Two leadership drives are the keys to the dramatic reductions in suicide deaths achieved by Zero Suicide organizations. The first is leadership mobilizing staff to believe that suicide can be prevented. The second is an unwavering focus maintaining that zero suicides is the goal. Leadership must both convince staff to see and believe that suicide can be prevented and provide tangible supports in a safe and blame-free environment—what is known as a just culture.
In a Zero Suicide approach:
- The organization has a policy specific to suicide care.
- The policy emphasizes the importance of the core components of safer suicide care, covered in detail in the seven sections of this Zero Suicide Toolkit:
- LEAD system-wide culture change committed to reducing suicides
- TRAIN a competent, confident, and caring workforce up-to-date in suicide care
- IDENTIFY patients with suicide risk via comprehensive screenings
- ENGAGE all individuals at-risk of suicide in a suicide care management plan
- TREAT suicidal thoughts and behaviors using evidence-based treatments
- TRANSITION individuals through care with warm hand-offs and supportive contacts
- IMPROVE policies and procedures through a continuous quality improvement plan
- The organization’s policy specifies a program for preventing compassion fatigue among all staff who interact with patients at risk of suicide.
What type of formal commitment have we made to reduce suicide and provide safer suicide care among people who use the organization’s services? Are the suicide bereaved and those with lived experience in leadership and planning roles?
To Implement Zero Suicide
Establish a Zero Suicide Implementation Team
- A Zero Suicide implementation team is established with the charge, tasks, and roles of members clearly defined, including:
- A schedule for regular team meetings
- Authority for changing policies and procedures
- An evaluation plan designed to assess the impact of the initiative
- Responsibility for continuous quality improvement and the development of specific approaches to measuring and reporting on all suicide deaths
- The suicide bereaved and those with lived experience are part of the Implementation Team and participate in some or all of the following activities:
- Providing regular input and advice
- Assisting with workforce hiring and/or training
- Participation in evaluation and quality improvement efforts
- Participation in multiple aspects of suicide care
- The Implementation Team completes a Zero Suicide Organizational Self-Study and uses the results to set organizational goals.
- A budget supports Zero Suicide implementation.
- The Implementation Team explores ways to link Zero Suicide to other initiatives, such as trauma-informed care or substance abuse prevention and treatment programs.
- The Team reviews all of the organization’s policies to determine what new policies need to be developed. Policies and procedures include:
- Approaches to measuring and reporting on all suicide deaths
- Supports provided to staff that have experienced suicide death of a client
- Suicide care planning is embedded in the electronic health record
- Staff is trained on use of the electronic health record to track clients at risk for suicide.
For more information about the Self-Study and to view the tool, go to the Organization Self-Study tab. For more discussion on involving suicide attempt survivors, go to the Lived Experience tab. Each section of the Zero Suicide Toolkit describes a core component of the approach, including specific features that organizational policies should contain.
Ongoing Communication with Management and Staff
- The CEO or another member of senior management conducts a presentation about the Zero Suicide philosophy, approach, and key elements to the board of directors on Zero Suicide.
- The CEO and Implementation Team communicate the Zero Suicide philosophy, rationale, approach, and merits of this initiative to staff and establish a process for regular updates, at least annually.
- Changes as a result of the Zero Suicide initiative, including patient outcomes, are communicated to staff.
- The implementation team provides management with training on the Zero Suicide philosophy, essential elements, and implementation plan.
- The CEO and implementation team state a commitment to transparency and a no-blame culture when adverse events do occur.
Taking the Organizational Self-Study
About the Organizational Self-Study
The Zero Suicide Organizational Self-Study is designed to allow you to assess what core elements of safer suicide care your organization currently has in place. The self-study can be used early in the launch of a Zero Suicide initiative to assess organizational strengths and weaknesses and to develop a work plan. While the self-study is not exhaustive with regard to all issues that can affect patient care and outcomes, it reflects the core components that define the Zero Suicide comprehensive approach.
The organization’s Zero Suicide implementation team should complete the self-study, with input from staff involved in policymaking and care for patients at risk for suicide. There are a variety of ways for the implementation team to conduct the self-study, depending on the type and size of the organization.
