Towards Local Action (2017)

In 2017, RI International partnered with Suicide Prevention Australia and the International Initiative for Mental Health Leadership to host the fourth International Summit on Zero Suicide in Healthcare in Sydney, Australia.

Covington D, Murray S, Hogan, M, et al. Zero Applied: International Declaration to Local Action. International Initiative for Mental Health Leadership: Sydney Match Summit Report; 2017.


“The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming.” ~Theodore Roosevelt

“Is it rational to pursue zero suicide among patients in healthcare?” This is the question posed by Dr. Jan Mokkenstorm and colleagues in Suicide and Life Threatening Behavior Journal (in press) as they address objections that the science and published results aren’t yet in.


The US National Institute of Mental Health has just awarded a 5-year grant to Henry Ford Health System to evaluate an implementation of Zero Suicide across most of the Kaiser Permanente health system. And, Centerstone is partnering with EDC to publish its results in a peer reviewed journal (reductions in the death rate have been reported in US News & World Report, June 2015).

So, the science is in the works. But, here’s what we already know today.

Usual care is disastrous. Dr. Mark Olfson in the July 2017 JAMA Psychiatry carefully describes the very significant suicide risks for individuals in the immediate aftermath of a psychiatric hospitalization and the clear message for the efficacy of universal and continuing interventions and support following discharge. Yet, even when we know the practice works, only about half of US patients receive any outpatient care during the first week after psychiatric hospital discharge, and one-third receive no mental health care during the first month.

Outside inpatient settings, healthcare systems have simply not been accountable for suicide. Mental health professionals frequently report a complete lack of training to deliver interventions and care to prevent suicide. These standard approaches came under criticism in the New Zealand national media earlier this year. The Minister of Health’s response after studying Zero Suicide was to change the culture within the mental health workforce and galvanize society around known interventions. “It does seem that setting a goal, and it may be aspirational… actually just focuses efforts” (Dr. Jonathan Coleman, “Suicide Reduction Target Back on Table,” August 2017.)

The interventions that make up the elements of Zero Suicide are known to work. They all have research-based efficacy. Danish researcher Annette Erlangsen’s 2015 Lancet study showed a lower risk of deliberate self-harm and general mortality for those who received psychosocial therapy. In fact, direct treatment of suicide is more effective and cost-efficient than statins are for heart disease prevention (one fatal heart attack is prevented for every 83 people helped for statins versus one self-harm episode prevented for every 44 people treated with psychosocial therapy).

Findings are similar for routine screening for suicide risk. In 2015, Dr. Greg Simon and team concluded in Psychiatric Services that the PHQ-9 question 9 “identifies outpatients at increased risk for suicide attempt or death.” They added that “this excess risk emerges over several days and continues to grow for several months,” with an accuracy about twice as predictive of future suicide as cholesterol scores are of future heart attack death.

While there are few studies of safety planning, Craig Bryan’s findings in The Journal of Affective Disorders is promising (“Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers,” January 2017).

Finally, logic and the literature base on quality improvement suggest that we need a systematic, leadership-driven quality improvement approach for a wicked and complex problem like suicide. The Suicide Care in Systems Framework was published at virtually the same time as Dr. David While and others were concluding in the Lancet that a systematic implementation of crisis intervention in England and Wales saved hundreds of lives (February 2012).

So, as a scientific matter, we need more data. As a public health and quality of care matter, the evidence is already in.

The time is now. Together, we can, and must, do this. We hope this document created from the 2017 Sydney summit motivates healthcare and other leaders to move from an international declaration to local action and implementation.

introduction and overview

RI International and Suicide Prevention Australia were pleased to host the 3rd International Summit of Zero Suicide in Sydney, Australia, February 27 – 28, 2017, in conjunction with the International Initiative for Mental Health Leadership (IIMHL) Exchange.

Suicide is a leading cause of premature death within Australia. The Australian Bureau of Statistics reported 3,027 deaths by suicide in 2015 – 20% of premature deaths across the nation, and the highest single contributor to ‘potential years of life’ lost in the country.

While the number of suicide deaths continues to rise in Australia, the international community has seen dramatic results in suicide prevention within healthcare. We believe a focus on Zero Suicide in Healthcare is a necessary addition to other suicide prevention strategies. The US based Henry Ford Healthcare System ‘Perfect Depression Care’ program and its 75% reduction in suicide deaths in under 5 years – continues to inspire an international dream.

Suicide Prevention Australia is looking to launch a 5 year pilot of Zero Suicide across a number of sites. RI International and Suicide Prevention Australia joined together in Sydney with the purpose of continuing the worldwide networking and learning as we pursue this audacious dream together.

history of a movement

In 2001, the Henry Ford Health System pursued an opportunity within the Robert Wood Johnson Foundation’s “Pursuing Perfection National Collaborative” by developing the “Perfect Depression Care” to better serve their 200,000 patients. Their Behavioral Health Services Division Team asked themselves “how would we know when depression care was truly perfect?” A psychiatric nurse offered, “If depression care was truly perfect, no patient would die from suicide.” The overall outcome of the care delivery overhaul that resulted from this paradigm shift was a dramatic and statistically significant 80% reduction in suicide, maintained for over a decade, including one year when the perfection goal of zero suicides was actually achieved.

That audacious idea has subsequently initiated a radical transformation within the mental health and healthcare delivery systems and how the world thinks about suicide prevention. This bold goal — to eliminate suicide – has galvanized these life-saving systems to consider how they might redesign their philosophy, process and monitoring to dramatically improve patient outcomes.

