WSR 16-09-098
PROPOSED RULES
DEPARTMENT OF HEALTH
[Filed April 19, 2016, 1:32 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-19-153.
Title of Rule and Other Identifying Information: Chapter 246-12 WAC, department of health is proposing to add a new Part 14 and new sections to establish minimum standards for suicide prevention trainings for health care professionals.
Hearing Location(s): Department of Health, Town Center 2, Room 145, 111 Israel Road S.E., Tumwater, WA 98501, on May 25, 2016, at 9:30 a.m.
Date of Intended Adoption: June 1, 2016.
Submit Written Comments to: Karyn Brownson, Department of Health, P.O. Box 47853, Olympia, WA 98504, e-mail https://fortress.wa.gov/doh/policyreview, fax (360) 236-2830, by May 25, 2016.
Assistance for Persons with Disabilities: Contact Karyn Brownson by May 20, 2016, TTY (800) 833-6388 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of the proposed rule is to establish minimum standards for suicide assessment, treatment, and management trainings, required to be taken by certain health care professionals. In 2014, ESHB 2315, codified as RCW 43.70.442, was enacted requiring certain health care professionals to complete training in suicide assessment, treatment, and management to help in the identification, referral, or management of patients at risk for suicide. In 2015, ESHB 1424 amended RCW 43.70.442, requiring the department of health to develop minimum standards for the suicide prevention training programs for health care professionals. Training programs that meet the minimum standards will be published on a model list. The proposed rule includes requirements for trainings to include information on veterans and issues related to imminent harm via lethal means or self-injurious behaviors.
Reasons Supporting Proposal: Suicide is a serious public health problem in Washington. The state's suicide rate is almost fifteen per one hundred thousand population, eleven percent higher than the national rate. The proposed rules are necessary to comply with RCW 43.70.442, which requires the department to adopt rules by June 30, 2016, that establish minimum standards for the training programs that will be included on the model list.
Statutory Authority for Adoption: RCW 43.70.442.
Statute Being Implemented: RCW 43.70.442.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of health, governmental.
Name of Agency Personnel Responsible for Drafting: Karyn Brownson, 111 Israel Road S.E., Tumwater, WA 98504-7853, (360) 236-2803; Implementation and Enforcement: Kathy Schmitt, 111 Israel Road S.E., Tumwater, WA 98504-7853, (360) 236-2985.
A small business economic impact statement has been prepared under chapter 19.85 RCW.
Small Business Economic Impact Statement
SECTION 1: Describe the proposed rule, including: A brief history of the issue; an explanation of why the proposed rule is needed; and a brief description of the probable compliance requirements and the kinds of professional services that a small business is likely to need in order to comply with the proposed rule.
Suicide is a serious public health problem in Washington state. The state's suicide rate is almost fifteen per one hundred thousand population, eleven percent higher than the national rate. On average, three people die by suicide every day, and Washington families and communities are grieving the loss of over five thousand people to suicide from 2010 to 2014. In an average week, there are sixty-five hospitalizations from self-inflicted injury. Recent survey data tell us that more than four percent of adults and twenty percent of tenth graders in Washington seriously considered suicide in the past year.1 In 2013 and 2014, the legislature enacted laws, codified as RCW 43.70.442, requiring certain health professionals to complete training in suicide assessment, treatment and management to help them identify patients at risk for suicide. In 2015, the legislature enacted ESHB 1424 (chapter 249, Laws of 2015), which amended RCW 43.70.442. ESHB 1424 requires the department of health (department) to develop minimum standards for the suicide prevention training programs for health care professionals required to complete suicide prevention training. Training programs that meet the minimum standards will be published on a model list, by July 1, 2017. After July 1, 2017, health care professionals must select a training program from the model list.
1 Washington state department of health: Death Certificate Data; Hospital Discharge Data; Comprehensive Hospitalization Abstract Reporting System (CHARS) data. Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Washington, 2014. HHS Publication No. SMA–15–4895WA. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. Looking Glass Analytics (2015). Healthy Youth Survey 2014 Report of Results: Statewide Results, Grade 10. http://www.askhys.net/library/2014/StateGr10.pdf.
