36C25619R0111-0001003.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 1167

Transmittal Sheet

May 12, 2017

MENTAL HEALTH ENVIRONMENT OF CARE CHECKLIST FOR MENTAL HEALTH

UNITS TREATING SUICIDAL PATIENTS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive provides policy to ensure the provision of safe and secure mental health services on mental health units treating suicidal patients in VHA.

2. SUMMARY OF CONTENT: This directive requires the use of the Mental Health Environment of Care Checklist (MHEOCC) in the treatment of suicidal patients and in the design of space for the treatment of mental health conditions in Emergency Departments and Urgent Care Centers by all VHA health care units treating suicidal patients. The directive assigns oversight responsibility to the Office of Mental Health Operations and Veterans Integrated Service Network Directors, and it assigns implementation responsibility to VA medical facility leadership.

3. RELATED ISSUES: VHA Handbook 1160.06.

4. RESPONSIBLE OFFICE: The Office of Mental Health Operations (10NC5) is responsible for the contents of this VHA directive. Questions may be referred to VHA10NC5Action@va.gov.

5. RESCISSIONS: None.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of May 2022. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

Poonam Alaigh, M.D.

Acting Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List on May 19, 2017.

mailto:VHA10NC5Action@va.gov

May 12, 2017 VHA DIRECTIVE 1167 i

CONTENTS

MENTAL HEALTH ENVIRONMENT OF CARE CHECKLIST FOR MENTAL HEALTH

UNITS TREATING SUICIDAL PATIENTS

1. PURPOSE 1

2. BACKGROUND 1

3. DEFINITIONS 2

4. POLICY 3

5. RESPONSIBILITIES 3

6. REFERENCES 6

APPENDIX A

RISK ASSESSMENT MATRIX FOR MHEOCC A-1

MENTAL HEALTH ENVIRONMENT OF CARE CHECKLIST FOR MENTAL HEALTH

UNITS TREATING SUICIDAL PATIENTS

1. PURPOSE

This Veterans Health Administration (VHA) directive provides policy to ensure the provision of safe and secure mental health services on mental health units treating suicidal patients in VHA. AUTHORITY: Title 38 United States Code (U.S.C.) 7301(b).

2. BACKGROUND

a. The Mental Health Environment of Care Checklist (MHEOCC) was designed to help facilities identify and address environmental risks for suicide and suicide attempts while Veterans are being treated on acute inpatient mental health units and other areas.

It is one part of a comprehensive system to reduce suicide in our Veteran population.

Inpatient mental health units should provide safety in an environment that is at the same time a warm, therapeutic, recovery-oriented milieu (see Inpatient Mental Health Handbook 1160.06). It is critical that facilities have a reliable protocol for identifying Veterans at risk for suicide, assessing the level of suicide risk, and providing appropriate treatment in a safe, healing environment (see:

http://www.healthquality.va.gov/guidelines/MH/srb/VASuicidePreventionPocketGuideSp reads.pdf for a suicide risk assessment tool). Clinical assessment should be ongoing, so that Veterans who become suicidal while in less restrictive settings can be identified and moved to a treatment environment designed to provide the appropriate level of care. In addition, facility-wide protocols should be in place to communicate the risk of suicide among the patient’s treating clinicians as directed by VHA Directive 2008-036 (Use of Patient Record Flags to Identify Patients at High Risk for Suicide).

b. The MHEOCC should be applied to all acute mental health units and consideration should be given to its recommendations when designing or renovating Emergency Department space where patients at high acute risk for suicide might be treated. The checklist should not be used to evaluate Residential Rehabilitation Programs, Community Living Centers, or Medical Units due to the nature of the care being provided in these settings. There may be times when a suicidal patient is being treated in a medical unit environment, such as an Intensive Care Unit or general medical area, because of medical and/or surgical needs. These patients should be placed on a one-to-one observation, as clinically appropriate, since the MHEOCC is not used in the design or review of these units.

c. In January 2014, all facilities with inpatient mental health units began using the Patient Safety Assessment Tool (PSAT) to respond to the MHEOCC survey and to track the hazards identified using the action-tracking feature of the PSAT. Also, beginning in the second quarter of Fiscal Year (FY) 2014, all facilities with inpatient mental health units began using the PSAT to track the implementation and progress of abatement plans for hazards identified using the MHEOCC.

d. The environment on an inpatient mental health unit is an element of treatment and must engender an experience of hope, healing, and recovery while maintaining http://www.healthquality.va.gov/guidelines/MH/srb/VASuicidePreventionPocketGuideSpreads.pdf http://www.healthquality.va.gov/guidelines/MH/srb/VASuicidePreventionPocketGuideSpreads.pdf safety in accordance with the MHEOCC. While new facilities can more easily incorporate warm and inviting design elements into the environment, there are many design elements that can be introduced into existing units that would create such an environment. NOTE: For more information, see The Mental Health Facilities Design Guide at: http://www.cfm.va.gov/til/dGuide/dgMH.pdf,The Inpatient Mental Health Services Handbook 1160.06 at:

http://vaww.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_N umber and the Mental Health Environment of Care Checklist at:

http://vaww.ncps.med.va.gov/index.html. These are internal VA Web sites that are not available to the public.

