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Zero Applied: From International Declaration to Local Action


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DRAFT: In 2017, RI International partnered with Suicide Prevention Australia and the International Initiative for Mental Health Leadership to host the fourth International Summit on Zero Suicide in Healthcare in Sydney, Australia.

Published in: Healthcare
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Zero Applied: From International Declaration to Local Action

  1. 1. SYDNEY AUSTRALIA SUMMIT 2017 I sydney australia summit 2017 Lorem Ipsum Dolor Sit Amet Sydney 2017 From International Declaration to Local Action
  2. 2. II SYDNEY AUSTRALIA SUMMIT 2017 Special thanks to the following for their support of the 2017 Sydney, Australia Zero Suicide International summit, which generated the content in this report.
  5. 5. SYDNEY AUSTRALIA SUMMIT 2017 1 Foreword : Message from Co-leads “The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming.” ~Theodore Roosevelt “Is it rational to pursue zero suicide among patients in healthcare?” This is the question posed by Dr. Jan Mokkenstorm and colleagues in Suicide and Life Threatening Behavior Journal (in press) as they address objections that the science and published results aren’t yet in. The US National Institute of Mental Health has just awarded a 5-year grant to Henry Ford Health System to evaluate an implementation of Zero Suicide across most of the Kaiser Permanente health system. And, Centerstone is partnering with EDC to publish its results in a peer reviewed journal (reductions in the death rate have been reported in US News & World Report, June 2015). So, the science is in the works. But, here’s what we already know today. Usual care is disastrous. Dr. Mark Olfson in the July 2017 JAMA Psychiatry carefully describes the very significant suicide risks for individuals in the immediate aftermath of a psychiatric hospitalization and the clear message for the efficacy of universal and continuing interventions and support following discharge. Yet, even when we know the practice works, only about half of US patients receive any outpatient care during the first week after psychiatric hospital discharge, and one-third receive no mental health care during the first month. Outside inpatient settings, healthcare systems have simply not been accountable for suicide. Mental health professionals frequently report a complete lack of training to deliver interventions and care to prevent suicide. These standard approaches came under criticism in the New Zealand national media earlier this year. The Minister of Health’s response after studying Zero Suicide was to change the culture Dr. Michael Hogan with Sally Spencer-Thomas, Virna Little and Ursula Whiteside
  6. 6. 2 SYDNEY AUSTRALIA SUMMIT 2017 within the mental health workforce and galvanize society around known interventions. “It does seem that setting a goal, and it may be aspirational… actually just focuses efforts” (Dr. Jonathan Coleman, “Suicide Reduction Target Back on Table,” August 2017.) The interventions that make up the elements of Zero Suicide are known to work. They all have research- based efficacy. Danish researcher Annette Erlangsen’s 2015 Lancet study showed a lower risk of deliberate self-harm and general mortality for those who received psychosocial therapy. In fact, direct treatment of suicide is more effective and cost-efficient than statins are for heart disease prevention (one fatal heart attack is prevented for every 83 people helped for statins versus one self-harm episode prevented for every 44 people treated with psychosocial therapy). Findings are similar for routine screening for suicide risk. In 2015, Dr. Greg Simon and team concluded in Psychiatric Services that the PHQ-9 question 9 “identifies outpatients at increased risk for suicide attempt or death.” They added that “this excess risk emerges over several days and continues to grow for several months,” with an accuracy about twice as predictive of future suicide as cholesterol scores are of future heart attack death. While there are few studies of safety planning, Craig Bryan’s findings in The Journal of Affective Disorders is promising (“Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers,” January 2017). Finally, logic and the literature base on quality improvement suggest that we need a systematic, leadership-driven quality improvement approach for a wicked and complex problem like suicide. The Suicide Care in Systems Framework was published at virtually the same time as Dr. David While and others were concluding in the Lancet that a systematic implementation of crisis intervention in England and Wales saved hundreds of lives (February 2012). So, as a scientific matter, we need more data. As a public health and quality of care matter, the evidence is already in. The time is now. Together, we can, and must, do this. We hope this document created from the 2017 Sydney summit motivates healthcare and other leaders to move from an international declaration to local action and implementation. David W. Covington, LPC, MBA CEO & President RI International Michael F. Hogan, PhD Principal Hogan Health Solutions
  7. 7. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 3 Introduction & Overview “’Zero Suicide’ is about pushing back on the inevitability of suicide.” ~Sue Murray, Suicide Prevention Australia IIMHL 2017 Sydney RI International and Suicide Prevention Australia were pleased to host the 3rd International Summit of Zero Suicide in Sydney, Australia, February 27 – 28, 2017, in conjunction with the International Initiative for Mental Health Leadership (IIMHL) Exchange. Suicide is a leading cause of premature death within Australia. The Australian Bureau of Statistics reported 3,027 deaths by suicide in 2015 – 20% of premature deaths across the nation, and the highest single contributor to ‘potential years of life’ lost in the country. While the number of suicide deaths continues to rise in Australia, the international community has seen dramatic results in suicide prevention within healthcare. We believe a focus on Zero Suicide in Healthcare is a necessary addition to other suicide prevention strategies. The US based Henry Ford Healthcare System ‘Perfect Depression Care’ program and its 75% reduction in suicide deaths in under 5 years – continues to inspire an international dream. Suicide Prevention Australia is looking to launch a 5 year pilot of Zero Suicide across a number of sites. RI International and Suicide Prevention Australia joined together in Sydney with the purpose of continuing the worldwide networking and learning as we pursue this audacious dream together. History of a Movement In 2001, the Henry Ford Health System pursued an opportunity within the Robert Wood Johnson Foundation’s "Pursuing Perfection National Collaborative” by developing the “Perfect Depression Care” to better serve their 200,000 patients. Their Behavioral Health Services Division Team asked themselves “how would we know when depression care was truly perfect?” A psychiatric nurse offered, “If David Covington and Sue Murray
  8. 8. 4 SYDNEY AUSTRALIA SUMMIT 2017 Participating Countries International Zero Suicide Summits Australia Canada China Denmark England/UK French Polynesia Hong Kong Ireland Japan Korea Malaysia Netherlands New Zealand Northern Ireland/UK Spain Taiwan United States
  9. 9. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 5 depression care was truly perfect, no patient would die from suicide.” The overall outcome of the care delivery overhaul that resulted from this paradigm shift was a dramatic and statistically significant 80% reduction in suicide, maintained for over a decade, including one year when the perfection goal of zero suicides was actually achieved. That audacious idea has subsequently initiated a radical transformation within the mental health and healthcare delivery systems and how the world thinks about suicide prevention. This bold goal — to eliminate suicide – has galvanized these life-saving systems to consider how they might redesign their philosophy, process and monitoring to dramatically improve patient outcomes. The International Zero Suicide in Healthcare movement began in Oxford as part of an exchange of the IIMHL with fifteen individuals from four countries joining together to create a vision. In 2016, the second International Summit was held in Atlanta, Georgia (USA) where 50 leaders from 13 countries came together for forge an International Declaration for Zero Suicide in Healthcare. As of this publication, the Declaration has been downloaded over 13,000 times. In addition, the Suicide Prevention Resource Center published a “Zero Suicide in Healthcare Toolkit” designed to help guide health and behavioral healthcare organizations through a seven-step process of implementing the tactics. The theme of the 3rd Summit in Sydney was “From International Declaration to Local Action” and the and the presentations and conversations held there are summarized in this document oriented around five key topics: Lead/Activate, Deploy/Scale, Clinical Pathway/Protocol, Treat/Engage/Peer Supports and Research/Evaluation. Several stories, metaphors and analogies provide a helpful description of where the Zero Suicide in Healthcare movement is now and where it needs to go: • David Covington opened the conference stating “Zero Suicide in Healthcare has been a flame attracting attention. Now it needs to become a torch that can spread the flame globally.” He also noted, “Hospital acquired infections were once thought of as inevitable. The most significant intervention to have an impact in reducing infection was following simple handwashing protocols. Once we believe change is possible, the most profound process adjustments are often quite simple.” Figure 1 EDC Zero Suicide Institute
  10. 10. 6 SYDNEY AUSTRALIA SUMMIT 2017 • The group also reflected on the inspiration of Don Berwick in Crossing the Quality Chasm. On the topic of process improvement in healthcare he stated, “I think healthcare is more about love than about most other things. If there isn't at the core of this two human beings who have agreed to be in a relationship where one is trying to help relieve the suffering of another, which is love, you can't get to the right answer here.” • Mike Hogan encouraged ongoing learning: “Developmentally, Zero Suicide is a toddler needing a community, supervision and sometimes redirection. We are here to help it grow.” Historically, suicide prevention leaders have minimized healthcare efforts, saying they won’t save everyone. When we look at help-seeking data of people who have died of suicide, only 45% of have a mental health diagnosis the year before their death by suicide; only 1/3 of people had a behavioral health visit before their death, and only 5-10% of people were in inpatient care before their death. However, 85% of people had a healthcare visit before suicide. The Zero Suicide in Healthcare model emphasizes that with good screening and connection to care, far fewer people will fall through the cracks. Thus, the following core perquisites of the model are integral to its success: 1) A reorientation in healthcare to embrace suicide prevention. It’s not “someone else’s” job, healthcare is where people at risk for suicide are showing up, and systems and providers need to be prepared. 2) A bold, uncompromising mindset shift from “no one can do anything” to “everyone can do something” to achieve zero suicide. This priority is held both top down and bottom up throughout the system. 3) A learning environment where system failures provide opportunities for improvement- not blame. 4) Lived expertise of people experiencing suicidal thoughts and attempts and their family and is highly valued in the iterative process improvement and strategy design to cultivate empathy, decrease fear and improve the patient experience. 5) “Care” is part of healthcare. Healthy providers, in healthy systems are better able to care for people. Care goes beyond harm reduction to promote well-being and life enhancement. Summit Spotlight Kevin Hines, The Ripple Effect “The Golden Gate Bridge presents a 70 year struggle of a conversation about aesthetics and the inevitability of suicide; for 70 years we didn’t spend the money to build a bridge barrier because we didn’t believe.”
