1. The Zero Suicide Movement Julie Goldstein Grumet, Ph.D. June 30, 2015
Photo: Overhead view of crowd of smiling people all looking up at the camera.

2. Twitter logo (blue bird silhouette).
#zerosuicide
Twitter logo (blue bird silhouette).

3. Photo montage: Various faces, smiling or pensive.
2/28/2019
Suicide Prevention Resource Center
Promoting a public health approach to suicide prevention
Photo montage: Various faces, smiling or pensive.
The nation’s only federally supported resource center devoted to advancing the National Strategy for Suicide Prevention.
SPRC is funded by SAMHSA and we oversee the ZS initiative. We also have a host of training and resources available on our website:

4. National Action Alliance for Suicide Prevention
The National Action Alliance for Suicide Prevention is the public-private partnership advancing the National Strategy for Suicide Prevention.

5. Defining the Problem: Health Care Is Not Suicide Safe
45 percent of people who died by suicide had contact with primary care providers in the month before death. Among older adults, it’s 78 percent.
19 percent of people who died by suicide had contact with mental health services in the month before death.
South Carolina: 10 percent of people who died by suicide were seen in an emergency department in the 2 months before death.
Many suicides take place in and around health care: 40-50% of deaths have been within a month of a primary care visit, approximately 15-20% of suicide deaths annually are among people receiving care in the mental health system, 10% of suicide deaths are among people who had been in ED in past 2 months.

6. Defining the Problem: Behavioral Health Care Is Not Suicide Safe
Ohio: Between 2007 and 2011, 20.2 percent of people who died from suicide were seen in the public behavioral health system within 2 years of death.
New York: In 2012 there were 226 suicide deaths among consumers of public mental health services, accounting for 13 percent of all suicide deaths in the state.
Vermont: In 2013, 20.4 percent of the people who died from suicide had at least one service from state-funded mental health or substance misuse treatment agencies within 1 year of death.

7. Zero Suicide…
Makes suicide prevention a core responsibility of health care
Applies new knowledge and proven tools for suicide care
Supports efforts to humanize crisis and acute care
Is a systematic approach in health systems, not “the heroic efforts of crisis staff and individual clinicians”
Is embedded in the National Strategy for Suicide Prevention
While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., ... & 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. The Lancet, 379(9820),
ZS builds on the awareness that system-wide approaches have worked. A few examples of this are in the Air Force, Henry Ford Health System.
Reducing suicides to zero may be aspirational but reducing suicides generally for those in your care is essential and really a core responsibility of health care. Consider -- do you know the numbers of suicides that happen for those in your care including those recently discharged from your care? Or do the organizations that you work in have a systematic approach to collect this?
Transforming health care to provide safe, available, and effective practices is embedded in the National Strategy.
GOAL 8: Promote suicide prevention as a core component of health care services.
GOAL 9: Promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.

8. Elements of Zero Suicide
So ZS is a framework for providing systematic, clinical suicide prevention and care. As Mike said, a comprehensive ZS approach could be adopted by an outpt BH care facility, an inpatient hospital, or a primary care clinic that had BH providers on staff. Zero suicide is about how the health care system addresses suicide care.
In any system, the outer box really highlights the pieces that need to be in place
a leadership commitment to safety, accountability, and transparency.
And a work force --- beyond just the clinical care team -- that is competent, confident and caring.
The inside box are the components of care
including systematically identifying and assessing for suicide risk, providing care that directly targets and treats suicidality using effective, evidence-based treatments, and contact, engagement and support, especially after acute care.
You need to review data gathered in each of these areas and determine where changes can be made.

