Zero Suicide © Organizational Self Assessment
Automated for ease of use
Date of Survey Submission:
-
Month
-
Day
Year
Date
Submitted by:
First Name
Last Name
Email:
example@example.com
This form is best filled out by a leadership team consisting of people who know the (a) clinical operations, (b) quality processes, (c) electronic record capabilities, and (d) executive vision. Please list the Name and Title of each person who participated in this process with you.
Name of your organization:
Please Select
ABIT CONSULTING GROUP
ABSTINENT LIVING/TURNING PT
AC3/ DAVIS ARCHWAY HOUSE
ACCLAIM AUTISM
ADELPHOI VILLAGE
ALIFF COUNSELING SERVICES LLC
ALL BRIGHT ABA LLC
ALLIES FOR GLOBAL HEALTH (Ellie Mental Health)
ALNAHHAL BEHAVIOR COUNSELING SERVICES INC
ALPINE COUNSELING LLC
ALTERNATIVE COUNSELING SA-NONHOSP
ANGEL E MCCURDY CP
ANGELCARE ABA LLC
APPLEBY COUNSELING LLC
ARS
ASCEND CLINICAL SERVICES
AVANTI COUNSELING
AVENUES RECOVERY MEDICAL CENTER AT VALLEY FORGE
B AND B THERAPY SOLUTION INC
BALANCED LIFE COUNSELING LLC
BALANCED WORLD
BEATA PECK LITTLE LPC
BEHAVIOR INTERVENTIONS IBHS
BEHAVIOR THERAPY INTERNATIONAL LLC IBHS
BEHAVIORAL HEALTH COUNSELING SERVICES LLC
BEHAVIORAL HEALTHCARE CORP MH-CLINIC
BEHAVIORAL SOLUTIONS MEDICAL
Belmont Behavioral Hospital
BERWICK HOSPITAL CENTER
BETTE A LANDIS LCSW
BLUEBIRD COUNSELING LLC
BLUEPRINTS FOR ADDICTION RECOVERY INC
BOWLING GREEN BRANDYWINE SA-NONHOSP
BRADFORD RECOVERY CENTER LLC SA-NONHOSP
Bradley Center, Inc
BREAKTHROUGH MUSIC THERAPY LLC
BRIGHT BEGINNINGS THERAPEUTIC SERVICES LLC DBA ATTAIN ABA
Brooke Glen Behavioral Hospital IP Psych
BTI CENTER SERVICES IBHS
BY YOUR SIDE COUNSELING
CAMPBELL PSYCHOLOGICAL SERVICES
CAROLYN A MOTTOR-RIVERA LPC
CAROLYN T BRUEY PSYD
CATHOLIC CHARITIES INC
CENTER FOR BEHAVIORAL HEALTH
CENTER FOR HOPE AND HEALING LLC
Chambersburg Hospital IP Hosp
CHESTER COUNTY INTERMEDIATE UNIT IBHS
CHI ST JOSEPH CHILDRENS HEALTH
CHILDRENS CTR FOR TREATMENT & ED RTF
CHILDRENS HOME OF YORK
CHOR YFS CAROLE AND RAY NEAG CENTER
Clarion Hospital IP Hosp
CLARVIDA IBHS
Clem-Mar House, Inc.
CMU TCM (Pathways Forward)
CNNH Therapy dba NEURABILITIES HEALTHCARE
COBYS FAMILY SERVICES INC
Cohan Counseling Services
COLLABORATIVE MENTAL WELLNESS
COMMONWEALTH CLINICAL GROUP
COMMUNITY CARE AND ADDICTION RECOVERY SERV
COMMUNITY SPECIALIST CORP
COMPREHENSIVE CARE COUNSELING LLC
CONESTOGA BEHAVIORAL SERVICES LLC
CONNECTIONS PA LLC
COREY LEE ALLEMAN
Cornell Abraxas, Inc
County of Dauphin Crisis
CSG
CUMBERLAND-PERRY D&A COMM SA-OP
D&A REHAB SERVICES SA-NONHOS
DALL, ANNE V.