  11. 11. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 7 Lendlease : How Construction Achieved Zero Fatalities Models for this type of system overhaul exist and healthcare systems have much to learn from other industries that focus on safety. In 2001, Lendlease, a multinational 15,000 employee construction company made a commitment to be incident and injury free. At the beginning of the implementation of this priority they held “commitment workshops” for every worker and leader. While these workshops created strong awareness, this awareness didn’t translate to stronger performance. Awareness was necessary but not sufficient to create sustainable change; practice changes were also needed. Next, Lendlease created global minimum requirements for safety that every site had to adhere to – no exceptions. They walked away from clients that could not comply. The job fatality count dropped from 72 from 2001-2013 to zero fatalities from 2013 to 2016. Now they have a new aspirational goal from just getting to zero to moving beyond zero and striving to ensure that people’s lives are actually enhanced when they come to work. To do this they needed to get rid of sacred cows, like compliance forms, and move their sites ahead to anticipate prevention needs. The near misses and critical incidents go under the microscope and then all the way up the prevention chain in the spirit of learning and improving. The shift that Lendlease has made that inspires the healthcare community is the shift from “what do I do to manage the risk to me” (as the system) and instead focus on what is best for the culture of safety. When we focus on the first in behavioral health we think short-term: “I keep you safe by putting you in a place where you can’t hurt yourself -- a locked unit where your freedom to ‘chose’ is taken away and then I send you home with no follow up. Thus, I wash my hands of the responsibility.” When the long-term safety and health for the person is the priority, different decisions are made. The outline of this document will share both “lessons learned” from the pioneers, like Lendlease, who are leading implementation efforts around the world, and residual “questions and concerns” we need to continue to consider. Summit Spotlight Chris Doyle, Lendlease “Creating a strong safety culture did not create a strong safety performance. The need for change comes from bottom up, but creating change comes from top down. Move the aspiration from getting to zero to going beyond zero. Learn all of the causes of a catastrophe and become fixated on prevention.”
  12. 12. 8 SYDNEY AUSTRALIA SUMMIT 2017 Profile in Leadership: Sue Murray Sue Murray, Suicide Prevention Australia Profiles in Zero Suicide Leadership Sue has been a passionate advocate for improving the health and well-being of the community throughout her career, and brings tremendous experience as Chief Executive for Suicide Prevention Australia (SPA). Her roles at the NSW Cancer Council set the stage for leadership with the AMA (NSW) and Leukaemia (NSW). She moved to a leadership role with the National Breast Cancer Foundation in 2000. During the 10 years Sue led the NBCF she positioned the organization as one of the most highly recognized organizations in the community sector. This brought significant growth in the number of companies and individuals choosing to support breast cancer research. It also enabled the NBCF to publish Australia’s first ever National Action Plan for Breast Cancer Research and Funding which has changed the way breast cancer research is supported and managed in Australia. Using her experience with NBCF Sue moved to the George Institute for Global Health to support fundraising for their research into the prevention of chronic disease and injury particularly in disadvantaged populations across Australia, India, China and the UK. Sue is the former Chair of Macquarie Community College; a director of Research Australia; a member of the Sydney Advisory Committee for the Centre for Social Impact; and a member of Chief Executive Women.
  13. 13. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 9 Section 1: Lead/Activate “Be vocal, be visionary, be visible. There is no shame in stepping forward, but there is great risk in holding back and just hoping for the best.” ~Higher Education Center Lessons Learned Bold leadership and grassroots support are essential to the success of the Zero Suicide in Healthcare initiative. Leaders must be willing to first put aside hubris or shame and own the problem; then they need to make an unwavering commitment to change and the creation of a safe environment within which that change can occur. When there is engagement as learning partners in the process, real change can happen. Dr. Jan Mokkenstorm from 113 Suicide Prevention in the Netherlands shared the three main take- aways they learned on how to successfully engage leadership and activate groundswell interest in Zero Suicide in Healthcare. 1) Networks Like any major endeavor, the first step in wide-scale change is to “seek first to understand.” “Change agents” from 113 Suicide Prevention facilitated listening sessions and asked provider organizations “what are you doing for suicide prevention and how can we help?” Additionally, engaging networks of people who have experienced behavioral healthcare in the midst of suicidal thoughts and behaviors and their family members is also critical in building trust within this new system. Bringing people with lived experience and peer specialists into the dialogue during the program design phase – as valued and equal consultants in the process – goes a long way in rebuilding trust within a community that has often been harmed by the behavioral healthcare system. Of equal importance is the notion that their insights will help challenge ideas often immune to criticism and affirm good ideas that might not otherwise be considered. Dr. Jan Mokkenstorm, Psychiatrist, Researcher, Netherlands Section 1
  14. 14. 10 SYDNEY AUSTRALIA SUMMIT 2017 “After experiencing 11 suicides and my own dark time, I became the go-to person in my community. Others knew I’ve walked that path, and I became a bridge between the people and services. People with lived experience are the bridges. We walk shoulder to shoulder.” ~ Greg Van Borssum 2) Narrative Engage the community in the conversation with something provocative. Compelling stories, images and metaphors ignite curiosity. When trying to increase buy-in, use these stories to help people see the vision of what might be possible. For example, Dr. Mokkenstorm recounted a major flood in the Netherlands in 1953 when the dikes were not able to contain the water and 1,836 people died. Major investments went into rebuilding so that the system worked safely. 3) Numbers Stories move the heart and data convinces the mind. How can we use data to help tell the story of progress and performance to increase hope and sway skeptics? How can we engage providers in the feedback monitoring process so they react to the data with continuous efforts toward improvement? For example, when we compare road traffic mortality and suicide mortality, we see a drastic reduction in road traffic deaths while suicide rates have remained relatively stable or on a gentle incline. This comparison prompts the conversation – what have we done differently? Comparison data can help motivate leaders to do better. By plotting performance data based on regular monitoring systems we may obtain feedback on how we are benchmarking against other groups and healthy competition can emerge. In a learning environment, groups that are under performing are not blamed, but rather studied to better understand what is driving the quality. 4) Public Health Approach Professor Paul Yip from the University of Hong Kong reminded us that the Zero Suicide in Healthcare approach must be embedded in a larger public health approach to suicide prevention. For example, he showed the striking evidence of a drastic reduction in suicide after access to charcoal (a common means of suicide in Hong Kong) was restricted and journalists were coached on safe reporting of suicide.