3. DEFINITIONS

a. Direct Line of Sight Observation. Direct line-of-sight observation is defined as constant observation of the patient by staff. Staff can observe multiple patients, but must remain in the area with patients, such that if a patient needs immediate intervention, the staff member can intervene and call other staff to help as needed.

Observation by cameras cannot substitute for direct line-of-sight observation.

b. Interdisciplinary Safety Inspection Team. The ISIT is the team that conducts the inspection of the mental health unit using the MHEOCC. The team should include the Suicide Prevention Coordinator, a Patient Safety Manager, a Facility Safety Officer, a Mental Health Unit Nurse Manager, a non-mental health Unit Nurse Manager, an inpatient Licensed Independent Practitioner, the Local Recovery Coordinator, an outpatient mental health provider (e.g. an out-patient case manager, clinician, or Peer Specialist), a representative from Engineering, a representative from Environmental Services and a Pharmacist to ensure the security of medication storage areas. It is important that a representative from Facilities Management be available to answer questions on the current construction standards used to build the unit (especially doors, windows, floors, fixtures, and ceilings, in accordance with the Mental Health Facilities Design Guide, as well as current VA codes, policy, and standards). In order to increase the team’s perceptive acuity, more than half the team shall consist of clinical staff who do not regularly work on the unit being inspected and who are not accustomed to its surroundings. In smaller facilities, other personnel can be assigned to the ISIT – the overall goal being to have a number of people who are not acclimated to the unit but who are aware of the many ways the environment can be used for self-harm. This team shall be a mandatory subcommittee of the facility’s environment of care team. Team membership should be recorded, as well as the date of last training in the MHEOCC, in the ISIT meeting minutes.

c. MHEOCC for Units Treating Suicidal Patients. The MHEOCC is a checklist designed to help identify and abate suicide hazards on mental health units and other areas treating patients at high acute risk for suicide. It consists of criteria applicable to all rooms on the unit, as well as specific criteria for areas such as bedrooms, bathrooms, seclusion rooms, and staff work stations. The MHEOCC can be accessed at http://vaww.ncps.med.va.gov/guidelines.html#mhc. NOTE: This is an internal VA Web site that is not available to the public.

http://www.cfm.va.gov/til/dGuide/dgMH.pdf http://vaww.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number http://vaww.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number http://vaww.ncps.med.va.gov/index.html http://vaww.ncps.med.va.gov/guidelines.html#mhc

d. MHEOCC Review Board. The MHEOCC Review Board is comprised of representatives from the VHA National Center for Patient Safety (NCPS), VHA Office of Mental Health Operations (OMHO) and VHA Mental Health Services (MHS), and meets as needed to resolve questions about the MHEOCC and the management and abatement of identified suicide hazards.

e. One-to-One Observation. One-to-one observation is defined as the constant observation of one patient by one staff. Staff providing one-to-one observation should only be observing one patient at a time and have no other responsibilities during the assignment to one-to-one observation. While under one-to-one observation, any restroom visit requires an escort who can visually monitor the patient for suicidal behavior. Such restrictions on the Veteran’s freedom must be consistent with statutory and regulatory authority, and be sensitive to privacy and dignity. Observation by cameras cannot substitute for one-to-one observation.

f. Patient Safety Assessment Tool. The PSAT is a web-based assessment tool managed by the VHA National Center for Patient Safety (NCPS). Access to the PSAT is authorized by each facility’s Patient Safety Manager, Patient Safety Officer or PSAT point of contact. The PSAT can be accessed at http://vaww.epsat.ncps.med.va.gov/WebPSAT/WebPSAT.html. NOTE: This is an internal VA Web site that is not available to the public.

4. POLICY

It is VHA policy that all mental health units treating suicidal patients use the MHEOCC to review their units for suicide hazards at least every 6 months and submit the review via the PSAT each time it is completed. In accordance with Standards for Mental Health Coverage in Emergency Departments and Urgent Care Clinics in VHA Facilities, it is also VHA policy that the MHEOCC is used to provide guidance in designing space used for the evaluation of patients presenting to Emergency Departments and Urgent Care Clinics for mental health conditions. Rooms in Emergency Departments and Urgent Care Clinics that must be in compliance with the MHEOCC should be reviewed using the MHEOCC every 6 months.