DANA R KEENER CP
DAWN CROSSON CP
DAYSTAR CENTER
DEBORAH A FUSS LCSW
DEBORAH STAUFFER LCSW
DEVINE GUIDANCE LLC
DIAKON
DIANNE E ELSOM LCSW
DIVERSIFIED TREATMENT ALTERNATIVE CENTERS
DOWNTOWN COUNSELING CTR LLC
DR KENNETH G SMALL AND ASSOCIATES
DR YESENIA COLON RIVERA PSYCHOLOGICAL SERVICES LLC
DUBOIS REGIONAL MED CTR
Eagleville Hospital
EARLY PSYCHIATRIC AND COUNS SVCS
EAST END BEHAVIORAL HEALTH
ELEVATED MENTAL HEALTH SERVICES
ELWYN OF PENNSYLVANIA AND DELAWARE
EM&E HEALTH PLLC
EMPATHWAY COUNSELING LLC
EMPOWERING MINDS BEHAVIORAL HEALTH PLLC
ERICKA PINCKNEY LPC
ERROL M AKSU
ESPERANZA HOPE
EVIDENCE BASED THERAPY AND WELLNESS LLC
EXCENTIA HUMAN SERVICES
EXPRESSIVE PATHWAYS IBHS
FAIRMOUNT BH
FAMILY FIRST HEALTH CORPORATION - FQHC
FINDING NORTH COUNSELING LLC
FIRETREE
FOCUS COUNSELING SERVICES LLC
FOUNDATIONS BH
FRANKLIN FAMILY SERVICES
FRANKLIN/FULTON D&A
FREEMAN M CHAKARA PC
FRESH START COUNSELING CENTER LLC
FRIENDS BH SYS
FRITZ COUNSELING SERVICES INC
Gateway Rehabilitation
GAUDENIZA
Genesis House, Inc.
GEORGE JR REPUBLIC-RTF SPECIAL 7
GETHSEMANE COUNSELING & COACHING
Good Friends, Inc.
Good Vibes Counseling LLC
GOOD WORKS LIFE RECOVERY HOUSE
GYM-JAM THERAPEUTICS INC
Hamilton Health Center FQHC
HANNAH L AVERS LCSW
Harborcreek Youth Services
HAROLD J MILLER CP
HARRISBURG AREA LEARNING ACADEMY
Harwood House
HAVEN
HELPING HANDS FAMILY PENNSYLVANIA LLC
HEMPFIELD BEHAVIORAL HEALTH
HERSHEY MED CTR
HIGHLAND HOUSE
Hoffman Homes, Inc.
HOLCOMB BH SYSTEMS
HOLISTIC BEHAVIORAL HEALTH IBHS
HOLISTIC WELLCARE COUNSELING LLC
HOLY SPIRIT HOSP
HUGH S SMITH PHD AND ASSOC
HUNTINGTON CREEK REC CTR ADULTS
INNER VISION COUNSELING SERVICES INC
INTEGRATIVE COUNSELING SERVICES PC
J.C. BLAIR MEM HOSP
JAMES A HECK PHD
JEANNE M FISK
JEWISH FAMILY SERVICES
JOANNE PANTANELLA-CRUMLING LCSW
JOHN T HOWER
JOSEPH YASKIN
KELLY S DRYZAL LPC
KENNETH SUTTON PC
Keystone Rural Health Center FQHC
KEYSTONE SERVICE SYSTEMS PSS
KIDSPEACE CHILDRENS HOSPITAL INC
KIMBERLY A LOVELOCK PSYD
KIRKBRIDE CENTER
KISSEL HILL COUNSELING ASSOCIATES
KOSTE, THOMAS
KPB WEWER LLC
KREM CAPITAL
L L MULHOLLEM COUNSELING AND PSYCHOTHERAPY LLC
LANCASTER BEHAVIORAL HEALTH HOSPITAL
LANCASTER CO BH & DEV SERV CRISIS
LANCASTER GENERAL HOSPITAL
LaRocco Counseling Inc
