St. Joseph’s Health Care London is a large academic health care organization serving London, Ontario, Canada and the surrounding region. They began implementing Zero Suicide in 2016. After assessing for organizational readiness and staff experience with providing care for patients at risk for suicide, they developed a comprehensive training plan and instituted new protocols and workflows related to treating patients at risk for suicide.
St. Joseph’s observed several key improvements from 2016 to 2019:
- Increase in screening rates from 0% to over 90% for individuals in the Adult Ambulatory Mental Health Care program
- Increase in completed suicide risk assessments from 48% to 100% for individuals in the Adult Ambulatory Mental Health Care Program
- Increase in comfort levels related to discussing suicide and the destigmatization of the word suicide among both clinicians and those receiving care (based upon qualitative data provided by focus groups)
Mental Health Care at St. Joseph’s Health Care London
The mental health care program at St. Joseph’s Health Care London spans two specialized facilities— Parkwood Institute’s Mental Health Care Building (Parkwood Institute) and Southwest Centre for Forensic Mental Health Care (Southwest Centre)—serving London-Middlesex and Elgin Counties as well as the surrounding region. Parkwood Institute’s Mental Health Care Building is a tertiary hospital for those living with severe and persistent mental illness, while Southwest Centre is a forensic facility serving those who have been involved in the criminal justice system as a result of a mental illness. Both hospitals provide inpatient and outpatient services for adolescents, adults, and older adults. Services include the following:
- Dual diagnosis program
- Concurrent disorders services
- Treatment and rehabilitation program
- Specialized health services, such as electroconvulsive therapy and transcranial magnetic stimulation treatments
- Geriatric and adolescent psychiatry programs
- Community outreach
- Ambulatory teams
Implementation
In early 2016, Dr. Paul Links, then Chair and Chief of Psychiatry for St. Joseph’s, learned of the Zero Suicide model being implemented in the United States and felt it would be a great fit for Canadian mental health care services. Suicide is the ninth leading cause of death in Canada, and statistics show that about one-third of those who die by suicide have seen a mental health provider within one month of their death. This statistic indicated an opportunity for us to open up a conversation about suicide in our health care setting, to give people the chance to speak comfortably about their suicidal thoughts and behaviors, and to provide them with effective care and treatment.
To implement Zero Suicide, we began with a phased approach, first implementing it within our Adult Ambulatory Mental Health Care Program at Parkwood Institute. The second phase expanded implementation to the remaining mental health inpatient units and ambulatory programs across both mental health facilities as well as the Operational Stress Injury Clinic, which is part of our Veterans’ Care Program. The third phase will involve a rollout of the initiative to our community partners.
We began by using the Zero Suicide Organizational Self-Study to assess for gaps in suicide care, including staff training and support for safe care transitions. To explore the perspectives of our clinical staff, we also administered the Zero Suicide Workforce Survey before any planning began. Departmental results varied, but there were some common themes: a high level of discomfort discussing suicide and fear of not being supported, of facing consequences from professional organizations in the event of a suicide death, and that asking about suicide might be a trigger for patients. About 67% of staff indicated that they had never received training on suicide-specific evidence-based treatments to address suicide risk. The results of this survey showed that we had a long way to go in building our staff’s comfort and confidence in caring for suicidal individuals. They also highlighted the need to focus on supporting staff when an incident occurs.
To address these issues, we developed a training and education plan to provide staff with suicide risk assessment and management tools, including the Columbia-Suicide Severity Rating Scale (C-SSRS), risk formulation, mental status exams, safety planning, lethal means counseling, risk documentation, and others as indicated by the Workforce Survey. The plan also included the development of clearly outlined procedures that aligned with the seven essential elements of Zero Suicide. Following phase 1, we compared the results of our pre- and post-implementation workforce surveys.
Impact of Training and Suicide Care Interventions
We are now in post-implementation and the new workflows are being followed. Our data show that between 2016 and 2019, implementing processes for regular suicide risk assessment, screening, and safety planning resulted in over 90% of individuals in our ambulatory program receiving a C-SSRS screener at every visit with their primary clinician, with 100% of new admissions to the program receiving a thorough C-SSRS lifetime assessment.
