Using the Zero Suicide framework to meet accreditation standards on the way to safer suicide care.

Focusing On Safety

Accrediting organizations are prioritizing safe suicide care.

Healthcare systems play an integral role in suicide prevention. Accrediting organizations are adopting suicide prevention as a core priority, and compliance standards continue to evolve to better support health systems in caring for people at risk of suicide. 

Photo of doctor holding out hand with medical symbol floating above it.

Current Accreditation Guidance

In May 2019, the Joint Commission (TJC) updated its National Patient Safety Goal (NPSG) on Suicide Prevention in Healthcare Settings (NPSG 15.01.01), which aims to “improve the quality and safety of care for those who are being treated for behavioral health conditions and those who are identified as high risk for suicide.” NPSG 15.01.01 currently applies to all Joint Commission-accredited hospitals, behavioral healthcare organizations, and critical-access hospitals. 

The NPSG 15.01.01 performance elements apply to:

  • Persons receiving care in psychiatric hospitals
  • Persons being evaluated in or treated for behavioral health conditions as their primary reason for care (in hospitals and/or critical access hospitals)
  • Persons in psychiatric distinct part units in critical access hospitals
  • All persons who express suicidal ideation during the course of care 

See the Suicide Prevention R3 report available via this web page for full details.

The NPSG 15.01.01 standards follow TJC’s now retired Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings, which represented landmark compliance guidance in 2016.

The Commission on Accreditation of Rehabilitation Facilities (CARF) added screening for suicide risk to its assessment standards in 2019, which are applicable to programs accredited under CARF Behavioral Health and Opioid Treatment Program Standards Manuals. The suicide risk screening requirement follows the addition of Comprehensive Suicide Prevention Program standards in 2018.

The goals of these compliance standards align with the Zero Suicide framework and require health systems to ensure their care includes suicide screening, risk assessments, training for staff, and safety planning. Establishing these suicide prevention practices as an accreditation requirement for healthcare systems was a tremendous step forward in the identification and treatment for people at risk of suicide.

Accreditation Resources

The following resources are intended to provide information about accreditation and compliance standards, and insights from national leaders on meeting and in some cases exceeding standards specific to suicide prevention within health systems: