Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Sep 17:30:100999.
doi: 10.1016/j.conctc.2022.100999. eCollection 2022 Dec.

Studying the implementation of Zero Suicide in a large health system: Challenges, adaptations, and lessons learned

Edwin D Boudreaux  1 , Celine Larkin  2 , Ana Vallejo Sefair  1 , Eric Mick  3 , Karen Clements  3 , Lori Pelletier  4 , Chengwu Yang  3 , Catarina Kiefe  3
Affiliations

Studying the implementation of Zero Suicide in a large health system: Challenges, adaptations, and lessons learned

Edwin D Boudreaux et al. Contemp Clin Trials Commun. .

Abstract

Background: Suicide remains the 10th leading cause of death in the United States. Many patients presenting to healthcare settings with suicide risk are not identified and their risk mitigated during routine care. Our aim is to describe the planned methodology for studying the implementation of the Zero Suicide framework, a systems-based model designed to improve suicide risk detection and treatment, within a large healthcare system.

Methods: We planned to use a stepped wedge design to roll-out the Zero Suicide framework over 4 years with a total of 39 clinical units, spanning emergency department, inpatient, and outpatient settings, involving ∼310,000 patients. We used Lean, a widely adopted a continuous quality improvement (CQI) model, to implement improvements using a centralize "hub" working with smaller "spoke" teams comprising CQI personnel, unit managers, and frontline staff.

Results: Over the course of the study, five major disruptions impacted our research methods, including a change in The Joint Commission's safety standards for suicide risk mitigation yielding massive system-wide changes and the COVID-19 pandemic. What had been an ambitious program at onset became increasingly challenging because of the disruptions, requiring significant adaptations to our implementation approach and our study methods.

Conclusions: Real-life obstacles interfered markedly with our plans. While we were ultimately successful in implementing Zero Suicide, these obstacles led to adaptations to our approach and timeline and required substantial changes in our study methodology. Future studies of quality improvement efforts that cut across multiple units and settings within a given health system should avoid using a stepped-wedge design with randomization at the unit level if there is the potential for sentinel, system-wide events.

Keywords: (CQI), continuous quality improvement; (ED), Emergency Department; (EHR), lectronic health record; (GIS), Geographic Information Systems; (NIMH), National Institute of Mental Health; (SOS), System of Safety; Implementation science; Mental health; Quality improvement; Suicide; Suicide prevention.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Relation between zero suicide, best practice, lean CQI, and evaluation and outcomes.
Fig. 2
Fig. 2
Hub and spoke Team Design.
Fig. 3
Fig. 3
Definitions of Core Lean Tools to be Implemented During SOS.
See this image and copyright information in PMC

References

    1. Centers for Disease Control and Prevention CDC 10 leading causes of death by age group. 2014. https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_gr... United States - 2014. Retrieved from:
    1. Ahmad F.B., Anderson R.N. The leading causes of death in the US for 2020. JAMA. 2021;325(18):1829–1830. - PMC - PubMed
    1. Ting S.A., et al. Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008. Gen. Hosp. Psychiatr. 2012;34(5):557–565. - PMC - PubMed
    1. Holland K.M., et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatr. 2021;78(4):372–379. - PMC - PubMed
    1. Allen M.H., et al. Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. Suicide Life-Threatening Behav. 2013;43(3):313–323. - PubMed

LinkOut - more resources