Zero Suicide operationalizes the core components of safer suicide care as seven elements.
Together, the seven elements of safe and effective suicide care make up the Zero Suicide Framework.
The seven elements of Zero Suicide represent what experts in the field of suicide prevention have identified as the core components of safe care for individuals with suicidal thoughts and urges. They represent a holistic approach to suicide prevention within health and behavioral health care systems.
The Zero Suicide Framework for Safe Suicide Care
Foundational Principles
Zero Suicide is based on the following foundational principles:
- Core Values—the belief and commitment that suicide can be eliminated in a population under care by improving service access and quality and through practicing continuous quality improvement.
- Systems Management—taking systematic steps across systems of care to create a culture that no longer finds suicide acceptable, setting aggressive but achievable goals to eliminate suicide attempts and deaths, and organizing service delivery and support accordingly.
- Evidence-Based Clinical Care Practices—adopting practices that research shows reduce suicide deaths and behaviors and that are delivered through the entire system of care and that emphasize productive patient-staff interactions.
To adopt and implement Zero Suicide means incorporating the seven elements that together make up the Zero Suicide framework. These elements operationalize the principles above. The seven elements described throughout this toolkit are not an exhaustive collection of all that must transpire to transform health care to be suicide safe but do provide a roadmap to deliver safer, more effective care. This bundle of interventions, when used consistently, with training and fidelity, have demonstrated results that suicide and suicide attempts in health care can be reduced.
Framework Fidelity
Fidelity and adherence to these practices is vital. While adverse events may still occur, celebrating successes is essential, and supporting the team is crucial. Furthermore, a just and restorative culture must be present. According to the Harvard Business Review, “a learning organization is an organization skilled at creating, acquiring, and transferring knowledge, and at modifying its behavior to reflect new knowledge and insights. This definition begins with a simple truth: new ideas are essential if learning is to take place”. Health care leaders and professionals who pursue Zero Suicide must be learning organizations dedicated to systemwide change that advances best practices in suicide care.
Zero Suicide Elements
Lead system-wide culture change committed to reducing suicides.
Acknowledge that top leadership commitment and dedicated front line champions are both necessary for success. 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.
Train a competent, confident, and caring workforce.
Train a competent, confident, and caring workforce. Interactions with staff are a critical part of any patient experience. This is doubly true for many suicidal individuals who have had experiences with health care providers or interventions where their needs were not met, their suicidality not reduced, and worse, where they were stigmatized or traumatized. For many people at risk, this is their first encounter with the behavioral health care system. Any door must be the right door – through which the staff, both clinical and non-clinical, engage people at risk by encouraging them to believe treatment can work, that the staff care about them, instilling a commitment to come back to the next appointment. Understanding that ambivalence—the desire to find a solution to the intense pain they feel versus the innate human desire to live—is essential for any clinician working with a patient at risk of suicide.
Identify individuals with suicide risk via comprehensive screening and assessment.
For those who screen positive, the use of a standardized risk assessment tool and risk formulation needs to be conducted to determine the course of treatment and next steps. People should be screened at every visit with a health care professional and all health care providers need to be comfortable asking about suicide directly and without judgment.
Engage all individuals at-risk of suicide using a suicide care management plan.
Talk with individuals openly about their suicide risk and the treatment available to address it. Those who screen positive for suicide should develop a collaborative safety plan with a clinician or health care worker before going home. The safety plan, also called a wellness plan or crisis response plan, needs to address means safety. Individuals at risk for suicide should understand their suicide care management plan which includes what to expect from treatment, the placement on a high-risk pathway, and what that means both for ongoing appointments as well as for missed appointments. It is the organization’s responsibility to keep the patient engaged in and coming to care by being patient-centered, committed to quality, safe, timely, and culturally relevant treatment and care.
Treat suicidal thoughts and behaviors directly using evidence-based treatments.
Research in the last 10 to 15 years has emerged to suggest that suicide can be targeted directly through treatments that focus explicitly on the suicide risk, both to keep patients safe and to help them to thrive. Randomized controlled trials have found that Cognitive Therapy for Suicide Prevention (CT-SP), dialectical behavior therapy (DBT), and the Collaborative Assessment and Management of Suicide (CAMS) all reduce suicide and suicidal behaviors. Even brief interventions delivered during single in-person encounters are effective at reducing suicide behaviors. It is essential that clinicians apply these techniques that are known to reduce suicide, but they must be trained in these modalities.
Transition individuals through care with warm hand-offs and supportive contacts.
Patients are at the highest risk for suicide in the immediate aftermath of a psychiatric hospitalization. There is a clear need for universal and continuing interventions and support following discharge. Despite the evidence that it is critical for safety, only about half of patients receive any outpatient care during the first week after psychiatric hospital discharge, and one-third receive no mental health care at all during the first month after discharge. Linkages to providers through warm handoffs must be created as well as more support and helping patients understand what to expect from care is necessary. Providers should routinely use caring contacts, appointment reminders, and bridge appointments to ensure that patients went to appointments and plan to keep on going.
Improve policies and procedures through continuous quality improvement.
Collect and examine data routinely, and maintain fidelity to the processes established for the system. 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, which would include supporting clinicians and staff following the suicide death of a patient.