Good afternoon or good morning, depending on where you're calling in from. I am Julie Goldstein Grumman, Senior Healthcare Advisor at the Suicide Prevention Resource Center. While people are logging in, I'll give you a quick moment to use the Q&A section to maybe tell us who you are, where you're calling in from, and something you're hoping to learn from today. It's always lovely to see the great representation that we have across the country. So feel free to share in the Q&A a little bit about who you are, and then we'll get started in just a minute while people have a chance to log in. Thank you for joining us. We're going to go ahead and get started. Julia, I am going to turn it over to you for a little housekeeping. All right. Fantastic. Hi, everybody. Thank you for joining. My name is Julia Lowenthal. I work for the Suicide Prevention Resource Center. Welcome to today's panel discussion on Suicide Prevention and Healthcare Accreditation with the Joint Commission. Just a couple of housekeeping things. As Julie said, this is a funding disclaimer here. SPRC is supported by a grant from the Substance Abuse and Mental Health Services Administration. So the views, opinions, and content of this webinar do not necessarily reflect that of SAMHSA, CMHS, or HHS. We have no financial relations or conflicts of interest to report. The Suicide Prevention Resource Center fulfills its goal of advancing the national strategy for suicide prevention by building capacity and infrastructure for effective suicide prevention across the country through training, consultation, and developing resources for a variety of settings from states, tribal communities, and health systems, and that reach individuals across the lifespan. SPRC also fosters key national partnerships that engage a wide range of stakeholders and also serves as the secretariat for the National Action Alliance for Suicide Prevention. Here we have a land acknowledgement. I'm going to pause for just a moment and hope you all will take a minute to read it. Thank you for that. This webinar offers one AMA PRA category one credit, excuse me. Information about claiming this credit will be displayed at the conclusion of this webinar. If you've joined from the desktop application of GoToWebinar, you can access handouts such as a PDF of the slides by navigating to the handouts area of the control panel. And if you use the instant join viewer, you can do the same by clicking the page symbol on your display. How to participate. We will be compiling and holding questions for the Q&A period toward the end of today's webinar, but please feel free to submit questions throughout the presentation as you think of them. You can use the attendee control panel to get to the questions area and click the question mark if using the instant join viewer. And now I will pass it back to our moderator for today, Julie Goldstein-Gromit. Thanks, Julia. So I'm going to introduce our speakers. Today is a little bit of a different style than some of the other webinars you might have joined us for. It's really a very informal panel discussion because we know that this information is really important to you. And it's a chance to hear from both the joint commission and from two leading healthcare systems about how do they implement the joint commission's national patient safety goal. I am Julie Goldstein-Gromit. I'm the senior healthcare advisor at the Suicide Prevention Resource Center, and I'm the director of the Zero Suicide Institute. Next slide, Julia. So our learning objectives are to understand which suicide care and intervention practices are required to meet the joint commission's national patient safety goal, discuss frequently encountered challenges, and describe suicide prevention as a quality improvement initiative. But it's far more than that. We really do want to give you the depth and breadth of not only how to meet these goals, but also how two healthcare systems have really implemented these in their own healthcare systems and, in fact, exceeded these goals. Next slide. With me today is Gina Malfeo-Martin. She's an associate director in the Standards Interpretation Group for the Behavioral Healthcare Hospital Psychiatric and Lab Programs at the joint commission. Gina provides leadership and guidance within the team in all aspects of the accreditation process through clinical expertise and customer relation management. Dr. Brian Amidani is a licensed clinical and macro master's level social worker in Michigan. He serves as director of the Center for Health Policy and Health Services Research and director of research for the Department of Psychiatry at Henry Ford Health. Dr. Ed Boudreau is a clinical psychologist. He has focused on integrating behavioral health across a variety of medical settings, including emergency medicine, inpatient, and primary care. So I think we'll have a lot to learn from our speakers and so thrilled to have you join in this informal panel discussion. First, though, I'm going to turn it over to you, Gina, to set the stage. Great. Thank you, Julie, and hello, everyone. So as some of you may know, the joint commission assembled a technical advisory panel. This was back in 2017, so it's hard to believe that was five years ago, but it was. And this panel was made up of experts in the field as well as our partners over at the Center for Medicare and Medicaid. And the purpose of this was really to come to a consensus and provide guidance and recommendations for health care organizations, specifically on safeguards to prevent suicide. Unfortunately, we were continuing to see an uptick in suicides that were occurring in health care. So these consensus recommendations were published at the end of 2017. And at that time, there was really a strong emphasis on environmental safety. But this also subsequently led to the revisions of our current National Patient Safety Goal, which some of you may know is National Patient Safety Goal 150101. And this went live in 2019. And the revised elements of performance are really meant to highlight the importance of health care organizations having a suicide risk reduction program. And so since then, we have really been working diligently with our accredited organizations in reducing the suicide risk through these elements of performances, particularly with an emphasis in health care, but also those that may occur post-discharge from a health care setting. So elements of performance two through seven really focus on the clinical aspects of suicide risk reduction, which is going to be the focus of our discussions today. And then element of performance one focuses on the environmental safety. So two through seven focus on things like screening, assessment, determining levels of risk, implementing mitigation policies, procedures, and then overall monitoring of the effectiveness of a health care organization suicide risk reduction program. Next slide, please. The previous slide was just a very brief overview. If you want to see the full standards and other supportive information that led us to where we are today, please feel free to go to our webpage. We have a suicide prevention portal. This is open to the public. You do not have to be an accreditation organization to view this information. Next slide, please. Here's just a couple examples of some things you'll find on this page. We have what we call our R3 report, as well as a comprehensive compendium of resources that can help organizations come into compliance with these requirements. I will turn it back over to Julie. Thank you, Gina. And I really want to thank you and the Joint Commission for all the collaboration that we've had in really thinking about how do we bring this information to health care systems. I think, you know, it was really an incredible groundbreaking advancement to update the National Patient Safety Goal. And we know, though, it did elicit a lot of questions. And here we are today to try to help health care systems to both to meet these goals, to advance these goals, and clearly to save lives. So, Gina, there are a lot of resources included in the R3. So can you explain really the purpose of the R3 report and the companion resource? Like, do organizations have latitude in how they meet these requirements? Because there are a lot of resources already specified. So what's the latitude that organizations have in how they meet these requirements? For example, can different screening tools be used than what might be listed in the R3? Sure. Yes, of course. So the Joint Commission uses R3 reports anytime we have new standard requirements coming out. And they stand for rationale, references, and the requirement itself. So the R3 will tell you the requirement. It will give some rationale behind the requirement, and also provide some references that support the need for the requirement. So it's important for the Joint Commission when we develop new standards that they are evidence-based. And what's going out on the field is supporting the need for the standard. So accrediting organizations, you know, as an accrediting organization, our focus is really laying the framework, and then allowing organizations to fill in the rest of that structure. So screening, for example, our element of performance, too, talks about using a validated screening tool. We provide some examples, both in our R3 as well as our compendium of resources. You know, but organizations ultimately have that flexibility and that ability to determine which of those validated tools is best for their setting services, their population. You know, the R3 references maybe one or two resources that support the needs and the requirements. And then, of course, the resource compendium, you know, contains known and researched tools, but certainly there may be other acceptable tools that are validated that organizations can use. You know, in those cases, the Joint Commission will be looking, you know, at the organization to show us that evidence. And that typically can be done by showing the research that the tool has been scientifically tested and validated to be used as a suicide risk screener. I think that's really helpful, because I know that's a question that we hear a lot. And how do you actually show the evidence, I think, is helpful for a lot of systems to hear what that means. But Brian, how do you screen at Henry Ford? How did you guys pick a screening