Organizational Self-Assessment for Suicide Safer Care/Zero Suicide National Action Alliance for Suicide Prevention

Transcription

1 Organizational Self-Assessment for Suicide Safer Care/Zero Suicide National Action Alliance for Suicide Prevention Name of Organization: Date Survey Completed: Background: The Organizational Self-Assessment is designed to allow you to assess what dimensions of safer care your organization currently has in place. It is one of a set of tools developed to help organizations establish safer care practices. Please visit for additional resources. The Self-Assessment can be used early in the launch of a Zero Suicide initiative to assess organizational strengths and weaknesses, to develop a work plan, and as the basis for periodic progress assessments. Staff involved in the policy-making and care for patients at risk for should complete the Self-Assessment as part of an Implementation Team. The Team should complete this tool together during one of their initial meetings. Information about putting together a Zero Suicide Implementation Team can be found on our website. Once the Implementation Team completes this self-assessment, they are asked to share it with our staff for review and feedback. While the Self-Assessment is not exhaustive with regard to all issues that can affect patient care and outcomes, it does reflect dimensions that define the Zero Suicide comprehensive approach. Team Completing Survey: ZS Organizational Self-Assessment 1

2 Dimensions of Suicide Safer Care: For each item, please circle the number where your organization falls on a scale of 1-5. If you wish to describe or elaborate on any item, please do so in the space provided. Developing a Leadership-driven, Safety-Oriented Culture: What type of formal commitment has leadership made to reduce and provide safer care among people who use the organization s services? has no formal policy on prevention and care. has one or more formal policies that relate to prevention, such as clinical risk policies, but no specific safe care policy. has a formal written policy specifically addressing prevention and safe care. Policy addresses one or two components such as training or screening. has a formal written policy specifically addressing prevention and safe care. The policy addresses multiple dimensions of care to include: workforce competency, identification of risk, interventions tiered for risk, treatment, followup during transitions. has a formal written policy specifically addressing prevention and safe care with all elements identified previously. Prevention of compassion fatigue is a part of the formal policy. We regularly provide updates to staff. All staff in organization are aware care plan and policy exist and can describe. Developing a Leadership-driven, Safety-Oriented Culture: What type of formal commitment has leadership made to reduce and provide safer care among people who use the organization s services? No staff are tasked specifically with One or more staff have duties One or more staff are clearly tasked A team of individuals is A multidisciplinary team ZS Organizational Self-Assessment 2

3 prevention practices at the organization level. related to safe care practices or training on prevention. Responsibilities are diffuse. Staff do not have the authority to change policies. with leading organizational prevention efforts and have authority to identify and recommend changes to policies and practices. tasked with examining prevention policies and practices. The team meets occasionally or as needed. Team does not have full authority to make policy/practice changes but can make recommendations to leadership. is tasked with continuous quality improvement related to safe care practices. The team meets regularly and has the authority to make changes to policies and practices. There is a budget for prevention and care training and tools. Suicide attempt and loss survivors in leadership and planning roles: What is the role of attempt and loss survivors in the development of the organization s care policy? Suicide attempt or loss survivors are not involved in the development of prevention activities within the organization. Suicide attempt or loss survivors have informal roles within the organization, such as serving as volunteers. The role of attempt or loss survivors is limited to one specific activity, such as leading a support group. Suicide attempt and loss survivors are part of our guidance team and provide regular input in our planning process. Two or more attempt or loss survivors participate in a variety of prevention activities, such as sitting on decision-making teams or boards, participate in policy decisions, assist with workforce hiring and/or training, and participate in evaluation and quality improvement. ZS Organizational Self-Assessment 3

4 Systematically identifying and assessing risk levels: How does the organization screen risk in the people we serve? Organization relies on clinical judgment or individuallydeveloped screeners. A validated screening measure is utilized at intake for all individuals receiving care from the organization. A validated screening measure is utilized at intake for a identified subsample of individuals (e.g., crisis calls, adults only, behavioral health only). A validated screening measure is utilized at intake and when possible warning signs are observed for all individuals receiving care from the organization. A validated screening measure is utilized at intake and when warning signs are observed for all individuals receiving care from the organization. Suicide risk is reassessed or reevaluated at every visit for those at risk. On inpatient units, assessments reducing risk levels take input from multiple sources. All staff use same tool. Patients are screened prior to discharge. Systematically identifying and assessing risk levels: How does the organization assess risk in the people served? has no routine procedure for risk assessments that follow the use of a screen. Providers conducting risk assessments have no specialized training and do not use a standard risk Providers conducting risk assessments receive specialized in-house training and/or use A risk assessment is conducted by a clinician trained to use an evidencebased tool. Results are documented in A comprehensive assessment of risk and protective factors is conducted by a trained clinician for all individuals ZS Organizational Self-Assessment 4