NOTE: An updated version of the MHEOCC is available on the PSAT every 6 months.

VHA staff can log into the PSAT and link to the updated MHEOCC at:

http://vaww.epsat.ncps.med.va.gov/WebPSAT/WebPSAT.html

5. RESPONSIBILITIES

a. Executive Director for the Office of Mental Health Operations. The Executive Director for the Office of Mental Health Operations (OMHO) is responsible for:

(1) Ensuring that all facilities in VHA with an acute mental health unit treating suicidal patients use the MHEOCC to review these units every 6 months.

http://vaww.epsat.ncps.med.va.gov/WebPSAT/WebPSAT.html

(2) Appointing a MHEOCC work group, to include VHA Central Office Mental Health Program Offices and VHA National Center for Patient Safety (NCPS), to review the results of MHEOCC surveys and abatement plans of facilities; to ensure that all facilities with an inpatient mental health unit treating suicidal patients have completed the survey every 6 months; and to ensure that identified hazards are abated.

(3) Collaborating with NCPS and VHA Mental Health Services (MHS) to review and respond to questions from facilities and/or VISNs about whether or how identified hazards should be abated. This collaboration will take place through the MHEOCC Review Board (see paragraph 6.c. for more information on the review board); the following are the responsibilities of the Review Board:

(a) Any environmental suicide hazard that is identified by the facility must be abated or appealed to the MHEOCC review board for review within 6 months of identifying the hazard.

(b) If the MHEOCC review board finds that a specific hazard is acceptable, the item will be considered closed. This finding should be documented by the Interdisciplinary Safety Inspection Team (ISIT) in the PSAT electronic record.

(c) If the review board finds that the hazard must be abated, the facility should develop an abatement plan within 48 hours and enter that plan into the PSAT. There must be an immediate mitigation of the identified hazard (e.g. staff observation of the hazard or closing the area to patients) and the hazard should be abated within 6 months and tracked until completion.

(d) The review board will also review perceived discrepancies between the MHEOCC and VHA policy, handbooks or directives.

b. Chief Safety and Risk Awareness Officer, VHA National Center for Patient Safety. The VHA Chief Safety and Risk Awareness Officer is responsible for:

(1) Ensuring the content of the MHEOCC is updated as needed.

(2) Ensuring that the PSAT is updated to reflect the most recent version of the

MHEOCC.

(3) Collaborating with VHA Mental Health Program Offices to review and respond to questions from facilities and/or VISNs about whether or how identified hazards should be abated.

c. Veterans Integrated Service Network Director. Each Veterans Integrated Service Network (VISN) Director is responsible for:

(1) Ensuring that each facility within the VISN that has acute inpatient mental health units submits their MHEOCC review via the PSAT every 6 months.

(2) Ensuring that the VISN has informed and updated the NCPS regarding their PSAT point of contact and their facilities’ PSAT points of contact.

(3) Ensuring that each facility has adequate hardware and software to utilize the

PSAT.

d. VA Medical Facility Director. The Director of each VA medical facility that has an inpatient mental health unit treating suicidal patients is responsible for:

(1) Designating an Interdisciplinary Safety Inspection Team (ISIT) as defined below.

(2) Ensuring that this team conducts environment of care rounds on all inpatient mental health units (not including Mental Health Residential Rehabilitation Treatment Programs) using the MHEOCC at least every 6 months.

(3) Ensuring that the findings of these rounds are entered in the PSAT available at http://vaww.epsat.ncps.med.va.gov/WebPSAT/WebPSAT.html. NOTE: This is an internal VA Web site that is not available to the public.

e. Facility Chief of Staff, Nurse Executive, and Mental Health Care Line Manager or Equivalent. The VA Medical Facility Chief of Staff (COS), Nurse Executive, and Mental Health Care Line Manager are responsible for ensuring that:

(1) An individual and a backup individual are designated to complete the PSAT.

(2) The Patient Safety Manager, Facility Safety Officer, Facility Engineer, Facility Planner, and Mental Health Care Line Manager (or other designated mental health personnel) work together to understand the hazards, develop appropriate abatement plans to track progress toward completion of corrective actions, and keep the Facility Director updated about progress.

(3) Every 6 months, an updated MHEOCC review is entered into PSAT. These should be submitted no later than the 15th day following the end of the first and third quarter (respectively, by January 15 and July 15). These reports should be reviewed and monitored by the appropriate VISN level staff, including the Mental Health Service Line Manager, Safety Engineer, and Patient Safety Officer. These semi-annual reports will also be reviewed by OMHO.

