ACHCU Releases Suicide Risk Assessment Toolkit for Hospitals

Experts designed the suicide risk assessment toolkit to facilitate data collection and analysis related to screening assessments and subsequent action plans.

ACHCU Releases Suicide Risk Assessment Toolkit for Hospitals

Photo: Nattawit, Adobe Stock

ACHCU, the educational and training division of the Accreditation Commission for Health Care, Inc. (ACHC), has launched its new Suicide Risk Screening and Assessment Support Toolkit for acute care and critical access hospitals.

The ACHCU toolkit supports policy development and effective implementation through two elements: a template policy and a quality improvement tool for non-behavioral health settings.

“It is a hospital’s duty to provide a safe setting for all patients, which is why we developed this resource to help organizations identify those at risk of self-harm and monitor action taken on a departmental basis to ensure their safety,” said Deanna Scatena, associate program director for acute care hospitals and critical access hospitals for ACHC. “By training our health care professionals to measure the effectiveness of their self-harm mitigation strategies, we empower them to focus on continuous improvement in this area of identified risk.”

More than 700,000 people worldwide die by suicide each year and, according to the Centers for Disease Control and Prevention (CDC), more than 12 million adults seriously considered suicide in 2020 in the U.S. alone. An individual’s risk for suicide is dynamic, changing over time based on affective states, life events, and the complex interplay of risk and protective factors. Evaluation of these factors plays an important role in an overall risk assessment, says ACHC.

ACHCU experts designed the suicide risk assessment toolkit to facilitate data collection and analysis related to screening assessments and subsequent action plans. The tool focuses on audits of medical records to evaluate consistency of screening for risk, escalation to full assessment when indicated, and documented plans of care with identified interventions for patients as needed. The tool aggregates the data in a dashboard to accelerate identification of gaps and facilitate internal quality improvement activities.

The toolkit’s template policy element provides a well-developed starting point for a hospital-specific policy or plan and is intended to be customized to meet the needs and processes of any organization, according to the non-profit. The quality improvement tool’s purpose is to meet the requirement of care in a safe setting. It facilitates a monthly audit of medical records to assess compliance with universal screening. It then evaluates the actions taken to support the safety of patients identified through the screening process to be at risk.

“Screening for suicidal ideation is the starting point and most hospitals are proactive in this intent,” said Scatena. “Once a patient is identified with risk factors, the next actions taken are critical. This tool guides and strengthens quality care from the perspective of the individual patient. Together with our ligature risk assessment tool, which approaches the same safety issue from an environmental perspective, these resources support the safe setting that hospitals strive to provide.”

For more information about ACHCU educational tools and resources email [email protected] or visit

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