The core recommendations of Zero Suicide in Healthcare initiatives fall into three categories: Leadership, Continual Improvement, and Patient Support. They are built on a foundation of core values: that not one of our patients dies by suicide and that our work should be modified to accomplish the goal, not the other way around.
- Foster a safety-oriented culture committed to dramatically reducing suicide among people under care;
- A just culture that avoids blame, ensures professionals perform at their best and everyone learns from adverse incidents and near misses;
- Develop an effective strategy and action plan revolving around clinical leadership, with clear targets, and firm dates for their attainment;
- Monitor progress using standardized data collection linked to these goals, keep the helm straight and stick to the target of zero; and
- Connect to and exchange with other leaders and organizations to learn, to help and to accelerate change and improvement in healthcare.
- Apply a data-driven quality improvement approach in regards to routine care to suggest system changes that will lead to improved patient outcomes and better care for those at risk.
- Invest in training for healthcare teams and non-specialized health workers/caregivers, which focuses on identification, assessment, and collaborative management of suicidal behavior, and early identification of people with mental health and alcohol/substance misuse difficulties, chronic pain, and acute emotional distress.
- Learn from every fatal outcome and near-miss. Perform adverse incident reviews following patient suicides within 72 hours, summarizing the “root cause” contextual issues, and ensure fact-finding investigations are completed within two months. Every death by suicide should be regarded as a systems failure. Identify the problem, disseminate lessons learned to the entire organization and improve the system as soon as possible.
- Ensure every person has a timely and adequate pathway to care and supports;
- Systematically identify, assess and monitor suicidality in the entire patient population, and along the entire treatment pathway, for purposes of triage and indication to appropriate levels of acuity and intensity of care;
- Use effective, evidence-based care, including collaborative safety planning, restriction of lethal means, and effective treatment of suicidality;
- Respond to people at risk for suicide and people who have attempted suicide with follow up care and provision of community support to them and their family, especially after acute care;
- Overcome patient confidentiality concerns to engage families in suicide prevention planning; and
- Provide post-event support for families bereaved by suicide and for family and friends of attempt survivors, as well as health care providers.
Leaders in both the US Airforce and Henry Ford Health System initiatives reported that they believed the elements above were interdependent and synergistic, with none alone providing the critical component that made the difference in dramatically reducing rates. Today we have a series of specific practices available to healthcare that were relatively unknown even a decade ago. These include a focus on follow-up, continuity of care, and collaborative safety planning including the engagement of family and friends.
Clinical Staff Support Zero Suicide
Beyond the tragedy for individuals and family, healthcare systems have given scant attention to the impact of suicide upon their employed professionals. About one-third have an acute emotional reaction to a suicide death (like friends or family) and some depart the workforce as a result.
Since 2009, Zero Suicide leaders have surveyed more than 30,000 in the mental health workforce across nine US states, asking clinicians, case managers, peer specialists, and other community mental health center staff to rate their own skills, training, and supports to effectively engage those at risk of suicide.
The results of the survey indicate about 50% of respondents at least “agree” that they have what is needed (skills, training and supports/supervision). About one in four report that someone under their care and responsibility has died by suicide (and for almost half that group, this tragedy has occurred more than once).
Attaining This Goal is Possible
Setting ambitious goals and reaching them is well within our grasp. Consider the reduction of coercion and compulsion. Ten years ago, isolating patients was the norm in psychiatry in most of the world. Now, it’s considered a highly exceptional, last-resort measure in many countries, and the approach continues to spread. Who would have thought that patients in a closed ward would come to be separated as rarely and briefly as they do now? This goal is being achieved by proclaiming that isolation should no longer exist and by striving towards bringing an end to isolating patients completely.
Some may argue that setting a goal of zero suicides is unrealistic. Unattainable. Irresponsible. Against a backdrop of fear for “shaming and blaming,” it is understandable that mental health providers want to manage expectations concerning the possibility of preventing suicides. It is a reason why some healthcare professional have avoided committing to a concrete goal or target to reduce the number of suicides. After all, not having tried is not having failed.
Yet there are pioneers in the Zero Suicide approach. The Henry Ford Health System (HFHS) in the US is one such example. The cornerstone of their program is a Perfect Depression Care program, which has one objective: do everything that can help against depression and avoid doing things that could stand in the way of that.