“Is it rational to pursue zero suicide among patients in health care?” This question was posed by Mokkenstorm and colleagues1 as they addressed objections that the science and published results aren’t yet in. Growing evidence, however, demonstrates remarkable success at reducing the number of lives lost to suicide in health care systems that have committed to the systematic “suicide care” approach known as “Zero Suicide.”
Psychiatric leadership is essential to the success of efforts toward zero suicide. More than a slogan, the approach applies evidence about what works in the detection, treatment, and management of individuals with intense suicidality within a culture determined to learn together and make a dramatic difference. Three essential steps—routinely asking about suicide, developing a collaborative crisis/safety plan including counseling on lethal means, and delivering direct treatment for suicidality for those at elevated risk—have produced exceptional results in several systems.
The concept of zero in quality improvement has been around for more than 50 years, with James Halpin introducing the zero defects movement in 1966. By 1976, the concept of “target zero” had moved to reducing accidents in Japan. In the 1980s, Dr Don Berwick and the Institute for Healthcare Improvement reached out to NASA for a dialogue about applying quality improvement to health care, ie, one small step for quality and one giant leap for health care safety. More recently, “Innovating to Zero” has been called one of the 10 megatrends for innovation.2
Efforts by the mental health system to realize zero suicide
Health care in the United States has focused on quality improvement since the 1960s, but it has only introduced the concepts of high-reliability science in the past 20 years. High-reliability organizations aggressively pursue perfection, an approach, for example, that has driven commercial aviation in the US to achieve remarkable levels of safety in air travel. This approach is characterized by a deference to front-line expertise, a preoccupation with learning about failures and “near misses” and a relentless focus on the target of zero defects.
The Henry Ford Health System (HFHS) in Detroit was the first to apply these concepts in behavioral health care, which focused on the relentless assessment of suicidality across their continuum of psychiatric care. The result was an audacious goal to achieve zero suicides in their mental health programs. The effort was labelled “perfect depression care.” In a 2015 National Public Radio story, Silberner wrote: “The story of the health system’s success is a story of persistence, confidence, hope, and a strict adherence to a very specific approach.”3
The population served by HFHS includes individuals with acute and serious mental illness whose hazard ratio suggests they are 12 times more likely to die of suicide than are those in the general population.4 Nevertheless, HFHS reported a 75% reduction in the first 4 years of implementation of their perfect depression care model and zero deaths during all of 2009. Over the period of implementation, the effort succeeded in reducing suicide deaths among a population under psychiatric care to about the level in the general population.