Rule making is necessary to comply with ESHB 1424, which requires the department to adopt rules by June 30, 2016, establishing minimum standards for the training programs that will be included on the model list. It will ensure a basic level of consistency and quality in the trainings on suicide taken by health professionals.
In addition, appropriate training for health professionals on suicide assessment, treatment and management will prevent suicide. A study examining a large body of research found that forty-five percent of people who died by suicide had seen a primary care provider within the month before their death, seventy-seven percent within the year before, and thirty percent had received mental health care during the last year of life.2 The London School of Economics found a high return on investment from suicide intervention training for health professionals because of cost savings from prevented suicides.3
2 American Foundation for Suicide Prevention. (2015). Key Research Findings. https://www.afsp.org/understanding-suicide/key-research-findings.
3 Knapp M, McDaid D and Parsonage M (eds.). Mental Health Promotion and Prevention: The Economic Case. Personal Social Services Research Unit, London School of Economics and Political Science. 2011. http://www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf.
SECTION 2: Identify which businesses are required to comply with the proposed rule using the North American Industry Classification System (NAICS) codes and what the minor cost thresholds are.
Table A:
NAICS
Code
(4, 5 or 6 digit)
NAICS Business
Description
# of
businesses
in WA
Minor Cost
Threshold =
1% of Average
Annual Payroll
611430
Professional and Management Development
Training
202
3,642.57
611699
All Other
Miscellaneous
Schools and
Instruction
250
2,131.16
813319
Other Social
Advocacy
Organizations
161
1,883.91
SECTION 3: Analyze the probable cost of compliance. Identify the probable costs to comply with the proposed rule, including: Cost of equipment, supplies, labor, professional services and increased administrative costs; and whether compliance with the proposed rule will cause businesses to lose sales or revenue.
The proposed rules apply only to training providers who choose to provide training on suicide that complies with RCW 43.74.442. Department analysis shows that training providers are more likely to gain than to lose revenue because of these rules over time. Individuals and businesses could choose to create a training in line with the minimum standards in these rules in pursuit of financial gain from the large pool of health professionals required to get training. Training providers who do not choose to follow these minimum standards will be unable to provide training to designated health professionals that will meet the requirements of RCW 43.70.442 after July 1, 2017. However, they will still be able to provide training for other appropriate audiences.
After talking with training developers of several types (large business, small business, small nonprofit and individual expert consultant), we have estimated that revising an existing training to comply with the minimum standards would take one hundred hours of staff time and creating a new training would take one thousand hours of staff time. At an approximate wage of $50 per hour, the development of a new training would cost $50,000 and revision of an existing training would cost $5,000. We expect significantly more training providers to revise or add to existing trainings than to create entirely new trainings.
SECTION 4: Analyze whether the proposed rule may impose more than minor costs on businesses in the industry.
The costs to affected businesses for revising or creating trainings is estimated at $5,000 to revise current program up to $50,000 to create a new training program. This would impose costs above the one percent of average annual payroll threshold of $1,883.91 – 3,642.57.
SECTION 5: Determine whether the proposed rule may have a disproportionate impact on small businesses as compared to the ten percent of businesses that are the largest businesses required to comply with the proposed rule.
Complying with the minimum standards in these rules may be more costly for training providers that are large or lucrative businesses. The high cost is due to having a larger and more highly-compensated staff to develop the materials, and a greater quantity to [of] materials to print. On the other hand, the cost of developing a new training may be more burdensome for less-resourced businesses. Whether to create or alter a training for compliance with the minimum standards is a business decision.
SECTION 6: If the proposed rule has a disproportionate impact on small businesses, identify the steps taken to reduce the costs of the rule on small businesses. If the costs cannot be reduced provide a clear explanation of why.
We have made an effort to mitigate the cost of developing or revising training by making an agreement with the department of veterans affairs to provide free content on veterans that suicide prevention trainings must include under RCW 43.70.442. The content will be accessible by training providers if they choose to use it. Additionally, training providers who choose to comply with these minimum standards will financially benefit from charging contract trainers to attend a training of trainers, and charging health professionals to attend training.
SECTION 7: Describe how small businesses were involved in the development of the proposed rule.
