1. Confidential: Quality Improvement Material The Suicide Risk Assessment in the Psychiatric Population Team Members Mary Kenny, RN MS Lisa Beck, LCSW Lisa Beck, LCSW Murali Rao, MD Thomas Nutter, MD EPIC Support Team Center for Clinical Effectiveness Vada Grant, RN

2. Confidential: Quality Improvement Material Opportunity For Improvement Suicide is a major, preventable public health problem. In 2004, it was the eleventh leading cause of death in the U.S., accounting for 32,429 deaths. Suicide is a major, preventable public health problem. In 2004, it was the eleventh leading cause of death in the U.S., accounting for 32,429 deaths. 1)NIMH.Suicide in the U.S.: Statistics and Prevention. 1)NIMH.Suicide in the U.S.: Statistics and Prevention. 2007. Accessed at http://www.nimh.nih.gov/health/publications/suicide 2007. Accessed at http://www.nimh.nih.gov/health/publications/suicide Project Aim Statement Project Aim Statement Achieve a 90% compliance rate of completed suicide risk assessments for the psychiatry patient population. Achieve a 90% compliance rate of completed suicide risk assessments for the psychiatry patient population.

3. Confidential: Quality Improvement Material Joint Commission In the Joint Commission Accreditation Program: Behavioral Health Care, the National Patient Safety Goal XV, Goal 15- The organization identifies safety risks inherent in its patient population. In the Joint Commission Accreditation Program: Behavioral Health Care, the National Patient Safety Goal XV, Goal 15- The organization identifies safety risks inherent in its patient population. A. Identifying Individuals at Risk for Suicide. A. Identifying Individuals at Risk for Suicide.

4. Confidential: Quality Improvement Material Background: To assess compliance with regulatory requirements An audit on the monthly Suicide Risk Assessments was conducted from April ’07 through May ’08 with 84% compliance rate for the Department of Psychiatry. An audit on the monthly Suicide Risk Assessments was conducted from April ’07 through May ’08 with 84% compliance rate for the Department of Psychiatry. A project was initiated to improve overall compliance. A project was initiated to improve overall compliance. Reasons for not doing were that most staff were unaware of the Joint Commission requirement that every patient be screened at every visit for suicide risk Reasons for not doing were that most staff were unaware of the Joint Commission requirement that every patient be screened at every visit for suicide risk

5. Confidential: Quality Improvement Material Magnet Forces: 6 Quality of Care 6 Quality of Care 7 Quality Improvement 7 Quality Improvement 9 Autonomy 9 Autonomy 13 Interdisciplinary Relationships 13 Interdisciplinary Relationships

6. Confidential: Quality Improvement Material Measurement Goal and Target Denominator: 20 charts randomly selected on a monthly basis for audit documentation of suicide risk assessment. 10 charts will be from LOC and 10 charts will be from Fahey. Therefore, the total number of audited charts per quarter = 60 charts. Denominator: 20 charts randomly selected on a monthly basis for audit documentation of suicide risk assessment. 10 charts will be from LOC and 10 charts will be from Fahey. Therefore, the total number of audited charts per quarter = 60 charts. Numerator: The number of charts audited with a complete suicide risk assessment. Numerator: The number of charts audited with a complete suicide risk assessment. Goal: 90% or better compliance rate with a stretch goal of 100%. Goal: 90% or better compliance rate with a stretch goal of 100%. Source of Goal or Target: Chart audit per RN. Source of Goal or Target: Chart audit per RN.

7. Confidential: Quality Improvement Material Solutions: 1) Education of National Patient Safety Goal #15 to all key stakeholders. 1) Education of National Patient Safety Goal #15 to all key stakeholders. 2) Task Force of administrative and clinical staff from Psychiatry formed to identify specific criteria to address and document in the chart. 2) Task Force of administrative and clinical staff from Psychiatry formed to identify specific criteria to address and document in the chart. 3) Relevant articles on this topic reviewed along with the Joint Commission National Patient Safety Goal#15. 3) Relevant articles on this topic reviewed along with the Joint Commission National Patient Safety Goal#15. 4)EPIC template created for the Initial Assessments documents. 4)EPIC template created for the Initial Assessments documents.

8. Confidential: Quality Improvement Material Solutions: 5) Doubled the number of charts audited monthly from 10 to 20 to obtain more data. 5) Doubled the number of charts audited monthly from 10 to 20 to obtain more data. 6) Pilot audit completed August – October ‘08. 6) Pilot audit completed August – October ‘08. 7) Expanded Quality Improvement project to monthly review, project ongoing. 7) Expanded Quality Improvement project to monthly review, project ongoing. 8) Report to key stakeholders. 8) Report to key stakeholders. 9) Celebrate Success! 9) Celebrate Success!

9. Confidential: Quality Improvement Material In the last 10 months, a 90% or higher compliance rate has been attained for completion of a suicide risk assessment In the last 10 months, a 90% or higher compliance rate has been attained for completion of a suicide risk assessment Stretch Goal 100% Goal 90%

10. Confidential: Quality Improvement Material Suicide Risk Assessment RISK ASSESSMENT RISK ASSESSMENT –Informant: *** –Is there a weapon or stash of medication in the home (if “yes,” describe)? *** –Is there any concern about risk in caring for kids (if “yes,” describe)? *** –Does the patient feel safe in their living environment (if “no,” describe)? *** A. RISK ASSESSMENT – Suicide A. RISK ASSESSMENT – Suicide –Has the patient made any previous suicide attempt's)? {YES/NO:18465} –Does the patient express any thoughts about wanting to die or about being dead? {YES/NO:18465} –Is the patient experiencing suicidal ideation? {YES/NO:18465} B. RISK ASSESSMENT – Homicide B. RISK ASSESSMENT – Homicide – Is the person expressing any homicidal ideation or plan? {YES/NO:18465} Risk Assessment/Treatment Plan: Risk Assessment/Treatment Plan: – Patient given verbal instructions to call 911 / go to nearest ER if having suicidal ideation and or if s/he thinks s/he would act on this. Pt verbalized understanding the instructions given and verbalized willingness to follow through. –Patient given printed information with suicide hotlines as noted below:

11. Confidential: Quality Improvement Material Next Steps 1)Continue monthly audits tracking department compliance rate. 2) Continue to address noncompliance issues with individual providers. 3) Keep Dept. of Psychiatry staff informed of compliance rate. 4) Have local resource flyer available for those positive for suicide. Inform staff of flyer location. 5) Establish guidelines for including suicide risk assessment expectation in the orientation for new providers to the dept. 6) Continue to work towards stretch goal of 100% compliance in completing suicide risk assessment.