The document summarizes the evaluation of New Zealand's Suicide and Self-Harm Prevention Collaborative, which used collaborative methodologies across 14 district health boards to improve practices for assessing and managing people at risk of suicide. Key findings were that the collaborative approach was successful in implementing guidelines and driving quality improvement, but required significant resources. Success factors included effective national and local support structures, learning and applying the breakthrough methodology, and having local project teams represent all relevant departments.

1. Evaluation of the NZGG Suicide and
Self-Harm Prevention Collaborative
Julian King and Michelle Moss
10 September 2010
Julian King & Associates Limited
www.julianking.co.nz Health Outcomes International

2. Key messages
• Collaborative methodologies…
– are a successful method of guideline
implementation and quality improvement
– are resource intensive
– may be undertaken again in the future
• Success factors
– Evaluation has identified features of the approach
that are thought to contribute to its effectiveness

3. The Collaborative
A Collaborative is a network of people who share information, build on
existing knowledge, develop expertise and solve problems for a common
purpose, driven by the interest of the community involved (NICS).
• Local DHB project teams with support of NZGG national
implementation team
• Using the Breakthrough methodology (www.ihi.org)
• Undertook pathway mapping, identified gaps/ barriers/
opportunities for improving the assessment and management
of people at risk of suicide
• Trialled & implemented small changes
• Measured and monitored progress toward meeting targets
• 2 phases
– Phase 1 (2005-07) 10 DHBs
– Phase 2 (2008-10) 14 DHBs (incl 9 from Phase 1)

4. The evaluation
• Objectives – to review:
– Quality of project implementation
– Impacts
– Stakeholder satisfaction
• Methods – principally qualitative:
– Interviews with all project coordinators, NZGG
implementation team, consumer panel, nominated
advisory group members, 6 DHB project teams
– Descriptive analysis of target data (not gathered for
evaluation purposes)

5. Intervention logic
Processes Outcomes
(Who) (What) (Intermediate) (Long term)
Support project Improved
NZGG team
teams practice
Measurable
improvements
DHB Learn against targets for
change
Project Team Methodology
Improved Mental
Health
Apply
Methodology Reduced
significant self
-
harm
Support,
DHB
Facilitate access Reduced suicide
Management
to resources
Culturally Responsive.......... Whakawhanaungatanga ..........Local Flexibility
(How)

6. PDSA cycle
What are we trying to
accomplish?
ACT PLAN
Implement the Plan the change
changes that have that is to be
How will we know that a been proven to be trialled
change is an improvement? effective
STUDY DO
What changes can we make Evaluate the Conduct a trial of
that will result in an impact of the trial the proposed
change
improvement?

7. Improved practice
What changes did the Collaborative
achieve?

8. Access
Aim: people at risk of suicide get seen sooner in ED
• What happened in the DHBs?
– Pre-existing assessment tools and templates were
adapted to suit local contexts
– Assessment tools were trialled to assess how well
they worked in practice
– Tools were implemented
– Staff were trained around initial assessment

9. Access
Aim: people at risk of suicide get seen sooner in ED
• What were the impacts?
– Improved processes
– Improved knowledge about self-harm and suicide
– Increased skills and confidence to ask relevant
questions of people at risk
– Mental health issues being detected and acted on
more promptly
There is increased confidence of ED staff because of training and the tools. People
used to be left just sitting there...there were no key processes...nurses felt
uncomfortable and didn’t know how to talk about self-harm and suicide...most ED
staff have the confidence to deal with this client group now, which they didn’t have
before. (ED Nurse Manager)

10. Assessment: Mental Health
Aim: people at risk of suicide get a timely and
comprehensive mental health assessment
• What happened in the DHBs?
– Mental Health Services were alerted and engaged
with more promptly
– Communication channels between ED and Mental
Health were developed
– Processes for mental health assessment take place
prior to medical clearance
– Mental Health staff increased presence in ED
– Improved electronic records were introduced

11. Assessment: Mental Health
Aim: people at risk of suicide get a timely and
comprehensive mental health assessment
• What were the impacts?
– Improved communication and relationships
between ED and Mental Health
– More prompt and thorough comprehensive
assessment
The relationship between ED and Mental Health is more open. ED can now
say to Mental Health that they need to get to ED to do assessment quicker.
(Service Manager, Mental Health and Addiction Services)

