Improve policies and procedures through continuous quality improvement.

Data is Essential

Data-driven quality improvement is essential to ensure improved patient outcomes and better care for those at risk of suicide.

Specifying all aspects of suicide care in the clinical workflow and monitored in an electronic health record will provide necessary data to identify successes and failures in care.  

However, continuous quality improvement can only be effectively implemented in a safety-oriented, "just" culture free of blame for individual clinicians when a patient attempts or dies by suicide.

In a Zero Suicide approach:

A data-driven quality improvement approach involves assessing two main categories:

  • Fidelity to the essential systems, policy, and patient care components of the Zero Suicide model
  • Patient care outcomes that should come about when the organization implements those essential components

Questions

What is our plan for applying a data-driven quality improvement approach, including both fidelity to the Zero Suicide model and patient-care outcomes? How do we measure and track suicide deaths for those in our care?

To Implement Zero Suicide

Assess Fidelity to the Zero Suicide Model

  • Create a plan to assess the organization’s fidelity to the Zero Suicide model. Completing a fidelity assessment will allow you to:
    • Determine how closely the elements of the Zero Suicide model are being followed
    • Check on quality
    • Help identify opportunities for improvement

You will find more information about assessing fidelity to the Zero Suicide model at the tab Fidelity Assessment above. 

Measure Patient-Care Outcomes

Create a plan to set patient-care goals and to evaluate the outcomes that systems, policy, and patient-care changes are designed to produce, using the Zero Suicide Data Elements Worksheet.

  • Create a plan to collect and review patient-care data every six to twelve months.
  • Provide feedback regularly to senior leadership and staff on progress toward patient-care goals in conjunction with the systems, policy, and patient care practice changes being made in the organization’s Zero Suicide approach.

You will find more information about measuring outcomes at the Patient Care Measures tab above.

Assessing Fidelity

Return to the Organizational Self-Study

If you began your review of this toolkit with the Lead section, you will remember that the first step an organization should take is to complete the Zero Suicide Organizational Self-Study. The self-study is a tool that is designed to allow you to assess what core elements of suicide safer care your organization currently has in place. 

Used alone, the results of the self-study will show where an organization’s suicide care practices are already effective and where they can be strengthened, which will inform the overall work plan. 

A year or so after your organization has launched a comprehensive suicide care approach, you should also use the self-study to measure your organization's progress, as an assessment of fidelity to the Zero Suicide approach. Completing the self-study every year will tell you and your organization how well you are adhering to the Zero Suicide model and point out the next areas that need strengthening. 

 

Measuring Patient Care Outcomes

Work Plan

In creating an evaluation plan for a Zero Suicide initiative, the implementation team should:

  • Identify patient-care outcomes that indicate that systems and policy changes may be having the desired effect on actual practice. 
  • Assess care outcomes for all patients who have a suicide care management plan.
  • Develop, review, and improve efforts for collecting data on suicide attempts and deaths for those in care. 
  • Assess the experience and satisfaction of patients who are or have been engaged in a suicide care management plan.

Data Elements Worksheet

To assist in this process, the Zero Suicide Data Elements Worksheet provides suggestions for what data elements to measure in an evaluation plan. These include:

  • Screening 
  • Assessment 
  • Safety plan development 
  • Lethal means counseling 
  • Missed appointment follow-up 
  • Acute care transition 

The Data Elements Worksheet suggests additional rates that are useful for health and behavioral health care organizations to examine, if possible:

  • ED usage 
  • Inpatient admissions 
  • Number of suicide attempts among all patients
  • Number of suicide attempts among patients with identified risk
  • Suicide among all patients
  • Suicide among patients with identified suicide risk

The Data Elements Worksheet includes a description of each measure, including guidance as to how to measure. 

You’ll find the Zero Suicide Data Elements Worksheet in the Tools section below.

Apply Data-driven Quality Improvement

The basic next step to measure improvements in the quality of suicide care is to:

  • Enlist the implementation team in developing an evaluation plan, including a plan to evaluate progress, using the Organizational Self-Study, and measure results, using the Zero Suicide Data Elements Worksheet.

There are several additional items to help you plan these next actions:

Quick Guide to Getting Started with Zero Suicide. This one-page tool lists ten basic actions to take to implement a Zero Suicide initiative. Use this tool to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.