(4) For each environmental safety concern identified, a plan of corrective action is developed collaboratively by the team leader, the unit nurse manager, appropriate engineering and environmental services staff, and other necessary stakeholders. The plan shall note who is responsible for implementing the correction and the deadline for completion. Items that the ISIT rated as a 5 should be corrected on an emergency basis within 24 hours. (See the Risk Level Classification Chart below for instructions on assessment of risk.) All hazards must have a mitigation plan in place to mitigate the hazards before the final abatement. For example, if it is going to take 24 hours before an anchor point can be removed from the unit, a plan must be in place to ensure that patients cannot harm themselves prior to the removal of the anchor point.

(5) All staff members who work on inpatient mental health units, such as housekeeping, chaplains, and outpatient providers, as well as members of the ISIT, receive training on the environmental hazards that represent a threat to suicidal patients, and how to identify and correct them. This training must include orientation to the content and proper use of the MHEOCC. Training should occur upon staff orientation and annually thereafter. NOTE: This training is available on the TMS System: VA 1290945 (clinical) and VA 1290950 (non-clinical).

https://www.tms.va.gov/learning/user/login.jsp

6. REFERENCES

a. VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, or subsequent policy issue:

http://www.va.gov/vhapublications/publications.cfm?Pub=1

b. VHA Directive 1101.05, Emergency Medicine:

http://www.va.gov/vhapublications/publications.cfm?Pub=1

c. VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, or subsequent policy issue:

http://www.va.gov/vhapublications/publications.cfm?Pub=2

d. VHA Handbook 1160.06, Inpatient Mental Health Services, or subsequent policy issue: http://www.va.gov/vhapublications/publications.cfm?Pub=2

e. Mental Health Environment of Care Checklist, VHA National Center for Patient Safety, Department of Veterans Affairs, Version 11.08.2013:

http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

f. Mental Health Facilities Design Guide:

http://www.cfm.va.gov/til/dGuide/dgMH.pdf https://www.tms.va.gov/learning/user/login.jsp http://www.va.gov/vhapublications/publications.cfm?Pub=1 http://www.va.gov/vhapublications/publications.cfm?Pub=1 http://www.va.gov/vhapublications/publications.cfm?Pub=2 http://www.va.gov/vhapublications/publications.cfm?Pub=2 http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp http://www.cfm.va.gov/til/dGuide/dgMH.pdf

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APPENDIX A

RISK ASSESSMENT MATRIX FOR MHEOCC

1. RISK ASSESSMENT MATRIX: The Risk Assessment Matrix is an expression of risk that combines the elements of hazard severity and mishap probability. Using the matrix shown below, the risk score is expressed as a single score that can be used to help determine hazard abatement priorities. It identifies the importance of the deficiency as categorized subjectively by the ISIT.

Probability Severity:

Catastrophic

Severity:

Major

Severity:

Moderate

Severity:

Minor

Frequent 5 5 3 2 Occasional 5 4 2 2 Uncommon 4 4 2 1

Remote 3 3 1 1

Examples

Risk Level 5 is a situation that requires immediate attention, such as an open window in a patient room that is high above the ground, or stores of medications in the patient’s room - patients should not be allowed in the room until the situation is fixed.

Risk Level 4 is a situation that should be abated with 24 hours, such as an anchor point in a patient bedroom or bathroom. The situation should be monitored until abated.

Risk Level 3 is a situation that should have action plans for mitigation in place within 5 days, such as the need to secure patient phones and computers, exposed wires from the TV in the day room.

Risk Level 2 is a situation that should have action plans for mitigation on the bi-yearly PSAT action plan such as sharp corners on walls or picture frames.

Risk Level 1 is a situation that have a very low level of risk and no possibility of patient death such as use of cordless phones without staff supervision or access to soap with limited staff supervision.

2. HAZARD SEVERITY: The hazard severity is an assessment of the worst possible consequence, defined by degree of injury, which may occur as a result of the identified safely concern.

Effect Injury Catastrophic Death or permanent loss of function Major Permanent lessening of function, temporary total disability

Moderate Injury/illness requiring medical/surgical intervention, lost workdays, compensable injury/illness

Minor First aid or minor supportive medical treatment

APPENDIX A

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3. MISHAP PROBABILITY: The mishap probability is the likelihood that the identified safety concern will result in a negative consequence, based on an assessment of such factors as location, exposure in terms of cycles or hours of operation, and the affected population.

Frequent. Likely to occur immediately or within a short period of time (may happen several times in a year)

Occasional. Probably will occur (may happen several times in 1-2 years)

Uncommon. Possible to occur (may happen sometime in 2-5 years)

Remote. Unlikely to occur (may happen sometimes in 5-30 years)