Ligature Risks: Ensuring Compliance with CMS Hospital CoPs and TJC Requirements

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Start Time:12:00 AM
End Time:12:00 AM
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Provided by MHA Health Institute
Health Institute

Date & Time

Tuesday, Feb. 26
9 - 11 a.m.

Register on or before Tuesday, Feb. 19, to ensure delivery of instructional materials.

MHA members — $225
Nonmembers — $275

The webinar registration fee is for one phone line connection. Each additional phone line connection will be charged a registration fee. Get more value by inviting colleagues to join you on the one connection.

This webinar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation. This webinar also is eligible for use of the MHA Health Institute coupon. Coupons were mailed to MHA-member hospital CEOs on Dec. 17.


all staff, nurses and providers in hospital behavioral units, psychiatric hospitals, hospital emergency departments and on hospital units where suicidal patients are taken care of (ICUs, medical‐surgical units, OB and postpartum units and outpatient areas)

The following program content was provided by the speaker.


This webinar will focus on the requirements for hospitals to prevent ligature risk and self‐ harm from patients that are suicidal. The Joint Commission announced this is one of their top four focus areas. Additionally, the Centers for Medicare & Medicaid Services provided requirements for hospitals to prevent ligature risk and self‐harm from patients that are suicidal.

Our speaker will share tools and resources to help facilities identify CMS and TJC updates that hospitals should implement. CMS updates include what units need to be ligature resistant, and what patient and environmental assessments need to be completed, along with the policy and procedure requirements. TJC has 16 requirements to ensure compliance with their standards, which include psychiatric hospitals, behavioral health units, general acute care inpatient units, outpatient units and emergency departments. Zero Suicide Campaign and the TJC Sentinel Event Alerts on suicide also will be discussed.


At the conclusion of this session, participants will be able to:

  • identify the two CMS tag numbers that set forth requirements to prevent ligature risks for patients with suicidal ideations
  • discuss TJC requirements for hospitals to follow to prevent patients from self-harm, including hanging or strangulation
  • describe the CMS recommendation for education in orientation when policies change every two years


Sue Dill Calloway, J.D., MSN, R.N.
Patient Safety and Healthcare Consulting and Education Company
Columbus, Ohio

Sue Dill Calloway has been a nurse attorney and consultant for more than 30 years. Currently, she is president of Patient Safety and Healthcare Education and Consulting and was previously the chief learning officer for the Emergency Medicine Patient Safety Foundation. She has conducted many educational programs for nurses, physicians and other health care providers. Dill Calloway has authored more than 100 books and numerous articles. She is a frequent speaker and is well known across the country in the area of health care law, risk management and patient safety.