Behavioral Health – Observations from the Field    

This Behavioral Health article is designed to focus on the types of observations and survey findings we are seeing and hearing about from organizations related to the field of Behavioral Health. We hope you find this informative, and should you have any questions on any of the content, please reach out to us.

National Patient Safety Goal:  Preventing Suicide

We continue to observe opportunities for improvement and hear about TJC survey findings related to this safety goal. Four areas are dominant at this time:

• Failure to provide a safe environment.

Ensuring a safe environment for potentially suicidal patients requires staff to review the room and its contents and remove those items that are not directly required for the care of the current patient that could be used to harm oneself or others. Emergency Departments have the most solid and consistent processes. Where opportunity is consistently found is upon transfer of that patient to non-behavioral health care locations. Perhaps the patient requires the services on a medical-surgical unit. It is here where we often find staff are unfamiliar with the need to inspect and prepare the room to keep the patient as safe as possible. Utilizing a standardized room safety checklist and requiring two staff members to independently review the room for compliance prior to the patient being placed in the room is a technique we often see organizations use.

Another significant risk exists when visitors are permitted to bring personal items into the patient’s environment. Establishing a screening or clearing process where visitors can secure their personal items while a staff member instructs them on the potential dangers their personal items create is also popular.

• Failure to screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reasons for care.

Screening for suicide risk is essential if we are going to create a safe environment for these patients to receive care. It is equally essential that the screening happens immediately upon arrival to the hospital. Staff education and understanding on the difference between a screening and an assessment will help staff become comfortable with completing the screening process. We have heard staff verbalize that they are not clinical and cannot perform the screening. The screening is completed by the patient answering the questions. Organizations that delay the screening run the risk of a patient harming themselves in the waiting room, rest room or other public area of the organization. The screening tools should be designed to easily identify a person that is at risk so that support staff will know immediately how to intervene to keep the patient safe.

• Failure to continue to assess the patients’ risk for suicide.

While some opportunity still exists to ensure that patients seeking care with primary diagnoses of behavioral health illnesses are screened and assessed; we often find that the assessment of suicide risk concludes once the Psychiatrist or Licensed Independent Provider completes their initial assessment. Often this leaves the patient at high risk for suicide and obligates the organization to continue to provide 1:1 monitoring for an extended period. Ensuring that the reassessment process is defined and communicated within your organization is essential. In addition, consider adding a review of those patients at risk of suicide as a component of your daily safety huddle. This will help to keep this information top-of-mind amongst staff. And while we have spoken about the reassessment process, it is essential that staff understand and have a process to trigger a suicide risk assessment at any time during a patient’s admission.

• Failure to complete or maintain an environmental ligature risk assessment.

The formalized risk assessment process is a newer process to healthcare organizations. The physical plant environment is often continually changing within each healthcare organization. We often will see that an organization completed the initial risk assessment, specifically for ligature risks, but does not have a process or frequency to update the risk assessment, even though the physical environment may have changed. Hence the assessment of potential risks is outdated. This is often a Requirement for Improvement on Accreditation reports. Organizations are encouraged to establish a set frequency and set criteria for reconducting or refreshing their environmental risk assessment. Even with a schedule for conducting the risk assessment, we often still find means by which a patient may harm themselves or others. Diving deeper into the organizations process, we often find that there is no training component for staff that play a supportive role to the behavioral health unit. For instance, do you have a process when onboarding a new member of the physical plant/maintenance team to share with them the safety requirements for these units? Many facilities do not have a process and as a result, the wrong supplies are used to repair the environment.

Care, Treatment and Planning – Treatment Planning

 Treatment Planning remains a problematic area. Many organizations believe that computerization of the process will help, when, we often observe that the treatment planning process becomes more generic, and less patient specific when computerized tools are used. Two components of the treatment planning process remain problematic. First, we frequently see opportunities for the treatment plan to be further individualized to the patient, or clients’ needs and personal history. For instance, clients with low or non-existent literacy abilities are being provided documents to read. We also often see weak documentation regarding the patient, or client’s participation in the treatment planning process. Documentation of the patient/client’s refusal to participate should include why they are refusing. For instance, is the patient too depressed to participate or too angry to participate. We also often see that the treatment plan is not updated when a patient is no longer considered at risk for suicide.

In closing, the 2022 survey process continues to focus on patient safety, and prevention of patient harm. Therefore, it is vital that staff are trained and competent in ensuring behavioral health patients are provided a safe environment.

Another hot topic, Infection Prevention, remains an area that receives intense scrutiny. Watch for our May article for detailed information on Infection Prevention- Observations from the Field.