For example, a large, multi-site organization might ask the leader of each geographic location to complete the self-study for that location. The results could inform individualized planning for each location and at the same time suggest actions that the corporate leadership may need to take.
Since each member of the implementation team will likely be the leader of a significant area of the organization, another option is to have all the team members complete the self-study. A designated team member could consolidate the ratings, which could be a starting point for a discussion of goal setting and work plan development. Alternatively, the team might complete one self-study together, coming to consensus on each item.
Accessing the Organizational Self-Study
The Zero Suicide Organizational Self-Study is available in two formats:
Involving People with Lived Experience
Until recently, the field of suicide prevention has rarely tapped the first-person knowledge of suicidal behavior and real-world wisdom that suicide attempt survivors bring to the table. The field, along with health and behavioral health care organizations, is now beginning to engage the people with the most intimate information about suicidal thoughts, feelings, and actions—those who have lived through such experiences.
The Suicide Attempt Survivors Task Force of the National Action Alliance for Suicide Prevention recently issued the report The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from Lived Experience. The report offers a set of core values to inform suicide prevention and care as well as specific recommendations for health and behavioral healthcare organizations and program developers.
For the organization developing a Zero Suicide approach, one of the first actions should be to partner with people with lived experience in developing, implementing, and evaluating efforts. For example, a Zero Suicide Implementation Team should include at least one person with lived experience.
Suggestions for Involvement
The Way Forward suggests several ways in which people with lived experience can be involved in improving suicide care:
- Suicide prevention and behavioral health care organizations can engage, hire, and/or collaborate with peer support professionals. They should also include attempt survivors as key partners in suicide prevention efforts.
- Providers of crisis or emergency services can develop formal partnerships with organizations that offer peer support services and especially organizations that are operated or driven by people with lived experience.
- Suicide prevention and behavioral health groups can engage attempt survivors as partners in developing, implementing, and evaluating efforts.
- All types of providers can use a certified peer specialist on care coordination teams. This involvement can have direct benefits for a person receiving care, including role modeling and improved problem-solving.1
- 1. National Action Alliance for Suicide Prevention, Suicide Attempt Survivors Task Force. (2014). The way forward: Pathways to hope, recovery, and wellness with insights from lived experience. Washington, DC: Author. Retrieved from http://actionallianceforsuicideprevention.org/sites/actionallianceforsui...
Create a Leadership Culture for Safer Suicide Care
The basic next steps to create a leadership culture to provide safer suicide care are:
- Review the online Zero Suicide Toolkit.
- Challenge your organization to adopt a comprehensive suicide care approach using the readings and tools in the Lead section of the toolkit.
- Convene your Zero Suicide implementation team.
- Discuss and complete the Zero Suicide Organizational Self-Study, provided in the Tools below.
- Create a work plan and set priorities, using the Zero Suicide Work Plan Template, also provided in Tools.
- Create a plan to collect data to support evaluation and quality improvement, using the Zero Suicide Data Elements Worksheet, available in the Improve section of the Toolkit.
- Announce to staff the launch and adoption of an enhanced suicide care approach.
Use the Quick Guide to Getting Started with Zero Suicide to get an overall vision of the path you will take to adopt this comprehensive suicide care approach.
System change occurs with sustained and committed leaders who learn and improve practices following adverse events.
Overview: Critical Elements for Effective Leadership
There are several key components to effective leadership for organizations implementing Zero Suicide: (1) utilizing lessons learned from high-reliability organizations, (2) fostering a just culture, (3) maintaining focus on a comprehensive approach to preventing suicide deaths in their systems, and (4) focusing on continuous quality improvement and fidelity to the Zero Suicide model.
High-reliability organizations (HROs), like airlines, rely on leadership to foster a culture of safety. Weick and Sutcliff describe a key element of this culture as “collective mindfulness.”1,2 In this type of organizational culture, all levels of workers are attentive to and report errors, failures, and weak signals.1,2 Workers in HROs know to be always on alert and are incentivized to speak up about even small issues, creating a responsive culture poised to correct unsafe conditions before safety is compromised.1,2
In these organizations, leadership supports a just culture where experience and patient safety—not rank or title—are at the center of patient care and decision-making. Chassin and Loeb argue that leadership must make a commitment to achieving zero patient harm, promoting a culture of safety, and emphasizing evidence-based approaches1—all critical elements of Zero Suicide.