LAUREL LIFE SERVICES
LEBANON CO COMMISSION ON D&A
LEBANON COUNTY MH/ID/EI
LEBANON TREATMENT CENTER
Libertae, Inc. SA-NonHosp
LIFE AND LOVE COUNSELING LLC
LIFE SOLUTIONS BEHAVIORAL COUNSELING SERVICES
LIFESPAN PSYCHOLOGICAL SERVICE
LIVING UNLIMITED INC
MAGIS MENTAL HEALTH, LLC
MAHANTAM INC dba SUCCESS ON THE SPECTRUM
MALVERN CONSTITUTION LLC
MARC L TURGEON DO
MARK A ZENGERLE
MARTHALEE T BROD CP
MATTERS OF THE HEART COUNSELING LLC
MAZZITTI AND SULLIVAN
MEADOWS PSYCH CTR
MEDITELECARE OF PENNSYLVANIA LLC
MELINDA C BIDDLE LPC
MENTAL PEACE PSYCHIATRY LLC
MERAKEY STEVENS CENTER FBMH
MHA OF FRANKLIN COUNTY PSS
MICHAEL C BUONOMO CP
MICHAEL MEKETON LCSW
MICHELE MARTIN CP
MOHR COUNSELING SERVICES LLC
MOMENTUM SERVICES, LLC
MONTGOMERY CO EMERG SVCS
MOUNTAIN VIEW COUNSELING LLC
MUKHERJEE, SATYAJIT
MULTICULTURAL COUNSELING AND CONSULTING LLC
MUMMAU, KAREN A.
Naaman Center
NASR
NEW DIRECTION WELLNESS CENTER FUNCTIONAL PSYCHIATRY LLC
NEW HORIZONS COUNSELING SERVICES INC
NEW JOURNEY FAMILY CENTER
NEWPORT COUNSELING CENTER
NICHOLAS PAPPAS PHD
NOAHS HOUSE INC
NUESTRA CLINICA
ONE STOP WELLNESS
OUTSIDE IN SCHOOL
PA COMPREHENSIVE BEHAVIORAL HEALTH IBHS
PA COMPREHENSIVE BH SVCS
PA COUNSELING SVCS
PA Mentor, Inc.
PA PSYCHIATRIC INSTITUTE IP PSYCH
PARAGON BEHAVIORAL HEALTH SERVICES LLC
PATHWAYS COUNSELING SERVICES
PEERSTAR LLC PSS
PENN STATE HEALTH COMMUNITY MEDICAL GROUP
PERRY HUMAN SERVICES
PERSEUS HOUSE INC
PHOENIX DOMUS LLC
PHOENIX MENTAL HEALTH SERVICES LLC
PINNACLE HEALTH MEDICAL SERVICES
POCONO MOUNTAIN RECOVERY CENTER
PONESSA BEHAVIORAL HEALTH
Pressley Ridge Schools
PYRAMID HEALTHCARE INC SA OP
R3 Recovery Services
READING BEHAVIORAL HEALTHCARE LLC
RECHARGE YOUR LIFE LLC
RECOVERY INSIGHT INC PSS
REDEMPTION WELLNESS SERVICES LLC
RESILIENT ROOTS THERAPY LLC
RESOLVE MENTAL WELLNESS LLC
RESTORE COUNSELING SERVICES LLC
RESTORING BALANCE COUNSELING LLC
RIVERSIDE ASSOCIATES PC
ROBERT M STEIN
ROGER B KELLY CP
ROGERS, KENNETH
Roots of Healing LLC
ROXBURY PSYCHIATRIC HOSP
Sadler Health Center Corp FQHC
SAMARA HOUSE SA-NONHOSP
SAMARITAN COUNSELING CENTER
Sarah A. Reed Children's Center
SARAH JANE BENTLEY FOUNDATION
Sasha Winters
SHA-RON D ALLEN LPC
SILVERLINING HEALTH AND WELLNESS
SMALL, KENNETH G.
