Problem: Between 2011 and 2014, of patients attending the SMV Outpatient programs, there were recorded suicide attempts or deaths by suicide Goal Statement: Zero suicide attempts or deaths by suicide

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Define Measure Analyze Improve Control
Zero suicide attempts or deaths by suicide.
Customer: SMV Outpatients
Problem: Between 2011 and 2014, of patients attending the
SMV Outpatient programs, there were recorded suicide
attempts or deaths by suicide.
Sponsor/Green Belt: Christiana Paul
Process Owner: Nancy Burlak & Serene Lause-Gardini
Black Belt: Matt Hayden
Team: S. Griffiths, S. Whittemore; C. Atterton, N. Bavar, V. Campbell, L. Kramer,
L. Hoyt, D. Schwartz, L. McJunkin, J. Ruvo, J. Wojciechowski, C. Westfall,
R. McDade, J. McWaters, C. Huang
Safety Pillar
Goal Statement
Link to Strategic Goals
Team
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16

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Measure / Analyze
 Retrospective analysis of 16 identified
outpatient events; 50 data points
examined.
 Qualitative & Quantitative did not result in a
clear root cause(s)
 Findings Included:
 High variability in workflow and documentation
 No effective prioritization of outpatient
population for risk
 Current Assessment was task, not value added
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16
Need for Standard Work & Evidence-
Based Practice

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Improvements Identified &
Underway
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb’16
 Columbia-Suicide Severity Rating Scale
(C-SSRS)
 Cultural Change Regarding Suicide
Assessment
 Asking can Save A Life; Ask every time, like BP
 Common Definitions
 Develop clinical pathways and expectations
 Link C-SSRS Rating to EBP Treatment Interventions
 Staff Communication and Training
 Suicide Risk Assessment
 Department Protocol
 Safety Planning
 Treatment Planning

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Linking C-SSRS Rating
to Evidence Based Practice
Treatment Interventions
Interpersonal Theory of Suicide—
Thomas Joiner

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C-SSRS in our EMR

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The Clinician’s Perspective
Define Measure Analyze Improve Control
SMV Outpatient Zero Suicide
Initiative Oct ‘14 to Feb ‘16