Abstract
Perspectives on suicide prevention in health and behavioral health systems have widened in recent years from focusing primarily on the skills and practices of individual providers to now taking in the goal of creating a suicide-safer healthcare system as a whole. This movement has been inspired by other quality initiatives in healthcare that aim to eliminate medical errors, improve continuity, and improve organizational innovation by reducing the occurrence of preventable outcomes. In the field of suicide prevention, this movement has included the aspirational goal of ‘zero suicides’ in care.
A Introduction
A Health Systems Approach: Widening the Lens on Suicide Prevention
Perspectives on suicide prevention in health and behavioral health systems have widened in recent years from focusing primarily on the skills and practices of individual providers to now taking in the goal of creating a suicide-safer healthcare system as a whole. This movement has been inspired by other quality initiatives in healthcare that aim to eliminate medical errors, improve continuity, and improve organizational innovation by reducing the occurrence of preventable untoward outcomes. In the field of suicide prevention, this movement has included the aspirational goal of “zero suicides” in care.
B Principles
Suicide prevention frameworks are increasingly focusing on creating safer systems of care, which involves developing a culture of safety and prevention, implementing effective policies and practices, and building up a workforce that is continually engaged and supported with education and development.
A systems approach to suicide prevention is rooted in patient safety “zero defect care” principles that encourage a commitment to the aspirational goal of “zero suicides.”
The integration of lived experience of suicide into leadership teams, care system design, and workforce education is critical if prevention efforts are to match the needs of patients.
A constructive, responsive, and non-blaming process for responding to suicide events is essential for systems aiming toward a zero suicide goal.
While treatment pathways defined by risk stratification can provide useful starting points, resources should be allocated based on assessments of individual circumstances.
Services should be designed not just with the needs of at-risk persons in mind, but by working with service users, family members, and others with lived experience related to suicide.
Reaching toward the goal of zero suicides in care requires a continuous quality improvement mindset and commitment.
Effective care at the systems level requires a shared language and conceptual framework that enables all parts of the systems to communicate effectively and work toward the same ends.
Workforce education should include education by those with a lived experience of suicide risk.
“One and done” training should be replaced with educational models that promote continuous learning and the onboarding of new staff into a shared culture of prevention.
Figure 10.1. Suicide prevention in health systems (zero suicide)
Suicide prevention in health systems involves commitment to a culture of safety and prevention; best practice, pathways, and policies; and workforce engagement and education. Lived experience and continuous improvement play an important role in each of these areas.
C Culture of Safety and Prevention
A health systems approach to suicide prevention calls for the transformation of health, behavioral health, and community organizations so that prevention is considered a core responsibility and priority. This involves making a sustained organizational commitment to a culture of safety and the prevention of suicide. It also means pursuing a systems approach to care, with services being designed specifically to take account of the needs of individuals at risk for suicide, and ensuring that the structures available for the care of patients are appropriate to their needs.1
Leadership Commitment
A commitment to work toward the prevention of all suicides (often called a “zero suicide” goal) does not assume that every suicide that has taken place in the past could have been prevented. Rather, it reflects a culture dedicated to quality improvement and patient safety. In order to foster such a culture, leaders at high levels should insist on: 1) the integration of lived experience perspectives into the system of care; 2) the development of processes directed at the goal of continuous quality improvement; and 3) the creation of a culture of supportive and restorative post-incident learning.
Toward Zero Suicides in Care in New South Wales, Australia
The government of New South Wales (NSW) in Australia invested AU$90 million in a set of coordinated initiatives aimed at moving toward the goal of zero suicides in the NSW health systems. These programs include a strong focus on workforce education in a common recovery-oriented framework (co-taught by persons with clinical and lived experience) and codesign of systems with those with lived experience of suicide. Initiatives include proactive follow-up and outreach measures and community-based care options such as alternatives to emergency department care. This whole system approach engages consumers and family members in every project and promotes a non-blaming, continuous learning approach to quality improvement and response to adverse events.
https://suicidepreventioncentralcoast.org.au/wp-content/uploads/2019/07/towards-zero.pdf
From Zero Defect to Zero Suicide to Suicide Prevention in Health Systems
The goal of zero suicide has its roots in the wider “zero defect” approach to patient safety. Zero defect was originally developed as a quality control principle for aerospace and automobile manufacturing in the 1960s. The goal of achieving perfect outcomes in patient safety attracted interest in medical circles in the late 1990s and was first applied in a behavioral health context by the Henry Ford Health System in Detroit. Treating the death of a patient through suicide as the ultimate defective outcome of mental healthcare, clinicians in the system worked to implement what they called “Perfect Depression Care.” The outcome of this program was a radical reduction in suicide deaths (80% over 10 years), and clinical studies soon provided supporting evidence for the effectiveness of the approach. In the years since, zero suicide has become an aspirational goal at both national and international levels.
