Improve policies and procedures through continuous quality improvement.

In a Zero Suicide approach, a data-driven quality improvement approach involves assessing two main categories: fidelity to the essential systems, policy, and care components of the Zero Suicide framework and; care outcomes that should come about when the organization implements those essential components. Continuous quality improvement can only be effectively implemented in a safety-oriented, "just" culture free of blame for individual clinicians when someone with whom they are working attempts to end their life or dies by suicide.

IMPROVE Indigenized

The basic premise of the Zero Suicide approach is that, if fidelity to the framework is part of the culture of the organization, the way care is delivered, outcomes will improve. To simplify the concept of fidelity, let’s look at it like this:

When we get ready to plant some crops to feed our family, there are steps we need to take in order for those crops to thrive and sustain us through the next growing season. If we skip a step or two, it is likely that our efforts to grow our food will fail. We need to ensure that the soil is prepared properly, that there is a good balance between sun and water, and that we have healthy seed to plant. We will ensure that we are attentive to the young seedlings, protecting them from things that may compromise their growth and then, once they are fruitful, we will harvest.

For a health/behavioral health care system, the implementation of Zero Suicide is much like this. There are seven steps that ensure a good harvest (outcome) and, if we skip a step or two, all of our work in trying to implement the other steps may not provide us with the outcomes we expect. This is called fidelity to a framework; following specified steps to prepare the ground, to plant the seed and to protect the crops along the way. So fidelity to the Zero Suicide framework when we are implementing in our health/behavioral health care systems means that each and every element is connected to the other, making not a line, but a circle. All portions of that circle are sacred and attention and honor is paid to each of the elements that make it up. 

However, it is difficult to determine what is working and what needs to change if there is no record of what types of interventions are being implemented. Therefore, even if data is collected by paper and pencil, it is critical that it be recorded, maintained and shared.

The Zero Suicide Data Elements Worksheet is a helpful tool when deciding what types of data to collect in order to evaluate: 1) fidelity to the Zero Suicide framework and; 2) how this fidelity is impacting your health/behavioral health care system. To begin, the scope of the impact of loss by suicide is critical to know. If you do not have this information, it is not possible to know whether or not the implementation of Zero Suicide is helping to reduce the loss of life by suicide in the system. As mentioned previously, some Tribes have prohibited, through Tribal Resolution, the release of certain data, deaths by suicide being one of these, so obtaining this data may be challenging. A toolkit with some suggestions on surveillance in Indian Country is located here: SPRC Suicide Surveillance Strategies for American Indian and Alaska Native Communities.

In some Tribal systems, deaths by suicide are recorded as traffic accidents, accidental overdoses or other types of accidents…even though there is evidence to suggest that these deaths were a direct result of self-harm. This false recording is often a result of the surviving family’s request to keep this part of the loss away from the records because of shame. Many Tribes (but certainly not all) across Indian Country believe that, if a person ends their own life, their spirit does not automatically “walk” to Creator, but that it stays in a land apart from Creator. Sacred ceremonies conducted by Traditional Healers amongst some of the Tribes seek to retrieve those spirits and take them to Creator.

Our Tribe believes in “ghost sickness.” We do not talk about anyone who has ended their own life. We believe that if we do, it will bring that energy to us and will cause others to do the same (take their life). So we don’t talk about it at all. —Cultural Liaison working with one of the Southwestern Tribes on Zero Suicide1

My job in Sundance is to go out into the Spirit World to a place where the spirits of those who ended their own lives reside. Because they took their own lives, they are blinded to where they need to go in order to enter the sacred space where Creator resides. Through sacred ceremonies, special prayers and through the use of our traditional medicines, we can help those spirits find their way to Creator by acting as their eyes, their guides. Once they are on this road, Creator welcomes them home.

— Anishinabek Buffalo Dancer2

Continued frank and open dialogue, informed by the cultural ways of the Tribe, with the Tribal leadership, Elders, Traditional Healers, youth, and the rest of the community regarding loss by suicide will act to “take the sting” out of this topic. However, as stated throughout this document, extreme care needs to be taken to understand how the Tribe articulates death and dying, especially loss of life by suicide, so cues should always be taken from the Elders of the community as well as from the Tribal leadership. This can mean the difference between the Tribe’s acceptance of suicide-safer care and the rejection of it.