SOJOURNER HOUSE
SOLEANA SILVA LCP
SOLEDAD ARROYO-SILVA LPC
SOUTHWOOD PSYCH HOSP
SUBSTANCE ABUSE SVCS
Summit School
SUN POINT FOUNDATION INC
SUSAN E FARNSWORTH
SWANK EARLY SKILLS DEVELOPMENT LLC
TEAMCARE BH
TEEN CHALLENGE WESTERN TRAINING CTR INC
TENIOLA O OSUNDEKO LCSW
TERI HAGEN PC
THE BGH CLINIC
THE MINDFUL OASIS
THE RETREAT AT WHITE BIRCH
THERAPY GROUP LLC
THOUGHTFUL WELLNESS LLC
THRIVE COUNSELING CONSULTING TRAINING AND WELLNESS
TIMOTHY S ZEIGER PSYD PLLC
TOWSEY, CARLA
TRANSFORMATIVE PATHWAYS LLC
TRANSFORM YOUR LIFE COUNSELING LLC
Treatment Trends, Inc.
TRUENORTH WELLNESS
UNION COMMUNITY CARE
UNIVERSAL HS RECOVERY-KEYSTONE SA-NONHOSP
UPMC-Altoona
VISTA FOUNDATION
WB MUSIC THERAPY LLC
WEIGEL COUNSELING ASSOCIATES
WELCOMING CONNECTIONS LLC
WELLSPAN PHILHAVEN
WHITE DEER RUN COVE FORGE SA-NONHOSP
WHOLE LIFE COUNSELING & CONSULTING
WILLIAMSTOWN COUNSELING LLC
WINNERS CIRCLE CENTER INC
YOUTH ADVOCATE PROG FBMH
YOUTH COUNSELING SERVICES LLC
ZIEGLER CHRISTOPHER J
Who is point person for your organization on the Zero Suicide topic:
First Name
Last Name
What type of commitment has leadership made to reduce suicide and provide safer suicide care?
1) The organization has no processes specific to suicide prevention and care, other than what to do when someone mentions suicide during intake or a session.
2) The organization has 1-2 formal processes specific to suicide care.
3) The organization has written processes specific to suicide care. They have been developed for at least 3 different components of Zero Suicide.
4) The organization has processes and protocols specific to suicide care. They address at least 5 components of Zero Suicide. Staff receive training on processes as part of their orientations or when new ones developed. Processes are reviewed and modified at least annually.
5) Processes address all components of Zero Suicide listed above. Staff receives annual training on processes and when new ones are introduced. Processes are reviewed and modified annually and as needed.
Comment:
Screening
Do you have a written agency protocol specific to this component of suicide care?
Yes
No
Is this component embedded in your electronic health record or easily identifiable in your written documentation?
Yes
No
Do you provide staff training specific to this component of suicide care?
Yes
No
Assessment
Do you have a written agency protocol specific to this component of suicide care?
Yes
No
Is this component embedded in your electronic health record or easily identifiable in your written documentation?
Yes
No
Do you provide staff training specific to this component of suicide care?
Yes
No
Lethal Means Restriction
Do you have a written agency protocol specific to this component of suicide care?
Yes
No
Is this component embedded in your electronic health record or easily identifiable in your written documentation?
Yes
No
Do you provide staff training specific to this component of suicide care?
Yes
No
Safety Planning
Do you have a written agency protocol specific to this component of suicide care?
Yes
No
Is this component embedded in your electronic health record or easily identifiable in your written documentation?
Yes
No
Do you provide staff training specific to this component of suicide care?
Yes
No
Suicide Care Management Plan
Do you have a written agency protocol specific to this component of suicide care?
Yes
No
Is this component embedded in your electronic health record or easily identifiable in your written documentation?
Yes
No
Do you provide staff training specific to this component of suicide care?
Yes
No
Back
Next
Save & Continue
Create a Leadership-Driven, Safety-Oriented Culture
What type of formal commitment has leadership made through staffing to reduce suicide and provide safer suicide care?
1) The organization does not have dedicated staff to build and manage suicide care processes.