We held three group meetings with stakeholders, two in person and one via GoToMeeting. We also communicated with stakeholders by phone and e-mail between meetings. Small businesses involved in suicide prevention training participated in these stakeholder meetings and were in contact with us throughout the project. Those who participated gave positive feedback on the draft rules and did not respond when we asked stakeholders to contact us with major objections to the content. Stakeholder input contributed very significantly to the content of the rule.
SECTION 8: Identify the estimated number of jobs that will be created or lost as the result of compliance with the proposed rule.
The department's analysis concluded that there may be jobs created by this rule. Compliance will allow trainers to make significant revenue by training a portion of the approximately one hundred seventy-five thousand health professional[s] currently required to take training on suicide assessment, treatment and management.
A copy of the statement may be obtained by contacting Karyn Brownson, Department of Health, P.O. Box 47853, Olympia, WA 98504, phone (360) 236-2803, fax (360) 236-2830, e-mail karyn.brownson@doh.wa.gov.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Karyn Brownson, Department of Health, P.O. Box 47853, Olympia, WA 98504, phone (360) 236-2803, fax (360) 236-2830, e-mail karyn.brownson@doh.wa.gov.
April 19, 2016
John Wiesman, DrPH, MPH
Secretary
PART 14
MINIMUM STANDARDS FOR SUICIDE PREVENTION TRAINING FOR HEALTH CARE PROFESSIONALS
NEW SECTION
WAC 246-12-601 Purpose.
The purpose of WAC 246-12-610 through 246-12-650 is to set minimum standards for suicide prevention trainings for health care professionals to be included on a model list of department of health-approved trainings. Both trainers and health care professions may set standards for trainings that exceed these standards. Training specific to a profession must comply with that profession's rules for continuing education.
NEW SECTION
WAC 246-12-610 Definitions.
The definitions in this section apply throughout WAC 246-12-601 through 246-12-650 unless the context clearly requires otherwise.
(1) "Department" means the Washington state department of health.
(2) "Health professional" means an individual licensed or holding a retired active license in one of the health professions listed in RCW 43.70.442 as required to take training in suicide assessment, including screening and referral, suicide treatment, and suicide management.
(3) "Model list" means the list of trainings that meet minimum standards established by the department of health pursuant to RCW 43.70.442.
(4) "Referral" means facilitating a client or patient's linkage to other resources.
(5) "Screening" means asking questions to identify a person at risk of suicide and to determine the need for further risk assessment or referral. Screening may be the first step of suicide risk assessment.
(6) "Secretary" means the secretary of the department of health or the secretary's designee.
(7) "Suicide assessment" or "suicide risk assessment" means a structured process to gather accurate information from a client or patient to determine risk of suicide.
(8) "Suicide treatment and management" means engagement and collaboration between a health professional or team and client or patient to resolve suicide risk by addressing the factors contributing to risk, and ongoing monitoring and adjustment of treatment and safety plans.
(9) "Training in suicide assessment, treatment, and management" means empirically supported training approved by the appropriate disciplining authority that contains the following elements: Suicide assessment, including screening and referral, suicide treatment, and suicide management.
NEW SECTION
WAC 246-12-620 Training delivery.
Minimum standards for training delivery:
(1) Training must be provided using a modality and number of sessions in accordance with each health profession's rules for continuing education and suicide prevention training.
(2) Trainings must include opportunities for skill practice through group activities or self-guided exercises.
(3) Trainings must meet the standards for content identified in WAC 246-12-630 and 246-12-640.
(4) Trainers must meet the qualifications identified in WAC 246-12-640.
NEW SECTION
WAC 246-12-630 Training content.
Minimum standards for training content:
(1) Training content must be based on current empirical research and known best practices.
(2) Training must reflect sensitivity and relevance to the cultures and backgrounds of the relevant client or patient populations.
(3) Content for six-hour trainings must include the following. These are minimum time requirements for each of these content areas. Additional time or content must be added to total at least six hours.
(a) A minimum of ninety minutes on suicide assessment. Content must include:
(i) How to structure an interview to gather information from a client or patient on suicide risk and protective factors and warning signs, including substance abuse;
(ii) How to use the information referenced in (a)(i) of this subsection to understand the risk of suicide;
(iii) Appropriate actions and referrals for various levels of risk; and
(iv) How to appropriately document suicide risk assessment.
