Suicide Prevention and Health Care Accreditation: A Panel Discussion with the Joint Commission
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Expires on Aug 05, 2025
Credit Offered
1.5 CME Credits
1.5 COP Credits

Available: 08/5/2022 - 08/5/2025


FREE - $0

Funding for this initiative was made possible (in part) by Grant No. RS20201621-05 from the Suicide Prevention Resource Center (SPRC). The Suicide Prevention Resource Center is the sole owner of the activity content, including views expressed in written materials and by the speakers.  

Health care systems play an integral role in suicide prevention. Data show that 83% of people who die by suicide have seen a health care provider within a year preceding their death.1 In 2012, the U.S. Surgeon General and the National Action Alliance for Suicide Prevention published a revised national strategy recognizing the important role health care systems and health care providers have in suicide prevention. The report called on health care systems to make suicide prevention a “core component” of their work. The report also led to the development and wide adoption of the Zero Suicide framework, a quality improvement model with recommendations on values, culture, measurements, and practices that health care systems should adopt to address suicide risk. 

In 2019, the Joint Commission updated its National Patient Safety Goal (NPSG) on Suicide Prevention in Healthcare Settings (NPSG 15.01.01), which aims to “improve the quality of care for those who are being treated for behavioral health conditions and those who are identified as high risk for suicide.” This goal aligns with the Zero Suicide framework and requires health systems to ensure their care includes suicide screening, risk assessments, training for staff, and safety planning. Establishing these suicide prevention practices as an accreditation requirement for health care systems was a tremendous step forward in the identification and treatment for people at risk of suicide.   

This live panel discussion will focus on how to meet NPSG 15.01.01. The expert panel includes associate director Gina Malfeo-Martin, MSN, RN, of the Joint Commission; Ed Boudreaux, PhD, of the University of Massachusetts Chan Medical School; and Brian Ahmedani, PhD, of Henry Ford Health. The panel discussion will focus on addressing common questions and issues frequently encountered by agencies seeking to meet NPSG 15.01.01 and how two leading health care systems achieve and even exceed the goal.


Recorded webinar, non-interactive, self-paced distance learning activity.

This presentation was recorded on August 4, 2022.

Learning Objectives

  • Implement suicide care and intervention practices and are required to meet the Joint Commission’s NPSG 15.01.01.
  • Identify frequently encountered challenges in implementing NPSG 15.01.01.
  • Describe suicide prevention as a quality improvement initiative.

Target Audience

Psychiatrist, Psychologist, Physician (non-psychiatrist), Physician Assistant , Other mental health professionals   

Instructional Level


Estimate Time to Complete

Estimated Duration: 1.5 hours
Program Start Date: August 5, 2022
Program End Date: August 5, 2025

How to Earn Credit

Participants who wish to earn AMA PRA Category 1 Credit or a certificate of participation may do so by viewing the live presentation and completing the evaluation. After evaluating the program, course participants will be provided with an opportunity to claim hours of participation and print an official CME certificate (physicians) or certificate of participation (other disciplines) showing the event date and hours earned.     

Continuing Education Credit


The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.      

The APA designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Faculty and Planner Disclosures

The American Psychiatric Association adheres to the ACCME’s Standards for Integrity and Independence in Accredited Continuing Medical Education. Any individuals in a position to control the content of a CME activity — including faculty, planners, reviewers or others — are required to disclose all relevant financial relationships with ineligible entities (commercial interests). All relevant conflicts of interest have been mitigated prior to the commencement of the activity.   

