The QPR Institute’s Suicide Risk Reduction Program
“People only accept change in necessity and see necessity only in crisis."
- Jean Monnet
A simple question:
How many suicides do you expect among those your organization serves?
Zero?
One every few years?
One or two per year?
One per month?
If zero is not the right number of suicides, what is the right number?
If you believe that the number of suicides experienced by the patients/students/consumers your organization serves is “within normal limits” you are part of the problem.
But since you are reading this, you could become part of the solution.
Our systems approach
As a national leader in suicide prevention training and education, the QPR Institute endorses all current and emergent consumer safety standards and expectations – including those for patients at elevated risk of suicidal behaviors.
Our systems approach to suicide risk reduction does not rest entirely on staff training or improved published policies, but on organizational leadership’s willingness to recognize a need for change.
Within established “cultures of safety” it is beliefs, values and actions that define an organization’s mission and outcomes. To prevent suicide, organizations must be willing to explore current practices, study error prevention and consider becoming a “high reliability organization.”
The QPR Institute’s Suicide Risk Reduction Program is built on the concepts, practices and operational philosophy of high reliability organizations.
HROs
High reliability organizations (HROs) are prepared to confront and mitigate the occurrence of “unexpected events” like patient or student suicide. HROs focus on failure and make every effort to avoid preventable errors by dealing effectively with emergent crises quickly.
The QPR Institute’s Systems Approach to Suicide Risk Reduction is modeled on the research and recommendations of Karl E. Weick and Kathleen M. Sutcliffe, and their studies of “high reliability organizations.”
These authors’ studies of nuclear power plants, air traffic controllers, aircraft carriers, hospitals and other high-risk work environments provide essential lessons and tools to help organizations address and improve safety practices, policies and protocols.
Patient, student or employee suicide is a severe, irreversible and extremely harmful outcome.
It is also avoidable.
In his endorsement of the Weick and Sutcliffe’s work, Donald M. Berwick, MD, MPP, president and CEO, Institute for Healthcare Improvement, and now acting administrator of the Centers for Medicare & Medicaid Services, states, “Improving patient safety has, at long last, risen high on the priority list – where it belongs – for healthcare leaders.”
Don’t be blindsided
The fundamental question any organization needs to ask itself is, “What is the worst thing that could happen to a person whose health and safety is our responsibility?”
Your staff may not ask this question, but you must.
For example, inpatient suicide is now listed by the Agency for Healthcare Research and Quality as a “never event” like wrong-site surgery. Basically, inpatient suicide should not happen. The fact that it does (estimated three hospital suicides per day in the US) suggests something needs fixing, but only if leadership accepts the premise that the number of expected suicides is zero.
Similarly, approximately three college students die by suicide each day in the US. If leadership assumes suicide occurs only on other campuses, and are assured by staff that students on their campus are “safe,” it is only a matter of time until leadership may be forced to deal with an unexpected event that could produce, as in the case of Virginia Tech, lasting and permanent damage to the reputation and financial health of a college or university.
Studies of organizations show that persons in high positions of power often get nothing but “filtered” information and usually “good news.”
When bad news must be reported – including patient or student suicide – it will likely be slanted, minimized and accompanied by a minor recommendation for a tweak in policy or that a staff person needs more training.
Information “filtered” up to you through your chain of command can lead to poor management decisions. After the crash of the Columbia, the Columbia Accident Investigation Board identified a lack of deference to expertise (at the ground level) as a key contributor to the tragedy. After Katrina, FEMA’s filtering of damage reports to President Bush led to severe, avoidable adverse outcomes, including placing a permanent stain on his presidency.
If you are the ED or CEO and only listen to your program directors where patients at risk of suicide are served in clinical care settings, you may be listening to the wrong people. Their need to “look good to the boss” can severely limit critical information you need to make the right policy decisions and take the right actions.
In HROs management gets "grease on its hands" by learning directly from line staff what safety concerns they have, what risks are known, what risks are unknown, and what line staff believe can be done to mitigate both known and unknown risks.
Such organizations become both “mindful” and “resilient.”
In a clinical setting, what percentage of your active patients has experienced the single most powerful predictor of eventual death by suicide?
One percent?
Ten percent?
Fifty percent?
A suicide attempt by history is the single best predictor of patient suicide.
If your clinical staff cannot answer this question, you cannot answer this question, and if you cannot answer this question, are you sufficiently informed about what screening procedures, assessment protocols and training need to be in place to not just to identify this risk, but mitigate it?
If your organization is interested in exploring how to move from the aftermath of a recent “never event” to consideration of adopting our suicide risk reduction training programs, we strongly encourage you to: After you have conducted your review, we invite you to explore our integrated, licensed, modularized, registered “best practices” menu of exportable online or onsite classroom training options. We provide train-the-trainer services as well.
As an early adopter of our systems model, we invite you to review the program “in action” by viewing the slide presentation provided here by the Devereux Foundation when it was invited to keynote the Joint Commission’s 2009 Conference on Patient Safety. You will be able to see, graphically, how a systems model actually works and – provided sustainability of the program is maintained by your leadership - the results you might reasonably expect. According the US Air Force study (link to PDF), a systems approach to creating a culture of safety to prevent suicide is likely to reduce rates of:
We are also happy to explore options for the installation of our programs by telephone conference.
Thank you for your time.
Staff and Faculty, the QPR Institute A second simple question:
Time to change?