  15. 15. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 11 Additionally, with the lens of a public health approach, leadership can foster a more collaborative interplay between clinical and community approaches to healing. Questions & Concerns Dr. Jan Mokkenstorm addressed some of the most often cited challenges and questions. 1) Language “’Zero Suicide sounds more like church than science,” was Dr. Mokkenstorm’s reflection in 2013 when he first heard about the philosophy. The word “zero” is often what is actually provoking resistance. Should we be pragmatic about the language of “zero” to increase the adoption? Many emphasize that “Zero Suicide” is not a marketing ploy or a target but rather an aspirational goal, and this communication often helps diffuse the rejection of “zero.” If we push back on this logic and state a goal of a 10% or 20% reduction, isn’t this language just as arbitrary as zero? Isn’t it far less inspirational? Every number we choose as a goal is a guess and not scientific. “’Zero’ ignites the magic – it agitates and mobilizes.” ~David Covington Furthermore, there may be confusion between ideas of “zero tolerance” and “zero suicide” that can also cause concern (cited in the United Kingdom, for example). Finally, while a goal of zero suicide attempts and deaths is admirable, suicidal thoughts and feelings are common and can be transformative for people when major life changes are needed. When you use the language of zero, you may think about things differently than if you are trying to reduce by 20%. Dr. Paul Yip, Researcher, Hong Kong
  16. 16. 12 SYDNEY AUSTRALIA SUMMIT 2017 Will the “Zero Suicide” mantra help provide non-stigmatizing support for people living with these experiences or will it be misinterpreted as not welcome? Pragmatic changes in language that communicate the same message might be beneficial when getting initial buy-in from a resisting community: • “Zero Suicide Mindset” • “One suicide is too many.” • “What in your system is letting people falling through the cracks?” One of the take-aways from systems that have been implementing and advocating for the “Zero Suicide” approach is that we cannot be distracted and diverted by the sometimes paralyzing debate about the language – but focus on the data of what is working to move us toward this goal. Practices are much harder to adopt than language. 2) Physician-Assisted Death/End of Life Issues The concept of Zero Suicide sometimes evokes the question, “Do we make people live all the time, even when they are suffering so much?”, especially in jurisdictions where physician-assisted services is an accepted part of healthcare. How do we distinguish between physical end of life suffering related to a terminal illness and emotional hopelessness? Does the explanation that our goal is to make sure no one dies alone and in despair help with this concern? 3) Suicide Bereaved People experiencing suicide grief often find it hurtful and judgmental that others make an assumption that the death of their loved one wasn’t inevitable or inexplicable. They often believe they did everything in their power to keep their loved one here, or alternatively, that their loved one’s suicide was not preventable because no warning signs were given. However, when people are in mourning we often seek answers that console ourselves, and we look to find peace with suicide to the point where we may even rationalize it is normal. What may be helpful for this population to understand is that the Zero Suicide model is really focusing on system responsibility, not individual situations. We want to be confident that ourselves and our loved ones are receiving suicide-safe care – even in primary care. The Zero Suicide in Healthcare model is also relevant for those wanting to prevent suicide grief for others. 4) Clinician Anxiety When hearing that they might be held accountable for “Zero Suicides” on their watch, clinicians may become fearful of litigation or intense scrutiny and blame. When the belief is suicide is inevitable we Summit Spotlight David Jobes, Catholic University “I was a skeptic that became a convert. I used to think we should advocate for the ‘best possible care in suicide risk,’ but this rally cry didn’t do it. ‘Zero Suicide’ provokes conversation and thinking. If we don’t have an ambitious model, we are not going to get there.”
  17. 17. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 13 may remove the guilt of caregivers, but we don’t evolve. Organizations must be willing to create a just culture and place human capital above financial. Teams must take a close look at sentinel events with a “no blame, no shame” attitude, and focus on continuous improvement. The Zero Suicide perspective declares a singular provider responsibility view dead and shifts to a system view, “we are all responsible to make our system as safe as possible through the best possible care.” Zero Suicide asserts that suicide deaths are system failures, and we must continuously be learning together from both tragic outcomes and near misses. “We have seen a positive culture change since adopting Zero Suicide. You know you are shifting culture when you see nonclinical staff feeling empowered to intervene and say something if they see something that concerns them. People feel collectively responsible, confident and competent.” ~Becky Stoll 5) Perceived Cost The idea that we must invest in a systems overhaul is daunting, and those who are uncertain often believe that time and cost are significant barriers to change. Those programs that have begun implementing Zero Suicide in Healthcare programs have seen those fears to be unfounded. “It is possible to do this with the resources you already have. It’s about reorganizing your priorities. Henry Ford previously showed that the gross contribution to the health system improved by almost eight-fold during the first three years of the implementation of the Perfect Depression Care program.” ~Dr. Brian Ahmedani Most outcomes can be accomplished by reorganizing resources that already exist.
  18. 18. 14 SYDNEY AUSTRALIA SUMMIT 2017 Profile in Leadership: Dr. Mike Hogan Dr. Michael Hogan, Consultant HHS Profiles in Zero Suicide Leadership Michael Hogan served as New York State Commissioner of Mental Health from 2007-2012, which operated 23 accredited psychiatric hospitals, and oversaw New York’s $5 billion public MH system serving 650,000 individuals annually. Previously Dr. Hogan served as director of mental health for Ohio (1991-2007) and Commissioner of the Connecticut DMH from 1987-1991. He chaired the President’s New Freedom Commission on Mental Health in 2002-2003. He served as the first BH representative on the board of The Joint Commission (2007-2015) and chaired its Standards Committee. He has served as a member of the National Action Alliance for Suicide Prevention since it was created in 2010, co- chairing task forces on clinical care and interventions and crisis care. He is a member of the NIMH National Mental Health Advisory Council. Previously, he served on the NIMH Council (1994-1998), as President of NRI (1989-2000). He has been recognized by the National Governor’s Association, the National Alliance on Mental Illness, the Campaign for Mental Health Reform, the ACMHA and the American Psychiatric Association. He is a graduate of Cornell University, and earned a MS degree from the State University College in Brockport NY, and a Ph.D. from Syracuse University.
  19. 19. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 15 Section 2: Deploy/Scale “Bolts get broken off. Don’t bolt it on, bake it in. Competent and caring suicide care should be in the bread, through and through.” ~David Covington Lessons Learned Dr. Virna Little of The Institute for Family Health in New York shared her challenges and advancements in implementing the Zero Suicide in Healthcare model into a community-based primary care setting. These “lessons learned” help with efficiency and economies of scale across multiple site systems. 1) Senior Leadership Commitment Taking a step from awareness to action, one important piece of the leadership paradigm shift is to ensure senior leadership commits to a Zero Suicide pledge as an aspiration, not a target, and acknowledges that all team members have responsibilities to work toward this goal. This bold, cultural ideal – publicly declared to the workforce – can have a galvanizing effect on the team. 2) Making Suicide Risk a Tracked Priority Making suicide risk a priority throughout the system helps all members of the team – clinical and nonclinical – realize they have a role to play. The code of “suicide risk” was added on the problem list in the electronic health record (EHR) and automatically increased surveillance for all those who were coming into contact with the record. At The Institute for Family Health, an alert system within the EHR flags patients who are experiencing suicide risk by adding a “red banner” as a visual reminder to their record. Thus, all health communications and interventions have awareness that this major health indicator requires surveillance and link together data observed by different systems of care. Section 2 Virna Little, Institute for Family Health, and Sue Murray, Suicide Prevention Australia
  20. 20. 16 SYDNEY AUSTRALIA SUMMIT 2017 3) Mandatory Training for All Training is tied to values. Only half of people who are providing mental health care feel like they are confident and comfortable working with people who are suicidal. No profession within mental health has licensure requirement on suicide intervention competence to practice. Thus, mandatory saturation training helps everyone in the system have a shared framework, language, and process for supporting people experiencing suicide risk. Dr. Little emphasized that everyone receives some dose of intervention training (like SafeTalk or AMSR). By ensuring all staff had the same training, the odds were good that anytime the patient interfaced with the system, the staff member would realize he or she had an important role of prevention, whether that was as their dental provider, diabetes educator, or even administrative or facilities staff. Training on minimum standards of suicide risk reduction practices is just a foundation. Supervisors need to build confidence and competence through on-going state-of-the-art training in suicide-focused recovery-oriented treatment. Otherwise, how will supervisor oversee new mental health providers to meet minimal standards when they themselves are uncomfortable? 4) Technology Engagement A patient portal in healthcare allows patients to interact with their healthcare providers on-line and links patient records across providers. Patients are subsequently better able to communicate with providers, get test results, request prescription refills, view clinic visits recommendations, and more. Through the patient portal, higher risk clients, as part of their safety plan, can type a message to a provider at 2:00 AM or receive instructions on how best to access crisis support. The ability to feel connected is helpful for people at risk for suicide. As monitoring the record of high risk clients is scrutinized, supervisors can track whether or not certain pieces of the protocol have been completed and can give work groups process improvement feedback based on these tracking mechanisms. New apps can also help clients troubleshoot solutions, track sleep/mood, monitor their medication, and so on. All of this data can be deposited into the EHR to give providers feedback on what is happening between medical appointments. Furthermore, with these apps clients can get reminders and resources “just in time.” Centerstone, Centerstone was featured in US News & World Report for their Zero Suicide outcomes in 2015.
