Accréditation Sans Frontières · ASF Health Standards 9.0
Standard 13 · Psychiatry & Mental Health
6 criteria · base standard
Base standard. 6 criteria, of which 3 non-negotiable. Each criterion is numbered 13.Y, with its classification and verification questions.
Criteria
- 13.1 Suicide Risk Screening and Continuous Observation for High-Risk Patients (NON-NEGOTIABLE)
- 13.2 Environmental Ligature Risk Is Identified and Mitigated (NON-NEGOTIABLE)
- 13.3 Restraint and Seclusion Used as Last Resort, With Strict Documentation (NON-NEGOTIABLE)
- 13.4 Psychiatric Medication Management Follows a Defined Interaction and Monitoring Protocol (CORE)
- 13.5 Staff Are Trained and Drilled in De-escalation, Not Only Briefed (CORE)
- 13.6 Discharge Safety Planning With Follow-Up Care Arranged (STANDARD)
13.1 Suicide Risk Screening and Continuous Observation for High-Risk Patients
NON-NEGOTIABLE
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.
VERIFICATION QUESTIONS
- Is screening performed using a validated tool, applied consistently to every admission, not left to clinical impression alone?
A structured tool catches risk more reliably than impression alone, particularly for a patient who may not spontaneously disclose risk. - Is a high-risk observation level maintained continuously and documented, with no gaps in practice?
A documented observation level that is not maintained in practice provides no protection. - Is observation level reassessed as risk changes during the admission, not fixed at the initial screening?
Risk can change during an admission; a level set once at intake may no longer reflect current status.
13.2 Environmental Ligature Risk Is Identified and Mitigated
NON-NEGOTIABLE
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.
VERIFICATION QUESTIONS
- Has a systematic, documented ligature risk assessment been performed for the unit, not assumed from general psychiatric unit design standards?
A specific, documented assessment of this unit's actual environment, not an assumption based on general design principles. - Are identified hazards mitigated, not noted but left unaddressed?
A hazard identified but not corrected provides no protection. - Is the assessment repeated when the physical environment changes, not treated as a one-time exercise?
New furnishings or fixtures can introduce new hazards not present at the original assessment.
13.3 Restraint and Seclusion Used as Last Resort, With Strict Documentation
NON-NEGOTIABLE
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.
VERIFICATION QUESTIONS
- Is there documented evidence that de-escalation was attempted before restraint or seclusion, not restraint used as a first response?
Restraint as a last resort, with evidence of what was tried first, not the default response to agitation. - Is every episode individually, specifically justified and time-limited, not a blanket order applied without case-specific review?
A blanket or open-ended restraint order is a specific, serious failure mode this criterion exists to prevent. - Is there a timely review process checking whether restraint remains necessary, not continued without active reassessment?
Ongoing restraint without active, timely reassessment can persist well past clinical need.
13.4 Psychiatric Medication Management Follows a Defined Interaction and Monitoring Protocol
CORE
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.
VERIFICATION QUESTIONS
- Is interaction screening performed for every new psychiatric medication order, not assumed from the prescriber's general knowledge alone?
A systematic check, not reliance on an individual prescriber's memory for every known interaction. - Is required monitoring, such as specific lab tests for certain medications, scheduled and tracked, not left to chance?
Specific, required monitoring completed on schedule, not assumed to happen. - Is there a documented process for what happens when monitoring reveals an abnormal result?
Detection without a clinical response provides limited protective value.
13.5 Staff Are Trained and Drilled in De-escalation, Not Only Briefed
CORE
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.
VERIFICATION QUESTIONS
- Has de-escalation training included practical drilling, not only a written policy or lecture-style session?
Practical, scenario-based training functions differently under stress than a document only read. - Is training refreshed on a defined schedule, not completed once at hiring and never revisited?
Skills can fade without periodic reinforcement, particularly for a skill used infrequently by some staff. - Can staff describe their actual de-escalation approach confidently when asked, not struggle to articulate a concrete technique?
A confident, concrete description suggests the training has taken hold, rather than being only technically completed.
13.6 Discharge Safety Planning With Follow-Up Care Arranged
STANDARD
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.
VERIFICATION QUESTIONS
- Does every discharge include a documented, individualised safety plan, not a generic handout given regardless of the patient's specific situation?
An individualised plan, not a standard form applied identically to every patient. - Is follow-up care arranged and confirmed before discharge, not a verbal suggestion with no actual appointment secured?
A confirmed appointment, not a recommendation the patient must arrange themselves during a known high-risk period. - Is there a documented process for following up if the patient misses their first post-discharge appointment?
A specific, active process for re-engagement during the known highest-risk window, not simply noting the missed appointment. ————————————————————