IHA/JCR CSR Program: Managing Environment of Care and Ligature Risk Standards: Nov. 7

Time: 8:30 AM


IHA Naperville
1151 E. Warrenville Road

IHA Springfield (via videoconference)
700 South 2nd Street


This workshop is part of Joint Commission Resources’ Continuous Service Readiness (CSR) program, a unique subscription-based program that pairs your staff—both onsite and offsite—with an expert on Joint Commission accreditation standards. Learn more about the CSR program.

Hospitals and health systems subscribed to the CSR program can send up to three staff members at no charge.

NEW! IHA members that do not subscribe to the CSR program may attend this workshop for a registration fee of $269 per person.

Register Online

Taught by Joint Commission Resources (JCR) accreditation experts, this one-day program will explore two topics: 1) updated requirements and challenging standards for mitigating patient ligature and self-harm across multiple settings of care and 2) changes to and top-cited standards within the Environment of Care (EC) and Life Safety (LS) chapters.

In 2017, the Centers for Medicare & Medicaid Services and The Joint Commission placed unprecedented focus on eliminating ligature risk in hospitals. Since then, both organizations have worked to clarify their requirements for the safe provision of care for patients at risk of self-harm or causing harm to others. Join expert faculty for an in-depth discussion of current hospital requirements and other “hot topics” in behavioral health during the program’s morning session.

Participants will spend the afternoon session exploring the EC and LS chapters and accreditation standards. JCR accreditation experts will review and clarify frequently cited 2018 accreditation standards, review surveyor areas of focus and share best practices for conducting EC risk assessments.

This workshop offers you unparalleled access to expert faculty and the opportunity to discuss compliance strategies with like-minded peers from hospitals throughout Illinois.


8:30 am
Continental Breakfast and Networking

8:55 am
Welcome and Introductions

9 am
Managing Ligature Risk and Self Harm Risks
Suzanne D. Harrison, MPH
Continuous Service Readiness Consultant, Joint Commission Resources

10:30 am

10:45 am
Behavioral Health: The Current Landscape of “Hot Topics”
Suzanne D. Harrison


12:45 pm
Environment of Care and Life Safety
Michael Kuechenmeister FASHE, CHFM, CHC, CPE
Consultant, Joint Commission Resources

2:15 pm

2:30 pm
Environment of Care and Life Safety, continued
Michael Kuechenmeister

3:30 pm
Drawing and Adjourn


At the end of this program, you’ll be able to:

  • Outline the requirements for ligature and self-harm risk assessment and mitigation within psychiatric settings, general acute inpatient units and the emergency room. Name two strategies to reduce related risk in each of these settings.

  • Identify how behavioral health, ligature and self-harm standards are applied and cited during surveys.

  • Describe how current behavioral health “hot topics” apply within your organization and how related standards are applied and cited during surveys.

  • Review standard changes within the Environment of Care (EC) and Life Safety (LS) chapters.

  • Identify the most cited EC and LS standard deficiencies of 2017 and discuss recent accreditation survey trends.

  • Describe how to conduct effective EC risk assessments.

Who Should Attend

This workshop will benefit managers, directors and executives in:

  • Compliance

  • Risk management

  • Behavioral health

  • Facility management

  • Quality improvement

  • Patient safety

  • Emergency management

  • Nursing

  • Other clinical care areas


Suzanne Harrison, MPH
Consultant, Joint Commission Resources

An expert in behavioral healthcare operations, Harrison previously served as a hospital vice president and chief operating officer, a director of multiple hospital departments and an administrator of a physician practice. Her expertise in behavioral healthcare operations, including substance use disorder treatment, comes from her work in specialty and general acute care hospitals and freestanding settings encompassing all levels of care. As a consultant, Harrison provides guidance on strategic/tactical planning; outcome measurement and clinical benchmarking; leadership development and education; staffing and productivity; customer satisfaction; and regulatory compliance including survey preparation.

Michael Kuechenmeister FASHE, CHFM, CHC, CPE
Consultant, Joint Commission Resources

With over 35 years of experience in healthcare engineering services, Kuechenmeister oversees the plant operations of a hospital in Ohio and provides healthcare engineering expertise for organizations needing assistance with Joint Commission requirements.

Kuechenmeister is active nationally, representing The American Society for Health Care Engineering (ASHE) for the Office of Homeland Security and the Hospital Emergency Planning Taskforce of the Federal Emergency Management Agency.