  21. 21. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 17 headquartered in Nashville, Tennessee, is piloting apps that even include Fitbit technology that tracks patient movement. The app can be set up to alert the provider if the individual has not moved after an extended period of time. When a sustained lack of engagement or series of missed appointments occur, the app can alert the clinician or the patient to activate their safety net to help connect the patient with their previously identified support network. “Electronic health records – they bring the rhythm. When you don’t think about the notes you play, you can make the music. We are now making music with our patients.” ~Virna Little 5) Continuous Process Improvement through Evaluation and Listening to Lived Experience Developing screening and assessment instruments • Outreach and engagement • Emergency departments • Mobile crisis teams • Treatment teams • Safety planning • Peer to peer support groups and networks • Follow up care/facilitating connections to services, natural community supports and resources • Research and evaluation Zero Suicide in Healthcare is about the relentless pursuit of excellence, not about one intervention. To this end, we need better clinical quality measures based on the client’s experience. After hospitalization, we need to know more than whether or not they are taking anti-depressants 90 days out. Systems must rigorously evaluate the effectiveness of their interventions by asking the patients directly about what is working and what is not. “It’s a car we are building but they are the ones driving it; user feedback is critical,” ~David Jobes Leaders must also look at what is happening should the data spike or slide in the wrong direction. For instance, in Centerstone, a very large, multi-setting community mental healthcare system saw a 64% reduction in suicide in the first two years of implementation; however, this was followed by a spike. When the records of those who died were reviewed, an interesting finding emerged: 47% of the people dying of suicide were only engaged with the system for medication checks. This revelation resulted in a new protocol: patients needed to be vetted more closely for “med check only” status and medical staff were advised not to let patients self-select for medication only. In just a brief period of time with this new protocol the “med check only” patient group has dropped significantly and stayed down. Another great high impact, lower cost intervention is the use of peers in recovery. New crisis models emphasize the importance of peers as a critical link in the chain of survival. Integrating trained and supervised peer specialists into the intervention pathway helps build the workforce in a very cost effective way. “The two biggest contemporary movements in suicide prevention are Zero Suicide and Lived Experience. How do we bring these together? Integrating paraprofessional peers is key. It’s cost effective and patients like the connection.” ~David Jobes
  22. 22. 18 SYDNEY AUSTRALIA SUMMIT 2017 6) Create a “Just Culture” Learning Environment About 1/3 of clinicians experience a suicide of someone in their care. Half of those clinicians experience more than one suicide. Often they receive one of two possible reactions. Either they are blamed for being negligent or incompetent, or they are given a pat on the head and told, “You did everything you could, now go back to work.” What is the result of these responses? Good people leave the field and opportunities for learning are missed. The Zero Suicide in Healthcare model offers a different approach. The clinical pathway involves a whole team that provides support to one another with a commitment that when misses and critical incidents occur they are shared to accelerate learning, not to place blame. The “Restorative Just Culture” framework allows for these types of conversations ( Retributive Culture Restorative Culture • Which rule is broken? • Who did it? • How bad was the breach, and what should the consequences be? • Who gets to decide this? • Who is hurt? • What do they need? • Whose obligation is it to meet that need? • How do you involve the community in this conversation? “No blame. No Shame. Be nimble.” ~Becky Stoll Questions & Concerns Dr. Little addressed some of the most often cited challenges and questions. 1) Overburdening Under-resourced Systems Many systems considering adopting Zero Suicide for Healthcare can become intimidated as they contemplate how best to integrate these new processes. Rather than think of the Zero Suicide as a “new program” to be added to an already overstressed workforce, Zero Suicide is about putting systems in place that makes jobs run better and result in better care for patients. Instead of behavioral health department singularly feeling the burden of adding new processes, the implementation focus is on how integration of the new process helps the entire healthcare team. For example with integrated and flagged shared electronic records, the provider giving the flu shot or the pap smear can see whether or not someone has followed up on their well-being plan and can support follow through. 2) Overemphasis on Harm Reduction The majority of implementation examples shared by systems already practicing Zero Suicide in Healthcare focus on “safety planning.” Concerns emerged that this perspective is limited and instead we need a less paternal approach that balances harm reduction with well-being promotion and might be better called a “shared care plan.” Client strengths and existing coping should be acknowledged within the care plan in addition to things they can do to “stay safe.” People living with suicidal thoughts are
  23. 23. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 19 often not inspired to “stay safe” – that is often the goal of the provider; they are inspired by the hope of a life worth living for. 3) Better Strategic Engagement of Lived Experience and Culturally Diverse Groups Given new models of crisis care (i.e., Crisis Now), can the Zero Suicide for Healthcare model do a better job advocating for peer specialist services, suicide attempt survivor support groups, and respite programs? Likewise young indigenous people all over the globe are over-represented in suicide – the services offered in health system are not often experienced as culturally congruent with First Nation values and practices. Underrepresented and high risk groups demand, “We must do better” – not just in the design of the model but throughout the whole implementation process by developing advisory committees comprised of people living with a number of diverse perspectives (lived experience, culture, geography, etc.). “When we learn together how to best align lived experience with people who are at an early and painful part of their experience, Zero Suicide will work so much better.” ~Eduardo Vega 4) Complex Presentations How does the Zero Suicide in Healthcare model work when patients engage in repeated self-injury, have complex co-morbid diagnostic presentations, or are homicidal and suicidal? What, if anything needs to be done differently? 5) Staff Self-Care and Iatrogenic Effects Providers can cause adverse conditions in patients by how they interact with them. Healthy providers tend to contribute to healthy outcomes in their patients. Thus, staff well-being is important to the success of the Zero Suicide in Healthcare model. An effective Zero Suicide implementation works hard to check in to see how the processes are working for staff and patients. Successful systems provide opportunities for staff to renew by allowing for relaxation, training, networking, and reflection. “We should come away from work feeling good instead of beaten down. We must address this. We have such a privileged role to play. Why have we made it so difficult for ourselves?” ~ Dr. Michael Hogan 6) Minimum Standard of Care While Striving for Excellence While we are working toward perfection with Zero Suicide, can we also get “good enough” care going? Can we define a minimum standard of care for inpatient, emergency care, outpatient, and behavioral health? At a minimum, we should ask about suicide and link to resources; these activities should be foundational to psychological safety standards. If we look to the Lendlease examples described in the introduction, our current trajectory will take us 15 years to get to safety. How can we accelerate this process so we can embark on the pursuit of well-being and enhanced performance within our healthcare systems?
  25. 25. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 21 Section 3: Clinical Pathway/Protocol Lessons Learned Becky Stoll has led the Centerstone implementation for the past five years in the US, while Kathryn Turner’s Zero Suicide program at Australia’s Gold Coast Health is one year old. Both leaders have leveraged clinical pathways to integrate learning and standardize the support and engagement of individuals at risk. 1) Screening and Prevention Oriented Risk Formulation When implementing the Zero Suicide in Healthcare model, on-going screening with validated tools are required. A number of the implementation sites use the Columbia Suicide Severity Rating Scale (assessment of suicide risk) and/or the PHQ-9 (an assessment of depression symptoms including a suicidal thoughts screening item). Mental health professionals often believe that assessments of suicide risk must result in expressed predictive level of risk: “low,” “moderate,” or “high” despite scant evidence of the usefulness of this approach or its basis in science. By contrast the Zero Suicide in Healthcare approach is to synthesize information for the main purpose of informing recovery planning. This shift from a predictive to a preventive formulation helps clinicians reduce their fear on being “wrong” and focuses them instead on what matters most in the client’s healing and providing standardized best-care interventions. Pisani, Murrie and Silverman’s approach to “prevention oriented risk formulation” gives clinicians an informed way to create a treatment plan. For example, “risk status” is how the client’s general risk factors compare to others in general population. “Risk state” is about how they compare to their own baseline risk. The “foreseeable change” part of the formulation helps clinicians anticipate what might quickly change in the patient’s life that would have an effect on safety. Section 3 Becky Stoll, Centerstone
  26. 26. 22 SYDNEY AUSTRALIA SUMMIT 2017 Of note is the therapeutic alliance and perceived importance of on-going screening and risk formulation. How providers treat the screening makes all the difference in how people relate to the clinician. Often clinicians need training on how to go beyond stated intent and increase validity of the responses (e.g., Shawn Shea’s “Practical Art of Suicide Assessment”). Training clinicians in the CASE approach to interviewing (Chronological Assessment of Suicide Events) can assist them with a structure and tools to move beyond the stated intent to explore the reflected and withheld intent. 2) Safety Planning The key to an effective “safety plan” is to engage an interdisciplinary collaborative effort using the electronic health record (EHR). A safety plan process within the Zero Suicide in Healthcare model allows information to be available to all providers during all visits for review or modification. Patients are also able to access the document via a patient portal for reference. Additionally, “Safety Planning Apps” are becoming increasingly prevalent and practical as information about safety planning, available support tools, coping skills, and wellness commitments can be sent to or accessed by the client at any time of day via their phone, and 90% of the Earth’s 7.2 billion people have some access to basic services. These easy-to-use technology tools give clients and providers a way to triage responses, offer educational materials, and connect to resources AND collect patient data to better understand patterns of risk and resilience.
  27. 27. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 23 “We get up today and try to hit zero. If we string a week together, that’s great, but we’re focused on today.” ~Becky Stoll 3) Monitoring Collecting data on our patients at risk for suicide only matters if there is a system in place to track the data and a protocol in place to respond to concerning changes – ideally this process is “baked in” to the EHR. For example, what happens when patients who have been identified at heightened risk for suicide cancel or no show? How does the healthcare system keep our focus on them? Becky Stoll of Centerstone shared that of the 10,000 people being served at any given time by her healthcare system, about 500 people are “on the pathway” – meaning they are being intentionally and closely monitored by the treatment team. All patients in all service lines are screened for suicide risk, including these “on the pathway” patients every time they are seen in this care system. Every time.