2) The organization has one leadership or supervisory individual who is responsible for developing suicide-related processes and care expectations. Responsibilities are diffuse. Individual does not have the authority to change policies.
3) The organization has assembled an implementation team that meets on an as-needed basis to discuss suicide care. The team has authority to identify and recommend changes to suicide care practices.
4) The organization has a formal Zero Suicide implementation team that meets regularly. The team is responsible for developing guidelines and sharing with staff.
5) The Zero Suicide implementation team meets regularly and is multidisciplinary. Staff members serve on the team for terms of one to two years. The team modifies processes based on data review and staff input.
What is the role of suicide attempt and loss survivors in the organization's design, implementation, and improvement of suicide care policies and activities?
1) Suicide attempt or loss survivors are not explicitly involved in the development of suicide prevention activities within the organization.
2) Suicide attempt or loss survivors have ad hoc or informal roles within the organization, such as serving as volunteers or peer supports.
3) Suicide attempt or loss survivors are specifically and formally included in the organization’s general approach to suicide care, but involvement is limited to one specific activity, such as leading a support group or staffing a crisis hotline. Survivors informally provide input into the organization’s suicide care policies.
4) Suicide attempt and loss survivors participate as active members of decision-making teams, such as the Zero Suicide implementation team.
5) Suicide attempt and loss survivors participate in a variety of suicide prevention activities within the organization, such as sitting on decision-making teams or boards, participating in policy decisions, assisting with employee hiring and training, and participating in evaluation and quality improvement.
Comment:
Develop a Competent, Confident, and Caring Workforce
How does the organization formally assess staff on their perception of their confidence, skills, and perceived support to care for individuals at risk for suicide?
1) There is no formal assessment of staff on their perception of confidence and skills in providing suicide care.
2) Clinicians who provide direct patient care are routinely asked to provide suggestions for training.
3) Clinical staff complete a formal assessment of skills, needs, and supports regarding suicide care. Training is tied to the results of this assessment.
4) A formal assessment of the perception of confidence and skills in providing suicide care is completed by all staff (clinical and non-clinical). Comprehensive organizational training plans are tied to the results.
5) A formal assessment of the perception of confidence and skills in providing suicide care is completed by all staff and reassessed at least every three years. Organizational training and policies are developed and enhanced in response to perceived staff weaknesses.
What basic training on identifying people at risk for suicide or providing suicide care has been provided to NON-CLINICAL staff?
1) There is no organization-supported training on suicide care and no requirement for staff to complete training on suicide risk identification.
2) Training is available on suicide risk identification and care through the organization but not required of staff.
3) Training is required of select staff (e.g., crisis staff) and is available throughout the organization.
4) Training on suicide risk identification and care is required of all organization staff. The training used is considered a best practice and was not internally developed.
5) Training on suicide risk identification and care is required of all organization staff. The training used is considered a best practice. Staff repeat training at regular intervals.
Please indicate the training approach or curriculum the organization uses to train all staff on suicide risk identification and care:
Please indicate the minimum number of hours of training required annually for staff in suicide risk identification and care:
What advanced training on identifying people at risk for suicide, suicide assessment, risk formulation, and ongoing management has been provided to CLINICAL staff?
1) There is no organization-supported training on identification of people at risk for suicide, suicide assessment, risk formulation, and ongoing management, and no requirement for clinical staff to complete training on suicide.
2) Training is available on identification of people at risk for suicide, suicide assessment, risk formulation, and ongoing management through the organization, but it is not required of clinical staff.
3) Training is required of select staff (e.g., psychiatrists) and is available throughout the organization.
4) Training on identification of people at risk for suicide, suicide assessment, risk formulation, and ongoing management is required of all clinical staff. The training used is considered a best practice and was not internally developed.
5) Training on identification of people at risk for suicide, suicide assessment, risk formulation, and ongoing management is required of all clinical staff. The training used is considered a best practice. Staff repeat training at regular intervals.
Please indicate the training approach or curriculum the organization uses to train clinical staff on advanced suicide prevention skills:
Systematically Identify and Assess Suicide Risk
What are the organization's policies for screening for suicide risk?
