Initiation, Review, and/or Update to Suicide Safety Plan for Individuals With Suicidal Thoughts, Behaviour, or Suicide Risk

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Traditional Merit-Based Incentive Payment System (MIPS) Clinical Quality Measures
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
Service Delivery and Care Planning

Defining Attributes

Definition

Percentage of adult aged 18 years and older with suicidal ideation or behaviour symptoms.

Numerator

Patients for whom a completed suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician at the time the suicidal ideation behaviour or risk is identified (concurrent or within 24 hours of index clinical encounter), during the measurement period.

Denominator

Patients aged 18 years and older with a mental and/or substance use disorder with suicidal ideation and/or behaviour symptoms or suicide risk at a clinical encounter during the denominator identification period.

Exclusions

Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders (ICD-10-CM) and patients who died during the measurement period (M1356) are excluded.

Use of Risk Adjustment
No
Risk Adjustments
Stratifications

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

MIPS Clinical Quality Measures (CQMS)

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

Traditional MIPS

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
04 November 2025