tool? Well, I mean, I think, at least in our hospital settings, we, you know, we followed, you know, research. You know, in our hospitals, you know, we've been following actually a lot of ads work with the SAFE study. And so that really led us to the PSS3 for our emergency settings and hospitals. We really wanted, you know, in our mind, we wanted pragmatic tools that can be implemented that have a strong evidence base, and that can help guide our decision making for what needs to happen next. So if we're sticking specifically to screening tools, and I want to acknowledge that there's a difference between screening and assessment, those are two different things. But specifically related to screening tools, we really thought a lot about some of the evidence. And I think there was quite a bit of consensus that we should stick to that kind of a protocol and use the tool that was used in that study. I also am very, we very much value, and I would recommend that people value consistency as well. If every doc in every setting uses different tools, then it's very hard for people to know what those tools mean across settings. So that's another, I think, high priority thing for people to think about. You said you used a lot of the guidance that was in the EdSAFE study. Is that tool listed in the R3 as a screener? It is. The PSS3 is one of the recommended tools in the report. Ed, I'm guessing you use the PSS3. Yeah, we use the PSS3. Well, we actually use the patient safety screener, which is the first three items are the patient safety screener three. So those are the mandatory items. So there's a mandatory three items that patients are asked. And then if they're positive, using our clinical criteria on the PSS3, they get six additional questions that are meant to further stratify the person's risk. Now, this is a triage stratification. I think that's important to point out because we'll get, I think, dive a little bit deeper into stratification using your risk assessment later. But most places, especially if you're in acute care, but also if you're in outpatient care, are going to want to have some kind of initial stratification that helps to guide the next steps. And I won't get into the controversy around stratification versus the spectrum conceptualization of suicide risk. Maybe we'll talk a little bit about that later. But we use the patient safety screener in the UMass health system throughout the entire health system. Once again, like Brian said, the consistency is really, really important. Because if you can get everyone to use and understand how to administer the same instrument, and people are talking the same language, and you don't have this disconnection between, for example, screening in their emergency department, and then when that person gets admitted to an inpatient medical unit or the ICU, or even the inpatient psychiatric unit, then they're using a different measurement. They don't understand what the results from the previous measurement are. When we first started our journey with using the ED-SAFE study as an example, when we first started, we worked with eight emergency departments throughout the country, and they were all doing something different. There was no standardization whatsoever. And most of those places were using homegrown items that they just created themselves. So that was a huge challenge with trying to standardize that process. And we've been working since then. That was 2010. We've been working since then in the UMass health system to help to standardize the process and to really focus on the quality of the screening as well. So I think those two things are important. You can standardize the questions in the process, but you also want to try, if you can, to pay attention to the way the screener is being administered. Because I think how you ask the questions and the way you approach the screening is probably just as important as the standardization. And I think the Joint Commission does a good job with setting the minimum standard of saying, okay, we're going to now really focus on empirically oriented evidence based tools. That's the first criteria. And I think that's the minimum standard. And I think what we are trying to do is recognize that it's not just that, that you have to also embed the screening within an environment of safety and acceptance so that the person feels comfortable with answering those questions. Yeah, I think that's such a great point. Certainly a lot of what we try to talk to healthcare systems about is not just what you do, but how you do it. But Gina, so kind of given what Ed said, what does the Joint Commission look for in systems to show that they're meeting the requirements? What are surveyors looking for? Sure. So, well, I'll talk to it kind of by setting. In the hospital setting, it's really important based on our minimum standard that any patient that's being either evaluated or treating for behavioral health condition receives that screening. We often get asked, well, what does that mean? Really, a behavioral health condition can be a symptom such as anxiety. It can be an actual diagnosis such as depression. And these are individuals we want to make sure right up front are screened without question using a validated tool. This also includes those with substance use disorders, which we get asked often. Sometimes these conditions are very obvious. They're the reason the individual is seeking treatment or presenting, whether it be for mental health services or to an emergency department. And other times these may not be as obvious, and it may be something that ends up coming up during the course of treatment. So an example I often give is maybe a patient that presents with chest pain. The priority is to rule out a cardiac condition, right? And once they rule that out and they do further assessment, they determine that, no, this individual is actually having a panic attack. So that now becomes that primary focus. So it may not be something they initially presented with, but it's kind of been drilled down during the course of care. So those are the types of individuals we want to make sure receive that, at minimum, receive that screening using the validated tool. When I talk to organizations, I always encourage them to focus on broadening their screening, not restricting it. So don't look for reasons not to screen. Look for reasons to screen. Basically, when in doubt, screen. Those of us on this call and probably many other in the field know that research shows us that screening for suicide does not increase somebody's risk for suicide and actually can save a life. So that's really important. And we keep that in the back of our minds when we talk about this. And then, of course, there are some organizations that do choose to screen all patients. And, of course, that's above our minimum standard, but it's always acceptable to go above and beyond what our minimum requirements would be. Now, for our behavioral health settings and services, that's pretty straightforward. We would expect to see everybody screened using a validated tool. It's presumed because they're receiving behavioral health care services that there is some sort of underlining behavioral health condition. So since you mentioned universal screening, Ed, I'll turn to you. What does your hospital do with regard to universal screening? Yeah, our health system, UMass Memorial, universally screens all patients who present to acute care. That was a decision that we made early in our journey in large part because of the work that I do and the work that my team and many others have shown where if you use a clinically indicated approach where the person is only screened if they are presenting with the primary behavioral health condition, that's actually a good practice because, frankly, it wasn't happening very consistently before the Joint Commission really started focusing on it. So I think that is an excellent way to start, but it does miss people. It misses people who are presenting with medical problems as their primary presenting complaint, but who also have significant psychiatric comorbidities or who maybe don't even have psychiatric comorbidities but are still suicidal because that does exist particularly in some medical populations where their conditions are intractable and they're in a lot of pain or having disability that kind of drives them to want to end it. So I think that our studies have shown convincingly and it's been replicated through many other studies that if you broaden to universal screening, you're going to identify an important group of patients who have significant levels of suicide risk but who are being missed with indicated screening. So I always focus on a practical approach. If the health system is already struggling with getting good screening for their behavioral health patients, if that's a challenge, then by all means really focus on that first because that is the most important subgroup. But if that has been implemented and people are feeling like they're doing a good job and they want to broaden their public health reach and sort of do an aspirational effort rather than the minimal effort, then I think they can consider expanding to universal screening. Ryan, what do you think? Yeah, I mean, I agree. I think Ed made some really good points and I think I agree with them. Our data shows that actually half of people who die by suicide never have a behavioral health condition. So it's really important to to make sure that you're screening everybody. And, you know, actually the original Sentinel event alert that preceded the National Safety Goal actually recommended, you know, from Joint Commission actually recommended screening everybody. So that there's sort of the minimum standard of screening people with behavioral health conditions. But then what I would say is the most, you know, our data are showing that, you know, most people actually who end up dying by suicide don't have a depression diagnosis. Only half have a mental health diagnosis. So if and that if you screen for depression, some of the many, many people will screen negative and won't, you know, won't ever get asked about suicide risk. So it is actually important to screen everybody. And many people will screen positive on that item, on the suicide risk questions who don't have other indicators that we're aware of. Those people need to be