Leadership must also maintain a focus on a comprehensive and accountability-centered approach. Findings from organizations implementing a comprehensive approach to reducing rates of suicide and other related measures highlight the importance of this style of leadership.
From 1990 to 2002, the U.S. Air Force implemented a comprehensive suicide prevention program at the community level.4 This program used 11 interventions across 15 functional areas including community-based social service providers, health care delivery, and operational supervision of the occupational community. Interventions included policy changes, senior leadership development, improvements in training, and social network enhancements. This initiative was associated with a 33 percent risk reduction for suicide deaths.4
A comprehensive approach in health care that reduced suicide rates was developed by the Henry Ford Health System (HFHS) and informs the Zero Suicide approach. HFHS’s “Perfect Depression Care” used suicide deaths as the measure of effective depression care in their system. Their goal was “zero defect” mental health care that included 100 percent patient satisfaction and 100 percent accuracy. To achieve this goal, they emphasized a comprehensive approach and strong leadership focus on patient safety and continuous quality improvement. This program reduced the suicide rate among patients receiving behavioral health care from an average of 96 per 100,000 in 1999–2000 to an average of 24 per 100,000 in 2001–2010, a reduction of approximately 75 percent.5
Recommendation: Learn from Organizations Implementing Zero Suicide
The Zero Suicide approach was refined, implemented, and tested over the past several years by behavioral health and integrated primary care programs. These organizations demonstrate that Zero Suicide can be feasibly implemented in ordinary care settings with significant reductions in suicide deaths and other related measures. For example:
At Centerstone, a large, multistate behavioral health nonprofit headquartered in Tennessee, the baseline rate for suicide before Zero Suicide implementation was 31 per 100,000; the suicide rate two years into implementation dropped to 11 per 100,000, a reduction of about 65 percent.
— Becky Stoll, personal communication, Feb. 22, 2016
Conclusion: Invest in Multifaceted Strategies
Current research suggests that no single approach will reduce suicide among individuals who are in care. Comprehensive, multi-component, system-wide approaches to suicide prevention have been shown to be effective in broad and diverse settings and likely are the keys to reducing suicide.4,5,6,7 The Zero Suicide approach offers a Toolkit that guides implementers in the process of embedding interconnecting evidence-based practices for suicide prevention into health care systems. One way to assess what components of the comprehensive Zero Suicide approach are currently in place and the degree to which the components are embedded within key clinical areas is to administer the Zero Suicide Organizational Self-Study. It helps to assess organizational and clinical area-specific strengths and opportunities for development across each of the seven elements of Zero Suicide. The Zero Suicide Organizational Self-Study should be retaken on an annual basis as a fidelity check for your organization.
- 1. a. b. c. d. Chassin, M.R., & Loeb. J.M. (2013). High-reliability health care: getting there from here. The Milbank Quarterly, 91(3), 459-490. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1468-0009.12023/abstract
- 2. a. b. c. Weick, K., & Sutcliffe, K. (2007). Managing the Unexpected: Resilient performance in the age of uncertainty (2nd ed.). San Francisco: John Wiley & Sons, Inc.
- 4. a. b. c. Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C., & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. British Medical Journal, 327. Retrieved from http://www.bmj.com/content/327/7428/1376
- 5. a. b. Coffey, M.J., Coffey, C.E., & Ahmedani, B.K. (2015). Suicide in a health maintenance organization population. JAMA Psychiatry, 72(3), 294-296. Retrieved from http://archpsyc.jamanetwork.com/article.aspx?articleID=2091661
- 6. Martin, G., Swannell, S., Milner, A., & Gullestrup, J. (2016). Mates in Construction Suicide Prevention Program: A Five Year Review. Journal of Community Medicine & Health Education, 6(4), 465. Retrieved from https://www.omicsonline.org/open-access/mates-in-construction-suicide-pr...
- 7. While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., Appleby, L., & Kapur, N. (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997−2006: a cross-sectional and before-and-after observational study. Lancet, 379(9820), 1005-1012. Retrieved from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61712-1/abstract