How Boards Can Support Suicide Prevention Initiatives
Hartford HealthCare’s Marissa Sicley-Rogers and Jennifer Ferrand discuss their Zero Suicide Initiative
By Sue Ellen Wagner
September is National Suicide Prevention Awareness Month. AHA Trustee Services is hoping to educate our readers about suicide prevention and the role that hospital and health system boards can play in this important public health issue.
In 2015, Hartford (Conn.) HealthCare’s Institute of Living was one of the first 20 organizations worldwide to be accepted into and trained by The Zero Suicide Academy, a two-day training for senior leaders of health and behavioral health organizations seeking to reduce suicide among patients in their care.
Sue Ellen Wagner, vice president, trustee engagement and strategy at the AHA, interviewed Marissa Sicley-Rogers, operational lead for Hartford HealthCare’s Behavioral Health Network (BHN) Zero Suicide initiative, and Jennifer Ferrand, director of well-being at Hartford Healthcare, to learn more about how boards can support suicide prevention programs.
Sue Ellen Wagner: Can you tell us about Hartford HealthCare’s Zero Suicide Initiative? Please also discuss the successes you have had with the program and any plans to enhance it.
Marissa Sicley-Rogers: Suicide prevention is a foundational element of Hartford HealthCare’s organizational commitment to reduce harm and our Balanced Scorecard goal of creating a culture of safety. Our Zero Suicide journey began in 2016 when leaders from one of our behavioral health hospitals attended the Zero Suicide Academy and learned how to implement this quality and safety initiative for transforming suicide prevention in health and behavioral health care systems. In 2018, we expanded this work to all of our behavioral health service areas, reflecting our commitment to the aspirational goal of zero suicide deaths among individuals in our care. Hartford HealthCare’s Behavioral Health Network is comprised of seven different behavioral health entities providing services to individuals across the lifespan including psychiatric inpatient, residential, partial hospitalization, intensive outpatient and outpatient care. After focusing on our behavioral health areas for the first several years, we are now in the process of expanding our Zero Suicide efforts to non-behavioral health settings as well.
Our work has been guided and informed by the Zero Suicide model, which is both a set of tools and a commitment to the fundamental belief that suicide is preventable. There are seven core elements of a Zero Suicide culture: Lead, Train, Identify, Engage, Treat, Transition and Improve. Our organization has successfully developed and implemented standard Zero Suicide practices aligned with all elements. I’ll highlight several of our key accomplishments that reflect the mission of this framework.
In order to effectively treat individuals with suicidal ideation and behavior, we need a systematic way of identifying who is at risk. To accomplish this, we selected and implemented a single suicide screening measure across all our settings and collaborated with our IT and clinical informatics partners to build a tool into our electronic health record that will support suicide screening, comprehensive risk assessment, clinical decision support and effective documentation. This ensures a standardized approach to suicide risk assessment across the system with a universal language and objective risk stratification, and is compliant with The Joint Commission’s national patient safety goal for suicide risk assessment. Not only does this allow us to better identify individuals at risk, but our providers are pleased to have a tool that prompts complex decision-making and streamlines documentation.
We have learned that one of the most impactful things organizations can do to prevent suicide attempts and deaths is to reduce access to lethal means, such as using a lock box. Several BHN entities have been involved in a statewide Lockbox initiative sponsored by United Way of Connecticut. This involves disseminating lockboxes to patients and families and providing Counseling on Access to Lethal Means (CALM). Since May 2020, we have disseminated almost 900 lockboxes. Other accomplishments include developing and implementing an electronic safety plan document that can be viewed and utilized across treatment settings by both patients and their treatment teams.