connected to care. Certainly the greatest risk population are those people who have mental health conditions or substance use disorders, and those people definitely need to be screened. But if we want to reach everybody who's at risk, we feel it's important to screen everybody. Sheena, any last words about universal screening you want to add? No. Again, the Joint Commission supports organizations that want to take that extra step. At the time that we did our technical advisory panel, the research and the experts were not strong enough to have us as an accrediting organization require it. I think Ed made a good point. Some organizations are still really struggling just to implement the basics, let alone to take that extra step and be screening everybody. Another thing that was raised is sometimes when we use depression screener instead of a suicide screener and that sometimes we just miss people even using a suicide risk screener because sometimes people don't acknowledge their suicide risk even with a standardized screening tool. How can healthcare systems address this? Ed, let's start with you. Well, I think first off, no screener is going to be perfect. We just have to recognize that we should choose a screener and design a screening process that's most likely to help us identify people who are at risk and to stratify their risk so that we know what to do next. So I think recognizing that we are tasked with doing the best that we can in both the screener choice and the process, like we talked about earlier, I do think that focusing on the process and on fidelity to the actual interaction with the person whenever you're screening is important to help minimize false negatives. So I think that's what many people are worried about is if you use a standardized screener, what happens if the person is really suicidal but they are negative on your screener? And that clearly happens. But I think you can minimize the chance if you're first off, you minimize the chance if you use a standardized evidence-based screener because that's what they're designed for. But if you use a process that conveys caring and an empathetic approach and provides a rationale for the screening, you're more likely to get people to share their thoughts with the person doing the assessment or the screening. But it's going to miss some people and there may be other clinical indicators or risk factors or warning signs that are really causing concern. So I think you can't strip clinical judgment and other observations and other information from the screening process. The most classic example I find is a person who's presenting and someone else in the person's life is really worried about them. Someone else has brought them into the emergency department, for example, saying he said that he was going to kill himself. And then now when the clinician is doing the screener and they're asking the standardized questions, the person is saying, no, I didn't say that. I don't want to kill myself. So you have two different points of view here. Under those circumstances, I wouldn't automatically exclude the person from additional assessment and mental health evaluation and other services just because at that moment, the person is saying that they weren't thinking about killing themselves, especially with other evidence like a collateral or a significant other saying that they weren't. They're acting erratically or having other evidence that the person really had suicide risk. So I think standardized screening is great. I think it's important to set the context and it's important to use your clinical judgment and other information and incorporate that into the screen process. Ryan, anything you want to add? No, I mentioned just a minute ago, I'll just follow up on that. I agree with what Ed said. There are a non-insignificant number of people who will screen positive on suicide risk screening tools that won't screen positive for depression. Depression is not suicide risk. They're actually independent and we need to think about them independently. So if you gateway, certainly what Ed said is really important. There are a lot of people that just won't screen positive to anything and we do need to pay attention to clinical indicators, warning signs, risk factors, and act upon those things. But certainly a screening protocol that starts with let's make sure that somebody screens positive for depression before we even ask about suicide risk misses quite a few people who will screen positive on that suicide risk question. And they could have some other behavioral health issue or not have any of those conditions at all, which is why that universal approach is the kind of utopian way of doing it, even though it may not be feasible in every setting. It is at least important to ask the suicide risk question or questions right up front to everybody at least who is indicated to be at risk. Tina, from where you sit, have you had a lot of systems asking you about what if they're missing somebody using their standardized screening tools? Yeah. I don't know that they ask about it more so than we kind of come upon it or sort of point out some of the opportunities. I agree completely with what Ed said. The collateral information is so important. We've had situations where the collateral information's there, they have it, and they don't use it. And that's really unfortunate because it's led to some negative outcomes. Mental health should be part of any regular systems assessment. We all know that that would be the ideal world. Unfortunately, we're still in healthcare. I think we still compartmentalize. We have the sort of medical concept and then this mental health concept. And the more that we work to bridge that gap and make it about the whole person, I think really is what's going to lead to breakthroughs in this area. But in the meantime, the things Ed and Brian said make sense. And again, that use of that collateral information is so important. We talk about the concept of being able to see the forest for the trees and not missing something that's right in front of you because you're so focused on the broader picture. And I'd be curious, and you may not know the answer to this off the top of your head, but I'd be curious what some of your data is telling you with regard to adverse events that the Joint Commission collects. Are you finding people are getting missed? I mean, I can't speak to formal data. We are in the process of pulling some of that now that we're a few years into the new requirements. But I do know as somebody who works in the Standards Interpretation Group, I get to see things that are identified at organizations. Yes, we do identify opportunities. There's very overt opportunities, things that were very obvious, patients that came in with very obvious symptoms that should have been screened. And then there's these other ones that may be a little grayer or they really didn't think, oh, this was an opportunity that we missed. And again, part of what we do is helping organizations identify those opportunities and putting better systems in place to catch some of those. So, clearly, we've spent a lot of time talking about screening, but what we also, and different than screening is risk assessment, and it's critical that we have more thorough suicide risk assessment occur. So, Gina, what needs to be a part of a suicide risk assessment to satisfy this requirement? Okay. So, those of you familiar with the standard know that it's somewhat prescriptive. But at minimum, we require anybody who screens positive is required to be assessed. And that assessment is required to be evidence-based. So, we'll talk a little bit about what that means, but what must include? It must include the inquiry of ideation. And really, that goes beyond just, you know, are you having suicidal thoughts? But that looks into the frequency, intensity, duration, really that assessment of that ideation. Plan is required. So, do they have a plan? What are the specifics of the plan, timing, location, lethality, you know, availability? Have there been any preparatory acts, intent? So, really, the extent to which the individual, you know, either expects to carry out the plan or also believes that the plan may or may not be lethal versus maybe just self-injurious. And then if there's been any suicidal or self-harm behaviors, as well as those risk and protective factors. So, the risk factors being, you know, any of those. It could be individual, biological, psychological, family, community, cultural, societal. Those are all the types of characteristics that may contribute or increase the risk for suicide. And then those protective factors. So, those internal, external characteristics that are associated with the lower likelihood of negative outcomes. They can also reduce a risk factor's impact. For example, a safer environment may reduce a particular risk factor. So, when we talk about an evidence-based process, this can be accomplished using an evidence-based assessment tool. Again, there's a lot out there. But again, it's less prescriptive than the screening requirement because we know a lot of the things we've already talked about. There's a lot of factors that go into assessment. So, including these as part of your overall assessment, utilizing that clinical judgment piece, and then pulling all that information together to determine that overall level of risk is really what we're looking for at the Joint Commission. So, Brian, what's your approach at Henry Ford to assessment? Yeah. There are a lot of resources available in the Joint Commission's section that, for example, some tools that people can use. We actually use our own tool at Henry Ford, and that's something we've been using for... Kudos to our staff here who have really been at the forefront of thinking about suicide prevention for many years before some of these tools were even available. So, we had developed a Henry Ford suicide risk assessment tool that does have all of those elements that Gina mentioned. But as Gina also mentioned, there are a lot of other factors that increase risk for people. So, the minimum requirement is to ask about things like ideation plan, intent, means, things like that. But in our mind, there's a lot of factors that contribute to increase risk, decrease risk for people. So, we ask a lot about... We've constructed our risk assessment based on all of