Improvements to Suicide Risk Assessment process are live
11/15/23 01:30:pm
Changes to our Suicide Risk Assessment process are live as of November 13 for patients 12 and older, with plans to be completed next month for the new process for children 11 and under. Thank you to all the train the trainers for their efforts to learn and teach the process in their areas. The new process will help us be as effective as possible in preventing patient suicides while also reducing patient and staff burden. These changes are based on feedback across all levels of care from nurses, therapists, providers, leaders, and Barrins, our external auditing partner.
What’s changed and why:
1. Removal of consolidation and voice contact requirement. Instead of the current consolidation process for inpatient and residential levels of care, we are now requiring that nurses or therapists who complete an initial Suicide Risk Assessment or Suicide Risk Reassessment must have direct voice contact with the provider if they assess a patient to be high or severe risk. In addition, attending providers may choose to complete their own Suicide Risk Reassessment when they first meet with a patient for the psychiatric evaluation if they have concerns about the risk level assigned to the patient. Attending providers may change the risk level from the original determination by the nurse or therapist by completing their own reassessment. We heard from many of you that there were challenges and frustrations associated with the consolidation process and hope this is helpful.
2. Recognition of the need for clinical judgment. We are making it clearer in the Suicide Risk Assessment, Suicide Risk Reassessment, and through training that we encourage the use of clinical judgment to arrive at a risk determination. Many of the patients who have died by suicide while in our care were rated at low risk, which often indicates that the patient was set on attempting and wanting to hide that from their care team. If you question the responses of a patient, please use your knowledge of your patient and clinical judgment to arrive at the risk determination you believe to be best. The tools are meant to serve as guidelines to help you arrive at your ultimate risk determination.
3. Chronic high suicidal ideation (SI) ratings. We know that at times patients chronically rate their SI at a 6 or 7. This may occur for many different reasons. In these cases, the attending provider can enter a communication order as they see fit so that an Suicide Risk Reassessment isn’t needed after every high SI rating. Instead, the provider should indicate in the order their desired frequency of reassessment if high ratings continue.
4. Streamlined reassessment. We are using a new Suicide Risk Reassessment process in inpatient and residential care that will streamline the process and reduce patient and staff burden. This new reassessment is four to eight questions depending on the patient’s responses and pulls forward risk/protective factors that were endorsed in the past for ease of review and modification. The Suicide Risk Reassessment can be conducted by an RN, therapist, or attending provider. The reassessment should be completed if a patient rates SI at a 6 or 7 (see note about chronic high raters), as clinically indicated by the treatment team or if the patient engages in suicidal behaviors, and the reassessment will occur at regularly occurring intervals. The recurring reassessments will ensure that we have accurate ratings and also have a method for reducing a patient’s risk level as this ideally occurs during their treatment with us. Note that we will use special pediatric assessments for patients 11 and under (asQ Suicide-Screening/ Brief Suicide Safety Assessment (BSSA).
5. Cerner improvements. There are also opportunities to improve flow and visual management within Cerner. We will be working with our ITS team to explore potential improvements including:
- Modifications to the safety plan to capture information about access to lethal means and means restriction in both the treatment and home setting
- Having information about risk flow from Suicide Risk Assessment, Suicide Risk Reassessment, safety plan, and SI ratings in provider notes
- Add to the Suicide Risk Assessment and Suicide Risk Reassessment more about the importance of clinical judgment to inform final risk determination
- Having a clear list for each patient that includes past suicide attempts, methods, and approximate dates that flows into other documents in Cerner
- Prompting to complete necessary steps at the appropriate times
- More instruction or resources to support successful assessment/completion of the Suicide Risk Assessment and safety plan
6. Mandatory training. We have also identified the need for clearer training on our Suicide Risk Assessment, safety plan, and SI check-in processes as well as broader training to understand suicidality and how to discuss suicide with patients and families to inform our risk assessment. We will work to provide additional training in these areas moving forward. Phase One will include process trainings and on-unit leadership support. Phase Two will include broader training on suicide prevention strategies (above and beyond our internal SRA process).
In order to meet timeline expectations and ensure staff have the opportunity to learn the new SRA process, we will need your support! The SRA changes will affect providers, therapists, and nursing roles – the degree of responsibility for the SRA process between therapists and nurses will be somewhat dependent upon level of care.
Next steps
- Any staff who missed their training will be provided with a recording to watch instead.
- Talent Development is tracking completion to ensure that everyone who needs the training receives it.
- We have a Team on Microsoft Teams called the SRA Uplift Command Center where we have provided resources and have an open chat for people to ask questions about the process.
These revisions are the result of a Rapid Improvement Event as we continue to refine the processes we already have in place system wide.