Faculty Disclosures

  • Julie Goldstein Grumet, PhD, Vice President for Suicide Prevention Strategy, Director of the Zero Suicide Institute, and Senior Health Care Advisor to the Suicide Prevention Resource Center at the Education Development Center. She provides strategic direction to health care systems to improve the identification and treatment for people at risk for suicide. She has collaborated on numerous grants and publications about systems-based approaches to suicide prevention. Julie’s primary responsibility is to advance the development, dissemination, and effective implementation of comprehensive suicide care practices in various settings. She has expertise in behavioral health transformation, state and local community suicide prevention, quality improvement, and the use of evidence-based practices for suicide care in clinical settings. Julie has a Ph.D. in Clinical Psychology from The George Washington University and lives in Silver Spring, MD. Dr. Goldstein Grumet reports no financial relationships with commercial interest.  
  • Edwin Boudreaux received his PhD from Louisiana State University where he studied health psychology, and he completed his internship at the Medical University of South Carolina where he further specialized in addiction treatment. He is licensed as a clinical psychologist in Massachusetts. He has focused on integrating behavioral health across a variety of medical settings, including emergency medicine, inpatient, and primary care. Dr. Boudreaux has led suicide intervention work collaboratively with hospitals across the country that range broadly in size, culture, practitioner composition, infrastructure support, and mental health resource capacity. His suicide intervention work has included both traditional bedside interventions, as well as mHealth and telehealth interventions. He has strong experience with data collection systems, training, and protocols designed to capture systematic, suicide-related data from patients’ health records, telephone follow-up, and state and national vital statistics registries, such as the National Death Index. He serves as the Principal Investigator for the UMass Zero Suicide Framework implementation, which began in 2016. Dr. Boudreaux has served on expert consensus panels for the NIMH, the Society for Academic Emergency Medicine, the American College of Emergency Physicians, SAMHSA, the American Foundation for Suicide Prevention, and the National Action Alliance for Suicide Prevention. Dr. Boudreaux reports no financial relationships with commercial interest.
  • Brian Ahmedani received his PhD and MSW degrees from Michigan State University (MSU). He is a fully licensed clinical and macro masters-level social worker in the State of Michigan. Dr. Ahmedani also completed a NIH / NIDA-funded fellowship program in Drug Dependence Epidemiology. Currently, he serves as director of the Center for Health Policy and Health Services Research and director of research for the Department of Psychiatry at Henry Ford Health. He also maintains an appointment at MSU. His research interest focuses on the area of mental health services and interventions, with particular expertise in suicide prevention. He has served as PI or Site-PI on dozens of NIH, SAMHSA, and other grant-funded projects in suicide prevention within healthcare systems. His work is highly cited and has been published in many of the leading medical journals in the world. Dr. Ahmedani has been appointed chair of the Governor’s Suicide Prevention Commission in the State of Michigan and has served as an expert on several other policy and quality improvement committees across the nation. Dr. Ahmendani reports no financial relationships with commercial interest. 
  • Gina Malfeo-Martin is an Associate Director in the Standards Interpretation Group for the Behavioral Health Care, Hospital Psychiatric, and Lab Programs at The Joint Commission. In this role, she works closely with accredited organizations to identify vulnerabilities and improve their performance through the analysis of organization-specific data, and the provision of education, interpretation, mentoring, and coaching. Ms. Malfeo-Martin provides leadership and guidance within the team in all aspects of the accreditation process through clinical expertise and customer relationship management. In addition to this role, she was recently promoted to a Team Lead with additional leadership responsibilities and direct reports. She is a subject matter expert in the management of suicidal patients and development of a suicide prevention program as well as restraint and seclusion. Gina is the founder and co-chair of the Suicide and Ligature Review Panel at The Joint Commission. Certified in psychiatric-mental health nursing by the ANCC since 2012, Gina has over 17 years of psychiatric-mental health nursing experience. She has dedicated her nursing career to psychiatric-mental health and has had a variety of nursing roles within behavioral health. Prior to joining The Joint Commission, she served as a clinical nurse educator and, subsequently, a manager of inpatient behavioral health where she was responsible for clinical, operational, and financial oversight. She also worked as an adjunct professor of mental health clinical for undergraduate nursing students. In addition, she was a certified instructor for Crisis Prevention Intervention (CPI) for 5 years. Gina received her Bachelor of Science in Nursing degree from Northern Illinois University, Dekalb, Illinois, and her Master of Science in Nursing degree from Jacksonville University, Jacksonville, Florida. In 2019, she received a 40 under 40 Emerging Nurse Leaders award from the American Nurses Association. Gina reports no financial relationships with commercial interest. 


  • Ebony Harris, Associate Director of Online Learning at APA. Reports no financial relationships with commercial interests.

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