the evidence that's available out there using factors that increase risk and querying about those things in our risk assessment tool. Our tool is not listed in the resources, but we did work with the Joint Commission who asked us about our tool, and we provided all the resources and demonstrated all the evidence backing between each factor that's in our risk assessment tool and why it was in that position. So, this is one example of an organization that doesn't use one of the tools but has an evidence-informed approach, and we were able to back that up. So, we felt pretty strongly that there needed to be assessment of other factors beyond just some of the initial factors that are required. And so, we have, I think, a more comprehensive tool, but definitely those initial factors need to be assessed. Yeah. Clearly, your approach, Brian, is evidence-based, it's thoughtful, it's intentional, it's well designed, but it does deviate from the Joint Commission's recommendations that are on their Aug. 3. So, Gina, what are your thoughts about this? Well, I would humbly disagree. I don't think it deviates at all. I think it's exactly what we're looking for. Again, when we have compendium of resources, these are known, these are research tools. The experts in the field told us exactly what Brian is saying, that an all-encompassing assessment tool is not going to be right in every situation. These are the basic things we think that are important to be part of that assessment. So, if an organization has a way to incorporate these and has a thoughtful, evidence-based assessment, that's what we're looking for. So, really, I commend you for having the work and the energy to put into that. We have to think about healthcare across the gamut when we look at the Joint Commission. And we have, Brian, which I would say is kind of way up here, and then we have some organizations that this is very elementary and they're just starting. So, they need as much help as they can get. They need as much recommendations as they can get. We come across some organizations, they have very little, if any, psychiatric professional that they can call upon that can provide them assistance with either screening, assessing, or developing these processes. So, of course, those are the types of organizations. We want them to take what's already out there. They don't have the resources to reinvent the wheel. So, we're dealing with everything from that level all the way up to the clinical experts that we have no doubt get this and are doing these very comprehensive assessments. So, I'd say you're right in line with exactly what we're looking for. Yeah, thank you for clarifying that. I think that's exactly it, right? The requirements are not biblical to follow exactly what's done, but it's the purpose and the essence behind it. And I think what Brian's describing is how well they're purposefully doing risk assessment or any of the components within the National Patient Safety Goal. So, I know that we have heard that, oh, you can't use that because it's not listed. And so, I think this was an important clarification about the purpose and the guidance of the tools. Another question that comes up is whether systems can go straight to doing a risk assessment. So, is a screening required before the risk assessment? Or if you do a full suicide risk assessment, does that kind of meet both EP2 and EP3? Because while these are absolutely separate buckets, right? Risk assessment and suicide screening are not the same thing. Sometimes it's not a neat sequence of events in real life. So, Ed, let's start with you. What are your thoughts on this? Well, I think that you can look at screening and assessment as separate processes, and there's a way to conceptualize it that way. But I also think you can look at it as part of the same process. So, I don't think it's one or the other. I think what's going to drive the separateness of that process is probably going to be the setting. That's the biggest driver that I see is the setting. In the emergency department, for example, the person who's going to be doing the screening, because it has to happen quickly and up front, you don't want to screen a person after they've been in the emergency department for several hours and find out that they're suicidal and all that time they were sitting there without appropriate care and attention to their suicide risk. So, because of that, you have to do the screenings early, either at triage or during the initial nursing assessment. So, as early as it's realistic for an emergency department to do it, they have to do it. But it's usually going to be done by a nurse. And it's probably not realistic, at least it hasn't been realistic in my experience, to expect an emergency department nurse to do a full suicide risk assessment. So, they can very competently and accurately do a screening. But the assessment is more nuanced. I think it takes more training. It takes more time. They simply don't have the time and the training to do it. So, that process of screening and assessment in the emergency department is going to be a separate process. But I think in behavioral health treatment settings, it doesn't have to be a separate process. It's separate in that you're going to ask some initial questions of the patient. And if they, depending upon how they answer, you're going to go into a more in-depth assessment. That's essentially the difference between screening and assessment as it's in one process. If you have your initial questions are going to be targeting sort of lower level ideation to start at the beginning to determine if they've had passive ideation, or in other words, have they had thoughts of if they were just better off dead, they wish they would go to sleep and not wake up. And then maybe the next question is, well, have you ever thought about actually killing yourself? So, those are two screening questions that are common in many screeners. If the person says no to both of those, you're probably not going to ask additional questions around suicidal intent or suicidal plans because they just said no, they haven't had any thoughts. So, those two items end up acting as a screener, but they're also the segue to the additional more in-depth screen assessment questions that Gina mentioned that you would only ask if the person was positive on those first initial thought questions. And the same thing is true for behavior. You might not jump straight into asking about suicide attempts. You might ask something more in the preparatory range in your screening question about whether the person has ever done anything or practiced or rehearsed and looked up information about killing themselves. If they say no to that, you may not go necessarily to some additional questions because usually that type of behavior is going to precede an attempt. So, I think that it really depends upon the setting. Emergency department settings, outpatient settings are also more likely to be more distinct processes. Inpatient behavioral health settings, outpatient behavioral health settings, it's more likely to run into each other. Brian, any thoughts? Yeah, I mean, for us, exactly what I agree with that. For us, I mean, we do an assessment for everybody, irregardless of a screening. The screening is actually part of the assessment in behavioral health. Once people get to behavioral health, every single behavioral health condition increases risk for suicide. And there is not enough evidence to distinguish those people in that kind of a setting, even among people who screen negative. So, we really feel strongly about doing an assessment for everybody. The screening is part of the assessment. It informs the assessment. Just like what Ed said, you don't need to ask about plans and all sorts of things if they don't screen positive. That ideation question is not there. But you still, at least for us in that setting, want to ask about some of the other risk factors. But that's not necessarily feasible in other settings. You can't do a comprehensive suicide risk assessment in primary care with hundreds of thousands of people coming through. You need to be much more pragmatic, really think about the population that you're serving. So, in other settings, we would certainly start with a screening tool and have that triage into an assessment. The screening informs the assessment. But if somebody comes in with an indicated risk, like they're coming to the emergency department for a suicide attempt, for example, it is absolutely, I think, within reason to start and go right to an assessment to think about all those complex factors. They already demonstrated that their screener would be positive because they came in for a suicide attempt. And, June, I know sometimes people, just even thinking specifically about the risk assessment tools or even screeners in this case, what if systems are looking at modifying questions or language? What flexibility do they have? Well, we don't allow organizations to modify the language of the validated tools specific to the screening. It was very important when we had our technical advisory panel. And I think, as you mentioned this earlier, asking questions in a way that are going to get you the best answers. And what we sometimes see in the field when we're not following something such as a validated tool related to suicide, and people still have that awkwardness and feel uncomfortable asking questions. And some of you may have had this experience. I've met this experience when I've sought services in healthcare where somebody almost says to you, oh, well, you're not feeling suicidal, right? And it's like, they think they're doing the right thing. Oh, well, we're asking about it but I feel awkward about it so I'm gonna present it in a way in which well then no you're telling me I'm not so no I'm not gonna admit to that so that's kind of a little bit of the history there plus tools have been validated for a reason they've been validated using the questions that they have following the clinical pathways that come with the tools so we really look to make sure that a validated tool is being followed as it's intended to be followed now again there's more flexibility with that with that assessment piece like we talked about as long as that evidence-based process is followed we tend to see you know a little bit more flexibility with the way things are