12. Assessment: Cultural
Aim: Māori at risk of suicide offered timely
cultural assessment
• What happened in the DHBs?
– Collaboration between departments to develop
strategies for better cultural responsiveness
– More proactive efforts to offer Māori patients
cultural input
– Culture-specific questions included in initial
assessment
– Making available appropriate space in ED for
cultural assessment

13. Assessment: Cultural
Aim: Māori at risk of suicide offered timely
cultural assessment
• What were the impacts?
– Debate and dialogue was created
– Improved collaboration between Māori Health
and other departments
– Connections being made with Māori providers in
the community
– Possibilities for collaboration were being explored
– Models for cultural assessment were
appearing/being developed
– More of a “cultural lens” in ED

14. Discharge
Aim: discharge plans always provided (to patient,
whānau, others involved in their care)
• What happened in the DHBs?
– Discharge forms developed and implemented
– Mental health and ED notes included in discharge
plans
– Resources developed for family members to take
home
– One DHB designed a consumer satisfaction survey
– Use of lay person’s language in discharge plans
– Sending fax or electronic copies of the discharge form
to GPs and other care providers

15. Discharge
Aim: discharge plans always provided (to patient,
whānau, others involved in their care)
• What were the impacts?
– More people at risk of suicide and self-harm who
were discharged received written discharge
summary
– Discharge plans contained more useful and clear
information
– More family/whānau received a copy of discharge
plan
– Better engagement with primary care

16. Follow up
Aim: more timely follow up appointments post
discharge, and follow up of DNAs
• What happened in the DHBs?
– Automatically referring people at risk of suicide to
mental health services
– Improving IT infrastructure so that patient notes could
be accessed by both MH and ED
– Developing processes for people referred to MH to be
contacted by that service prior to their follow up
appointment
– Developing as written policy that all current MH Unit
clients be seen by that service after discharge from ED
– Improving communication between the DHB and
services in the community

17. Follow Up
Aim: more timely follow up appointments post
discharge, and follow up of DNAs
• What were the impacts?
– Improved referral processes and continuity of care
– Improved follow up of DNAs (in the 4 DHBs that
implemented changes in this area)
Follow up is better. Before, ED usually had no idea what happened once
patient went to Mental Health. Now all info can be found in the notes.
(ED Nurse Manager)

18. Success factors
Doing a Collaborative well in
Aotearoa New Zealand…

19. National implementation team
• Credibility to engage with clinicians and
managers in relevant departments
• Useful mix of skills and disciplines (e.g.,
project management, clinical, consumer, etc.)
• Leadership style facilitates and models values
of the Collaborative methodology (e.g.,
whakawhanaungatanga)
• Generates excitement for the project

20. Effective national support
• Initial training workshop – provide foundation
• Regular teleconferences, meetings, workshops
• Relevant and useful for stakeholders
• Accessible to local project teams
• Facilitate setting of achievable goals and
timeframes

21. Local executive support
• Senior management “sign up” to core
requirements of project – written EOI
• DHB nominate appropriate project
coordinator and clinical leads from ED & MH
• Dedicated staff release time and resources
• Executive sponsors understand and champion
the project at senior management level

22. Local project teams
• Representatives from all departments
(ED, Mental Health, Māori Health, Māori Mental
Health)
• Consumer & family/whānau advisors
• Mix of innovators, leaders & technical experts
• Whole-team ownership & commitment to change
• Effective mechanisms for:
– Communication
– Progressing the project
– Overcoming logistical challenges (e.g., associated with
shift work, multiple departments involved)

23. Learning the methodology
• Initial team-building prior to induction workshop
• Good representation at induction workshop
• Lot of new information to absorb initially; workshop
needs to provide enough of a base to get started
– Familiarity with methodology (pathway mapping, testing
small changes, applying change methodologies)
– Familiarity with underpinning values
(e.g., whakawhanaungatanga: Commitment from the
different services to work together with respect, aroha and
share responsibility for one another)
– Understanding how to access support/expertise when
needed

24. Applying the methodology
• Pathway mapping to identify gaps, barriers and
opportunities for improvement
– In conjunction with Guideline
– Consumer-centred approach
– Ground rules (respect diversity, differences of opinion)
• Breakthrough methods
– Defining the problem, clear and agreed aims/ goals/
measures, test changes and monitor improvement
prior to implementation

25. For more information
• The Collaborative & implementation team: www.nzgg.org.nz
• Breakthrough methodology: www.ihi.org
• The Evaluation report: www.tepou.org.nz
• The Evaluators: www.julianking.co.nz | www.hoi.com.au