You go back, Jack, and do it again……

By Steve MacArthur, Hospital Safety Consultant

I had really planned on speaking about something other than risk assessments this week, but there’s that whole dynamic of planning resulting in the amusement of deities which has once again held true.

In this week’s installment, our friends in Chicago have sharpened their pencils (and placed them in a safe place once their edits were completed) in their guidance to behavioral health organizations, as well as hospitals,  and the expectations for patient safety risk assessments in non-inpatient settings (residential, partial hospitalization, day treatment, outpatient and intensive outpatient programming).

The overarching expectation is that, yes, organizations are expected to conduct risk assessments in these environments to identify elements in the environment that could be used by patients to harm themselves, visitors and/or staff. The results of the assessment would then be used to determine what conditions can be abated/mitigated, etc., and any remaining risks communicated to staff so they would be aware of the potential impact to individual(s) that develop serious suicidal ideation so they can safely manage care until the patient is either stabilized or moved to a safer level of environment, so to speak.

This is not to say that these non-inpatient spaces have to be ligature-resistant in design; as non-inpatient behavioral health settings, patients can leave, which really distills the management of the at-risk patient down to the identification of increasing risk factors by the clinical folks and their interactions with the patients.

You can find the FAQs here: (the FAQs for the behavioral health accreditation program and the hospital accreditation program follow the same link – as near as I can tell.)

So, if you have non-inpatient behavioral health environments in your portfolio – and you’ve not yet embarked upon the risk assessment voyage in these areas – now is the time for all good people to, yet again, expand their risk assessment horizons.

Wishing everyone a safe and celebratory Independence Day!

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at