The Joint Commission announced an added emphasis will be placed on the assessment of ligature attachment, suicide, and self-harm observations in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals. The article goes on to detail the penalties for infractions identified by surveyors.

Ligature attachment, suicide, and self-harm are very serious issues that the industry has been grappling with for more than 30 years. In some ways, we’re glad to see this increased emphasis and awareness of these issues among surveyors. In other ways, we’re concerned that this may lead to survey reports with a disproportionate number of references to this type of issue, sometimes based on the surveyors’ inadequate understanding of certain matters.

One challenge is the definition of what constitutes a ligature attachment point. The door hardware industry has been working unsuccessfully on this for many years. Some have adopted the “dental floss” definition of ligature that’s mentioned on some European websites. We’ve never considered dental floss to be a lethal weapon and have never known of its use in a serious attempt or successful suicide. However, the conventional wisdom regarding ligatures and attachment points envision the use of a cord, belt, or sheet (the ligature) affixed to an attachment point. The “dental floss” definition envisions elimination of attachment points to such an extreme that not only could sheets, belts, or ropes not be attached but neither could a ligature as fine as dental floss.

Some obvious attachment points that have been documented for decades are still found in some psychiatric facilities, including exposed toilet flush valves, open grab bars, exposed pipes below sinks, shower heads, shower valves, shower curtain rods, drapery rods, door knobs, and door hinges, just to name a few. There should be little grounds for further discussion about these being cited as hazards. However, many other possible items such as chair backs, toilets, and platform patient beds could be cited and are more controversial, depending on the patient populations being served and many other conditions that might be unique to a facility.

Some concern has been expressed about the immediate enforcement of this new emphasis and classifying each observation as a “requirement for improvement,” which is the first step toward conditional accreditation . We strongly suggest that The Joint Commission clarify these issues and train surveyors accordingly before enforcing this new position. Perhaps an initial period during which inspectors would identify infractions but not immediately penalize the facilities would allow for a better understanding of this shift.

The safety of patients, staff, and visitors is very important, but so is the therapeutic nature of the environment. Patients must be provided surroundings that are welcoming, relaxing, and comfortable, and not make them think they are being punished for being ill.

Overemphasis on or an unbalanced approach to safety can result in very prisonlike (and likely therapeutically deleterious) environments for patients and is contrary to the current trend toward more home-like built environments in all healthcare settings, and especially those built environments for the treatment of behavioral health patients.

What constitutes the right blend of safety and comfort is a very individualized issue and will vary widely among facilities, and even from unit to unit within a large facility. Great strides have been made in recent years on these issues, and it would be a shame to see a return to higher levels of institutionalized environments because of this new emphasis on ligature attachment points.

James M. Hunt, AIA, is president of Behavioral Health Facility Consulting LLC (Topeka, Kan.) and can be reached at David M. Sine, DrBE, CSP, ARM, CPHRM, is president of SafetyLogic Systems (Ann Abor, Mich.) and can be reached at