Addressing challenges and priorities through the fiduciary role
By Sue Ellen Wagner
I recently spoke with Cathy Frank, MD, chair of the Department of Psychiatry and Behavioral Health Services at Henry Ford Health, to learn more about how the health care system is addressing suicide prevention, a public health issue. vital that boards should know more about.
Sue Ellen Wagner:Why is suicide prevention a vital public health issue, and can you tell us about the Henry Ford Health Zero Suicide initiative?
Cathy Frank: In 2020, approximately 46,000 people in the United States committed suicide. Additionally, approximately 12.2 million people in the United States have suicidal thoughts at some point; about 3.2 million could develop a plan to end their lives; and 1.2 million people actually attempt suicide. If you translate that into causes of death, that makes suicide one of the leading causes of death in the United States and the second leading cause of death among children ages 10-14 and adults ages 25-34. Unfortunately, it is one of the leading causes of death. of those major health issues that people don’t tend to talk about, and it doesn’t get the same kind of media attention or funding that other major health issues do. If you look at the past few years, the prevalence of most major diseases in the United States has gone down; unfortunately, suicide has increased by about 30%.
Suicide has been an abiding interest in psychiatry for many decades. The year 2001 was a sentinel year in examining the quality of health care. At that time, the Institute of Medicine published a book called “Crossing the Quality Chasm”. Gail Warden, who was the CEO of Henry Ford at the time, was one of the authors. This book has brought to light the fact that although we may think that health care is superior in the United States, it often isn’t. Not because people don’t care, but because of a number of processes and errors. After the publication of this book, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement decided to issue a challenge to healthcare organizations across the country in what they called the national Pursuing Perfection collaboration. They set aside $26 million and challenged health care to find radical ways to improve quality.
The Department of Psychiatry at Henry Ford Health decided to apply for this grant, and we made it through the first cut but not the second; therefore, we were not funded for an implementation grant. But it started us on a journey of thinking about how to improve quality within psychiatry, and at that time we started a project called Perfect Depression Care. This prompted us to define what would make depression care “perfect”. One obvious thing is that if depression care were perfect, no one would die by suicide. Even though the suicide rate of those treated at Henry Ford at that time was lower than that of comparable clinical populations nationally, we decided that the elimination of suicide was a valuable and achievable goal. It started a journey that continues to this day and grew into an international suicide prevention movement. The most revolutionary aspect of the project was deciding that the goal could only be zero. When it comes to the automotive industry in Detroit, zero defects is a standard. We rarely consider zero defects in healthcare. We may all want zero defects, but as organizations we often set lower parameters.
Reaching zero became a revolutionary idea for Henry Ford Psychiatry. Internationally, not everyone uses the same method to get to zero. We have been one of the watchdog organizations in suicide research and are heavily involved in federally and privately funded research on suicide prevention.
What is the best method to achieve this? Based on the literature and research, we would say we have the best method, but that was the start of our journey. We then developed guidelines and methods to get to zero – and we actually got to zero.
With the introduction of Henry Ford Health’s Zero Suicide Initiative, we were able to reduce the suicide rate among our patients by 80%, as the suicide rate increased nationwide, including in the state. from Michigan. And for about 18 months in 2009-2010, we hit zero.
Wagner: Henry Ford Health has made many achievements in reducing suicide over the past few years. Can you tell us more about the success of the initiative?
Franc: There are a few key aspects to a zero suicide initiative. The first is that often people think that asking a patient if they are suicidal is the best or for some the only predictor. We know that denial of suicidal thoughts is actually a relatively weak predictor of suicide. One of the features of our program is to look at studied suicide risk factors, of which there are many, as a means of assessing suicide risk.
Risk factors for suicide include previous suicide attempts, family history of suicide, moderate to severe depression, mania, or psychosis. Other indicators include substance abuse, being a member of the armed forces (active or veteran), and a history of head trauma in the past year. There are many factors. What we’ve done over the years is take those factors and break them down into acute, high, moderate, and low risk. Notice that I didn’t say “no risk”, because we know that anyone who goes to a mental health facility for any problem is by definition at some risk. After identifying the risk, our goal is to work collaboratively with the patient to modify these risk factors through a variety of treatments and interventions.
There are a variety of strategies to reduce risk. First and foremost, we want to ensure that medication management and psychotherapy are evidence-based. Also, does this person require an inpatient setting or a partial inpatient or outpatient program? Do they need a rehab setting because they abuse substances? How to educate the patient on the risk of suicide and how to educate his relatives so that they are aware of it? How can I change how my clinics and hospitals operate so that patients have easy access to them if they need care?
As approximately 50% of suicide deaths are due to firearms, we also want to discuss lethal means with the patient as well as the family. We offer the use of self-management tools for patients. Henry Ford is increasingly turning to digital tools to complement traditional psychiatric therapies. We also recommend community support systems such as Alcoholics Anonymous or other recovery groups.
Wagner: Can you talk about the role the council has played in supporting the initiative since its early development, as well as the council’s strategy for suicide prevention going forward?
Franc: The Henry Ford Health Board of Directors has always been a strong supporter of quality initiatives. To use a term that is sometimes found in the literature: it is a radical quality commitment. Our Board of Directors has supported this concept and the journey of Zero Suicide.
When delivering a quality project, a just culture is important. And I think the only way people can make progress in quality improvement is with such a culture. Without a doubt, the people in the department have looked to the board of directors for advice.
If they see the board as supporting an initiative, that also means a lot. So the board not only supported the concept, but also provided financial support for what we needed to achieve and where we needed to go. As you know, with Joint Commission and CMS, suicide is a big issue these days, and it affects everything from medical-surgical beds to emergency rooms, primary care offices, health clinics behavior and hospitals. We know that half of people who commit suicide can see a primary care physician within 30 days of their death. The board recognized that Zero Suicide and the principles behind it are good for health care, well-being, and for everyone – not just those who can go to a psychiatric clinic.
Wagner: Do you have any advice for other governing boards who have an interest in helping to reduce and prevent the number of suicides in their communities and among healthcare personnel?
Franc: There remains a significant stigma around mental illness. Having a board talk about mental illness and mental health issues allows other staff and employees to talk about it as well.
I think COVID—despite the pain it has felt for everyone in the United States and around the world—has caused health care to talk more about burnout and stress in health care. As tragic as COVID has been, if I try to look for something good that has come out of it, it may have made us recognize the importance of emotional health and the terrible impact of mental illness.
Advice can be extremely important in supporting the well-being not only of the patients we care for, but also of our staff and employees. What psychiatry offers are indirect economic benefits to health care systems, and this obviously has an impact on the well-being and health of patients. So I think boards should be looking at that — the indirect savings and what that means for patients, families, employees, staff — not the bottom line.