It is helpful to choose three or four points on the Data Elements worksheet so that you can get a feel for how best to collect the data and how to synthesize it into reports that show forward movement in the creation of safer suicide care. An explanation of some data collected and used for quality improvement in Indian Country may be found here: Outcome Story: Chickasaw Nation Departments of Health and Family Services.

Beginning modestly will aid in the development of confidence around data collection. Positive outcome data (i.e. numbers of people who were seen in the ED during the month of July vs numbers of people who were screened for suicide risk) will be useful when applying for grants or when communicating the importance of a comprehensive plan for making death by suicide a “never event” in their community to Tribal leadership. While the information about numbers of Tribal members lost to suicide may be important to Tribal leadership, the numbers of lives saved through the implementation of the Zero Suicide framework within the health/behavioral health care system serving them would also be very important for them to know.

IHS, in working with their Zero Suicide Initiative grantees, recommends the following data points, among others, to be collected by their grantee systems:

  • Numbers of screenings performed (universal screening with a goal of 100% for every person who comes for services regardless of reason why)
  • Numbers of those above screening cut-off who receive a full suicide risk assessment (with a goal of 100%)
  • Numbers of those receiving a full risk assessment who have a collaboratively-developed safety plan (with a goal of 100%)
  • Numbers of those with a collaboratively-developed safety plan who have been counseled on reduction of access to lethal means (100% goal)
  • 100% of all behavioral health clinicians use evidence-based practices to directly treat those at risk for suicide
  • 100% follow-up on those who may be at risk for suicide to ensure safe transitions through care
  • 100% documentation of every loss by suicide

Most health/behavioral health care systems in Indian Country have departments that are dedicated to the coding and billing using data analytics based on service codes. Utilize these experts to create reports that can be helpful to the system when working to improve services.

Data Resource

IMPROVE: Key considerations for Indian Country

  • Not every Tribe or Tribal site has an electronic health record (EHR). Many are capturing data by paper and pencil. No matter what…capture it! Once it is captured, make certain to share it with staff, with leadership and with the Tribal community in which you are working. Plan out how to make sure that information is shared across providers and clinics so that suicide risk information follows individuals through every door they enter in health system.
  • It’s important to know the extent of the challenge of loss by suicide in the community before crafting responses to it. This knowledge will also assist with conveying the urgency of the need to address the challenge to the Chief/Governor/President/Chairperson, the Tribal Council or the community.
  • Decide upon four or five data points that would be helpful for the health/behavioral health care system to know in order to ensure that the goals of the system are being met, the most critical of these being the reduction of loss of life to suicide. These data points may include numbers of screenings that are completed, numbers of assessments done for individuals screening positive, numbers of individuals who are placed on a care pathway for safer suicide care, etc.
  • Utilize your Clinical Applications Coordinators (CACs) for the creation of pick lists to ensure that services that are being provided are billable and that data can be extracted for reports.
  • Regularly share data on positive impact with the leadership/implementation team, especially with the Chief/President/Governor/Chairperson, the Tribal Council, and Traditional Healers, Elders, youth and larger community. Data may be published in Tribal newsletters or presented at community gatherings, in infographics at health fairs, etc.

A note about research in Indian Country

Histories of forced relocation and multiple attempts at genocide, some of which are still occurring today, make trusting research and the people who do it difficult for many Native communities. Historically, some research has been used against Tribes and Tribal communities and, as a result, many of them have laws prohibiting the dissemination of their statistics.

As stated previously, keep in mind that federally-recognized Tribes are Sovereign Nations and have the right to self-determination, including what data they will share and what they will not.  

Many Tribes and Tribal people believe that respectful research never evaluates sacred cultural traditions and believe that the examination of those traditions by others is disrespectful and dishonoring. Up until the late 1970s, it was illegal and punishable by fines or imprisonment to practice traditional healing ways, religions or spirituality, as well as to use Traditional Healers and medicines. The memories remain of those centuries when Native ways were outlawed and many ceremonies continue to be inaccessible to others not of the Tribe or community. That should be respected and honored.

Academic institutions such as the Center for American Indian Health at Johns Hopkins University, working with staff enrolled in Tribes throughout the nation, have been able to partner with Indigenous communities in respectful, honoring ways to improve their health and well-being. Suicide-safer communities and the development of healing ways that support and promote those ways have been important parts of their work.

“If the research you are proposing to do doesn’t benefit the community, then it’s not research worth doing here.”

— Tribal Elder

  • 1.Cultural Liaison. (2018, February 12). Personal interview.
  • 2.Anishinabek buffalo dancer. (2018, July 15). Personal interview.