asked in the process of assessment one of the things that all often comes up to is time frames a lot of the validated tools have different time frames they're looking at you know acute screening versus chronic screening and those types of things and we really again look back at the tool and look at the research behind it allow most of them do allow those time frames to flex based on the settings and services and the immediacy of the suicide risk that you're you know trying to evaluate so generally time frame changes are acceptable but language changes would not be so and you brought up risk stratification earlier and said how healthcare systems do or do not do risk stratification varies and sometimes is even controversial can you say more sure so I think stratification is has come under fire recently because of the perception that stratifying people puts people in artificial categories and that actually the risk itself is probably not only a spectrum type of thing but it also fluctuates and sometimes it fluctuates really rapidly so that if you put a person in a stratification now at this moment maybe later in their visit if they have bad news or they're getting more agitated or they're you know withdrawing or having other symptoms that are agitating them that their risk increase or decrease and and that if we conceptualize people as a category we might be doing them a disservice and not really accurately representing the phenomenon and I agree with with that principle that and most of the literature suggests that suicide risk can be a spectrum and it is also very but that's a tension with the practical considerations of decision-making in busy health settings so there's the need to actually be able to make a decision about what to do with the individual and make decisions about what to do with them rapidly so the emergency department inpatient units this is true in primary care too we sometimes think that outpatient care settings are more flexible but often they aren't if you've ever worked within a primary care practice or learn anything about what the way they work time is super important schedule breakers which is what a positive for suicide risk often is because it derails them from their schedule is a real consideration and we shouldn't take it lightly so stratification ends up being important because it helps with decision-making I don't think that stratification is an end-all be-all I think you are the way I would encourage people to think about it is you want to get a triage stratification so what is our next step and how can we execute those next steps effectively and efficiently but then eventually the goal was probably going to be to get the person engaged with a behavioral health provider who can do a more in-depth assessment like what we've just been talking about so that that person's risk stratification can be conceptualized in a much broader basis and be monitored longitudinally over time so just like you know I've used this example before the recent examples for hypertension screening so as you guys know you go to primary care or any medical setting and they take your blood pressure and we know that one assessment of your blood pressure has very poor operating characteristics to actually predict whether you have hypertension that this diagnosis of hypertension so instead of one we usually rely on multiple screenings over time before we say okay at this person actually it needs some sort of intervention for hypertension in fact the gold standard in studies is to wear a device 24-7 and it monitors your blood pressure during the day you know so so I think we we have to think about something similar with suicide risk and with the strata it's not once you're in a strata you're there forever it implies you should do some additional screening additional assessment and adjust that person strata over time based off of the results that you get so that's I guess a few thoughts but my thoughts about stratification Brian how does Henry Ford use risk stratification I think this is a really important topic and it has a lot of implications and you know I agree with everything that Ed said I think there's a lot of pros and cons to risk stratification our risk assessment does generate a risk strata we have an acute high moderate and low risk once you get to the assessment you are at least at one of those four levels so you know even if you start the assessment you'll by definition be be at low risk just by by virtue of starting it because you've got into that assessment through a specific pathway or got it for a specific reason but you know one of the reasons that people don't really have it another reason I don't I think that Ed didn't mention but I you know I agree with everything you said but to add to that well another reason why people don't like it is because what it means if you know as soon as somebody's at high risk or acute risk you you have to have a one-to-one staff and it doesn't necessarily you know in a hospital or emergency setting and that's not really all that practical for a lot of a lot of systems it's really challenging to have a large number of staff there and and because of the nature of risk and because it can change not only can it increase during a stay but it also can dissipate so so somebody's risk may start out as high or acute but but an hour or two later may not be at that level that that's a you know that creates a challenge to kind of manage the kind of next steps down the line of what the implications are of having a higher acute risk strata but I will say that it is it is actually really important to have those risk strata for decision-making we have clear care pathways that are aligned which with each strata and dictate when the next step needs to occur not only what needs to occur but when it needs to occur and and actually I really do think that that's that's really important without that clear guidance then there's a lot of indecision about what should be happening and when it should be happening so you know having a structure really allows and make sure or encourages next or clinical action on that assessment where it's if you didn't have that strata then often things get missed things get duplicated where we're doing multiple things and and really we lose track of people they fall through the cracks so the strata are important but they're but they do cause they do cause some some you know anxiety and and I think rightfully so and I think we need you know moving forward we need to continue to this is the you know that the patient safety call is fantastic I'm glad we move forward with it but you know we'll continue to evolve to think about the best ways to push it forward and implement it and adapt it so Gina we're clearly starting to think about EP4 and EP5 right which you know have to do with plans and expectations and the protocols in place around documenting risk and monitoring risk so you know if you could speak a little bit to the Joint Commission's expectations in this area but but also your recommendations with regard to risk stratification sure um so yeah so as far as the standard go element of performance for talks about documenting an overall level of risk so stratifying that risk which is really done based off the assessment and then once that level of risk is determined what then is the organization going to do as far as mitigation and interventions go and I think although you know maybe it's hard to see it but I do think that our requirements kind of support what both of you have said because you know I I've heard I've heard it a little different in the field you know I've heard a lot of organizations that we're following all or nothing approaches somebody comes in they may be suicidal and that's it oh my gosh you have to be on a one-to-one we're taking all of your things away and they have this very drastic all-or-one approach and now that more organizations are looking at validated screening tools that provide stratified risk as well as then the assessment process that gives risk they've been able to back off that somewhat not every patient needs a one-to-one not every patient is falling into that imminent risk category so I think that's good I mean not only is that good as for utilization of resources but that's good for patients having that type of approach when you're really not an imminent risk we know can maybe send somebody back into their shell and not want to admit that they ever had a problem in the first place and we know and I hear this a lot especially in our adolescent populations well I'm sorry I said something now so you know when I work with organizations I encourage them to use the tools and use that risk stratification to determine those next steps now with that being said are we focused on those that are imminent or high risk yes of course we know a lot of the times when we look at the root causes of suicides that occur in healthcare a lot of them are individuals that we knew were imminent or high risk and unfortunately the safeguards weren't in place to prevent that from happening so obviously that is one of our big focuses those are the patients we want to make sure are either put in a safe environment or have you know a one-to-one observer or a way that they can be kept you know immediately safe until further assessment can be done the other piece that I think really supports what you're saying is that you know our element of performance five talks about policy requirements one of them is defining your reassessment guidelines that's going to vary based on the setting that you're looking at and some of the things you guys talked about you know the the fluctuation of suicide risk and that things can change and how often are you reassessing and then using those reassessment results to drive different interventions if it's appropriate you know maybe you can back off on your intervention interventions maybe something's changed and now you need to enhance the intervention so I do feel like we do try to support organizations flexibility with that taking into consideration the things that you've said the other important components of the policies that they talked about again we're focused on those that are high or imminent risk so we ask organizations to be very specific about what they have in place to keep those individuals safe and then what kind of training and competency are they