  28. 28. 24 SYDNEY AUSTRALIA SUMMIT 2017 If clients identified for tracking do not show up to appointments, they are considered “off the grid” and a protocol is set in place to try to locate them to check in on how they are doing. For instance, at Centerstone, if they miss an appointment, their name is sent to a “High Risk Follow-up Team” and displays in purple. Members of this team then commence an active search. Most times patients have simply forgotten; however, the clinical team at Centerstone estimates they thwarted at least 15-20 attempts through this process. The monitoring system also allows for structured follow up 24-48 hours after critical incidents. The “High Risk Follow-up Team” reviews questions with the patient, “Did you use safety plan? What worked? What didn’t? What is your next step?” When data are being monitored so closely through integrated technology, aggregate, population-based reporting is possible. For example, Gold Coast Health examines three populations for reports: 1) All patients: looking specifically at results on depression screening 2) Patients with depression: looking at recent scores on PHQ-9 and other screening outcomes 3) Patients experiencing suicidality: to review safety plan engagement These outcomes and trends can then be summarized on a dashboard through graphics for quick assimilation by clinical and administrative teams. “We are upskilling clinicians. This is not a tickbox approach. We get away from categorical risk prediction and move toward preventative risk formulation.” ~Kathryn Turner Summit Spotlight Becky Stoll, Centerstone “We screen our patients at every visit, in every service line – which often means I get lots of calls and emails. Staff: When do we screen? Becky: Every visit. Staff: When again? Becky: Every time.”
  29. 29. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 25 4) Care Transitions Transitions of care post suicide crisis are as essential to saving lives as the care during the crisis. Research has shown that the two weeks after psychiatric inpatient care is a very vulnerable time for patients to die of suicide (suicide rate has been documented as upwards of 200 times the general population). Furthermore, follow-up efforts post-discharge like caring letters or postcards have been very effective in reducing suicide. Zero Suicide in Healthcare implementation experts suggest that the care transition engagement needs to be more personal than other forms of healthcare. The follow up care is not just talking about how best to keep a wound clean or what medications should be taken when; relationships are critical. The handoff to the follow up care providers must be “warm and timely” – not a printed list of referral numbers. The discharging team must ensure patients have the correct next appointment set before they leave the crisis care team. Questions & Concerns Becky and Kathryn also shared some of the most often cited challenges and questions. 1) Intelligent Use of Technology Technology may provide for ease of and standardization of protocol implementation, but what about its cultural responsiveness? What if certain populations are not able to access, to understand the language, or to interface with apps (e.g., older adults). How are collateral perspectives, like carers (referred to as “care givers” in the US), integrated into the technology feedback protocol? Would people misuse the technology and overburden the system or skew data? Are there privacy concerns about shared records across systems of care? 2) Role of Carer What is the broader role of the carer in the clinical pathway/protocol? How can treatment teams best assess the role of the family member/carer in the collaborative safety planning period? People with social support have 73% reduced suicide risk. We need to create social spaces that promote support. ~ Professor Paul Yip 3) Is Predictive Modeling Effective? Why are we screening and formulating risk assessments when predictive modeling is not effective yet? No instrument is perfect. The consensus of the Zero Suicide experts is, “We can’t wait for perfect.” When we get stuck on this idea of perfect predictive modeling, we become immobilized. Rather move Kathryn Turner, Gold Coast Health
  30. 30. 26 SYDNEY AUSTRALIA SUMMIT 2017 toward formulation that informs care rather than prediction. Rather than ask “Will they?” ask “Might they, and can we do something about this?” There are some risks we know have stronger predictive power than others. For example, if a patient has had a previous suicide attempt the chances of them attempting again are much higher than someone who has not engaged in that behavior. When we measure movement along the clinical pathway, how can we help chart critical shifts in patient attitudes – like the shift from feeling ambivalent about suicide to feeling a strong desire to die. This is a tipping point of risk. Suicide becomes ego syntonic (consistent with one’s self-image) and moves from being a hot potato to a security blanket. At this juncture, clients become much harder to engage because they are at peace with their plan. 4) Does Repeat Screening on Risk Lead to Survey Fatigue and Negative Outlook? People are notified to expect repeat screening when they enter the clinical pathway or protocol for monitoring suicide risk. Their response to this request often reflects the delivery of the caregiver. If done apologetically, then response is not as engaged as if done with a tone of the importance that this potentially life-saving intervention deserves. Furthermore, would repeat screening and assessment interviews that routinely evoke negative historical events, behavior patterns and thoughts just continually reinforce a bleak view of humanity? How can these interventions illuminate strengths and resilience? How can the therapist forge an empathic bond while people are unpacking their suicidal history and current state? “The fatigue of the caregiver and the patient in administering screening and assessment for suicidal thoughts is directly related to how the provider handles the tool. ‘Thank you! This is incredibly helpful and let’s use this information to guide our time together,’ or ‘I’m going to keep asking you these questions because they are like doing a blood pressure measurement – they are that important’ is preferred over not mentioning the suicidal thoughts, ditching the assessment, or avoiding repeated discussions.” ~ Dr. Ursula Whiteside
  31. 31. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 27 Section 4: Engage/Treat “If you weren’t miserable you wouldn’t want to die. Let’s help you be less miserable.” ~Dr. Ursula Whiteside A general guiding principle throughout the treatment spectrum is to begin with considering the least intrusive types of interventions first before resorting to highly restrictive and expensive options. Too often a provider’s clinical decision-making is based on his or her fear rather on what is best for the client. Fears of legal issues or having a patient die under the provider’s care often override good sense and may result in “treatment” plans that use ineffective and even punishing approaches like restraint, isolation and the removal of human rights. We know what works. David Jobes reported 50-80 randomized control trials (RCTs) exist studying the impact of specific interventions on suicidal ideation and behaviors. From these studies we can conclude: • There is no support for the use of inpatient hospitalization; there are concerns about increased risk for suicide post-discharge • Mixed and inconsistent support for use of medication in decreasing suicide risk • RCT’s with replicated support: o Dialectical Behavior Therapy o Cognitive Therapy for Suicide Prevention o Collaborative Assessment and Management of Suicidality (CAMS) o Non-demand follow-up “caring contact” Many times the suicidal crisis can be de-escalated with compassionate and cost-effective interventions by peers and providers. What is needed? A stepped care model for suicide care. Section 4 Dr. Ursula Whiteside and Dr. David Jobes
  32. 32. 28 SYDNEY AUSTRALIA SUMMIT 2017 Figure 2. Dr. David Jobes, Catholic University 1) Micro-interventions Ursula Whiteside, Executive Director of “Now Matters Now,” an on-line video-based program where peers teach evidence-based coping skills to people living with suicidal thoughts, feelings and behavior, offered several slight shifts in healthcare provider behavior that can make a big difference. First, we must change biased language. Much of the language related to suicide that is generally used by professionals and the general public is full of judgment and stigmatized views or eliminates the complex identity of the person. For example, Dr. Whiteside recommended the following: Say this Instead of this Died of Suicide Committed Suicide Suicide Death Successful Attempt Suicide Attempt Unsuccessful Attempt Person Living with Suicidal Thoughts or Behavior Suicide Ideator or Attempter Suicide Completed Suicide
  33. 33. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 29 (Describe the Behavior or state “patient diagnosed with…”) Manipulative, Cry for Help, Suicidal Gesture, a Borderline Additional Dialectical Behavioral Therapy skills such as “opposite action,” “mindfulness of current emotions,” and “paced breathing,” can be conceptualized as micro-interventions and introduced in as few as 2 to 5 minutes. These skills are more extensively outlined in the framework developed by Marsha Linehan that can be self-taught through bibliotherapy or on-line, peer taught, or professionally facilitated. Other micro-interventions include having the patient enter the crisis line phone and text numbers directly into their phone, offering a caring message and statement of hope (“I see your strength and I look forward to seeing you again”), or providing statements that begin to reframe their understanding and approach to managing suicidal thoughts (“Suicidal thoughts are not by themselves dangerous, it is what you do with the suicidal thought that makes all the difference.”) “You always want them to leave with hope and something tangible – a picture to enter into their phone, a video to watch, a behavior to practice. Caring messages are key,” ~Ursula Whiteside Focus therapy on what is most important to the client and the emotions that drive the suicidal thoughts and behavior. When patients learn to manage intense emotions and are supported in addressing life problems, suicidal thoughts being to dissipate. Here are what people living with suicidal thoughts would like to tell their providers: • Treat my sleep problem • Gently examine my paranoid thoughts with me • I might feel like I’m bad or wrong for having these thoughts • I might feel like I’m “in trouble” for reporting ideation • Balance trusting me and my innate capabilities AND yourself as a clinician when what I reveal is potentially unsafe • Ask, “Would you tell me if you did have [plans, a gun, pills etc]?” then PAUSE and watch my response and nonverbals • Acknowledge that that this is a problem that researchers are still working on finding better cures for AND that you have great hope • Give me feedback about the way I am asking you for help (or not asking for help) • Know that I am telling you about my suicide ideation/plans because I want to live, I want help, and I want to work together • I may be paying very close attention to how you respond to what I say, and telling you more or less based on how open I think you are to hearing it and how much I trust you • I may want to prevent you from being stressed or I may want to not have to deal with the stress of your emotions on top of mine