The International Zero Suicide in Healthcare movement began in Oxford as part of an exchange of the IIMHL with fifteen individuals from four countries joining together to create a vision. In 2015, the second International Summit was held in Atlanta, Georgia (USA) where 50 leaders from 13 countries came together for forge an International Declaration for Zero Suicide in Healthcare. As of this publication, the Declaration has been downloaded over 13,000 times.

In addition, the Suicide Prevention Resource Center published a “Zero Suicide in Healthcare Toolkit” designed to help guide health and behavioral healthcare organizations through a seven-step process of implementing the tactics.

The theme of the 3rd Summit in Sydney was “From International Declaration to Local Action” and the and the presentations and conversations held there are summarized in this document oriented around five key topics: Lead/Activate, Deploy/Scale, Clinical Pathway/Protocol, Treat/Engage/Peer Supports and Research/Evaluation.

Several stories, metaphors and analogies provide a helpful description of where the Zero Suicide in Healthcare movement is now and where it needs to go:

  • David Covington opened the conference stating “Zero Suicide in Healthcare has been a flame attracting attention. Now it needs to become a torch that can spread the flame globally.” He also noted, “Hospital acquired infections were once thought of as inevitable. The most significant intervention to have an impact in reducing infection was following simple handwashing protocols. Once we believe change is possible, the most profound process adjustments are often quite simple.”
Summit Spotlight
Kevin Hines, The Ripple Effect

“The Golden Gate Bridge presents a 70 year struggle of a conversation about aesthetics and the inevitability of suicide; for 70 years we didn’t spend the money to build a bridge barrier because we didn’t believe.”

  • The group also reflected on the inspiration of Don Berwick in Crossing the Quality Chasm. On the topic of process improvement in healthcare he stated, “I think healthcare is more about love than about most other things. If there isn’t at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can’t get to the right answer here.”
  • Mike Hogan encouraged ongoing learning: “Developmentally, Zero Suicide is a toddler needing a community, supervision and sometimes redirection. We are here to help it grow.”

Historically, suicide prevention leaders have minimized healthcare efforts, saying they won’t save everyone. When we look at help-seeking data of people who have died of suicide, only 45% of have a mental health diagnosis the year before their death by suicide; only 1/3 of people had a behavioral health visit before their death, and only 5-10% of people were in inpatient care before their death.

However, 85% of people had a healthcare visit before suicide. The Zero Suicide in Healthcare model emphasizes that with good screening and connection to care, far fewer people will fall through the cracks. Thus, the following core perquisites of the model are integral to its success:

  • A reorientation in healthcare to embrace suicide prevention. It’s not “someone else’s” job, healthcare is where people at risk for suicide are showing up, and systems and providers need to be prepared.
  • A bold, uncompromising mindset shift from “no one can do anything” to “everyone can do something” to achieve zero suicide. This priority is held both top down and bottom up throughout the system.
  • A learning environment where system failures provide opportunities for improvement-not blame.
  • Lived expertise of people experiencing suicidal thoughts and attempts and their family and is highly valued in the iterative process improvement and strategy design to cultivate empathy, decrease fear and improve the patient experience.
  • “Care” is part of healthcare. Healthy providers, in healthy systems are better able to care for people. Care goes beyond harm reduction to promote well-being and life enhancement.


How Construction Achieved Zero Fatalities:

2017-07-06_9-41-28Models for this type of system overhaul exist and healthcare systems have much to learn from other industries that focus on safety. In 2001, Lendlease, a multinational 15,000 employee construction company made a commitment to be incident and injury free. At the beginning of the implementation of this priority they held “commitment workshops” for every worker and leader. While these workshops created strong awareness, this awareness didn’t translate to stronger performance. Awareness was necessary but not sufficient to create sustainable change; practice changes were also needed.

Next, Lendlease created global minimum requirements for safety that every site had to adhere to – no exceptions. They walked away from clients that could not comply. The job fatality count dropped from 72 from 2001-2013 to zero fatalities from 2013 to 2016. Now they have a new aspirational goal from just getting to zero to moving beyond zero and striving to ensure that people’s lives are actually enhanced when they come to work. To do this they needed to get rid of sacred cows, like compliance forms, and move their sites ahead to anticipate prevention needs. The near misses and critical incidents go under the microscope and then all the way up the prevention chain in the spirit of learning and improving.

Summit Spotlight
Chris Doyle, Lendlease

“Creating a strong safety culture did not create a strong safety performance. The need for change comes from bottom up, but creating change comes from top down. Move the aspiration from getting to zero to going beyond zero. Learn all of the causes of a catastrophe and become fixated on prevention.”

The shift that Lendlease has made that inspires the healthcare community is the shift from “what do I do to manage the risk to me” (as the system) and instead focus on what is best for the culture of safety. When we focus on the first in behavioral health we think short-term: “I keep you safe by putting you in a place where you can’t hurt yourself — a locked unit where your freedom to ‘chose’ is taken away and then I send you home with no follow up. Thus, I wash my hands of the responsibility.”

When the long-term safety and health for the person is the priority, different decisions are made. The outline of this document will share both “lessons learned” from the pioneers, like Lendlease, who are leading implementation efforts around the world, and residual “questions and concerns” we need to continue to consider.

The full report includes the following sections:

  • Lead/Activate
  • Deploy/Scale
  • Clinical Pathway/Protocol
  • Engage/Treat
  • Research/Evaluate