providing to staff so looking at any staff that interact or provide care or treatment to individuals at risk for suicide what kind of training do they receive do they have competence assessment in areas that would require competence assessment those are some specific things we're looking for in policies and procedures related to our elements of performance and then you know when we talk about I get we get asked a lot with you know competency and training you know who should we train really depending on your organization I always say a day in the life of when I was a nurse manager I would sit on the unit and kind of watch a day in the life of a patient and just kind of see who they interacted with throughout the day and that helped me see outside people that were entering the unit and other people that we may not have thought about and unfortunately it's not till an event or something adverse occurs that you think oh I didn't even think maybe that respiratory therapist needed to know that they shouldn't you know keep the the plastic bags or the tubing around a patient who's suicidal and so I always say kind of do that day in the life of those are the people that you should really be making sure get that training and they may not be actively involved in any of the screening or assessment processes or be providing direct interventions related to the suicide risk but it's important for them to know what it means to be providing treatment to a patient who's at risk for suicide so I kind of talked about again broadening your training making sure everybody at least has a general overview but that really is specific depending on the roles and responsibilities of those people regarding that aspect of it so you you're talking about training clearly in the in the practices and the policies that you're setting Brian what do you guys do how do you ensure that you feel like you have the right people trained yeah I mean I training is important it's important to know that you need to ask the questions the way that they were intended to be asked it's important to know in fact it's the probably the most important thing to be trained on is the process itself so that people know what they're supposed to do and when they're supposed to do it if you're not if people aren't working together as a team then then then you know then things fall through the cracks but as the best and optimal way to provide the top level of suicide prevention care in your system is to work as a team there's no individual person that can just follow a patient around all over the place all the time so if we can work together and people can become experts and the things that they're supposed to do for their job and that that that those things are those processes are connected across the system then we can have optimal suicide prevention care in each setting and connect that care not only within the hospital and emergency department but to the outpatient setting as well so so that so the training and you know in my mind and in our mind is tailored to what the staff role is and and everybody in that role should know the right way to do the things that they're supposed to do for their role as well as kind of what the overall process looks like and and so they're training everybody is important it's important to do when people start it's also important to refresh that training over time so that so people don't lose track it's very easy in the context of seeing dozens and dozens of patients to start to start altering the way that you do things you know so so it's important to refresh and and make sure that that the fidelity to doing the task is is is high if as soon as we start deterring or detouring from the the main pathway or the main task or process then it's it everything goes out of control so so having those structures is important aligning those structures with with when people are supposed to do things is important that's why I think the risk assessment and risk stratification works really well for us and and then making sure everybody who is in those roles knows what they're supposed to do and when they're supposed to do it I think is really really important and I'm sure when you're doing training something that comes up is probably some staff saying you know you're giving me all these standardized tools but I've years and years of clinical judgment and expertise so how do you help to balance the use of standardized tools along with some of that clinical judgment and expertise so that you can bring everybody into the fold to to work together yeah well I would say well that's great we should continue to embrace your clinical judgment and experience what I would say is that there's you know that there's no you know there's no clinician in the world that can do something exactly the same way every single time so you're gonna miss things you're gonna miss things in a high pressure environment you're gonna miss things when you have to assess 50,000 things during every single visit and so having a structure allows us to make sure that we're at least doing the things that we're supposed to be doing but what I would also say is you know good for you if you identify a risk factor or warning sign then please move forward with with additional levels of care that need to be that need to be done and don't rely only on the screening so if a screening or assessment occurs but you as a clinician have an indication that there there's an additional factor that needs that needs to be considered and and that that may elevate somebody's risk then we should take that into consideration and act upon that so so I would say hey go ahead and be a good clinician but but let's also have the standard process to mix with that mix with that and Ed how do you all I mean there's a lot to train on here and to ensure that these practices and policies are consistently adhered to and you know with staff turnover how do you all manage that yeah it's a huge challenge I think it's one of the biggest challenges in health care for any domain not just suicide prevention but you trying to train people to do any kind of protocol or any kind of procedure or get updated on some new technology or some new device even it poses massive challenges because most health systems aren't structured to really allow for sufficient training time that's separate from their clinical time so if you're expecting people to go through training while they're also caring for patients it's going to be very very difficult to get sufficient training so I think first off us the health system has to recognize that if it really wants to be able to invest in doing better care it's going to have to invest in training and having dedicated time that's paid for whatever professionals are trying to train to get trained right and to the degree that a health system embraces that from what I've seen from working with health systems across the country if they embrace that and they have dedicated time to train the training is going to be much better quality it's usually going to go beyond their electronic health their training systems so most health systems have these electronic systems that where all of your compliance training or annual or pressure training stuff goes through these these systems it's all virtual it's all on your computer and frankly I go through them every year and they're a waste of my time because they're often the same things every year they're dulled or you can skip forward you know really quickly and I don't think that really anyone gets much advantage skip forward nobody we know you don't I don't do that I just was using that as an example I do know how to use a fire extinguisher quite well now after 20 years of having refresher training so that's good but um but I think that it has to go beyond that that might be okay to introduce people to a concept but this is really very difficult work the protocols themselves like Brian mentioned are important so people know what to do and when that's super important but also the skills to execute each one of those tasks is really important just like we talked about you have to be trained on how to do a good screening if you really want to get good information and that's what that's super challenging I think that in our system what I observed is people became very creative about how to try to fit the constraints of the training time but still be better than just a couple of slides on a compliance training slide set for example the ICUs are very difficult to safety proof if you think they're seeing an ICU room when there's equipment everywhere how are you going to make that safe for a person who's there who's suicidal it's extremely challenging you can't remove all the equipment so what they did is they took a photograph of the regular ICU room and then they took a photograph of the safe ICU room and put it side by side and it was easily accessible so that if a person had to make the ICU room safe they could actually compare it to a visual jobbing which I thought was brilliant this was the nurse manager who came up with this and it was well received because it was very practical that one job a probably was more important than that you know the five slides on the training in that didn't actually have those those pictures so I think you have to come up with some creative ways to do it when one of the pediatrics units actually created a safe room one of their rooms they said okay this week this room it's going to be safe they removed it and had their staff at the beginning of the shift actually walk through that room to be able to look at and see what it looked like in real life to make that room safe so and that didn't take that much time it did take that room a bit out of use for a few days which was very challenging to find an alternate place to go to put on the patients but they were able to do it because they felt it was important enough for people to see it and not just hear what they had to do you say remove all of the dangerous equipment that might mean one thing to someone else and a different thing to another person so I think I think you have to become creative, figure out how you're gonna get the trainings to work, to make them meaningful, rather than just checking the box somewhere. And the highest level of training is gonna actually be auditing with feedback. And we've done this as well. If you're in a