Zero Suicide Organizational Self-Study. Every organization should complete the self-study as one of the first steps in adopting a Zero Suicide approach. While the self-study is available on the Lead section of the Zero Suicide online toolkit, it’s provided again here for your convenience.

Zero Suicide Work Plan Template. This form contains an expanded list of action steps to guide your implementation team in creating a full work plan to improve care and service delivery in each of the seven core Zero Suicide components.

Apply data-driven quality improvement.
Use data to inform system changes that will lead to improved patient outcomes and better care for those at risk.

Overview: A Commitment to Quality Improvement

Organizations that adopt a Zero Suicide approach apply continuous, data-driven quality improvement strategies to ensure improved patient outcomes and better care for those at risk of suicide. Organizations should create a plan to assess system-wide fidelity to a comprehensive suicide care model and to evaluate the outcomes that systems, policy, and patient care changes are designed to produce. 

An organizational commitment to continuous quality improvement is necessary in order to achieve the aim of zero deficits and zero harm. This commitment fosters a culture in which every staff member—no matter their credentials or role—is comfortable with, and even praised for, disclosing errors without deference to authority.1 When defining high-reliability organizations, Chassin and Loeb wrote that these organizations “assess the strength and resilience of their safety systems and the organization’s defenses that prevent errors from propagating and leading to harm.”2 These types of Learning Health Care Systems are only successful in safety-oriented, just cultures where individual providers are supported when a patient attempts or dies by suicide.3

Recommendation: Orient Toward Measurement

Three actions are central to a culture of safety that fully supports high reliability: trust, report, and improve.3,4 It is essential to have clear processes for holding employees accountable for adherence to protocols, procedures, and recognizing errors of any size.4

The Henry Ford Health System achieved results through their Perfect Depression Care initiative—one of the inspirations for the Zero Suicide approach—by mapping current care processes, implementing measures of care quality, continually assessing progress, and adjusting the plan as needed. Through data collection and monitoring, Henry Ford Health System and Centerstone, another early adopter of Zero Suicide, found that operational improvements led to clinical improvements:

5 6

The Zero Suicide approach is oriented toward measuring results and improving quality. To assess performance on suicide prevention, organizations should examine both process measures (e.g., screening rates and use of follow-up contacts) and outcomes of care (e.g., number of suicide attempts and deaths among people at risk). However, the category “suicide deaths of people under care” has not yet been adopted as a national health care measure. Due to this, and because official records of suicide deaths may lag significantly, measurement of rates of suicide may be useful primarily as an ultimate measure of safety and quality rather than for performance improvement. 

In creating an evaluation plan for your Zero Suicide initiative, the implementation team should: (1) identify patient care outcomes demonstrating whether systems and policy changes are impacting practice; (2) assess care outcomes for all patients who have a suicide care management plan; (3) develop, review, and improve data collection on suicide attempts and deaths among those in care; and (4) assess the experience and satisfaction of patients who are or have been engaged in a suicide care management plan. It is also important to ensure that you are choosing data that is meaningful for the implementation team and your staff more broadly. To assist in this process, the Zero Suicide Data Elements Worksheet available on the Zero Suicide website provides suggestions for what data elements to measure in an evaluation plan. 

Conclusion: Never Cease to Strive for Perfection

Measuring patient outcomes, maintaining fidelity to the model, and developing a meaningful work plan and evaluation plan are keys to successful Zero Suicide implementation. The Zero Suicide Organizational Self-Study tool is available to assist in tracking progress and fidelity. Administering and re-administering the Zero Suicide Workforce Survey is a good resource for tracking improvements in developing and maintaining a skilled and competent workforce. The prospect of continuous quality improvement can seem daunting, but, to quote surgeon and public health researcher Atul Gawande, “It isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to strive for it.”7

 

Readings

Incident Reports and Root Cause Analysis 2002-2008: What They Reveal about Suicides
  • Web
Breakthrough Series: Outcomes and Recommendations
  • PDF

Tools

Zero Suicide Data Elements Worksheet
  • PDF
Framework for Conducting a Root Cause Analysis and Action Plan
  • Web

SPRC and the National Action Alliance for Suicide Prevention are able to make this web site available thanks to support from Universal Health Services (UHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS) (grant 1 U79 SM0559945).

No official endorsement by SAMHSA, DHHS, or UHS for the information on this web site is intended or should be inferred.