5 assessment tool. Only clinical judgment is used in risk assessments. risk assessment tools. A standard risk assessment is documented in the medical record. If a suicidality screening tool is used, the screener used is: the medical record. Structured clinical judgment is used in risk assessment. All physicians use this tool. YES NO All nurses use this tool. YES NO All mental health professionals use this tool. YES NO Staff are credentialed to carry out this clinical function. YES NO using a validated tool. All staff use same tool. Suicide risk is reassessed or reevaluated at every visit (or based on continuous observation for inpatients) for those at risk, those who have had a personal crisis, change in health status, etc, as well as at discharge and on follow up. For inpatient units, multiple observations of reduced risk are required to reduce risk levels. PHQ-9 PHQ-2 Columbia Suicide Severity Rating-Scale (CSSR-S) National Suicide Prevention Lifeline Risk Assessment Standards Other tool (please name): Systematically identifying and assessing risk levels for inpatients: When does the organization assess and reassess risk in the people served who screen positive? assesses risk only at admission by a single clinician. reassesses risk throughout the episode of care based on staff Risk assessment stratification decisions to determine level of care or monitoring Clinical team risk assessment stratification decisions are reduced based on Clinical team risk assessment stratification decisions are reduced based on ZS Organizational Self-Assessment 5

6 clinical judgment. are made by: Physicians only YES NO Physicians and /or nurses YES NO Physicians, nurses and clinical team consultation YES NO multiple observations. Supported by the following available resources (check all that apply): Timely psychiatric consult Recruitment of family members for risk assessment input Means-restricted -proof environment Re-evaluation at each session multiple observations and through use of an empirical tool used by all staff. Supported by the following available resources (check all that apply): Timely psychiatric consult Recruitment of family members for risk assessment input Means-restricted -proof environment Line-of-sight supervision/no weight-bearing or loopable protrusions (or other environmental safety precautions) Re-evaluation at each session Up to line-of-sight supervision (or other environmental safety precautions) Timely clinical team consultation Timely clinical team consultation when increased risk may be present Reassessment at discharge with articulated followup post-discharge referral and contact plan ZS Organizational Self-Assessment 6

7 Ensuring every person has a pathway to care -- Organization has a clear management plan for outpatients: Which best describes the organization s approach to caring for and tracking people at risk for? There is no formal guidance related to care for individuals at risk for. Providers utilize best judgment and seek consultation if needed. Providers have some protocols or guidance for care. Care plan is limited to safety planning. Providers have clear protocols or guidance for care management for individuals at different risk levels, including frequency of contact, care planning, and safety planning. Providers have clear protocols for care management based on assessed risk and there is documented information sharing and collaboration amongst all relevant providers. Individuals at risk for are placed on a special care management plan. Protocols for removing someone from the pathway are clear. Suicide care management plan includes some or all of the following: Use of EHR modifications to assist in identifying and preventing Specific protocols for client engagement & frequency of appointments Coordination of care within the organization for high risk clients Chart reviews to determine that risk assessments are timely, complete and documented, and level of assessed risk matches the level of care provided. ZS Organizational Self-Assessment 7

8 If the organization has a care management plan/pathway for individuals at risk for, it includes: Psychoeducation groups specific to : Attempt survivor support groups: Drop-in visits without appointments: Outreach/contact/protocol for missed appointments or transitions in care: Coordination of care within the organization for high risk clients: If applicable, please describe any EHR modifications made to address? 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? There is no formal assessment of staff on their perception of confidence and skills in providing care. Clinicians who provide direct patient care complete a formal assessment of confidence and skills in providing care. Assessment of perception of confidence and skills in providing care is completed by all staff. Assessment of perception of confidence and skills in providing care is completed by all staff and reassessed at least every three years. Assessment of perception of confidence and skills in providing care is completed by all staff and reassessed at least every three years. Organizational training and policy reflects perceived staff weaknesses. ZS Organizational Self-Assessment 8

9 Competent, confident, and caring workforce: What basic training on identifying people at risk for or providing care has been provided to staff? There is no organizationsupported training on care. Training is available on identification and care through the organization but not required of staff. Training was locally developed. Training is available through the organization and required of selected staff (e.g., crisis staff, clinical staff) Training on identification and care is required of all organization staff. Training utilized is considered an best practice. Training on identification and care is required of all organization staff. Training utilized is considered an best practice. Retraining is required at least every 3 years. Please indicate the training approach/curriculum the organization uses to train all staff on basic prevention skills: ASIST: Kognito At-Risk in Primary Care: Kognito At-Risk in the ED: QPR (Question, Persuade, and Refer): QPR for Nurses (Question, Persuade, and Refer): QPR for Physicians, PAs and ARNPs: safetalk: Other (please name): Please indicate the number of minimum hours of training required annually for staff in identification and care Collaborative safety planning (for use with outpatients and/or at time of discharge for inpatients): What is the organization s approach for collaborative safety planning when an individual is at risk for? There is no formal Safety plans are Safety plans are Safety plans are A safety plan is protocol for required for all developed for all developed for all developed with ZS Organizational Self-Assessment 9