1) There is no systematic screening for suicide risk.
2) Individuals in designated higher-risk programs or categories (e.g., crisis calls) are screened.
3) Suicide risk is screened at intake for all individuals receiving behavioral health care.
4) Suicide risk is screened at intake for all individuals receiving either health or behavioral health care and is reassessed at every visit for those at risk.
5) Suicide risk is screened at intake for all individuals receiving health or behavioral health care and is reassessed at every visit for those at risk. Suicide risk is also screened when a patient has a change in status: transition in care level, change in setting, change to new provider, or potential new risk factors (e.g., change in life circumstances, such as divorce, unemployment, or a diagnosed illness).
How does the organization screen for suicide risk in the people it serves?
1) The organization relies on the clinical judgment of its staff regarding suicide risk.
2) The organization developed its own suicide screening tool but not all staff are required to use it.
3) The organization developed its own suicide screening tool that all staff are required to use.
4) The organization uses a validated screening tool that all staff are required to use.
5) The organization uses a validated screening tool and staff receive training on its use and are required to use it.
If a suicidality screening tool is used, please identify the screener used:
How does the organization assess suicide risk among those who screened positive?
1) The policy is to send clients who have screened positive for suicide to the emergency department for clearance AND/OR there is no routine procedure for risk assessments that follow the use of a suicide screen.
2) Risk assessment is required after screening, but the process or tool used is up to the judgment of individual clinicians AND/OR only psychiatrists can do risk assessments.
3) Providers conducting risk assessments use a standardized risk assessment tool, which may have been developed in-house. All patients who screen positive for suicide have a risk assessment. Suicide risk assessments are documented in the medical records.
4) All individuals with risk identified, either at intake screening or at any other point during care, are assessed by clinicians who use validated instruments or established protocols and who have received training. Assessment includes both risk and protective factors.
5) A suicide risk assessment is completed using a validated instrument and/or established protocol that includes assessment of both risk and protective factors and risk formulation. Staff receive training on risk assessment tool and approach. Risk is reassessed and integrated into treatment sessions for every visit for individuals with risk.
Comment:
Ensure Every Person has a Suicide Care Management Plan (Pathway to Care)
Which best describes the organization's approach to caring for and tracking people at risk for suicide?
1) Providers use best judgment in the care of individuals with suicidal thoughts or behaviors and seek consultation if needed. There is no formal guidance related to care for individuals at risk for suicide.
2) When suicide risk is detected, the care plan is limited to screening and referral to a senior clinician.
3) All providers are expected to provide care to those at risk for suicide. The organization has guidance for care management for individuals at different risk levels, including frequency of contact, care planning, and safety planning.
4) Electronic or paper health records are enhanced to embed all suicide care management components listed above. Providers have clear protocols or policies for care management for individuals with suicidal thoughts or behaviors, and information sharing and collaboration among all relevant providers are documented. Staff receive guidance on and clearly understand the organization’s suicide care management approach.
5) Individuals at risk for suicide are placed on a suicide care management plan. The organization has a consistent approach to suicide care management, which is embedded in the electronic health records and reflects all of the suicide care management components listed above. Protocols for putting someone on and taking someone off a care management plan are clear. Staff hold regular case conferences about patients who remain on suicide care management plans beyond a certain time frame, which is established by the implementation team.
Comment:
Collaborative Safety Planning
What is the organization's approach to collaborative safety planning when an individual is at risk for suicide?
1) Safety planning is neither systematically used by nor expected of staff.
2) Safety plans are expected for all individuals with elevated risk, but there is no formal guidance or policy around content. There is no standardized safety plan or documentation template. Plan quality varies across providers.
3) Safety plans are developed for all individuals at elevated risk. Safety plans rely on formal supports or contact (e.g., call provider, call helpline). Safety plans do not incorporate individualization, such as an individual’s strengths and natural supports. Plan quality varies across providers.