(b) A minimum of sixty minutes on treatment and management of suicide risk. Content must include:
(i) Available evidence-based treatments for patients and clients at risk of suicide, including counseling and medical interventions such as psychiatric medication and substance abuse care;
(ii) Strategies for safety planning and monitoring use of the safety plan;
(iii) Engagement of supportive third parties in maintaining patient or client safety;
(iv) Reducing access to lethal means for clients or patients in crisis; and
(v) Continuity of care through care transitions such as discharge and referral.
(c) A minimum of thirty minutes on veteran populations.
(i) Content must include population-specific data, risk and protective factors, and intervention strategies.
(ii) Training providers shall use the module developed by the department of veterans affairs or a resource with comparable content.
(d) A minimum of thirty minutes on risk of imminent harm through self-injurious behaviors or lethal means.
(i) Content on self-injurious behaviors must include how to recognize nonsuicidal self-injury and other self-injurious behaviors and assess the intent of self-injury through suicide risk assessment.
(ii) Content on lethal means must include:
(A) Objects, substances and actions commonly used in suicide attempts and impulsivity and lethality of means;
(B) Communication strategies for talking with patients and their support people about lethal means; and
(C) How screening for and restricting access to lethal means effectively prevents suicide.
(4) Content for three-hour trainings must include the following. These are minimum time requirements for each of these topics. Additional time or content must be added to total three hours.
(a) A minimum of seventy minutes on screening for suicide risk. Content must include:
(i) When and how to screen a client or patient for acute and chronic suicide risk and protective factors against suicide;
(ii) Appropriate screening tools, tailored for specific ages and populations if applicable; and
(iii) Strategies for screening and appropriate use of information gained through screening.
(b) A minimum of thirty minutes on referral. Content shall include:
(i) How to identify and select an appropriate resource;
(ii) Best practices for connecting a client or patient to a referral; and
(iii) Continuity of care when making referrals.
NEW SECTION
WAC 246-12-640 Training quality.
Minimum standards for training quality:
(1) For the purpose of continuing improvement, trainees shall be offered an evaluation assessing training quality and participant learning. Completed evaluations will be returned to the trainer or publisher of the training.
(2) Trainers and training developers must have demonstrated knowledge and experience related to suicide prevention and:
(a) An active license to practice as a health care professional; or
(b) A bachelor's degree or higher in public health, social science, education or a related field from an accredited college or university; or
(c) At least three years of experience delivering training in suicide prevention.
(3) Data referenced in the training must be current within four years, and research referenced in the training must be based on current empirical research and known best practices.
NEW SECTION
WAC 246-12-650 Training approval processes.
(1) The secretary will approve suicide prevention training programs that meet the requirements outlined in this chapter.
(2) The secretary shall determine a process to evaluate and approve trainings.
(3) Approved trainings will be published on the model list beginning January 1, 2017.
(4) If the secretary notifies a training program of the secretary's intent to deny approval and inclusion on the model list, the training program, through its authorized representative, may request an adjudicative proceeding pursuant to the appeal process in chapter 246-10 WAC. A request for an adjudicative proceeding must be in writing, state the basis for contesting the adverse action, include a copy of the adverse notice and be served on and received by the department within twenty-eight days of the date the department mailed the adverse notice. The authorized representative of the training program may submit a new application for the secretary's consideration.
(5) If the secretary notifies an approved training program of the secretary's intent to revoke approval, the training program, through its authorized representative, may request an adjudicative proceeding pursuant to the appeal process in chapter 246-10 WAC. A request for an adjudicative proceeding must be in writing, state the basis for contesting the adverse action, include a copy of the adverse notice and be served on and received by the department within twenty-eight days of the applicant's or license holder's receipt of the adverse notice. If a request for adjudicative proceeding is not received by the department within twenty-eight days of the date the department mailed the adverse notice, the secretary's decision is final. The authorized representative of the training program must provide proof that the deficiencies which resulted in withdrawal of the secretary's approval have been corrected before requesting reapproval.