10 safety planning. individuals with elevated risk, but there is no formal guidance or policy around content. Safety plan and documentation is individually developed. individuals at elevated risk. Safety plan relies predominantly on formal interventions (e.g., call provider, call helpline). Safety plan does not incorporate individualization such as an individual's strengths and natural supports. Plan quality varies significantly across providers. individuals at elevated risk and include risks and triggers and concrete coping strategies. The plan is shared with partners/significant others (with consent). All staff utilize same safety plan template. each individual at elevated risk of and incorporates significant others in the individuals life. The safety plan identifies risks and triggers and provides concrete strategies, prioritized from most natural to most formal or restrictive. All staff utilize same safety plan template which is evidencebased. If yes, the safety planning tool/approach we use is: We use Stanley/Brown Safety Plan Yes: No: How frequently is the safety plan reviewed with the individual? Collaborative safety planning and restriction of lethal means for outpatient settings: What is the organization s approach to lethal means reduction identified in an individual s safety plan? Safety steps are reviewed with the individual when the plan is developed. Means restriction counseling is rarely documented. Organization does not provide training on Means restriction is occasionally included on safety plans, but is limited to a general recommendation. Individualized planning and reducing access to means is not discussed. Means restriction is routinely included on safety plans. Family or significant others are occasionally involved. Organization provides training on counseling on access to lethal means. Means restriction is a standard component of all safety plans and families are included in means restriction planning when readily available, but outreach to families is limited. Specific action Means restriction is a standard component of all safety plans, family members are included in means restriction planning. Means restriction recommendatio ZS Organizational Self-Assessment 10

11 counseling on access to lethal means. taken to reduce access to lethal means. ns are reviewed regularly while the individual is at elevated risk. Other clinicians involved in care or transitions are aware of the safety steps. All staff take training on counseling on access to lethal means. Collaborative safety planning and restriction of lethal means for inpatient settings: What is the organization s approach to lethal means restriction? Close observation is the main safety measure, carried out by mental health techs. Facility relies on 15 checks but there may be little interaction with patient during checks. Close observation of high risk patients is the main safety measure. There is a protocol for observation. The protocol for observation requires continuous observation of patients' hands or line-of-sight. Staff competences in observation are periodically assessed. Orders for constant observation are very clear (e.g. patient should be observed in bathroom, while sleeping, eating). Staff competences in observation are periodically assessed. All staff take training on counseling on access to lethal means. Determination to take individual off of constant observation status made with input of multiple staff. Please describe or elaborate on the following approaches to safety planning and environmental safety: Please attach or include your contraband list. How do you manage contraband at intake? How often do you search for contraband? What is your search policy? What are your procedures for checking bags brought in by visitors? ZS Organizational Self-Assessment 11

12 Effective treatment of suicidality: What best describes the treatment/interventions specific to care used for patients at risk? Organization does not use a formal model for treatment for those at risk for. Clinicians rely on experience and best judgment in treatment. Organization utilizes evidencebased treatments for psychological disorders, but do not offer specific treatments for suicidality. offers one or more treatments targeting suicidal thoughts and behaviors but there is no assessment of treatment fidelity and outcomes. Individuals with risk receive evidencebased treatment specific to. Organization provides training in treatment model. Clinicians in the organization receive formal training in a specific treatment model: AMSR (Assessing and Managing Suicide Risk): CAMS (Collaborative Assessment and Management of Suicidality): CASE Approach: CBT (Cognitive Behavioral Therapy): Commitment to Living: DBT (Dialectical Behavior Therapy): QPRT (Suicide Risk Assessment and Management Training): RRSR (Recognizing and Responding to Suicide Risk): RRSR-Primary Care: Seeking Safety: SuicideCare: Individuals with risk receive treatment specific to in addition to treatments for other mental health issues. Organization provides training in treatment model. Fidelity to treatment and outcomes are assessed. Other: ZS Organizational Self-Assessment 12

13 Continuing contact and support: What is the organization s approach to engaging hard to reach individuals or those who are transitioning in care? has guidelines or policies related to follow-up of individuals. There are no guidelines specific to those at elevated risk. has guidelines and policies for follow up specific to individuals risk. Organizational guidelines are directed to the individual's level of risk and address follow-up after crisis contact, nonengagement in services, and transition from ER or psychiatric hospitalization. Organizational guidelines are directed to the individual's level of risk and address follow-up after crisis contact, nonengagement in services, and transition from ER or psychiatric hospitalization. Follow-up for high risk individuals includes active distance outreach, such as letters, phone calls, or s. Please indicate which, if any, follow up methods the organization employs: Texts of reminder appointments: Texts of support or encouragement: Caring post cards or letters: Use of apps: Follow up call within 24 hrs: 48 hrs: one week: two weeks: monthly: Mobile crisis team deployed for well checks in case of no answer to calls/texts: Other (please describe): Organizational guidelines are directed to the individual's level of risk and address follow-up after crisis contact, nonengagement in services, and transition from ER or psychiatric hospitalization. Follow-up for high risk individuals includes home or community visits when necessary. Organization works closely with community providers to conduct warm handoffs when individual transitions in care. Please include below or on additional paper any additional information regarding the organization s care management approach not already addressed: Once you have completed this Organizational Self-Assessment, please scan and it to Dr. Julie Goldstein Grumet, jgoldstein@edc.org; (202) for review and feedback. ZS Organizational Self-Assessment 13