QPR for Substance Abuse Professionals and Agencies

Thank you for your interest in preventing suicide.

An open letter…

Dear Counselor or Training Director:

If you are visiting this page, it is likely you or your agency has experienced one or more patient suicides.

A patient suicide is always an “unexpected event” that leads to a “brutal audit” of what went wrong.  As a “sentinel event” it may be reported to the Joint Commission, or to some funding source, a board or government agency.

An internal root cause analysis may follow, together with recommendations for change.

A lawsuit may be around the corner.

Question: Will this patient’s death affect the way you or your organization does business?

Background

The QPR Institute’s faculty is almost entirely cross trained in substance abuse and mental health. Our medical director, Dr. Richard Ries, is world famous in addiction medicine.  Ben Camp, M.S., is a college professor and an expert on suicide prevention and substance abuse.

Most of our faculty has also trained and supervised thousands of substance abuse counselors.

When it comes to substance abuse and suicide, we “get it.”

We also know that how to detect, assess, manage and treat suicidal patients has, until recently, not been the “standard of care” for most agencies and professionals working in the chemical dependency field.

These circumstances have now changed.

With SAMHSA’s recent Treatment Improvement Protocols (TIP 42 and 50) calling for greater education and attention to suicide prevention training and policy development, the QPR Institute is ready to help.

Organizational leadership is crucial

Leadership of any treatment facility, inpatient or outpatient, believes the consumers they serve are safe and will not die by suicide. 

Leadership is often mistaken.

In hospital and residential settings, patient suicide is now considered a “never event” – meaning the death should never have occurred.  Just like wrong-site surgery or sending a new baby home with the wrong mother, patient suicide is now seen as an avoidable medical error whose consequences are always horrific.

Moreover, if a patient suicide does happen, it is assumed something may be systemically amiss within the organization. 

A question has been asked by others of organizational leadership, “If zero patient suicide is not the goal of your organization, what is the number?”

Established social policy

In 2001 the National Strategy for Suicide Prevention was published and in 2002 the Institute of Medicine issued a report entitled, Reducing Suicide: a National Imperative.
The NSSP objective 7.3 reads, by 2005, increase the proportion of specialty mental health and substance abuse treatment centers that have policies, procedures and evaluation programs designed to assess suicide risk and intervene to reduce suicidal behaviors among their patients.”

With few exceptions, this recommendation has been ignored.

As a result, each day dozens of patients kill themselves while in our care, in our clinics and in our hospitals.

The fact that you are reading these words suggests that, perhaps, you or your organization may be ready to explore these recommendations and consider a commitment to change.

What we know

Experts agree that together with the provision of a safe treatment environment, competency-based training in the detection, assessment and management of suicidal patients can save lives.

We know that sobriety is the most important protective factor against suicide in persons suffering from addictive disorders.

We have a saying at the Institute, “There is no safety without sobriety.”

But without institutional leadership, individual practitioners cannot bring about the systemic changes necessary to prevent the “never event” of patient suicide.

Preventing patient suicide is seldom due to the failure of an individual employee, but rather is the result of organizational structure and function and, frankly, a lack of “mindfulness” about its operations and how to deal with known and unknown risk.

An invitation to change

We invite organizational leadership to explore patient safety from a different perspective, a perspective known to be effective in error prevention and the successful avoidance of loss of life.

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” or HROs.

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 patient safety practices, policies and protocols.

Patient suicide is a severe, irreversible, extremely harmful outcome. 

It is also avoidable.

If you or your organization are interested in exploring how to move from the aftermath of a recent “never event” patient suicide to consideration of adopting our suicide risk reduction training programs, we strongly encourage you to:

1. Read Managing the Unexpected: Resilient Performance in an Age of Uncertainty by Weick and Sutcliffe (John Wiley & Sons, 2007).
2. Conduct a desk audit of your organization’s current operational and training approach to suicidal patient safety (click here for a free sample audit checklist).
3. Explore our training programs and, as our guest, review any of those of interest.

We are also happy to explore options for the installation of our sustainable “best practice” training programs by telephone conference.

Thank you for your time.

Staff and Faculty, the QPR Institute