Transitions through care have been an equally important point of focus for our organization. Transition from inpatient psychiatric care, in particular, is a vulnerable, high-risk time. Studies have shown that post-discharge telephone calls reduce risk of suicide attempts. We developed a standard process known as Caring Connection Calls, which reflects Hartford HealthCare’s core value of caring and provides a critical opportunity for the system to assist the patient transitioning from different levels of care, follow up on missed appointments and check in on patients who have been identified as at higher suicide risk. Additionally, a growing body of research has demonstrated the effectiveness of proactive outreach as a means of reducing suicide attempts or ideation among those at risk. We partnered with a scented greeting card company to deliver a beautiful handmade product to our patients with messages of hope in support of their mental health journey. This project was also a clinical intervention for our patients as they wrote these inspiring messages. Future goals include enhancing our care transitions and patient engagement with this kind of non-demand outreach — such as cards, letters and text messages — and exploring ways technology may optimize efforts.
We have also focused on improving the safety of our environments of care and, in doing so, have established standards for ligature risk assessment and mitigation. All BHN inpatient units conduct quarterly risk assessments to identify and mitigate ligature risks in the care environments. All findings are documented in a standard system, and all ligature-free equipment is purchased from a standard guide. Rounding teams include staff from other entities. Having their fresh eyes enhances our detection of ligature risk in care environments.
Importantly, while we strive to make suicide a never event, we know we need to have an organized response support plan, known as postvention, in the event of a suicide death. The Postvention Team, which provides peer-to-peer support, was implemented as part of a broader Postvention Plan providing guidance for employees and programs, and direction on supporting families and other patients coping with loss. As part of the postvention process, we also routinely review safety event-related data and opportunities for growth and improvement in our operational and documentation processes.
These are just some examples of key organizational accomplishments and continued areas of focus that are in line with the Zero Suicide framework. We’ve made significant progress in our behavioral health settings. One of our next areas of focus will be to ensure that suicide risk screening occurs in our emergency department and primary care settings as routinely as it does in behavioral health. Moving our efforts further upstream to identify individuals who may be at early risk for suicide allows us to intervene sooner and more effectively, consistent with a primary prevention model of care.
Wagner: Have the rates of suicide increased during COVID?
Sicley-Rogers: The national suicide rate decreased for the first time in 10 years by roughly 2% from 2018 to 2019 and was staying at a lower rate during 2020. In Connecticut from 2018 to 2020, the rates of suicide for different age groups either declined or remained relatively stable. However, the literature supports that there should be more concern about a rise in suicide attempts and deaths now rather than at the height of a pandemic. For example, 2021 data showed significant increases in risk for suicide or self-injury in children. Additionally, the current workforce shortage heightens existing health care capacity issues. This is a cause for major concern as the need for care continues to increase and places an even greater demand on an already taxed workforce.
Wagner: Can you tell us a little bit about what the role is of the health system staff in the Zero Suicide Program?
Sicley-Rogers: The health system’s staff role is two-fold. First, we adopted the mission of Zero Suicide — that is, believing one suicide is too many and aspiring to eliminate suicide — and do the work of Zero Suicide with our patients. To accomplish this, during early adoption of Zero Suicide, our team obtained buy-in and investment from system leadership to make it an organizational priority by allocating support, time and resources to develop staff competency in delivering Zero Suicide-driven care. We also developed a system-level governance structure that includes subject matter experts to facilitate the work of each Zero Suicide project. Importantly, our governance structure includes individuals with lived experience and is aligned with both Zero Suicide best practices and the BHN’s recovery model.
Secondly, and in response to staff requests in organizational surveys, we provide systematic training in suicide risk assessment, collaborative safety planning and caring connection calls. We are also in the process of developing ligature awareness training so all staff are more competent at identifying safety risks in their specific care environments. Future goals include systematically training all staff in CALM and launching system-wide expectations for onboarding and annual review, along with annual staff competency assessments.
Wagner: Jennifer, Can you tell us what the board’s role is in this initiative?
Jennifer Ferrand: The board’s role is approval and sponsorship of our mission and initiatives, support for allocation of resources, and facilitation of communication both within the organization and between the organization and others in the broader community.
Suicide prevention is everyone’s work. When there is awareness of the importance of this work and commitment at the highest level of the organization, that commitment can be turned into actionable steps that can be meaningfully undertaken by all parts of the organization and its strategic community partners. In Hartford HealthCare, BHN leadership presents our suicide prevention efforts to each regional and parent board, and we are grateful for the board’s interest and engagement in this work.