  34. 34. 30 SYDNEY AUSTRALIA SUMMIT 2017 2) Paraprofessional Peer Support Peer support specialists and people with lived experience with suicidal intensity are an essential part of getting to zero suicide, not just an optional “add on” to clinical services or zero suicide implementation. Peer-to-peer support is an evidence-based practice that works because peers: • Offer hope as models of successful recovery and on-going self-care • Provide insight, feedback and support • Peers’ stories challenge negative stereotypes • Connection with peers is often quicker due to shared life experience • Peers have unique “lived expertise” as subject matter experts • Peers often forge a link and cultivate trust between the providers and people living with suicidal thoughts and behaviors • Peers support the healthcare providers by offering outreach, gatekeeper workshops, resource distribution and can become certified peer specialists through training. • New models of Suicide Attempt Survivor Support Groups, like the ones developed by US- based Didi Hirsch, also show an emerging evidence-base for effectiveness. It is important to plan for a potentially rocky integration of this new model of peers into the workforce – anything new is often challenging – especially in the case of changing the status quo. It is common to have early barriers or bumps and for leadership or clinicians to say “this isn’t going to work” or worse yet, “these people cannot do this work.” Support for the integration into an often hierarchical culture is key. We introduce barriers to success when there is just one peer, or a peer in a setting where no other staff have shared their lived experience. We must set up our environment for peers to thrive and not to confirm our prior beliefs that this is a bad idea or waiting for peer integration to fail. It is recommended that peers be connected to a larger network of peer providers outside the given setting or organization. "We can't clinically treat our way out of the Suicide problem. We need a large non-clinical empathic workforce,” ~David Jobes 3) Evidence-Based Brief Interventions Brief interventions for suicide risk reduction are demonstrating robust outcome in reduction in attempt behavior, hospitalizations, and more. These promising models include: • Counseling on Access to Lethal Means (SPRC) • Brief intervention using crisis response plan and reasons for living with suicidal soldiers (Bryan) • Teachable moments intervention (O’Connor) • Attempted Suicide Short Intervention Program (Michel) • Virtual Hope Kit (Bush)
  35. 35. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 31 4) Suicide-Specific Treatment While people who are being hospitalized for suicidal thoughts and feelings may be told that this is “treatment,” very few are receiving suicide specific treatment or evidence-based treatment shown to reduce suicide risk. • RCTs on Suicide Specific Treatment with replicated support: o Dialectical Behavior Therapy (DBT) o Cognitive Therapy for Suicide Prevention  Cognitive Therapy for Suicide Prevention (CT-SP) from Brown and Beck  Brief-Cognitive Behavioral Therapy (B-CBT) from Rudd and Bryan o Collaborative Assessment and Management of Suicidality (CAMS) Central to the success of treatment for suicidal patients is the therapeutic alliance. It is the clinician’s job is to provide hope, to sell the next visit, and to see to it that the client is willing, if not excited, to come back. We train clinicians on how to look at risk, but do we train them on empathy, compassion, and engagement when a person is suicidal? Therapeutic alliance is person centered care. 5) Sacred Cows Many sacred cows exist in “treatment as usual” models. For example, RCT trials for medication to reduce suicide risk is mixed at best. There is no support for the use of inpatient hospitalization; rather concerns about increased risk for suicide post-discharge seem better supported. Exposing these scientific facts is in essence saying “The emperor has no clothes” to a very large industry. Our “treatment as usual” has been to put people in hospitals without offering them suicide specific care and hoping for the best. This is not working. Those who oversee these services think they are effective and powerful, but generally speaking, they are not. People with the lived experience of poor hospitalizations or mismanaged medications are saying “this is enough’; however, the power of these existing systems is significant and the ability to change quickly is unlikely. Further, the evidence-based practices above have not yet spread to the larger health systems. For treatments like DBT, the training and resources required often outstrip the ability of the organization. Newer approaches, such as DBT skills group plus case management, appear to be highly effective and alternatives to the full-meal deal DBT.
  36. 36. 32 SYDNEY AUSTRALIA SUMMIT 2017 Profile in Leadership: MP Norman Lamb MP Norman Lamb, Parliamentarian Profiles in Zero Suicide Leadership Minister Norman Lamb is the son of Hubert Lamb, a leading climatologist. He studied Law at Leicester University and, after working as a Parliamentary Assistant for a Labour MP, built a career as a litigation solicitor, ultimately specialising in employment law. He was partner of Steeles Solicitors and is the author of 'Remedies in the Employment Tribunal'. Norman was elected to Norwich City Council becoming Leader of the Liberal Democrat opposition. He first stood for Parliament in North Norfolk in 1992. Norman married his wife, Mary, in 1984, and they have two sons. Norman is a long- standing Norwich City supporter and season-ticket holder. Norman became an International Development Spokesperson. He then joined the Treasury Team and was elected to the Treasury Select Committee. In 2005 he was appointed Shadow Secretary of State for Trade and Industry, championing the case for employee share ownership in Royal Mail. In 2006 he became Liberal Democrat Shadow Health Secretary. Following the 2010 General Election, Norman served first as Chief Parliamentary Advisor to Nick Clegg, the Deputy Prime Minister, and then as a junior minister at the Department of Business, Innovation and Skills, before he was promoted to Minister of State for Care and Support at the Department of Health. As Health Minister, Norman has worked to reform the UK’s broken care system, introducing a cap on care costs and ensuring that carers get the support they need. Norman is leading the drive to join-up our health and care system, with a greater focus on preventing ill-health. He is also challenging the NHS to ensure that mental health gets treated with the same priority as physical health, with access waiting standards being introduced in 2017.
  37. 37. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 33 Section 5: Research/Evaluate Henry Ford Health System’s Dr. Brian Ahmedani emphasized the importance of both fidelity and outcome assessment to get an overall picture of whether a program is implemented as was intended and capturing outcome data and for rapid cycle quality improvement and to measure success. Jacinta Hawgood (Griffith University’s Australian Institute for Suicide Research and Prevention) demonstrated that the evaluation plan should really be developed before implementation and adapted as the program moves forward. 1) Understand the Problem – Build a Logic Model Continuous process improvement is contingent upon strong evaluation. The first consideration of a complex program evaluation like the Zero Suicide in Healthcare model is to understanding the program and to determine how we would know if the program was implemented effectively. 2) Use Both Qualitative and Quantitative Measurement Capturing ideas from patients about what is important to them during critical junctures along the pathway in the aftermath of attempt or suicide crisis matters just as much as whether or not they are taking their medication 90 days after discharge. In fact, the point of view of the patient, their carer and the clinician are all helpful in understanding the story of the outcome. For quantitative measurement consider rating scales that measure quality of life in addition to those that measure risk. “The road to success is constantly under construction. We are always trying to make it better. If you’re a real scientist, you are always trying to make things better. Striving for zero is the only outcome we can have. ~Brian Ahmedani Questions & Concerns Brian and Jacinta also shared some of the most often cited challenges and questions. Section 5 Dr. Brian Ahmedani, Henry Ford Health System
  38. 38. 34 SYDNEY AUSTRALIA SUMMIT 2017 1) Measuring Social Impact and Social Drivers How can our evaluation processes capture the impact of these interventions beyond their effect on the target populations? What impact do they have on the broader community – e.g., on employment, violence, education, and more? Similarly, what are the social drivers – like a recession, immigration or marriage equality – that may affect suicide risk and how are these being accounted for when we examine rate changes in large systems of care? We must be mindful that for many populations (e.g., First Nation/Indigenous people, LGBTQ), the drivers for suffering are most often at the core about environmental and situational hardship, so we should not invalidate this with a sole focus on a mental health diagnosis and treatment plan. 2) Standardizing Coronal Criteria Different coroners may be using different criteria in their determination of ruling a death as a suicide versus an accident or homicide. How do we reconcile these data across communities? A spike in suicide death data might only reflect changes in death determination criteria. The greater the cultural taboo, the greater the chances that suicide is under-reported.
  39. 39. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 35 Making the Business Case for Zero The Sydney summit was designed to take a “pulse check” on implementation processes – successes and challenges – with the earliest adopters of the model. The hope is that with some of the findings generated from this report, we can accelerate the spread of this model and bring it to scale within nations and to new regions of the globe. One tactic in getting momentum behind a promising approach like Zero Suicide is to create a business case; another is to mobilize the early champions to engage new and needed partners in the effort. Making the Business Case Sue Murray of Suicide Prevention Australia shared the business case they have projected for their Zero Suicide pilot rollout. On one hand, if Australia did nothing different, suicide deaths would be expected to continue to rise from 3,000 to 5,000+ deaths in 2025, and the economic impact on Australia of $27.3 billion. If however, after a three-site pilot, the Zero Suicide in Healthcare model was able to nationally roll out and save approximately 520 lives by 2025, the national economic impact would be reduced by $2.7 billion each year. Next Steps Minister Norman Lamb closed the 3rd Summit with inspiring ideas summarizing our conversations and igniting the forerunners to bring the movement to its next stage. In order for Zero Suicide in Healthcare to be successful it must become integrated as part of core business. This journey is “a marathon, not a sprint” according to Becky Stoll, and one that requires brains, heart and courage. We must remember to balance protocol with people. Consistency with compassion. Those pioneers at the head of this expedition are paving the way for others. Confronting skeptics, challenging failed orthodoxy, and evangelizing the moral imperative of the effort. The time is now for the injustice of our old ways to end. We must continue on with our flag held high, “Harm is preventable. Our target is zero.” Summit Spotlight Minister Norman Lamb, UK Parliamentarian “There's a moral imperative that we commit to this.”
