Zero Suicide Initiative: Can Suicide Be A Never Event? Linda Durst, Ellen Blair, Patricia Graham, Nancy Hubbard Zero Suicide Academy Team (ZSAT) Institute of Living, Hartford Hospital September 8 th , 2016
Objectives for Today • Describe the Zero Suicide Approach: 7 Key Components – Present the evidence and best practices from other organizations which have implemented Zero Suicide successfully Zero Suicide 9/8/2016 2
What is Zero Suicide? • A methodology to eliminate suicide and a state of mind that one suicide is too many. • A priority of the National Action Alliance for Suicide Prevention • A goal of the National Strategy for Suicide Prevention • A project of the Suicide Prevention Resource Center • A framework for systematic, clinical suicide prevention in behavioral health and health care systems • A focus on safety and error reduction in healthcare • A set of best practices and tools for health systems and providers • It is critically important to design for zero even when it may not be theoretically possible…It’s about purposefully aiming for a higher level of performance. Zero Suicide 9/8/2016 3
How did Zero Suicide Academy Begin? • First ever held on June 2014 for a select group of health care organizations, chosen from multiple applications both national/international. • Participants learned how to incorporate best and promising practices into their organizations and processes to improve care and safety for those at risk for suicide. • Overarching Zero Suicide Philosophy : Suicide is preventable and health care systems need to embrace and work towards the aspirational goal of preventing ALL suicide deaths for patients in their care. If we don’t consider zero suicide a possibility we won’t work towards zero. Zero Suicide 9/8/2016 4
Applying for Zero Suicide Academy • Self -assessment and application process • This presentation is not to criticize our processes now, but to lay ground work, mind set and attitude, a different perspective. Zero Suicide 9/8/2016 5
“Over the decades, individual (mental health) clinicians have made heroic efforts to save lives… but systems of care have done very little.” Dr. Richard McKeon SAMHSA Zero Suicide 9/8/2016 6
The Seven Essential Components of Zero Suicide 5. Treat 1. Lead 2. Train 6. Transition 3. Identify 7. Improve 4. Engage Zero Suicide 9/8/2016 7
LEAD • Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. • Include survivors of suicide attempts and suicide loss in leadership and planning roles. • “Buy in” of leadership to support investment of staff development, time to learn and provide resources to accomplish these initiatives. • Formally inform organization of the plan to adopt zero suicide philosophy. Zero Suicide 9/8/2016 8
TRAIN • Develop a competent, confident, and caring workforce. • Step 1: Assess competence of workforce in suicide prevention. • Tailor training to needs of workforce, i.e. professional seminars, case conferences, training on established/validated tools. Zero Suicide 9/8/2016 9
IDENTIFY Systematically identify and assess suicide risk among people receiving care . a) Identify high risk patients b) Screen every visit c) Contact “no - shows” reliably if they are high risk d) Alert all clinicians that touch the patient of the patient’s risk e) Potential for utilizing technology of EHR Zero Suicide 9/8/2016 10
ENGAGE • Ensure every individual has a pathway to care that is both timely and adequate to meet his or her needs. • Include collaborative safety planning and restriction of lethal means. Zero Suicide 9/8/2016 11
TREAT • Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors, i.e. CAMS, DBT. • These methods should be utilized at all levels of care. Zero Suicide 9/8/2016 12
TRANSITION • The highest risk of suicide occurs during transitions, esp. inpatient to outpatient • Provide continuous contact and support, especially after acute care, i.e. f/up phone calls/ letter • Follow up closely and timely after transitions especially after inpatient discharge. • Ensure medications are provided until transitions are completed. Zero Suicide 9/8/2016 13
IMPROVE • Apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk, including metrics for current state and going forward. • Potential for application of LEAN Methodology to sustain improvement Zero Suicide 9/8/2016 14
Rationale for HealthCare Systems Adopting Zero Suicide This approach represents a commitment: – To patient safety, the most fundamental responsibility of health care – To the safety and support of clinical staff, who do the demanding work of treating and supporting suicidal patients – Suicide Care in Behavioral Health Care Settings Suicide prevention is a core responsibility for behavioral health care systems: Many licensed clinicians are not prepared, 39% report they don’t have the skills to engage and assist those at risk for suicide, 44% report they don’t have the training. Zero Suicide 9/8/2016 15
Statistics In the month before their death by suicide: • Half saw a general practitioner • 30% saw a mental health professional In the 60 days before their death by suicide: • 10% were seen in an emergency department Zero Suicide 9/8/2016 16
“Suicide represents a worst case failure in mental health care. We must work to make it a ‘never event’ in our programs and systems of care.” Dr. Mike Hogan National Action Alliance for Suicide Prevention Zero Suicide 9/8/2016 17
Joint Commission Sentinel Event Alert: Recommendations Detecting suicide ideation in non-acute or acute care settings. • Review each patient’s personal and family medical history for suicide risk factors • Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. • Review screening questionnaires before the patient leaves the appointment or is discharged. Zero Suicide 9/8/2016 18
Immediate Action and Safety Planning Take the following actions. using assessment results to inform the level of safety measures needed. • Keep patients in acute suicidal crisis in a safe health care environment under one- to-one observation. • For patients at lower risk of suicide, make personal and direct referrals and linkages to outpatient behavioral health and other providers for follow-up care within one week of initial assessment, rather than leaving it up to the patient to make the appointment. • Conduct safety planning by collaboratively identifying possible coping strategies with the patient and by providing resources for reducing risks • Restrict access to lethal means Zero Suicide 9/8/2016 19
Discharge Planning, Patient Education &Documentation Recommendations • Establish a collaborative, ongoing, and systematic assessment and treatment process with the patient involving the patient’s other providers, family and friends as appropriate. • To improve outcomes for at-risk patients, develop treatment and discharge plans that directly target suicidal ideation. • Educate all staff in patient care settings about how to identify and respond to patients with suicide ideation. • Document decisions regarding the care and referral of patients with suicide risk Zero Suicide 9/8/2016 20
Model Performance Improvement Plan • Identify leadership in your institution to implement recommendations. • Survey competence/confidence of your staff about suicide care and assessment • Screening using PHQ-2 and 9 should be implemented in all settings. • Implement Follow Up Phone Calls. • Increase education to all health care disciplines and in all settings, not only psychiatric, re: suicide care and prevention, i.e. VA treatment plan, nice plan for individual with suicidal ideation. • Increase collaboration between psychiatry and non-psychiatric settings; Plan grand rounds/ case conferences/Suicide Prevention Rounds. • Utilize Grants that are available to support organization’s efforts in suicide prevention and care. • Lethal Means restriction- address in all areas • Utilize electronic health record to track suicide ideation as primary symptom to guide us in suicide care planning and follow-up. Zero Suicide 9/8/2016 21
High Reliability Organization (HRO) • The Zero Suicide approach lends itself nicely to the high reliability culture of HHC • Make the commitment to become an HRO and reaching zero on several very important outcomes, such as hand washing, bloodstream infections, falls and ventilator-associated pneumonia- so why not suicide? • This is a Joint Commission goal for transforming healthcare. Zero Suicide 9/8/2016 22
Zero Suicide Culture Saves Lives Health and behavioral health care organizations have found: • Elements of this culture can be implemented without additional funding. • This culture reduces death by suicide. • Healthcare Systems Using The Zero Suicide Approach: – Henry Ford Health System, Detroit, MI – Centerstone, Tennessee – Catholic University of America, Washington, D.C., David Jobes: Showing early evidence of success with CAMS tool, with progression towards validation of this tool Zero Suicide 9/8/2016 23
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