Health care systems and leaders design for a "zero-based" mindset by changing the culture around suicide prevention and care. Industries such as the nuclear and airline industries aim for zero accidents and then organize all policies, practices, training, and responsibilities around achieving that goal. When you design for and expect “zero”, you think and transform differently than if you are designing for a 10% or 50% reduction. 

Hospitals call these incidents “never events” – events that should never happen such as leaving a foreign object inside a person after surgery, operating on the wrong side, or discharging an infant to the wrong person.  Suicide in patients seen by health care systems should be a never event. The system should be designed to ensure that patients are identified and treated when they are at risk for suicide. Evidence-based practices for suicide prevention exist and all health care providers should be trained in them. The health care organization should ensure that use of these practices is baked in to the culture, training, and continuous quality improvement of the system.

Forty-five percent of those who died by suicide saw a nonpsychiatric provider in the month before their death, and 77% saw a provider in the year before their death, though often these contacts were not to address primary mental health needs. Gatekeeper training and community interventions are designed for the public to route people identified with thoughts of suicide to medical providers (emergency room, primary care, mental health professional) with the presumption that they will get proper care and treatment. Overall, there is a significant lack of training, preparedness, comfort, competence, and skill in health care professionals, both medical and mental health, and this can and does lead to missed opportunities, poor care, and adverse outcomes. Many have never received training or aren’t aware that evidence-based suicide prevention interventions exist. A study of licensed mental health providers found that over 30% did not ask every patient whether they had any thoughts of suicide during their initial visits, a well-documented suicide mitigation strategy. Training primary care providers in screening and treating depression with assistance from psychiatrists, has been found to lower suicide rates, nonfatal suicide attempts, and suicidal thoughts. Evidence-based approaches to suicide identification and care are now available, and all providers should have this training.

Luoma JB, Martin CE, Pearson JL: Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry 2002; 159:909–916 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5072576/

Available for purchase: Roush, J.F.; Brown, S.L.; Jahn, D.R.; Mitchell, S.M.; Taylor, N.J.; Quinnett, P.; Ries, R. Mental health professionals’ suicide risk assessment and management practices: The impact of fear of suicide-related outcomes and comfort working with suicidal individuals. Crisis 2018, 39, 55–64

Mann, J.J.; Michel, C.A.; Auerbach, R.P.; Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review. American Journal of Psychiatry. 00:0; January 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9092896/

A systemwide approach to preventing suicide improves outcomes, closes gaps, and improves patient safety. True transformative change cannot be borne solely by the practitioners providing clinical care. The entire enterprise plays a role in keeping patients safe by adopting and embedding evidence based practices and ensuring they are used routinely; training all staff to use these interventions and about their unique role and responsibility when it comes to identifying and reducing suicide risk; collecting data to measure both outcomes as well as fidelity to use of these interventions; conducting continuous quality improvement to improve performance weaknesses; and normalizing suicide prevention and care practices for staff, people at risk, and their families as the expected standard of care. Health care systems that have implemented comprehensive suicide prevention initiatives are a version of high-reliability organizations (HROs) that, via relentless quality improvement and attention to detail, are able to perform high-risk work in complex domains without serious accidents or catastrophic events. Seeing suicide as a never event forces the organization to use best practices, apply continuous quality improvement, and emphasize reducing errors while holding the system to account, not individuals who work in the system. Health care providers should demand that their system adopt robust suicide care practices for the safety of their patients as well as for themselves.

https://zerosuicide.edc.org/

May, E. L. (2013). The Power of zero: Steps toward high reliability healthcare. Healthcare Executive, 28(2), 16.

