at the Brattleboro Retreat. Mr. Woodring has presented nationally on the assessment of suicide risk and has worked and consulted with emergency department doctors, nurses, and social workers in hospitals throughout New England on developing skills for rapidly assessing risk. Formerly the director of a Massachusetts emergency services team, Mr. Woodring also serves as an adjunct Associate Professor at the Smith College School for Social Work.