AFSP Project 2025: Leadership and Collaboration Across Systems to Achieve Specific Goals
The ultimate goal of zero suicide can only be approached via incremental steps involving achievable targets that can be hit within an easily conceptualized horizon. A model project of this sort is the AFSP Project 2025, which aims to reduce suicide across the USA by 20% by 2025. Taking their start-point from the goals of the National Strategy for Suicide Prevention, the AFSP project seeks to provide an actionable plan for implementing this strategy. After extensive background research and the running of many simulations, AFSP identified four broad areas that had the potential for the greatest impact on suicide deaths: firearms, healthcare systems, emergency departments, and the corrections system. By working with strategic partners in each of these areas, the goal of the project is to bring about systemic changes. AFSP predicts that over 9,000 lives can be saved by taking two measures: 1) improving assessment and screening to a level that successfully identifies even one in five of the people at risk of suicide in large healthcare systems; and 2) providing those identified as at risk with brief interventions and improved follow-up care. The effectiveness of the approach identified by AFSP relies on the integration of training, implementation of new procedures, and care that is fundamentally connected at different stages and across different locations within each healthcare system.
Objections and Alternatives to the Language of “Zero Suicide”
There are two common objections to the term “zero suicide” when it is first introduced to a health system. First, some argue that it is an unobtainable goal and that an excessive focus on an ideal distracts from realistic objectives. Second, clinicians and community members often worry that a zero suicide approach will entail consequences or blame if suicides do occur, as if it implies a “zero tolerance” policy.
These concerns are understandable. Achievable goals are vital and there has been an unfortunate history of clinicians being blamed in the aftermath of suicide. Nevertheless, there is no necessary conflict between an aspirational long-term goal and the supportive steps one might take to come closer to it right now. The direction of travel for short- and medium-term goals is clearly toward rather than away from zero suicides. When one target has been achieved, the next will surely be a step closer to zero. Dr. Kathy Turner, a leader in zero suicide system transformation at Gold Coast Mental Health (Australia), puts it this way: “When people object to the goal of zero suicide, my question for them is, what other goal would we have?”
Despite the importance of the goal, many health systems and localities opt not to use the language of “zero suicide” because of concerns about how that term will be understood and received by clinicians, patients, and community members. Decisions concerning how to brand a particular health systems approach must be made by local stakeholders with knowledge of the context and culture. For example, the New Zealand national strategy for suicide prevention, which was developed with a great deal of cultural stakeholder input, envisions “a future without suicide” under the broad heading “Every Life Matters.” What is most important is that the strategy encompasses the key areas of a systems approach and that a system and/or region has an inclusive program that all stakeholders can rally around.
A Future Without Suicide
The decision to use the term “zero suicide” must be considered in a cultural context. The New Zealand national suicide prevention strategy envisions a “future without suicide,” without reference to the term “zero suicide.”
– A future without suicide
– Achieving a future where there is no suicide is an
ambitious, long-term vision. When this vision is
achieved, the suicide rate will have reduced, and
every person and their whānau or family is more
likely to have increased confidence and feel their life
matters through:
whakapapa – having a strong identity, knowing
where they come from and where they belong
tūmanako – having self-worth and being optimistic
about their future
whanaungatanga – being connected with others:
friends, whānau and families, and wider communities
atawhaitanga – receiving support that responds
to their distress with compassion, respect, and
understanding, and supports healing and recovery
kia mōhio, kia mārama – knowing where and how
to access support
mauri tau – having easy access to support
that recognizes and responds to their needs
when they are affected by suicide
Lived Experience Integrated into Leadership
The integration of lived experience of suicide into care systems is a critical step toward putting the patient at the center of those systems. “Lived experience” is provided by listening to and prioritizing the perspectives of those who receive services related to suicide prevention care, or who might receive such services in the future, or who might have received such services if systems were organized differently. Lived experience perspectives may come from people who have struggled with suicide concerns themselves, people who provide ongoing care for those with suicide risk, and people who have lost friends, family members, or colleagues to suicide. The core goal of connecting with people at risk of suicide can only be achieved if these perspectives are not only genuinely understood but also are put at the center of a system-level approach. This means designing systems around the needs of those at risk and ensuring that people with lived experience take an active role in developing, or “co-designing,” systems of care.
In fostering a systems approach to suicide prevention, people with lived experience of suicide are given a significant role in decision-making bodies and are not just treated as an ancillary advisory group. A recent study of the co-production of services by service providers and users has emphasized that experience can only be drawn upon fully when service users are treated as fully respected members of the team, rather than people who should feel lucky to have their opinions heard. This means treating lived experience advocates and advisors in the same way that anyone else with specialized expert knowledge would be treated: Their hard work should be properly valued and they should be compensated financially for their time where appropriate, just like any other knowledge provider.2
Restorative Just Culture
The ultimate negative outcome in suicide prevention care is the death of the person being cared for. The loss of a patient can be devastating for clinicians and can sometimes lead to long-term negative mental health outcomes. Compounding this natural reaction to the loss of human life are additional stressors that result from typical incident review approaches that follow in the wake of a patient death. These can add fears about legal and career consequences at what is already a difficult time for all those involved.
Traditional forms of incident review seek to allocate responsibility for adverse outcomes by identifying departures from standard clinical procedures or failures to assess risk correctly. Such processes are problematic for a number of reasons. Not only do they rely on incorrect assumptions about the ability of clinicians to accurately stratify risk (see Chapter 7), but the search for a linear account of “what went wrong” also fails to recognize the complexity of the environmental and historical circumstances that can contribute to a suicide attempt. Just as importantly, the goal of apportioning blame in post-incident reviews can lead to a culture of silence within an organization, and this presents a great obstacle to the aim of continuously improving care.
“People are not a problem to be solved or standardised: they are the adaptive solution”
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