health system who can do it, I recognize it's challenging, but you can think about this auditing and feedback in a range. There might be an auditing of a chart with feedback provided to the treatment team based off of the chart audit. If you audit a chart, you'll find all kinds of problems with a lot of the care that's being provided. It's very apparent. So we've audited charts and found patients who screened positive who got no mental health assessment at all that night, got discharged. In those cases, giving people feedback specifically on what should have happened can be really, really useful, and it doesn't take that much time to do a chart audit like that. And then the Cadillac version that I like to point out, which we have done at various times, particularly when we're rolling out our new procedures, is we had nurse managers and nurse educators on those units responsible for actually visiting patients who were already identified as having suicide risk to look at the care that we're providing. Like what Gina mentioned, what's the day in the life look like? Well, what's this hour in the life look like for this patient? And do we seem to be complying with our own policies? You can develop a checklist often that's very simple that looks at the key performance indicators, KPIs for your policy, and you can do an audit, a real live audit, probably in five or 10 minutes of a patient. And then if you have that as a coaching approach so that it's not punitive, I'm not saying do this audit and then fuss at people when they're not doing it right because that will quickly generate a real negative reaction to the whole process. Instead, the individuals doing the audit have to look at it as coaching. And so this is a positive, this is a blame-free culture we're trying to promote. And we simply wanna make sure we're providing the best care for our patients. There may be things that we can help to tweak your performance to provide the absolute best care. We're trying to go from good to great. We're not trying to find people and penalize them for doing poorly. So I think if you take that auditing approach and that sort of stance, then you can really engage people. And one auditing experience is probably worth you know, dozens of hours of training in the classroom. I love those examples. I mean, that really make it so meaningful to the staff and really do actually change care, right? As opposed to like, I've watched a 30 session PowerPoint and now I know what I'm doing. Brian, what about you? Is there anything that you feel that you've done that really helps you to be more successful in meeting these requirements? And really, I mean, more than meeting the requirements and like truly changing care at Henry Ford. Yeah, I actually agree with all of those things. The auditing experience is actually quite, chart reviewing is actually quite impactful to recognize, you know, what's being done and what's not being done. You know, certainly we provide training for people for the skills that they need to do the tasks that they have and the process that needs to be done in each setting. And that's really important. It's also important to have people that help bring the pieces together. So in kind of medical settings, you know, we have embedded, you know, behavioral health staff that help facilitate some of those actions. And they're trained because, you know, it's often challenging, you know, when I just, I can imagine, you know, as a, you know, general medical provider, primary care, as a, you know, ED physician or as a hospital physician or staff that you have to know so much about every disease that you can't be really specialized in a certain disease. So if somebody has an advanced level of risk in any kind of disease, we bring a specialist in or somebody with expertise in that area to provide consultation in the same manner. You know, if somebody's at higher risk for suicide, having a behavioral health staff member that has more expert training and exactly how to do those assessments is really important. So in making sure that not only do we train them, but we also have, you know, we have shadowing and we have people that, you know, that can give them feedback regularly on performance. But absolutely, and I think it's important when we're giving feedback, this is probably going into another domain, but that we don't single out that person as having been failed, but recognizing that, you know, if somebody is not doing something the right way, it's probably a systematic problem. And that's really on us to make sure that they do know how to do it, not as an individual, but as a system that people, you know, people who are doing that role know how to do it the right way. And that's not a reflection of that individual person, but that we work together as a team to make sure that we're doing it the right way moving forward. So it's not a, hey, I got you a moment. It's really meant to be, hey, let's work together to make sure we're all doing this the right way and that we're all working on the same page. And that's, you know, it sounds utopian, but I think it's actually really, really important to do that. And I think it's so critical. Both of you, Ed and Brian talked about, it's a just culture. It's not trying to gotcha, right? It's not, it's looking to better and improve the system. And if we're all looking at that as the bullseye, then it doesn't have to feel so, you know, scary about messing up. It's actually find the errors. Let's fix them, right? If we do it together, we can plug those holes and do better. Gina, what do you guys look for? What are your surveyors looking for? And what have you seen as really powerful examples of training in this space? Well, I was gonna say, Ed and Brian are making my life easy over here. Not only have they given fantastic examples of training and education, they touched a lot on what we're looking for, for EP7. But I'll talk a little bit about the training and education. I think you guys hit the nail on the head. You know, obviously we require it. We're not prescriptive on what that looks like. So it's really up to the organization to determine that. But we know the organizations that have done things outside of the box, that have done things more hands-on, and then also have those approaches to do that re-education, re-training specific to the elements that they find non-compliant are the ones that are the most successful. And most of us that have been in leadership roles know that when you can target the specific issue and provide that very specific re-training, re-education, you're more likely to have success versus a global approach. So again, everybody needs the initial information. You got to find a way to get a lot of information out to a lot of people. So what do we do most often? We're using technology to do that. That's the reality. But then how are you following that up? And how are you enforcing that is really what's key. And I like some of the examples you gave with the auditing, not just looking at a chart, but also I think, Ed, you talked to actually seeing things visually in person. You know, that's kind of the boots on the ground approach that you talk about to make sure that you are actually reducing the risk for suicide. Are you doing what you think you're doing? Is what's happening what is outlined in your policies and procedures? And a lot of that can only be done by seeing it, by visualizing it. And again, a lot of people think, oh, that's going to take a lot of time. But as you said, most often not. You know, if you make it a priority, it doesn't need to be an every minute of everyday thing. But if you have it as part of your workflow to be able to look at some of those key things, you can pick up on things that there might be discrepancies or issues with the processes. We always talk about too, making sure you involve your frontline staff. Same thing with a just culture. It's very rarely, rarely a person problem. Most often some sort of process or resource issue. So engaging that frontline staff and the work that they're doing every day is so important because they can provide you that valuable feedback. Maybe why things aren't getting done the way you think they should be done. And we've seen a lot of organizations that take that feedback and end up having to revamp their whole process because it just wasn't working. It wasn't feasible. And if it's not feasible, we know it's not going to get done, right? With all the extra things and all the things you've mentioned that have to get done. But thank you. I think Ed and Brian gave some really great examples of both training and education, but also ways to meet that EP7 requirement, which talks about monitoring the overall implementation of your risk reduction strategies and then taking action when you do find those deficiencies. So I know people are, we have a lot of questions that are coming in and we'll do our best to get to several of them. I think we can probably, we're not going to get to all of them today, but hopefully we can find the ways to get them answered over the coming months. But before I turn to some of our questions that came in from participants, Gina, what are some questions that you've gotten that we didn't ask about here? What are some frequently asked questions that healthcare systems have called your office about that maybe you can share with us? I think one of the most common things is the questions about the specific screening or assessment tools. Again, many times it's a question related to either a tool that's already listed or as we've already discussed, is this a process or a tool that we can use? You know, the Joint Commission does not develop or research tools or evidence-based processes. So generally our default answer is we defer you back to the tool or process itself. Particularly if there's a specific clinical pathway associated with such, we're fully supportive of that. Because again, we didn't develop these tools, we didn't research them. We're going to the experts that did. So I'd say that's probably one of the most common things that we get questions on. And there were several questions on data. So I'm going to turn to my researchers, Brian and Ed. Brian, I'll start with you. What data are you using to monitor compliance with some of the activities beyond just chart audits? Yeah, this is probably my favorite topic, but I, you