The Joint Commission Revises Definition of Suicide in Sentinel Event Policy

The Joint Commission has updated the definition of suicide in its Sentinel Event Policy to include time frames with the highest risk for suicide and highlight the healthcare organization’s continued responsibility for ongoing assessment of the patient as they progress through their treatment plan. Effective Jan. 1, 2024, this revision applies to all Joint Commission accreditation and certification programs (with limited exceptions).

The revised definition of suicide in the Sentinel Event Policy reads Death caused by self-inflicted injurious behavior if any of the following apply:

  • While in a healthcare setting.
  • Within 7 days of discharge from inpatient services.
  • Within 7 days of discharge from emergency department.
  • While receiving or within 7 days of discharge from the following behavioral health care services:
    • Day Treatment/Partial Hospitalization Program/Intensive Outpatient Program.
    • Residential.
    • Group home.
    • Transitional supportive living.

The prior definition, which has now been replaced, was:

Suicide of any patient receiving care, treatment, and services in a staffed around the clock care setting or within 72 hours of discharge, including from the health care organization’s emergency department.

Members may visit the Joint Commission’s Sentinel Event Policy and Procedures webpage for more information.

Members with questions may contact Kelsey Ostergren at the MHA.

Webinar Reviews Ligature Risks and Regulatory Requirements

Suicide safety continues to be a priority for accrediting organizations such as the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC), requiring many providers to evaluate various policies and processes. They include how to keep suicidal patients safe when care is needed outside of the psychiatric unit, how to ensure suicidal safety in the emergency room, controlled entrances and exits, and more.

The MHA Health Foundation webinar Ligature Risks and Preventing Inpatient Suicide: Compliance with the CMS and TJC Standards will review ligature risks in behavioral health, emergency department, and the inpatient setting, compliance with regulatory and accreditation requirements, and more.

The webinar is scheduled from 10 a.m. to noon ET June 14, and MHA members can register for a connection fee of $200. Members with questions should contact Erica Leyko at the MHA.