9. A System-Wide Approach Saved Lives: Henry Ford Health System
These data are from a large health maintenance organization (HMO) serving about 200,000 members.
at baseline, they had an annual rate of 89 suicides per members
They implemented a quality improvement effort known as the Perfect Depression Care program in the Behavioral Health Services (BHS) division
Within 4 years, the suicide rate had decreased by 75%
Mention Centerstone 3.1/10,000 to 1.1/10,000 in about 20 months

10. Leadership Commitment and Culture Change
Leadership makes an explicit commitment to reducing suicide deaths among people under care and orients staff to this commitment.
Persons with lived experience are supported and participate in program design and delivery.
Organizational culture focuses on safety of staff as well as persons served; opportunities for dialogue and improvement without blame; and deference to expertise instead of rank.
I will briefly walk you through each of the components –
A commitment to a zero suicide approach begins with leadership. Leadership must make an explicit commitment to improving suicide care and acknowledge that suicides can be prevented through a change in their approach to care.
Suicide attempt and loss survivors should be invited to participate in a variety of suicide prevention activities within the organization, such as sitting on decision-making teams or boards, participating in policy decisions, assisting with employee hiring and training, and participating in evaluation and quality improvement.
Finally, the organizational culture must emphasize the safety of patients as well as of staff. There must be what Ed Coffey calls “a just culture” meaning that there are opportunities for dialogue and improvement without blame, even when adverse events occur.
Additionally, the organization must have plans in place to support staff when adverse events do happen – as part of a postvention approach - both to support the staff member as well as the family of patients who die by suicide.

11. Screening and Risk Assessment
Screen specifically for suicide risk, using a standardized screening tool, in any health care population with elevated risk.
Screening concerns lead to immediate clinical assessment by an appropriately credentialed “suicidality savvy” clinician.
In a comprehensive Zero Suicide approach, every new client or patient is screened for suicidal thoughts and behaviors. This should be the standard of care. For those with known risk, they should be screened at every visit.
Suicide risk should also be screened when a patient has a change in status like a transition in their care level, a change in setting, a change to new provider, or potential new risk factors are exposed like a change in life circumstances, such as divorce, unemployment, or a diagnosed illness.

12. Safety Planning and Means Restriction
All persons with suicide risk have a safety plan in hand when they leave care on the same day as the assessment.
Safety planning is collaborative and includes communication with family members and other caregivers and regular review and revision of the plan.
Means restriction is comprehensive and includes family and confirmation that access to means has been removed.
All persons with suicide risk should have a safety plan completed on the same day they are determined to be at any risk for suicide. It is imperative that they have a plan for how to cope when they leave the clinician’s office.
Collaborative safety planning is becoming the standard practice in many behavioral health organizations and health systems. A safety plan is a prioritized written list of coping strategies and sources of support developed by a clinician in collaboration with patients who are at high risk for suicide. Safety planning is an intervention in and of itself. It is not a no suicide contract as I’m sure you all know that those are not something we would recommend or that are effective at reducing suicide. But as an intervention, safety planning allows for collaboration between the pt and provider to uncover strategies that will work when the pt is feeling suicidal.
Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with a patient.
HFHS and Centerstone have a model of calling pts to confirm lethal means have been removed, checking that phone numbers work before the patient leaves the office. It is a collaborative process that involves family members to ensure the patient’s safety.

13. Employee Assessment and Training
Employees are assessed for the beliefs, training, and skills needed to care for persons at risk of suicide.
All employees, clinical and nonclinical, receive suicide prevention training appropriate to their role.
Safe suicide care begins the moment the patient walks through the door for the first time. It is essential that all staff members have the necessary skills to provide excellent care, which in turn will help staff to feel more confident in their ability to provide caring and effective assistance to patients with suicide risk.
We have many resources on the ZS website to describe the different training options that are available for staff with varying job responsibliities such as general gate keeper training for nonclinical staff and more specific treatment focused trainings for clinical staff. Is it likely that organizations in your community and probably even some of you are trainers in gatekeeper programs such as QPR and ASIST and perhaps you can tell local health care systems the programs you are already trained in and could provide to their staff.

