Patient Safety Policy

Purpose:  

This policy establishes Headway's standards for identifying, responding to, and continuously improving patient safety, including crisis detection, timely clinical response, escalation protocols, post-crisis care coordination, safety event reporting, and cross-functional safety governance. It also defines the respective roles of Headway and its network providers in promoting patient safety.

Applicability:  

This Policy applies to all Headway employees, contractors, temporary workers, contingent workers, the Senior Leadership Team, the Board of Directors, and Therapymatch, Inc., d/b/a as Headway, and its affiliates and subsidiaries (collectively, “Headway,” “we,” “us,” or “our”) and all of its associated Professional Corporations (PCs), including but not limited to all current and future PCs.

Definitions:

• Zero Suicide Framework — A systemic approach to suicide prevention in health and behavioral health care systems.
• Crisis Detection — The process of identifying safety risks through assessment tools,  clinical observation, or screening of patient interaction with our tools and products.
• Escalation — A defined, tiered process for responding to detected safety concerns.
• Safety Event — Any occurrence involving a patient that resulted in, or had the potential to result in, harm. Safety events include but are not limited to suicide attempts and deaths, self-harm, harm/violence or threatened harm to others; medication safety; follow-up, referrals, records, or access challenges; boundaries, conduct, or mandated report filing; technology, equipment, injuries, or facility hazards; or provider safety or wellbeing concerns.
• Near Miss — An event that had the potential to cause patient harm but did not, whether by intervention or by chance. Near misses are reportable on the same terms as safety events.

Policy:

Headway is committed to the Zero Suicide framework as a core component of its safety mission. Promoting patient safety requires cooperation between Headway’s internal patient safety program and the providers in its network, who manage patient risk in line with clinical best practice and licensing standards. This policy defines Headway’s role and the role of the providers we partner with, so that expectations are clear and safety risk is managed effectively.

Procedures:

1. Headway's Role
   1. Crisis Detection
      1. Headway monitors platform interactions (e.g., support tickets, free-text responses, PROMs, provider escalations, and Customer Care/Experience inputs) for indications that a patient or user may be experiencing a safety crisis. 
      2. During supported hours, Headway’s internal team routinely reviews safety signals and alerts to ensure appropriate follow-up (e.g., sharing crisis resources, proactive outreach) 
      3. When possible, Headway will coordinate with the patient's treating providers to ensure they are aware of the patient's clinical status.
   2. Crisis Response
      1. A crisis line is made available 24/7 to any individual HW believes may be at risk of experiencing a mental health safety crisis. 
      2. If Headway detects information suggesting that a patient may be at imminent risk of harm, and the patient’s contact information is available, counselors from the crisis line will conduct proactive outreach to provide risk assessment and crisis intervention. 
      3. If Headway detects information suggesting a duty to warn/protect or mandated reporting are indicated, Headway ensures these obligations are fulfilled according to licensure requirements and clinical best practice. 
      4. Crisis Counselors document intervention and outcomes and may escalate to emergency services as clinically indicated. 
         1. When possible, this information is shared with treating providers on the platform.
   3. Escalation
      1. Headway maintains escalation protocols to guide staff decision-making around involvement of emergency services, care coordination, mandated reporting and duty to warn/protect obligations, and provider notification.
      2. Non-clinical  staff escalate patient safety concerns to licensed clinical team members for appropriate triage and management.
   4. Clinical Documentation Oversight
      1. Headway monitors clinical documentation for evidence of proper safety screening, risk assessment, compliance with mandated reporting and duty to warn/protect laws, and safety planning.
      2. Headway offers training and remediation to providers who fall short of expected standards for assessing and managing safety risk.
   5. Patient Communication
      1. Disclaimers state plainly that Headway is not an emergency service.
      2. Patients are provided with information about crisis resources, including 911, 988, and/or the Headway crisis line.
   6. Provider Support
      1. Headway maintains provider-facing crisis resources through the Patient Safety Resource Hub, including the Hotline / Emergency Services Reference Materials and the Provider Guide for In Session Crisis Management.
2. Providers’ Role
   1. Clinical Risk Ownership
      1. Providers assess clinical risk in the course of treatment and are responsible for safety planning and crisis management within the provider-patient relationship in line with their training, clinical best practice, and the expectations of the law and their licensing board.
   2. Escalation
      1. Providers are responsible for ensuring continuity of care for patients in crisis, including coordinating referral to a higher level of care, consistent with the applicable standard of care and prohibitions against patient abandonment.
      2. Providers meet mandated reporting and duty to warn/protect obligations in accordance with applicable law.
   3. Documentation
      1. Providers document safety-relevant clinical decisions and interventions within their own clinical records, consistent with clinical best practice and licensure requirements.
   4. Use of Headway Resources
      1. Providers use the crisis resources and reference materials Headway makes available (Patient Safety Resource Hub, Hotline / Emergency Services Reference Materials, Provider Guide for In Session Crisis Management) as intended, and notify Headway per the Provider Communication Policy when appropriate.

References:

• Zero Suicide Framework (www.zerosuicide.com)
• Joint Commission National Patient Safety Goals
• Columbia-Suicide Severity Rating Scale (C-SSRS)
• Collaborative Assessment and Management of Suicidality (CAMS)