Why Boards Should Focus on Suicide Prevention
Addressing challenges and priorities through the trustee role
By Sue Ellen Wagner
I recently spoke with Cathy Frank, M.D., chair of Henry Ford Health’s Department of Psychiatry and Behavioral Health Services, to learn about how the health system is addressing suicide prevention, a vital public health issue that governing boards should know more about.
Sue Ellen Wagner:Why is suicide prevention a vital public health issue, and can you tell us about the Henry Ford Health Zero Suicide initiative?
Cathy Frank: In 2020, approximately 46,000 people in the United States took their life by suicide. In addition, an estimated 12.2 million people in the United States have suicidal thoughts at one time; about 3.2 million may develop a plan to end their life; and 1.2 million people actually make suicide attempts. If you translate this into causes of death, that makes suicide one of the top leading causes of death in the United States, and the second leading cause of death for children ages 10 to 14 and adults ages 25 to 34. Unfortunately, it is one of those major health problems that people don’t tend to talk about, nor does it get the same type of media attention or funding that other major health problems have. If you look at the last few years, most major illnesses in the United States have decreased in prevalence; unfortunately, suicide has increased by about 30%.
Suicide has been an abiding interest in psychiatry for many decades. The year 2001 was sentinel in looking at quality in health care. At that point, the Institute of Medicine published a book called “Crossing the Quality Chasm.” Gail Warden, who was the CEO of Henry Ford at the time, was one of the authors. That book shined a light on the fact that although we may think of health care as superior in the United States, it is often not. Not because people don’t care, but due to a number of processes and errors. After that book came out, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement decided to challenge health care organizations across the country to what they called Pursuing Perfection National Collaborative. They set aside $26 million and challenged health care to look at radical ways to improve quality.
Henry Ford Health’s Department of Psychiatry decided to apply for this grant, and we made it through the first cut but not the second; so we were not funded for an implementation grant. But it started us on a journey of thinking about how to improve quality within psychiatry, and at that time we began a project called Perfect Depression Care. It prompted us to define what would make depression care “perfect.” One obvious thing is that if depression care were perfect, no one would die from suicide. Even though the suicide rate of those treated at Henry Ford at that time was lower than comparable clinical populations nationally, we decided that to eliminate suicide was a valuable and achievable goal. This started a journey that continues to this day and has become an international movement to prevent suicide. The most revolutionary aspect of the project was deciding that the goal could only be zero. Looking at the automotive industry in Detroit, zero defects is a standard. We rarely consider zero defects in health care. We all may want zero defects, but as organizations we often set lower metrics.
Reaching zero became a revolutionary idea for Henry Ford Psychiatry. Not everyone internationally uses the same method to get to zero. We have been one of the sentinel organizations in suicide research and are very much involved in federally and privately funded research on suicide prevention.
What is the best method to get there? From the literature and research, we would say we have the best method, but that was our beginning part of our journey. We then developed guidelines and methods to get to zero — and actually achieved zero.
With the introduction of Henry Ford Health’s Zero Suicide initiative, we were able to reduce the rate of suicide among our patients by 80%, while the rate of suicide had increased nationally, including in the state of Michigan. And for about 18 months in 2009–2010, we achieved a rate of zero.
Wagner: Henry Ford Health has had many achievements in reducing suicide over the past several years. Can you tell us more about the success of the initiative?
Frank: There are a couple of key aspects to a zero suicide initiative. One is that often people think that asking a patient about whether they are suicidal is the best or to some the only predictor. We know that a denial of suicidal thoughts is actually a relatively poor predictor of suicide. One of the hallmarks of our program is looking at researched risk factors for suicide, of which there are many, as a means of gauging suicide risk.
Risk factors for suicide include previous suicide attempts, family history of suicide, moderate to severe depression, mania or psychosis. Other indicators include substance abuse, being an armed services member (either active or a veteran) and a history of traumatic brain injury in the previous year. There are numerous factors. What we have done over the years is taken those factors and divided them into acute, high, moderate and low risk. Notice I did not say “no risk” as we know that anyone who comes to a mental health facility for any problem by definition carries some risk. Our goal after identifying risk is to then work collaboratively with the patient to modify those risk factors through a variety of treatments and interventions.
There are a variety of strategies to reduce risk. First and foremost, we want to ensure that medication management and psychotherapy are evidence based. In addition, does this person need an inpatient setting or a partial hospitalization program or outpatient care? Do they need a rehab setting because they are abusing substances? How do I educate the patient about suicide risk, and how do I educate their significant others so they are aware of it? How do I change the way my clinics and hospitals operate so that patients have ready access if they need care?
As approximately 50% of suicide deaths are due to firearms, we also want to discuss lethal means with the patient as well as the family. We propose the use of self-management tools for patients. Henry Ford is increasingly looking at digital tools to supplement traditional psychiatric therapies. We also recommend community support systems such as Alcoholics Anonymous or other recovery groups.
Wagner: Can you talk about the role the board played in supporting the initiative from the beginning of its development, and also the board strategy for suicide prevention going forward?
Frank: The board at Henry Ford Health has always been robustly supportive of quality initiatives. To use a term that you sometimes see in the literature: It is a commitment to radical quality. Our board has supported that concept and the journey of Zero Suicide.
When you do any quality project, a just culture is important. And the only way I think people can move forward in quality improvement is with such a culture. Without question, people in the department looked to the board for guidance.
If they see the board as supporting an initiative, that also means quite a bit. So the board not only supported the concept but also contributed financial support for what we needed to get and where we needed to go. As you know, with Joint Commission and CMS, suicide is an important issue in this day and age, and it affects everything from medical-surgical beds to emergency rooms to primary care offices to behavioral health clinics and hospitals. We know that half of the people that take their lives may see a primary care physician within 30 days before their death. The board recognized that Zero Suicide and the principles underlying it are good for health care, wellness and for everybody — not just those who may come to a psychiatric clinic.
Wagner: Do you have any words of advice for other governing boards who have an interest in helping to decrease and prevent the number of suicides in their communities and among health care staff?
Frank: There remains a significant stigma regarding mental illness. For a board to talk about mental illness and mental health issues allows the rest of the staff and employees to talk about it too.
I think that COVID — despite how painful it has been for everyone in the United States and worldwide — pushed health care to talk more about burnout and stress in health care. As tragic as COVID has been, if I try to search for something good that came out of it, it might be that it allowed us to recognize the importance of emotional health and the terrible impact of mental illness.
Boards can be extremely important in supporting wellness not only for the patients under our care but also for our staff and employees. What psychiatry provides is indirect economic advantages to health care systems, and it obviously impacts the wellness and health of patients. So I think that boards should look at that aspect — indirect savings and what it means to patients, families, employees, staff — and not the bottom line.