Wagner: Can you inform us about Hartford HealthCare’s well-being initiatives to assist staff?
Ferrand: This is a really important question because we know our workforce is suffering. More than 50% of health care workers experience at least one symptom of burnout, including emotional exhaustion, reduced effectiveness or a sense of distance from one’s job.
Coupled with current workforce shortages, growing incivility, moral injury and other ongoing stressors, health care workers are at increased risk for mental health problems. Rates of suicide among health care workers are dynamic, but we believe 300 to 400 physicians die by suicide every year in the United States. Recent evidence suggests that nurses experience even higher rates of suicide than physicians, and female health care providers are at significantly higher risk for suicide than women in the general public. Due to the unacceptable risks to the well-being of our health care workforce, Hartford HealthCare established a system-wide Well-Being Department charged with improving the well-being culture and the system of care, and delivering support and resources to leaders, teams and colleagues.
Since its inception in 2019, the Well-Being Department has worked to improve the health care system by promoting a culture of well-being, supporting workplace safety and efficiency, and building personal and organizational resilience. Despite the challenges of COVID-19, and in anticipation of continued post-pandemic societal challenges, Hartford HealthCare has shown an unwavering commitment to this work. Our specific efforts, achieved through collaboration with many strategic partners, aim to put resources directly into the hands of our workforce, support and train our leaders, build models of team-based care and improve efficiency by streamlining processes and removing unnecessary tasks.
An important element of our well-being strategy, aligned with the National Academy of Medicine’s 2022 National Plan for Health Workforce Well-Being, is to support mental health and reduce stigma by increasing access to free and confidential support resources and decreasing barriers to utilization. Our patient-facing Zero Suicide initiative provides a framework for the development of a workforce suicide prevention program. Our vision for an ideal health care worker suicide prevention program includes five elements we’re currently prioritizing:
1. Education and training. To teach clinicians and colleagues how to recognize a colleague in crisis and intervene effectively, and promote self-reflection and early intervention in ourselves when we need help.
2. Support resources. Enhance access and proactively connect clinicians and colleagues to the behavioral health continuum of care, including peer support. This might include funding to support the mental health of health care workers and providing mental health care that is opt-out instead of opt-in.
3. Creating a culture of well-being. This includes removing structural barriers such as licensing and credentialing issues that prevent health care workers from getting help, dispelling myths and fears that prevent people from seeking mental health treatment, and supporting leaders as they set an example by seeking help for themselves and talking openly about it.
4. Advocacy. At a local and national level, conduct research to better understand the causes and solutions of health care worker burnout and create a road map for other health care organizations to follow.
5. Policies and procedures. Measure the burnout of our workforce annually, reporting and acting on the results, and creating policies and procedures for training the workforce and intervening proactively when someone’s in trouble.
Wagner: Can you provide insight for other hospitals or health system boards who want to focus on suicide prevention — how should they begin the discussion and what resources they will need?
Ferrand: Given the current threats to mental health and well-being in our communities, suicide prevention needs to be prioritized at the highest level in all health care organizations. Without a similar commitment to the well-being of the workforce, organizations will have difficulty achieving key goals around population health, patient experience and per capita cost.
After obtaining leadership commitment and engagement, we’ve learned that an important next step is assessing and building the organization’s capacity for measurement, both of patient outcomes as well as fidelity to the model of care. We’ve learned that technological infrastructure as well as coordination with external partners is necessary to support data collection and analysis. We’ve also learned that achieving quick wins early in the journey makes people feel good and helps the workforce stay motivated to do the difficult work of suicide prevention. At Hartford HealthCare, focusing on effective transitions through care and increasing the number of touches on our high-risk patients has had a positive impact on patients and colleagues. Increasing our opportunities to connect humanistically with the individuals we serve promotes both suicide prevention and workforce well-being.
Sue Ellen Wagner (firstname.lastname@example.org) is vice president, trustee engagement and strategy, at the American Hospital Association.
Please note that the views of interviewees do not always reflect the views of the AHA.