After launching our People-Centred Care Leadership Program in September, we are constantly on the lookout for exceptional people-centred practices and initiatives. Each year, HealthCareCAN, CPSI and HSO partner to offer the Patient Engagement in Patient Safety program which recognizes leading practices in this area. In 2019, one of the organizations and teams recognized was St. Joseph’s Healthcare London and their Zero Suicide Initiative. The team presented at the National Health Leadership Conference and we were lucky enough to capture some interviews with the team on video. Here, you can read more about this exceptional and important program, and watch the interviews from St. Joe’s passionate Zero Suicide team including a patient partner and his spouse.
Zero Suicide is a concept of care that provides best practice in suicide risk screening and assessment, risk formulation, and safety planning. The foundational belief of Zero Suicide is that suicide deaths for individuals under care within health and behavioural health systems are preventable. It presents both a bold goal and an aspirational challenge. The need for improvement at a system level is underscored by the sobering statistics on suicide. Suicide is the 9th leading cause of death in Canada. In the month prior to dying by suicide, a staggering 85% of individuals had been in direct contact with a health care provider. The programmatic approach of Zero Suicide is based on the realization that suicidal individuals often fall through the cracks in a sometimes fragmented and distracted health care system. A systematic approach to quality improvement in these settings is both available and necessary.
The challenge and implementation of Zero Suicide cannot be borne solely by the practitioners providing clinical care. Zero Suicide requires a system-wide approach that actively includes patients and caregivers, to improve outcomes and close gaps. Patient and family engagement is a vital part of the Zero Suicide philosophy, as well as other aspects such as commitment from leadership, support during high-risk times of transition, support for staff – both psychosocial and in regards to skills training, and the use of evidence-based treatments that directly target suicidality, among others.
Zero Suicide at St. Joseph’s Health Care London
St. Joseph’s Health Care London is the first organization in Canada to implement this model, which is being rolled out in three phases:
- Pilot phase (complete): Adult Ambulatory and Concurrent Disorders Services
- Phase II (currently in implementation): mental health inpatient units, remaining mental health ambulatory teams, Operational Stress Injury Clinic, Southwest Centre for Forensic Mental Health Care (inpatient and outpatient departments)
- Phase III (scheduled for 2020): reach-out to community partners such as Canadian Mental Health Association, schools, Indigenous care partners, first responders, etc.
As part of this implementation, clinicians are now expected to screen patients for risk at every visit (outpatients) or every day (inpatients) using an evidence-based screening tool, the Columbia – Suicide Severity Rating Scale. In addition, all new patients to St. Joseph’s mental health programs have a full lifetime assessment of suicide risk and will then collaboratively develop a Coping Plan with their clinician. This plan is a preventative plan that helps people to understand what the signs are they are becoming unwell, and how to stay well and self-manage their symptoms, including strategies for reducing isolation and increasing engagement in their treatment.
Feedback solicited from clinical staff, patients, and families has shown that the Coping Plans have been (and continue to be) successful in preventing crises, and clinicians are getting a much better “whole picture” of their patients’ risk levels and histories of suicidal ideation and behaviour. Overall, patients and clinicians are gaining comfort with the language and open discussion of suicide.
For patients who are at elevated risk, a working group also developed what is called a Suicide Management Plan, which covers all necessary information for an acute suicidal crisis. This plan helps the patient feel more in control of their situation and can often help them to avoid admission to bedded care. The Suicide Management Plan addresses access to lethal means and helps the patient and their clinician collaboratively develop a plan for removal of those means from their environment. This is one of the most vital aspects of suicide prevention, as impeding physical access to lethal means drastically reduces the risk of death by suicide in times of acute crisis.
Patient Engagement in Zero Suicide
The Zero Suicide pilot at St. Joseph’s invited suicide survivors and family members of those who had died by suicide or struggled with suicidal thoughts to be part of an advisory committee. This committee advised on all aspects of planning and implementation, including development of new tools and processes, selection of evidence-based assessments, wording of safety plans, and the introduction of the initiative to staff, patients, and families.
Patient representatives are included as part of the implementation working groups, where they join front-line clinicians, physicians, and administrators as processes and tools are developed. These patient members also advise on training and education, safety planning, communications to patients and families, among many other significant contributions. One patient member of the Safety Planning working group, Dr. Thomas Telfer, suggested using the previously described Coping Plan, rather than the community standard of a Crisis Plan. He identified that the goal should be to prevent patients from going into crisis in the first place. He advised, as a patient, “I can tell you that a suicide management plan is not enough. Patients need help to prevent them from potentially ever needing a suicide management plan. How can that not be part of zero suicide?” The working group was convinced and the Coping Plan was born. This contribution was invaluable and changed the entire course of the initiative in a positive way.
The project team finds innovative ways of reaching out to patients whenever there is a question about how to improve, or an instance where something was not working well. Rather than sit in their offices and make decisions about patient care, the team’s Clinical Lead spends a great deal of time on the units, side by side with patients and front-line staff, looking for opportunities to connect and to hear about how processes can be changed or improved. This patient-first philosophy is more than just words and is lived out every day by the project team. Rather than just taking snapshots in time, the team has a system for ongoing engagement with patients and families that is not usually part of hospital care.
For example, during the inpatient roll out, hospital staff and physicians shared a concern wondering if by asking about suicide more frequently, they might somehow increase suicidal ideation in the patients. Many suicide survivors share that they were not explicitly or sufficiently asked about suicide and felt that often the topic was uncomfortable for their provider. So, as part of the engagement process, the St. Joseph’s project team has also developed patient surveys to ask them how they would prefer to be asked about suicide and how often.
Patient engagement has been the most important contributor to the Zero Suicide process’s implemented across St. Joseph’s. The project team has been sharing its methodology and lessons learned with other organizations across the country, so the hard work of our patients and families is paying off in dividends as Zero Suicide works to improve suicide care nationwide.
Below, you will find a series of interviews that the CHA Learning team conducted during NHLC in 2019. They are of three members of the team: Dr. Sandra Northcott, who was the site chief for mental health at the time, Katerina Barton, who was the project lead, and Dr. Thomas Telfer, the patient partner involved in this project and who presented with the team. The fourth interview is of Dr. Telfer’s wife Patricia, who of course presents the incredibly important but often missed viewpoint of family members.
Dr. Sandra Northcott
Dr. Thomas Telfer