  40. 40. 36 SYDNEY AUSTRALIA SUMMIT 2017 Every life is precious. We focus on zero every day. Harm reduction is not good enough. How can we go past Zero to life enhancement and happiness? Challenging the culture and having a statement of ambition is important but not sufficient; we also need robust science and technology, training, quality improvement processes, open learning culture, and core values centered on putting the “care” back in “healthcare.” As we perfect these strategies, we must also become more effective at moving the mavericks to the mainstream. We must be more effective in bringing more people on board and proselytize our movement. We acknowledge the pain and suffering suicide brings when it touches our lives. Brought together by experience and unified by hope. ~Suicide Prevention Australia Example: The Business Case of Zero Suicide in Healthcare in Australia The Aim Roll out a Zero Suicide pilot program at selected sites across Australia. The Purpose – Target a 50% reduction in suicide within five years; – Adapt and calibrate Zero Suicide to the Australian healthcare system; – Build momentum towards the cultural shift that suicide is preventable; and – Strive towards the Big Hairy Audacious Goal (BHAG) by evaluating, revising and continuously improving the Zero Suicide roll out methodology and operating framework. The Pilot • Hospital network across 3 sites (hospitals with emergency departments); 15,000 staff; locality covering 1,000,000 people • Require $11.5 million in funding over a 5 year period, or the equivalent of $3.8 million per hospital • Accounting for the economic impact of suicide, this pilot is projected to save an estimated 12 lives annually by 2025, and is expected to achieve a benefit cost ratio (‘BCR’) of 13 The Benefit nationally A national roll out of Zero Suicide has the reasonable expectation to save approximately 520 lives per year by 2025 and reduce the national economic impact of suicide by an estimated $2.7 billion a year
  41. 41. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 37 Conclusion from MP Normal Lamb Full text of speech given by Norman Lamb Liberal Democrat MP for North Norfolk and former Minister of State for Care and Support, UK Government I wanted to start by thanking the contributors at this summit. I have enormous admiration for the work that you are all doing. You are the pioneers at the cutting edge, confronting sceptics and challenging orthodoxy. I wanted to explain why this is of interest to me not only professionally but on a very personal level. First, our oldest son, Archie, was diagnosed at the age of sixteen with obsessive-compulsive disorder. We have experienced the failures of the NHS, waiting too long for treatment. Archie has been through very difficult times with a punishing condition but there is a real injustice because when we were confronted by a long delay before we could get treatment started, we did what any family in these circumstances would do if they were able to – we paid for treatment for Archie. But I do not want to live in a country where people with resources can get access to treatment and others are left waiting. That is a real injustice. So I am on a mission to pursue the cause of equality for those who suffer from mental ill-health. Equality in terms of access to treatment on a timely basis – just as others enjoy. Then, two years ago in the summer of 2015, my older sister, Catherine, took her own life. She had been an inpatient for ten weeks. I was struck by what David Jobes said: "we put people in hospital where there is not suicide specific care." Catherine was in a unit with others with psychosis and with personality disorder. All of those in the unit were complex cases but was this a therapeutic environment in which to recover? There also seemed to be little involvement of family in decisions about Catherine's treatment.
  42. 42. 38 SYDNEY AUSTRALIA SUMMIT 2017 I was struck by what David Covington said about the small proportion of people in the United States who get suicide specific treatment – and yet we know that this can have a significant impact on reducing the death toll from suicide. This is surely intolerable and unconscionable. So this is important to me personally. But more broadly, we have to challenge injustice. In my family's case I have no interest in retribution. I only have an interest in learning from experience and in trying to reduce the risk of others ending up taking their own life. My introduction to the concept of Zero Suicide came from Joe Rafferty, Chief Executive of Mersey Care Mental Health Trust in the Liverpool area. He told me about Ed Coffey's work in Detroit. I was fascinated by this and found the case for a more audacious approach to suicide reduction to be very compelling. I managed to persuade the Deputy Prime Minister at the time, Nick Clegg, to join with me in launching a national challenge to NHS organisations to commit to a Zero Suicide Ambition. We were supported at that time by Professor Louis Appleby. I remember his profound comment: in all of his professional life studying individual suicides, it was always the case that something could have been done differently which might have saved that person's life. We now have three pioneering areas in England are – Mersey Care, East of England and the South-West. It is good to see Ellen Wilkinson from South-West England here in Sydney. In 2015 I left the Government following the general election but was then asked to chair the Commission on Mental Health in the West Midlands. This has culminated in an agreed action plan. It had been informed by my visit to meet Gary Belkin who had crafted the "Thrive NYC" strategy in New York. I had also visited Philadelphia. We are now starting to develop a global network of cities, all of which are taking citywide action on public mental health. One action included in the West Midlands plan is a commitment to a Zero Suicide Ambition. We have also established a working group to look at how to embed mental health in primary care and I was struck by the compelling case put by Virna Little in terms of the action they have taken in her primary care centres in Harlem in Manhattan. In essence, it seemed to me that this was good preventive care, identifying risk at a much earlier stage and taking action to support that individual to recover. This was very much in line with the approach taken in Detroit. They called the approach: "perfect depression care", screening people in primary care – particularly those with chronic conditions – identifying those who may be at risk of suicidal ideation. Ensuring that those people get fast access to support for their psychological challenges is highly attractive. In the West Midlands I believe that we have a real opportunity to combine the core Zero Suicide approach with health providers with a wider public mental health approach as described so effectively by Professor Paul Yip in his presentation. He talked about an umbrella over a community protecting
  43. 43. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 39 them from risk. If we are to have an impact on the overall suicide rate then we have to combine work in our health providers with a wider public mental health approach to achieve better prevention. We also have to look at the Criminal Justice System. Mike Doyle talked about the dreadful death toll in our prison system in England where there have been one hundred and nineteen suicides over the last twelve months. The same principles of expecting organisations to be audacious in committing to seeking to save every life must surely apply. Another action is that we will introduce a much greater use of what are known as "mental health treatment requirements" in three courts in the West Midlands. This is a sentencing option which seeks to address the underlying cause of offending behaviour where someone has a clear mental health condition. We are at the very start of a journey in the West Midlands and I do not know what progress we will make but we have a big opportunity. Reflections on the Summit I thought that Chris Doyle's, from Lendlease, presentation was very impressive. It reminded me also of the sign at the London construction site which said: "all harm is preventable – target zero". That culture is what we seek to apply to the mental health system. Lendlease have been incredibly successful by being audacious and by being clear that the death toll on construction sites was intolerable – and then introducing specific clear action to make the commitment a reality. So long as we are clear on what we mean by Zero Suicide – that every life is precious and so long as we remember Louis Appleby's experience that in every case something might have been done differently to save that person's life then it seems to me that the concept of Zero Suicide is absolutely right. I was struck by Becky's comment that: "we focus on zero every day". As we learned from Chris Doyle, there has to be a challenge to culture – a statement of ambition. This is necessary – but not enough. The task is to marry the challenging audacious ambition with: 1) Robust science 2) Smart use of technology – just as Virna Little has done in primary care in Harlem 3) Training of staff and embedding quality improvement methodology in everything that we do There has to be an open learning culture. Any one of these on their own will fail. In the UK we have a very good, evidence based national strategy – but it is having little impact on the numbers of those who take their own lives because the culture in too many organisations is not being challenged. Organisations are not giving sufficient priority to ending this awful death toll. So our mission is to:
  44. 44. 40 SYDNEY AUSTRALIA SUMMIT 2017 1) Promote the full package – THE AMBITION and THE SCIENCE and THE MECHANISMS TO ACHIEVE CHANGE 2) Secondly, how do we move from pioneers around the world to making this mainstream? There is a moral imperative that we do make this mainstream. We need evidence of impact of this approach and the lives that can be saved. We need champions who will go out and proselytize for this approach around the world. I will do what I can in the UK and beyond. As Jan Mokkenstorm said: "we must not limit this to harm reduction. It must be about promoting well- being, happiness and giving people a good life".