Suicide is a complex issue that requires a multi-pronged approach to address effectively. The goal of a suicide prevention program needs to incorporate policies, practices, and services using a systematic, data-driven process; address suicide prevention through multiple coordinated and evidence-based prevention strategies, identify issues relevant to the specific population and setting, and select appropriate strategies to address them. No single program, training, or intervention is going to reduce suicide. Effective suicide prevention is comprehensive: it requires a combination of efforts that work together to address different aspects of the problem. There are comprehensive approaches available for many unique settings such as schools, communities, faith, health care, and tribes.

https://www.sprc.org/effective-suicide-prevention

https://theactionalliance.org/sites/default/files/transformingcommunitiespaper.pdf

https://www.preventioninstitute.org/projects/updating-cdc-suicide-prevention-technical-package-application-during-catastrophic-events

Health care systems are already doing suicide prevention – they are already taking care of people thinking about suicide. There are incredible clinicians who work hard every day and save lives. However, most clinicians do not have training in suicide specific practices. Evidence based approaches specific to suicide prevention have emerged in the last 15 years or so, but these are typically not taught in graduate training and are not required continuing education. Therefore, most providers have little to no specific suicide prevention training in interventions that work to reduce suicide events such as Safety Planning Intervention, Dialectical Behavior Therapy, Collaborative Assessment and Management of Suicide or Cognitive Behavior Therapy for Suicide Prevention. Health care leaders often mistakenly assume that because they hire licensed staff, that those staff can treat people with suicide risk. While providers are generally well-intentioned and caring, lack of using suicide specific treatments can result in outcomes such as traumatizing people who are already in crisis or not mitigating the person’s suicide risk, even leading to their death.

Health care systems and leaders often don’t realize that 1) specific evidence-based practices exist in suicide prevention and 2) that their licensed providers aren’t using them. The good news is that progress is happening to improve this. In 2019, The Joint Commission (TJC) updated the National Patient Safety Goal (NPSG) for Suicide Prevention with the expectation that health care systems utilize these evidence-based practices. This was ground breaking and will greatly change how suicide care is provided. The bad news is that this particular NPSG is one of the worst met indicators by health care organizations accredited by TJC.  

Health care systems who have adopted the comprehensive Zero Suicide model have seen results, including the following: 

• Reductions in suicide deaths 

• Decreases in hospitalizations (or rehospitalizations) 

• Increases in quality and continuity of care 

• Improvement in post-discharge follow-up visit attendance 

• Improvements in screening rates according to protocol 

• Systemwide care pathway implementation 

• Fewer inpatient psychiatric hospital readmissions 

• Cost savings 

• Improved patient satisfaction 

Individual health care providers should seek out training in suicide specific interventions. Providers should seek training in evidence-based tools and interventions and adopt standardized care practices. There are screening and risk assessment tools that are validated for identifying people at risk for suicide. No one should be using a home-grown screener or risk assessment. Research shows that standardized screening tools identify people at risk more accurately than most clinicians do, even those who have years of experience. Similarly, using these standardized resources helps to reduce bias that might get introduced or anxiety that might creep in. For example, providers should not say things like, “I’m sorry I have to ask you this but…” or “You have never felt like this, right?” When providers don’t feel confident to treat suicide, they might inadvertently convey that to patients. Providers need to ask patients routinely about their thoughts of suicide and then design a treatment plan that targets a reduction in suicidality. Sessions should be organized around using interventions to address suicide such as safety planning, means safety, and therapy such as DBT, CBT-SP, CAMS, or ASSIP, and using caring contacts.  Providers need to provide empathy and offer hope. Providers can use all of the tools available but if they don’t make patients feel like they can get better, have hope, and build a life worth living, then patients won’t come back to the next appointment. Take all suggestions of suicide seriously. Ask directly about suicide so that the person knows that this is a subject that can be addressed with you and that you are going to partner on this journey and don’t judge their reasons for feeling this way. 

A safety plan is not the same thing as contracting for safety.  When I was in graduate school a million years ago, I was taught to use a no-suicide contract. That meant you had the client sign a contract “promising” that they wouldn’t kill themselves. Really these were meant to alleviate anxiety or shed responsibility in the provider, but actually did nothing to treat the person at risk. Suicide contracts are not a legal document and definitely do not reduce a person’s risk for suicide. No one should be using them. There are several validated tools for safety planning that exist and that are effective at reducing suicide behaviors. These help the individual at risk to develop skills and self-efficacy to identify early warning signs that their distress is increasing and learn to manage these symptoms. Examples of safety planning templates and frameworks that clinicians can use are: Safety Planning Intervention and Crisis Response Planning.