As we continue with the second phase, expanding the Zero Suicide approach to the rest of our mental health programs and to several non-mental health areas across our organization, we are seeing improvement in the quality of care during times of patient transition. Since implementing discharge follow-up calls on our mental health inpatient units, individuals discharged from these areas now receive a “caring contact” phone call within 24 hours of leaving the hospital, and they are offered an appointment with the associated ambulatory team within seven days.
Processes implemented and evaluated include the percentage of patients who had a C-SSRS lifetime assessment within a specified time frame of admission; C-SSRS screening completed at every mental health visit (or daily for inpatients); and a coping plan collaboratively developed on admission. We have also monitored the percentage of individuals on an active suicide management plan who did not appear for their scheduled appointment but were contacted during their appointment time. In addition, we have tracked incidences of suicide and self-harm reported in areas where Zero Suicide was implemented.
To collect these data, we began with baseline audits of each measure and then started tracking compliance as Zero Suicide was implemented across the programs. Most data have been collected manually since the first implementation. We have a full-time project support analyst devoted to the project who uses Excel software to collect and analyze the data. Recently, we have included the C-SSRS tools in our electronic health record (EHR) and will soon be able to pull electronic reports regarding compliance to the lifetime version and the screening tools. We can also access information on admissions, discharges, and progress notes through the EHR, which supplement the chart audits. Additionally, we track all critical incidents through our Patient Safety Reporting System. We also have a separate research project underway that will evaluate the clinical outcomes of our pilot implementation.
As we near the end of our second phase and are preparing for our community rollout, we are happy to report that when we re-administered the Zero Suicide Workforce survey post-implementation, we saw a significant increase in our Adult Ambulatory Program clinicians’ confidence, comfort, and skill levels when caring for suicidal individuals compared to baseline. Additionally, between 2016 and 2019, we saw an increase in screening rates from 0% to over 90% for individuals in the Adult Ambulatory Mental Health Care Program and an increase in completed suicide risk assessments from 48% to 100%. Focus groups, held from 2016 to early 2019, provided qualitative data showing an increase in comfort among both clinicians and those receiving care in discussing suicide and a destigmatization of the word suicide itself. For example, one participant said: “Before Zero Suicide rolled out, I didn’t feel comfortable even saying the word suicide, or I worried that talking about it would make things even worse for patients who were already thinking about it; but it turned out that they want to be asked. I’m learning more about patients I’ve had for years just by asking questions I’d never asked before.”
As a result of the early successes we have had with our Zero Suicide implementation, we have received some awards, such as the Sandra Letton Quality Award; recognition for patient safety and patient engagement from the Canadian Patient Safety Institute, Health Standards Organization, and HealthCareCAN; and national recognition as a leading practice with Accreditation Canada. We have also been featured in several local and national media interviews, which have helped us to connect with like-minded organizations and communities across the country.
Next Steps
We hope to build on our success by continuing our evaluation of electronic suicide screening, redesigning our safety plans to better suit the needs of our patients and clinicians, and further optimizing our tools and processes. We are in the beginning stages of meeting with community partners to assess their interest in partnership and support from St. Joseph’s in suicide prevention and care.
As part of the research studies happening alongside our quality improvement project, we will be tracking suicides, self-harm presenting to the local emergency department, and readmissions for suicidal ideation and behaviours. We have also begun tracking quality in addition to compliance, which means we are following up on how clinicians do their assessments and how they are documenting these assessments in an effort to focus on quality interactions and strong therapeutic relationships. In addition, we are reviewing the process for what happens when an incident does occur so that we can better support clinicians and patients alike. Our goal is to create a community where individuals feel comfortable discussing suicide at any interaction within the health care system or with a community service provider. The hope is that those who need support will be able to access appropriate, people-focused interventions where and when they need them and without fear of judgment or of falling through the cracks.
Authorship Details
- Katerina Barton, MA Leadership, PhD(c); Leader, Special Projects; St. Joseph’s Health Care, London (Canada)
For more information, contact Isabel Facey at isabel.facey@sjhc.london.on.ca