14. Suicide Care Management Plan
Design and use a care Suicide Care Management Plan, or pathway to care, that defines care expectations for all persons with suicide risk, to include
Identifying and assessing risk
Using effective, evidence-based care
Safety planning
Continuing contact, engagement, and support
Individuals at risk for suicide should be placed on a suicide care management plan which should include expectations about the frequency of visits for a patient with suicidal thoughts or behaviors and actions to be taken when the patient misses appointments or drops out of care. Patients are told ahead of time that the organization has a plan in place to ensure their safety and care for their suicidal thoughts. The patient is educated about this, much as they would be if they were recently diagnosed with cancer or heart disease. Clients should be told about treatment approaches and what to expect in care. Some Zero Suicide sites have the care management plan embedded in their electronic health record. Makes this work much easier. As well as scripts for how to describe the care plan to patients. When patients don’t show for appointments, alerts are sent to a crisis line or other entity that can follow up and determine the patient’s whereabouts and safety. Again, the patient is informed in advance what will happen if they don’t show and don’t alert the provider that they are missing the appointment so that the responsibility is shared by the organization to ensure the patient’s safety, rather than solely on the patient and his or her family.

15. Effective, Evidence-Based Treatment
Care directly targets and treats suicidality and behavioral health disorders using effective, evidence-based treatments.
Clinicians have historically focused on treating mental health problems, such as depression and anxiety, with the assumption that a patient’s suicidal thoughts and behaviors will cease once the depression or anxiety disorder is resolved. The research evidence strongly supports targeting and treating suicidal ideation and behaviors specifically and directly, independent of diagnosis, as well as any diagnosed mental health or substance abuse problem.
Three examples of evidence-based programs that have been shown to be effective in randomized controlled trials include: DBT, CBT-SP, and CAMS.
Additionally, attempt survivor support groups have been shown to be effective. As well as thinking of other ways to support patients through making peer supports or peer respite care available.

16. Follow-Up and Engagement
Persons with suicide risk get timely and assured transitions in care. Providers ensure the transition is completed.
Persons with suicide risk get personal contact during care and care transitions, with method and timing appropriate to their risk, needs, and preferences.
Care transitions are high-risk times for patients. Caregivers and clinicians must bridge patient transitions from inpatient, ED, or primary care to outpatient behavioral health care.
In a ZS approach, the responsibility lies on the provider, rather than on the patient and his or her family, to develop systems to ensure that patients make and keep appointments.
Activities such as appointment reminders via text or phone calls, calling the person to make sure they went to the appointment or to make sure they will continue to go. Or sending postcards to a recently discharged client offering support should the person need to return to care.
Crisis lines can also serve as a connection with the patient between outpatient visits. These services can be particularly helpful for patients with barriers to accessing outpatient mental health services. Partnerships with crisis centers can be established for them to take over this function.

17. Quality Improvement and Evaluation
Suicide deaths for the population under care are measured and reported on.
Continuous quality improvement is rooted in a Just Safety Culture.
First and forement, an organization must know how many patients under its care have died by suicide in order to recognize that this is an area that needs to be addressed. Also, they need to consider how far out they will track this. Some organizations track deaths for those in their care for only 30 days. We would recommend at least 6 months. Any organization adopting a ZS approach needs to frequently examine their data, their fidelity to this approach and look at how and where they can make changes. The input of those with lived experience is crucial here as they might be able to consider reasons for some of the findings or where improvements can be made in the system to address gaps.
So that is a quick overview of the entire ZS model. It really is both a philosophy as well as a set of best practices and tools.

18. Resources and Tools www.ZeroSuicide.com
This is our new website. There are sections on it for implementation resources – the green box on the right called the ZS toolkit. There is also a button on the left in the blueish box to join our active listserv. The top blue box provides an overview of ZS with some additional resources about what the ZS philosophy is.
Toolkit cover: Photos of man speaking, one woman listening sympathetically to another, man with arm around shoulder of adolescent boy.

19. Zero Suicide Champions
Champions challenge and lead health and behavioral health care systems to improve the care provided for individuals at risk for suicide.
One section of the website is devoted specifically to champions. Champions challenge and lead health and behavioral health care systems to improve the care provided for individuals at risk for suicide. You all can be champions for health care organizations to adopt a comprehensive approach.
– you are all interested in having health care systems adopt a safer, more comprehensive approach to care for those who come seeking help for suicide. We encourage you all to take what you’ve learned today and advocate for the health care systems in which you work, seek services or interact with in your community to examine what the do with regard to suicide care and consider whether they can do better--

20. Contact
Julie Goldstein Grumet, Ph.D. Director of Prevention and Practice Suicide Prevention Resource Center Education Development Center Phone: 202–572–