Joint Commission decision on ligature risks raises questions.

Hospital surveyors, in particular Joint Commission surveyors, are placing a major emphasis on ligature risks—the risk that suicidal patients will be able to hang themselves in the hospital.

From my limited experience, it appears that the Joint Commission may be going beyond the instructions from the Centers for Medicare & Medicaid Services (CMS) on this point. During a recent Joint Commission survey, the surveyor concluded that conditions in one emergency department (ED) posed an immediate danger to the health and safety of patients and preliminarily denied accreditation.

Two things really bother me about this decision from the Joint Commission. First, several of the alleged dangers cited by the surveyor do not appear to be a real threat to anyone. For example, toilet plumbing was mentioned as a possible hanging risk. Perhaps a rodent could use plumbing in an effort to hang itself, but that is not a realistic threat to human safety. I want to be clear that I am not making light of the ligature safety issues. Protecting patients should be paramount in any healthcare organization. However, I will freely mock enforcement actions that are illogical. But that is only the first of my concerns. The second is perhaps more troubling. The surveyor cited as the basis for the action a CMS memo dated Dec. 8, 2017. (You may find the memo here.) Here is a key sentence from that memo: “The focus of this memo does not apply to other healthcare settings such as acute care hospitals.”

Given that sentence, the fact that the Joint Commission cited the memo during an acute hospital survey is troubling. The memo goes on to say “Psychiatric patients requiring medical care in a non-psychiatric setting (medical inpatient unites, ED ICU, etc.) must be protected when demonstrating suicidal ideation. The protection would be that of utilizing safety measures such as 1:1 monitoring…”

Admittedly that subsequent sentence references EDs, which seems to be at odds with the sentence indicating the memo is inapplicable in acute care hospitals, but in context, it seems to be imploring hospitals to use common sense when caring for suicidal patients, and making sure actively suicidal patients are not left alone. That is entirely reasonable. The idea of removing all ligature risks from an emergency room is not.

Thus far, I have learned three important lessons from this episode.

First, hospitals should be acutely aware of ligature risks. In the ED, in addition to considering whether physical remedies are easily implemented, providing one-to-one supervision for patients at high risk of suicide should lower risk as well as completely satisfy the government’s direction on this matter. Second, some CMS memos continue to be imperfectly written and poorly understood. This memo is a shining example: it purports not to apply in acute care hospitals immediately before it discusses the ED. That isn’t great drafting.

The third lesson is a disturbing one. If you are frustrated by a Joint Commission finding, your appeal process is incredibly limited. Considerable time will pass before you have the chance for any hearing, and once that chance arrives, while you may bring a lawyer, that lawyer is only permitted to address procedural issues and is not allowed to speak about the substance.

In the words of Oliver North’s counsel, Brendan Sullivan, I am not a potted plant. The kangaroo court appeals process is merely one reason that hospitals may wish to carefully consider whether Joint Commission accreditation is a strategy they wish to pursue.

Program Note

Listen to David Glaser every Monday on Monitor Monday, 10-10:30 a.m. EST.


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