  45. 45. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 41 Appendix Summit Participants Government administrators, provider executive leaders, people with lived experience, and family members gathered in Sydney for the third Zero Suicide international summit: David W. Covington, LPC, MBA, RI International, Behavioral Health Link (US) Michael F. Hogan, PhD, Hogan Health Solutions (US) Susan Murray, Suicide Prevention Australia (Australia) Brian Ahmedani, PhD, Henry Ford Health System (US) Dr. Stéphane Amadeo, Association SOS SUICIDE (French Polynesia) Bart Andrews, PhD, Behavioral Health Response (US) Susan Beaton, Susan Beaton Consulting (Australia) Klaas Bets, Parnassiagroep (Netherlands) Professor Niels Buus, University of Sydney (Australia) Assoc. Prof. Dr. Lai Fong Chan, National University of Malaysia Medical Centre (Malaysia) Dr. Shu-Sen Chang, National Taiwan University (Taiwan) Jen Coulls, Tincat Consulting (Australia) Leilani Darwin, AMHFA instructor (Australia) Dr. Neil Coventry, Victorian Department of Health and Human Services (Australia) Ian Dawe, MHSc, MD, FRCPC, Ontario Hospital Association University of Toronto (Canada) Chris Doyle, Lendlease Corporation (Australia)
  46. 46. 42 SYDNEY AUSTRALIA SUMMIT 2017 Dr. Michael Doyle, South West Yorkshire Partnership NHS Trust (England/UK) Elma Fourie, MA Psych, ANZAP Psychotherapy, CMHN, RN, HealthScope – Sydney Clinic (Australia) Dr. Gerdien Franx, 113Online (Netherlands) Andrea Gabilondo, Osakidetza, Basque Public Health System (Spain) Shareh O. Ghani, MD, Magellan Health (US) Dr. Nathan Gibson, Office of the Chief Psychiatrist (Australia) Julie Goldstein Grumet, PhD, EDC - Suicide Prevention Resource Center (US) Dr. Margaret Grigg, Victorian Department Health and Human Services (Australia) Jacinta Hawgood, BSSc, BPsy (Hons), MClinPsy, MAPS, The Australian Institute for Suicide Research and Prevention, Griffith University (Australia) John Henden, Consultancy (England/UK) Sonia Higgins, Lendlease (Australia) Kevin Hines, 17th & Montgomery Productions (US) Margaret Hines, Partner, 17th & Montgomery Productions (US) Lynn James, SA Health (Australia) David Jobes, PhD, The Catholic University of America (US) Michael Johnson, MA, CAP, CARF International (US) D. Brian Karr, CPA, Alacura (US) Nikki Kelso, Suicide Prevention Australia (Australia) Corina Kemp, Far West Local Health District (Australia) Dr. Kenneth Kirkby, Department of Health and Human Services, Tasmania (Australia) Minister Norman Lamb, Liberal Democrat MP for North Norfolk (England/UK) Karin Lines, NSW Ministry of Health (Australia) Virna Little, PsyD, LCSW-r, SAP, CCM, The Institute for Family Health (US) Jennifer Lockman, M.S., Centerstone Research Institute (US) Harry Lovelock, Australian Psychological Society (Australia) Janet Martin, Queensland Department of Health (Australia) Helen McEntee, Government Minister, Department of Health (Ireland)
  47. 47. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 43 Richard McKeon, PhD, SAMHSA (US) Rachael McMahon, Mental Health Community Policing Initiative (Australia) Dan Mobbs, Queensland Centre for Mental Health Learning (Australia) Jan K. Mokkenstorm, MD, GGZinGeest and Free University Amsterdam (Netherlands) Claar Mooij, Lentis (Netherlands) Dr. Jong-Ik Park, Kangwon National University College of Medicine (Korea) Daniel Perkins, PhD, Clearinghouse for Military Family Readiness (US) Dr. Denise Riordan, Chief Psychiatrist, Northern Territory (Australia) Sally Spencer-Thomas, Carson J. Spencer Foundation (US) Becky Stoll, LCSW, Centerstone (US) Brenton Tainsh, LivingWorks Education (Australia) Corinda Taylor, Life Matters Suicide Prevention Trust (New Zealand) Maniam Thambu, IASP Congress Organizing Committee (Malaysia) Kristie Thorneywork, ACT Health (Australia) Professor Shinichi Tokuno, University of Tokyo (Japan) Dr. Kathryn Turner, Gold Coast Mental Health and Specialist Services (Australia) Nicole Turner, B.App.Sc., Indigenous Allied Health (Australia) Gregory Van Borssum, GVB Mind Warriors (Australia) Rita Van Maurik, Altrecht (Netherlands) Bas Van Wel, Dimence (Netherlands) Eduardo Vega, Dignity Recovery International (US) Anke Wammes, 113Online (Netherlands) Matthew Welch, RNMH, PGCAMHN, Gold Coast Hospital & Health (Australia) Ursula Whiteside, PhD, Zero Suicide Faculty, Consultant (US) Ellen Wilkinson, BM FRCPSYCH, Cornwall Partnership NHS Foundation Trust (England/UK) Alan Woodward, Lifeline Foundation for Suicide Prevention (Australia) Professor Paul Yip, Centre for Suicide Research and Prevention, University of Hong Kong Dr. Jie Zhang, SUNY Buffalo State (China)
  49. 49. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 45 Summit Agenda Sunday, February 26 – Social and Networking • 5:00pm Welcome Reception hosted by His Excellency General The Honourable David Hurley AC DSC (Ret’d) Governor of New South Wales. o Welcome to Country: Aunty Millie Ingram Monday, February 27 – Day One Programme (AMP Building, 33 Alfred St Sydney) • 8:30am Welcome and Introductions o Acknowledgement of Country: Leilani Darwin o Ms Megan Beer: Director AMP o Mr David Covington: RI International; Ms Sue Murray: Suicide Prevention Australia o Introductions and Summit Mission/Approach: Dr Mike Hogan 10:00am Break – Mid-morning Tea • 10:15am Fuel for the Fire o Why Zero Matters to Me: Mr Covington to interview with Mr Kevin Hines o Why Focus on Healthcare System, Caregiver Perspective: Ms Jen Coulls o The Language of Zero, Lessons Learned: Mr Chris Doyle, Lendlease Corporation • 11:00am Lead/Activate: Dr Jan Mokkenstorm and Professor Paul Yip 1:00pm Lunch • 2:30pm Deploy/Scale – Dr Virna Little and Ms Sue Murray Social and Networking • 6:30pm Dinner at the revolving O Bar and Dining on the 47th floor of Australia Square (264 George Street) sponsored by Mr Kevin and Ms Margaret Hines Tuesday, February 28 – Day Two Programme • 8:30am Clinical Pathway/Protocol – Ms Becky Stoll and Dr Kathryn Turner 10:30am Break – Morning Tea • 11:00am Treat/Engage/Peer Supports – Professor David Jobes and Dr Ursula Whiteside 1:00pm Lunch • 2:00pm Research/Evaluation: Ms Jacinta Hawgood & Mr Brian Ahmedani • 4:00pm Debrief and Action with reflections by Minister Norman Lamb International Initiative for Mental Health Leadership (IIMHL) Exchange Some participants in the Zero Suicide International summit will stay for the International Initiative for Mental Health Leadership (IIMHL) exchange at the Sydney Hilton later in the week. See for more info. Wednesday, March 1 – Day Off
  50. 50. 46 SYDNEY AUSTRALIA SUMMIT 2017 Thursday, March 2 – IIMHL Day One (Hilton Sydney, 488 George St) • Recap key match meetings, including Zero Suicide international summit Friday, March 3 – IIMHL Day Two • 10:00am Strong leadership to meet hardest challenges – Ms Peggy Brown and Mr David Covington Process During each two hour session, Dr. Mike Hogan facilitated according to the three stage rocket approach in the graphic above to ensure everyone was involved, we kept the enthusiasm high and we created a product that would benefit others following the summit: 1. Two brief 15 minute focused presentations by the experts highlighted in the agenda 2. Participative process and focus, beginning with a single question in inquiry mode 3. High points and summarized take-aways Steering Committee Special thanks to the Steering Committee of Dr. Shareh Ghani, Dr. Jan Mokkenstorm, Becky Stoll and Professor Paul Yip and their support to the summit organizing team in Sydney (David Covington, Dr. Michael Hogan, Nikki Kelso, and Sue Murray).
  51. 51. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 47
  52. 52. 48 SYDNEY AUSTRALIA SUMMIT 2017 Is Suicide Really a Choice? The clinical rationale for Zero Suicide in Healthcare.
  53. 53. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 49
  54. 54. 50 SYDNEY AUSTRALIA SUMMIT 2017 The 2015 Zero Suicide Atlanta Summit product has been viewed over 13,000 times Zero Suicide International Summits 2014 – Oxford, United Kingdom (IIMHL Manchester) 2015 – Atlanta, Georgia (IIMHL Vancouver, Canada) 2017 – Sydney, Australia (IIMHL Sydney) Planned 2018 – Amsterdam, Netherlands (ESSSB, Ghent, Belgium) 2019 – Auckland, New Zealand 2020 – Hong Kong, China
  55. 55. sydney australia summit 2017 SYDNEY AUSTRALIA SUMMIT 2017 51 Insert Amsterdam Advert Here 4 T H I N T E R N A T I O N A L S U M M I T Z E R O S U I C I D E I N H E A L T H C A R E Monday & Tuesday, September 3 – 4, 2018 2018 New Paradigms in Clinical Care Visit for more info.
  56. 56. 52 SYDNEY AUSTRALIA SUMMIT 2017 CrisisServicesTaskForce Adopt the mindset. Change the world. Zero is the only goal we can live with.