4) Safety plans are developed for all individuals at elevated risk and must include risks and triggers and concrete coping strategies. The safety plan is shared with the individual’s partner or family members (with consent). All staff use the same safety plan template and receive training in how to create a collaborative safety plan.
5) A safety plan is developed on the same day as the patient is assessed positive for suicide risk. The safety plan is shared with the individual’s partner or family members (with consent).The safety plan identifies risks and triggers and provides concrete coping strategies, prioritized from most natural to most formal or restrictive. Other clinicians involved in care or transitions are aware of the safety plan. Safety plans are reviewed and modified as needed at every visit with a person at risk.
Please indicate whether or not the organization uses the Stanley/Brown safety plan template:
Yes
No
How frequently is the safety plan reviewed with the individual?
Collaborative Restriction of Access to Lethal Means
What is the organization's approach to lethal means reduction?
1) Means restriction discussions and who to ask about lethal means are up to individual clinician’s clinical judgment. Means restriction counseling is rarely documented.
2) Means restriction is expected to be included on safety plans for all patients identified as at risk for suicide. Steps to restrict means are up to the individual clinician’s judgment. The organization does not provide any training on counseling on access to lethal means.
3) Means restriction is expected to be included on all safety plans. The organization provides training on counseling on access to lethal means. Steps to restrict means are up to the individual clinician’s judgment. Family or significant others may or may not be involved in reducing access to lethal means.
4) Means restriction is expected to be included on all safety plans, and families are included in means restriction planning. The organization provides training on counseling on access to lethal means. The organization sets policies regarding the minimum actions for restriction of access to means.
5) Means restriction is expected to be included on all safety plans. Contacting family to confirm removal of lethal means is the required, standard practice. The organization provides training on counseling on access to lethal means. Policies support these practices. Means restriction recommendations and plans are reviewed regularly while the individual is at an elevated risk.
Comment:
Back
Next
Save & Continue
Use Effective, Evidence-Based Treatments that Directly Target Suicidal Thoughts and Behaviors
What is the organization's approach to treatment of suicidal thoughts and behaviors?
1) Clinicians rely on experience and best judgment in risk management and treatment for all mental health disorders. The organization does not use a formal model of treatment for those at risk for suicide.
2) The organization may use evidence-based treatments for some psychological disorders, but it does not use evidence-based treatments that specifically target suicide.
3) Some clinical staff have received specific training in treating suicidal thoughts and behaviors and may use this in their practices.
4) Individuals with suicide risk receive empirically-supported treatment specifically for suicide (CAMS, CBT-SP or DBT) in addition to evidence-based treatments for other mental health issues. The organization regularly provides all staff with access to competency-based training in empirically supported treatments targeting suicidal thoughts.
5) The organization has invested in evidence-based treatments for suicide care (CAMs, CBT-SP or DBT), with designated staff receiving training in these models. The organization has a model for sustaining staff training. The organization offers additional treatment modalities for those chronically or continuously screening at high risk for suicide, such as DBT groups or attempt survivor groups.
Please indicate if clinicians in the organization receive formal training in a specific suicide treatment model, please specify the model used:
Provide Continuous Contact and Support
What is the organization's approach to engaging hard-to-reach individuals or those who are at risk and don't show for appointments?
1) There are no guidelines specific to reaching those at elevated suicide risk who don’t show for scheduled appointments.
2) The organization requires documentation by the clinician of those individuals who have elevated suicide risk and don’t show for an appointment, but the parameters and methods are up to individual clinician’s judgment.
3) Follow-up for individuals with suicide risk who don’t show for appointments includes active outreach, such as phone calls to the individual or his or her family members, until contact is made and the individual’s safety is ascertained.
4) Follow-up for individuals with suicide risk who don’t show for appointments includes active outreach, such as phone calls to the individual or his or her family members, until contact is made and the individual’s safety is ascertained. Organizational protocols are in place that address follow-up after no-shows. Training for staff supports improving engagement efforts.
