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

Edwin D Boudreaux; Celine Larkin; Ana Vallejo Sefair; Eric Mick; Karen Clements; Lori Pelletier; Chengwu Yang; Catarina Kiefe

doi:10.1016/j.conctc.2022.100999

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

Contemp Clin Trials Commun. 2022 Sep 17:30:100999. doi: 10.1016/j.conctc.2022.100999. eCollection 2022 Dec.

Authors

Edwin D Boudreaux¹, Celine Larkin², Ana Vallejo Sefair¹, Eric Mick³, Karen Clements³, Lori Pelletier⁴, Chengwu Yang³, Catarina Kiefe³

Affiliations

¹ Departments of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA.
² Departments of Emergency Medicine and Psychiatry, UMass Chan Medical School, Worcester, MA, USA.
³ Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, USA.
⁴ Connecticut Children's Hospital, Hartford, CT, USA.

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.

Grants and funding

R01 MH112138/MH/NIMH NIH HHS/United States