know, we- And we only have 10 minutes. Yeah, right. I've worked with you. Right, I'll summarize in two sentences or less. So basically we create metrics that align with the care processes that we're implementing and with the outcomes associated with different kinds of care and regularly collect those. We have, you know, suicide death data that come in from both the state of Michigan as well as our own records. We have attempts that we capture and we also create process metrics to track how we're doing. And again, that's not to say, hey, you know, this person is terrible. It's to say, hey, here's a pattern and let's figure out how to fill that gap. And that's really, really important to create those metrics and make sure that you have those metrics aligned to who's supposed to get that process or who's eligible to get that process and then who's actually getting it among those who are eligible. I've seen so many problems with those kinds of getting those metrics wrong, but very important to be able to have rapid cycle quality improvement, to be able to action, you know, to act on, you know, when you see gaps in care. Ed, any you wanna add? Yeah, I think you can think of the data issue as a ladder. The very first run in the ladder, which should be easiest and achievable by every organization is what I call the rule of 10. If you identify 10 patients with suicide risk and you review those charts, you will probably find some pretty glaring problems and you really only need 10 charts in my experience. This is not strongly researched, this is my experience, but if you do a chart review of 10 suicidal patients in your organization, you'll probably find the big things that are not happening that should be happening. And if you don't, if you get 10 out of 10, then you should really celebrate because if you've got 10 patients and you've done your protocol with fidelity on all 10, then you should really be proud of yourself. It almost never happens that that's the case. So I say the rule of 10. If you can do more than 10 across the organization, think about 10 at the unit level, think about 10 at the individual provider level. So you just think about rule of 10 and you can figure out how you can make it more and more granular, which would be more and more useful. Because if you can do 10 charts per clinician, you can actually get people personalized feedback then versus 10 for the whole system. So I would say start simple, start with what you can actually achieve. And then the top, the pinnacle is very sophisticated electronic health record reports that can tie into your key performance indicators or your metrics that can be run automatically and provide you a longitudinal perspective of what's happening and perhaps even benchmarking against individual units or hospitals, et cetera. That would be probably the top part of the ladder. Gina, the next question is for you. There's a lot of questions for you, I should tell you. What does the Joint Commission recommend in situations where there are more patients who have screened as high risk, like in an emergency department, but there are not enough one-to-one observers for them? You got nine positive, but not nine observers. Yeah, so I've worked with a lot of organizations that have high volume of mental health evaluations and suicidal patients. So the one thing we already kind of talked about was the idea of looking at your processes and do you have tools and processes in place that help you stratify that risk so that you're not necessarily over utilizing resources? The other thing we're seeing starting to become somewhat common in emergency departments is having specific or designated safe areas or rooms. And these are rooms where the risks are removed so that a patient can be safely housed there. A lot of times these are patients being housed waiting to be placed at a behavioral health facility or maybe they're waiting to have their medical clearance, those types of things. So they've developed specific areas or rooms that are really safe. So if you're housing a patient in that type of room, you're not gonna need, they're no longer at that same level of risk and you're not gonna need that intensive an observation. So those are kind of two of the most common things that we've seen. I just wanna jump in here, Julie. I think a lot of times this problem occurs because the person is not being re-screened or reassessed frequently. And that if you have a better process for re-screening and reassessment, you'll find that many of the patients who are in the high risk after they've been stabilized, and especially if they can get assessed by a behavioral health provider and not the initial screening done by the nurse, a lot of those high risk patients can probably be more appropriately stratified at a lower risk level, which probably won't require one-to-one. And I've seen organizations take a hard look at this and find that they can reduce their high risk by doing better assessment. Yeah, I think it's a really good point. There was a question that came in about using unlicensed staff to do some of the screening. And what is the joint commission recommend about who can do screening and risk assessments each shift? But you're raising the point that then we may over identify. And then in that case, what do you recommend? Yeah, a lot of that falls into scope of practice. You know, can unlicensed personnel screen in some situations based on, you know, training and competence? Can they assess? Generally not, you know, it's not within their scope of practice to be able to assess. So that really varies state by state. You have to be familiar with your scope of practice laws. And again, the organization has to evaluate the competency of those based on the responsibilities that they're given. I have about some, another question that came in was, if universal screening isn't feasible for some settings, how can we reach those at higher risk who aren't formally diagnosed with a mental health condition? Brian, I see you ready to go. Well, I'm not sure I have the answer. That's the right, the easiest one, which is, you know, I think this is a challenging question. It's certainly easier to screen fewer people. But if we, as soon as we start going around trying to find people who should be at higher risk, we're doing half of an assessment already. I mean, I think, you know, if you're saying, okay, we have to then screen people to find out who identifies as being transgender, and then we'd have to screen somebody to determine, you know, who has this risk factor or that risk factor, you know, in the end, it may be just, you know, and you try, and if you create automated processes to only screen this person or that person or this person or that person, that creates complexities too. So I guess, you know, certainly there are ways to mitigate, you know, to do indicated screening for groups that are at high risk. And if you have already have processes baked in to identify who those high risk people are, then those actions themselves take the extra time. But if you already have those, then certainly you can screen people who are indicated at higher risk. But I guess I would, you know, and I think the bare minimum that we should be doing is what the Joint Commission requirement is, is to screen everybody with a behavioral health condition. But I guess I would also argue that, you know, we can ask one more question and screen everybody for suicide risk that fits right in the structure of all the other screening stuff that we're doing for every other disease. And I don't know that it takes all that much extra time. The big time is when you identify somebody who's at risk, then there's steps that have to go down, and that's, I think, what causes the most challenges and trying to instruct, you know, structurally, how do you stop that and create the right care pathways for people? But the screening itself is not the part that takes the most time. I'm aware that there were so many great questions that came in and it was impossible to get to all of them. I think this is such an important topic and people are, you know, they wanna get it right, not just because they want to manage their accreditation, but because they really do wanna provide optimal, effective care and save lives. So this is the first, hopefully, of other conversations like this. I know Gina can be, people can submit additional questions to www.jointcommission.org and select ask a standards question, and it can be addressed there. We will take a look at the questions that came in and see what we can do about answering those that we may not have gotten to and share that with the audience. The Zero Suicide Listserv, perhaps one of my colleagues can put that in the Q&A. There, we already had it. You can certainly join the Zero Suicide Listserv conversation using the url, go.edc.org, forward slash CS Listserv. It's been a great place to have conversations like this. A, people don't wanna reinvent the wheel, but B, we have many of our presenters today and many others. We will probably post the responses to today's, both we will post when this has been archived and is ready available for you to share, but we will also post some of the responses to questions we didn't get to on the Zero Suicide Listserv. So please go ahead and sign up, and that way you know you'll receive it there as well, and you can continue this conversation. For the CMEs, I wanna make sure everybody is able to get their credit for today. So take a look at this slide so that you can be sure to get credit. I wanna thank our presenters. I really found today so informative. I appreciated everybody's honesty and thoughtfulness and willingness to really roll their sleeves up and think about solutions to ensure that we really are providing the best care possible. It is an evolution. I imagine if we have this conversation in another year, some practices in your systems will have changed because new data emerges, and you're continually looking to improve as learning institutions. So I wanna thank everybody, and I hope everybody enjoys the rest of their day. Thank you all. Thank you.

suicide prevention

healthcare accreditation

screening

risk assessment

documentation

training

validated screening tools

standardized processes

clinical judgment

ongoing education

competency assessment

comprehensive risk assessment

best practices