5) The organization may have an established memorandum of understanding with an outside agency to conduct follow-up calls. Follow-up and supportive contact for individuals on suicide care management plans are systematically tracked in electronic health records. Follow-up for high-risk individuals includes documented contact with the person within eight hours of the missed appointment. The organization has approaches, such as peer supports, peer-run crisis respite, home visits, or drop-in appointments, to address the needs of hard-to-reach patients.
What is the organization's approach to following up on patients who have recently been discharged from acute care settings (e.g., emergency departments, inpatient psychiatric hospitals)?
1) There are no specific guidelines for contact of those at elevated suicide risk following discharge from acute care settings.
2) The organization requires follow-up for individuals with suicide risk, but the parameters and methods are up to the individual clinician’s judgment.
3) Organizational guidelines are directed to the individual’s level of risk and address one or more of the following: follow-up after crisis contact, transition from an emergency department, or transition from psychiatric hospitalization.
4) Organizational guidelines are directed to the individual’s level of risk and address follow-up after crisis contact, non-engagement in services, transition from an emergency department, or transition from psychiatric hospitalization. Follow-up for high-risk individuals includes distance outreach, such as letters, phone calls, or e-mails.
5) Organizational guidelines are in place that address follow-up after crisis contact, no-shows, transition from an emergency department, or transition from psychiatric hospitalization. Follow-up for high-risk individuals includes in-person or virtual home or community visits when necessary. Follow-up and supportive contact for individuals on suicide care management plans are tracked in the electronic health record. Policies state that follow-up contact after discharge from acute settings occurs within 24 hours.
Comment:
Apply a Data-Driven Quality Improvement Approach
What is the organization's approach to reviewing deaths for those enrolled in care?
1) At best, when a suicide or adverse event happens while the client is in treatment, a team meets to discuss the case.
2) Root cause analysis is conducted on all suicide deaths of people in care.
3) Data from all root cause analyses are routinely examined to look at trends and to make changes to policies.
4) Root cause analysis is conducted on all suicide deaths of people in care as well as for those up to 30 days past case closed. Policies and training are updated as a result.
5) Root cause analysis is conducted on all suicide deaths of people in care as well as for those up to 6 months past case closed, and on all suicide attempts requiring medical attention. Policies and training are updated as a result.
What is the organization's approach to measuring suicide deaths?
1) The organization has no policy or process to measure suicide deaths for those enrolled in their care.
2) The organization measures the number of deaths for those who are enrolled in care based primarily on family report.
3) The organization has specific internal approaches to measuring and reporting on all suicide deaths for enrolled clients as well as those up to 30 days past case closed. Deaths are confirmed through coroner or medical examiner reports.
4) The organization annually crosswalks enrolled patients (e.g., from a claims database) against state vital statistics data or other federal data to determine the number of deaths for those enrolled in care up to 30 days past case closed.
5) The organization annually crosswalks enrolled patients (e.g., from a claims database) against state vital statistics data to determine the number of deaths for those enrolled in care. The organization tracks suicide deaths among clients for up to 6 months past case closed.
What is the organization's approach to quality improvement activities related to suicide prevention?
1) The organization has no specific policies related to suicide prevention and care, and it does not focus on suicide care other than care as usual. Care is left to the judgment of the clinical provider.
2) Suicide care is discussed as part of employee training and by those in supervision in clinical settings.
3) Early discussions about using technology and/or enhanced record keeping to track and chart suicide care are underway. Suicide care management is partially embedded in an EHR or paper record.
4) Suicide care is partially embedded in an electronic health record (EHR) or paper record. Data from suicide care management plans (using EHRs or chart reviews) are examined for fidelity to organizational policies, and discussed by a team responsible for this.
5) Suicide care is entirely embedded in EHR. Data from EHR or chart reviews are routinely examined (at least every two months) by a designated team to determine that staff are adhering to suicide care policies and to assess for reductions in suicide. EHR clinical workflows or paper records are updated regularly as the team reviews data and makes changes.
Comment:
Please tell us any thoughts, comments or concerns you have about the Zero Suicide Initiative, and/or this survey. Please remember, this survey will be your organization’s baseline response:
Save & Continue
Submit
Should be Empty: