Standards › ASF Health Standards v10 › Standard 52
Standard 52
Psychiatry and Mental Health
Psychiatry and mental health: suicide risk screened and high-risk patients observed, ligature risks mitigated, restraint and seclusion used as a last resort, psychiatric medicines monitored, staff drilled in de-escalation, and safe discharge with confirmed follow-up.
Every psychiatric admission undergoes suicide risk screening using a validated tool, with a patient identified as high-risk placed on a continuous, documented observation level — not a screening completed once at admission with no follow-through into the observation practice that should result.
Why it matters. A person admitted to a psychiatric unit may be at risk of taking their own life. Screening every admission with a validated tool, and watching those at high risk, can prevent a death.
How the surveyor verifies this criterion
Sample. Review screening and observation records for every psychiatric admission in the last 6 months, and the observation logs for high-risk patients.
1. Every psychiatric admission is screened for suicide risk with a validated tool.
Method. Check each sampled admission record for the screening result and the tool name.
Evidence to show. Suicide risk screening and continuous observation (PSY-SOP-001); suicide risk screening record (PSY-FRM-001).
Pass when. Every sampled admission has a validated screen recorded on admission.
2. A high-risk patient is placed on continuous, documented observation.
Method. Check each sampled high-risk patient for continuous observation entries at the set interval.
Evidence to show. Continuous observation log (PSY-REG-001).
Pass when. Every sampled high-risk patient has continuous observation recorded for the whole high-risk period.
3. Observation is stepped down only with a documented psychiatric decision.
Method. Check each step-down for the psychiatrist decision and the reason.
Evidence to show. Continuous observation log (PSY-REG-001).
Pass when. Every step-down has a recorded psychiatrist decision and reason.
Immediate fail (any one means the criterion is not met)
- A patient who says they will end their life is screened low, and is found unobserved in the bathroom.
Documents
E-learning
References
- World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. Geneva: WHO; 2019.
The psychiatric unit’s physical environment is systematically assessed for ligature and other self-harm risk points, with identified hazards mitigated through environmental design or removal — not a one-time assessment that is never revisited as fixtures and furnishings change.
Why it matters. A person in crisis may hang themselves with a cord, a sheet or a fitting in the room. A systematic check of the environment, with hazards removed, prevents that.
How the surveyor verifies this criterion
Sample. Review the ligature survey and mitigation records for the psychiatric unit, and inspect a sample of rooms.
1. The unit is systematically surveyed for ligature and self-harm risk points.
Method. Check the survey schedule and the survey record for each room.
Evidence to show. Ligature risk survey record (PSY-FRM-002).
Pass when. Every room and area is surveyed on the set schedule.
2. Identified hazards are mitigated.
Method. Check each recorded hazard for its mitigation and the date.
Evidence to show. Ligature risk mitigation register (PSY-REG-002).
Pass when. Every identified hazard has a recorded mitigation.
3. Mitigations are re-checked.
Method. Inspect a sample of rooms and check the re-check dates in the register.
Evidence to show. Ligature risk mitigation register (PSY-REG-002).
Pass when. Every mitigation is re-checked on the set schedule, and the rooms match the register.
Immediate fail (any one means the criterion is not met)
- A ligature point in a bedroom is recorded and not mitigated, and a patient uses it.
Documents
E-learning
References
- World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. Geneva: WHO; 2019.
Physical restraint or seclusion is used only after documented attempts at de-escalation have failed, for the minimum time necessary, with each episode individually justified, time-limited, and reviewed — not a default response to agitation or a measure extended past clinical necessity.
Why it matters. Restraint and seclusion can cause injury, distress and death. They must be the last resort, after real attempts to calm the person, and documented in full.
How the surveyor verifies this criterion
Sample. Review every restraint and seclusion episode on the unit in the last 12 months.
1. Restraint or seclusion is used only after documented de-escalation has failed.
Method. Check each sampled episode for the de-escalation record before use.
Evidence to show. Restraint and seclusion (CLN-POL-002, existing, reused); restraint and seclusion record (CLN-FRM-004, existing, reused).
Pass when. Every sampled episode has a documented de-escalation attempt before use.
2. Each episode is limited to the minimum time and individually justified.
Method. Check the start and end times and the justification for each sampled episode.
Evidence to show. Restraint and seclusion record (CLN-FRM-004, existing, reused).
Pass when. Every sampled episode has a justification and a recorded time limit.
3. Each episode is reviewed.
Method. Check each sampled episode for the review record.
Evidence to show. Root cause analysis of serious incidents (INC-SOP-001, existing, reused).
Pass when. Every sampled episode has a review record.
Immediate fail (any one means the criterion is not met)
- A patient is secluded for 14 hours with no documented review, and no de-escalation is recorded first.
Documents
No documents yet.
E-learning
References
- United Nations. Convention on the Rights of Persons with Disabilities. New York: UN; 2006.
Psychiatric medications, including those with significant interaction risk or requiring specific monitoring, are managed through a defined protocol covering interaction screening and required laboratory or clinical monitoring — not prescribed and administered without this structured safeguard.
Why it matters. Some psychiatric medicines interact with others or need careful monitoring, such as blood tests. A defined process for these keeps the treatment safe.
How the surveyor verifies this criterion
Sample. Review the medicine records of psychiatric patients on medicines with interaction risk or monitoring needs, for the last 6 months.
1. Psychiatric medicines are managed under a defined interaction and monitoring protocol.
Method. Compare the protocol with the medicines list for the unit.
Evidence to show. Psychiatric medicines: interaction and monitoring protocol (PSY-SOP-002).
Pass when. Every medicine on the list that needs monitoring is covered by the protocol.
2. Each prescription is checked for interactions before it starts.
Method. Check each sampled prescription for the interaction check.
Evidence to show. Psychiatric medicine monitoring record (PSY-FRM-003).
Pass when. Every sampled prescription has a recorded interaction check before it started.
3. Required monitoring tests are done on schedule.
Method. Compare the due and done dates in the monitoring record for each sampled patient.
Evidence to show. Psychiatric medicine monitoring record (PSY-FRM-003); medicines management policy (HOS-POL-001, existing, reused).
Pass when. Every required monitoring test was done on schedule.
Immediate fail (any one means the criterion is not met)
- A patient on a medicine needing blood monitoring has no test in a year, and toxicity is found late.
Documents
E-learning
References
- World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705
Staff working on the psychiatric unit are trained and practically drilled in de-escalation technique, not only given a written policy to read, with training refreshed on a defined schedule, not completed once at hiring.
Why it matters. De-escalation is a skill that has to be practised, not only explained. Staff who have drilled it are more likely to calm a situation than to restrain.
How the surveyor verifies this criterion
Sample. Review drill and training records for all unit staff for the last 2 years.
1. Unit staff are trained in de-escalation technique.
Method. Compare the training matrix with the unit staff list for the sample.
Evidence to show. Training matrix register (WRK-REG-001, existing, reused).
Pass when. Every unit staff member has recorded de-escalation training.
2. Staff take part in practical drills, not only written policy review.
Method. Check the drill register for each staff member who was drilled.
Evidence to show. De-escalation drill register (PSY-REG-003).
Pass when. Every unit staff member has a recorded practical drill in the period.
3. Training is refreshed at the defined interval.
Method. Compare each staff member’s refresher due date with the date of the review.
Evidence to show. De-escalation drill register (PSY-REG-003).
Pass when. No staff member is past the refresher due date.
Immediate fail (any one means the criterion is not met)
- A staff member has read the de-escalation policy but never practised it, and a patient assault goes unmanaged.
Documents
E-learning
References
- World Health Organization. Transforming and scaling up health professionals’ education and training. Geneva: WHO; 2013.
Before discharge, every psychiatric patient has a documented safety plan and an arranged, confirmed follow-up appointment — not a verbal recommendation to “follow up with your provider” with no actual appointment secured, because the risk is elevated in the period immediately after psychiatric discharge.
Why it matters. A person leaving psychiatric care is at a higher risk in the first days after discharge. A written safety plan and follow-up arranged before they leave reduce that risk.
How the surveyor verifies this criterion
Sample. Review discharge records of psychiatric patients in the last 6 months, for safety plans and follow-up appointments.
1. Every psychiatric patient has a documented safety plan before discharge.
Method. Check each sampled discharge record for the written safety plan.
Evidence to show. Discharge safety plan and follow-up confirmation (PSY-FRM-004).
Pass when. Every sampled discharge has a written safety plan.
2. A follow-up appointment is arranged and confirmed, not only recommended.
Method. Check each sampled discharge for the booked date and the confirmation with the patient.
Evidence to show. Follow-up booking before discharge (AFT-FRM-001, existing, reused); discharge safety plan and follow-up confirmation (PSY-FRM-004).
Pass when. Every sampled discharge has a booked and confirmed follow-up appointment.
3. A written aftercare plan is given at discharge.
Method. Check the discharge record for the written aftercare plan.
Evidence to show. Written aftercare plan at discharge (REH-SOP-005, existing, reused).
Pass when. Every sampled discharge has a written aftercare plan given to the patient.
Immediate fail (any one means the criterion is not met)
- A patient is discharged with a verbal suggestion to see a doctor, no appointment, and no safety plan, and returns in crisis the next day.
Documents
E-learning
References
- World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. Geneva: WHO; 2019.
Additional resources: guidelines in the GMJ library
These guidelines are held in the GMJ guideline library (news.gmj.ge). WHO and PAHO are the issuing bodies; MSF guidelines are marked MSF.
- Operational Considerations for Psychiatric Hospitals, Inpatient Units, and Other Psychiatric Institutions during the COVID-19 Pandemic · PAHO · criteria: Whole standard
Operational guidance for psychiatric hospitals and inpatient units on infection prevention, safe service delivery and protecting rights (COVID-19). - Depression — MSF Clinical guidelines · MSF · criteria: Whole standard
MSF guidance on diagnosing and managing major depressive disorder in humanitarian and resource-limited settings. - Anxiety — MSF Clinical guidelines · MSF · criteria: Whole standard
MSF guidance on recognition and pharmacological management of anxiety disorders in humanitarian settings.
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