Is your psychiatric hospital or unit ready for the next Joint Commission survey? Most leaders I speak to are confident they are. They have excellent staff, have hired a mock surveyor and are up to date on the most recent rules. Their last survey, 2 years ago, went very well. And yet, so many still struggle with the survey.
The Joint Commission recently released aggregate data for 2019 surveys. Of the 1,146 Behavioral Health settings they surveyed, they issued 222 citations for ligature risks alone including a shocking 20 identified as ITHS (Immediate Threat to Health and Safety). I don’t have to tell you how impactful to your operations an ITHS citation is. This is serious stuff. And yet, 20 facilities that were sure they were ready, found themselves dropping everything else they were doing to address an ITHS issue in their inpatient unit or ED.
If you are looking for a reference point, The Joint Commission issued only 9 ITHS citations in 1,417 General Hospital surveys in 2019.
How can this be? Surely everyone by now is aware of the heightened emphasis on ligature risks and overall safety in psychiatric units. I fully acknowledge that there is a certain vagueness to the rules that makes preparing for these surveys difficult. A surveyor might simply make a different judgement call than your clinical staff. Everyone in this industry is aware of that issue and the challenges it brings. Given that, the 222 citations actually seems low.
The 20 ITHS citations is not low. That is shocking. If you are responsible for safety in a psychiatric unit, hospital or emergency department space, that number should worry you. Are you sure you are ready?
