This document summarizes a presentation on implementing a "Zero Suicide" approach in health care systems. It discusses how individual clinicians have historically tried to prevent suicide but health systems have done little. It promotes training all staff in suicide prevention and safety planning, ensuring continuity of care for suicidal patients, and making suicide prevention an integral part of any health care system rather than an afterthought. The presentation provides data on suicide rates, risk factors, and examples of health systems like the US Air Force that have successfully reduced suicides through comprehensive prevention programs. It encourages all audiences to help implement a national suicide prevention strategy.

1. Zero Suicide in
Health Care: Not
Another Life to
Lose
DAVID COVINGTON, LPC, MBA—
CRISIS ACCESS, LLC
crisisaccess.com

2. Richard McKeon,
SAMHSA
“Over the decades, individual
[mental health] clinicians
have made heroic efforts to
save lives… but systems of
care have done very little.”

3. Largest Data
Set to Date:
UTAH

4. National Survey of 30,000 MH
Professionals Across Nine States
ZS Advisory Board (Mike
Hogan & David
Covington Co-leads)
6,816
1,123
658
8,344
2,507
771
6,292
Learning Collaborative,
Julie Goldstein-Grumet
Learning Collaborative,
Meena Dayak
1,562
3,802

5. “Why no mention of
firearms?”
never know what to say.”
succeed in
suicide.”
“I have attempted
suicide seriously once
in my life.”
“Many can be prevented,
some can't.”
“ALL health care
“If people are serious about it,
providers should have
they will complete it, no matter
training in suicide
“ them.”
prevention.”
what is done for
“I don't know how “Love the Columbia
scale”
to handle this topic,
“We need more
honestly.”
education on this
“I think suicide is in our
issue. No one
communities, but I do NOT think
wants to talk about
we should be spending tax
it!”
“My sister killed herself dollars to do ANYTHING about
just yesterday”
“I think about it.”
suicide
“This survey is somewhat
naive.”
everyday.”
“The t

6. Question 16 of 16. (Behavioral Health)
6

7. Question 13. TRAINING (Behavioral Health)
7

8. Question 14. SKILLS (Behavioral Health)
8

9. Question 15. SUPPORT (Behavioral Health)
9

10. Question 16 of 16. (Educators)
10

11. Question 13. TRAINING (Educators)
11

12. Question 14. SKILLS (Educators)
12

13. Question 15. SUPPORT (Educators)
13

14. Looking at Suicide
Differently

15. Polling Question #1
Someone who died by hanging with their
hands bound behind their back and feet
tied together was probably a murder, not
a suicide.
A. True
B. False

16. Pyramid of Suicidal
Behaviors
38,364
Suicides*
572,000
Hospitalizations**
752,000 Attempts
Requiring Medical Attention**
1,100,000
Suicide Attempts**
8,700,000
Seriously Considered Suicide**
Source: * National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. (2009). Web-based Injury Statistics Query and
Reporting System (WISQARS). Available from: www.cdc.gov/injury/wisqars/index.html.
**Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings,
NSDUH Series H-42, HHS Publication No. (SMA) 11-4667. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

17. Suicide Rates (2010 National
Average Rate 12.4)
14.0
6.8 to
10.5
16.9
10.6 to
13.9
14 to
16.9
13.9
10.6
6.8
10.5
14.5
17 to 23
17.1
23.2

18. Suicide Rates by Age, Race, &
Gender
White Male
AI/AN Male
Black Male
White Female
AI/AN Female
Black Female
50
Rate/100,000
45
40
35
30
25
20
15
10
5
0
5-9 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+
14 19 24 29 34 39 44 49 54 59 64 69 74 79 84
Age Group (Years)
Source: National Center for Health Statistics. Note: Non-Hispanic Ethnicity

19. What Have We
Learned Over
the Past
Decade

20. Polling Question #2
Suicide Can Be Prevented.
A. Never in Those Truly Intent on Suicide
B. Sometimes, but Only in Advance of
Acute Risk
C. Always, but Only in Advance of Acute
Risk
D. Always, Even Up to the Last Moment

27. Suicide Attempts:
• Female>>male
• Rates peak in adolescence
• Concern: Latina youth and LGBT
 Suicide Deaths:
• Male : female = 4:1
• Elderly white males
• Working aged males (60%)

28. Group A
Group B

29. Ambivalence is Universal
Diagnosis is Not Destiny:
Survivors Survive!

30. Polling Question #3
Suicide is (mark all that apply):
A.
B.
C.
D.
E.
A Choice
A Sign of Psychological Weakness
Akin to Murder (Only of the Self)
Akin to Cancer
All of the Above

31. Suicide is Not a Choice
Rabbi Kushner‟s Reference to
Ice Endurance Experiments

32. Survival is In Our Cells &
Souls
Death by suicide fearsome
and daunting prospect.

33. What are the
Implications for
Health
Systems?

34. The Forgotten
Patient

35. Polling Question #4
The risk of death by suicide for those
with Serious Mental Illness is how
much greater than the general
population?
A.
B.
C.
D.
The Same Rate
Two Times Greater
Four Times Greater
Six to Twelve Times Greater

37. Mike Hogan, Former State
MH Commissioner
“Suicide represents a worst
case failure in mental health
care. We must work to make it
a „never event‟ in our programs
and systems of care.”

38. Saving Lives Saves Money: Case
Examples

39. Reduction in Suicide Rates

40. What Inspired Zero
Suicide?

41. The Air Force Did It

42. Henry Ford Also Did It

43. What Does It Look Like to
Make Suicide Care Core
Business?

44. Suicide Care in System
Framework
From:
Training and tools
Individual provider
actions; suicide care as
“specialty”
Episodes of crisis
To:
Systems & culture change
Suicide prevention woven
into all aspects of care;
everyone’s job
Continuity of care

45. Lots of Groups Are Making
Progress
• Joint Commission National Patient
Safety Goal
• Veteran‟s Administration Training,
Surveillance and Enhanced Care
• NSPL Standards and Guidelines

46. What Can You Do to Help
Implement the National
Strategy?
alternatives to
hospitalization based on
trusting therapeutic
relationships
alternatives to ER such as
same-day scheduling for
MH services and in-home
crisis care
immediate and
continuous follow-up
after ER or Inpatient
discharge
Educate family members
and significant others

47. Case Study
Phoenix:
TERROS

48. TERROS, Phoenix, Arizona
One of a dozen founding organizations of
the AZ programmatic suicide deterrent
system in 2009.

49. Workforce Composition
Certified
Peer
Staff
Admin &6%
Non-clinical
26%
Case
Managers
30%
Physicians/
Nurses
3%
Clinicians/
Social Workers
35%
PC

50. 2009 Survey
25%
18%
Suicide
deaths
reported by
clinicians
57%
None
One
Two or More
11% of Agency Staff
Report Specific Suicide
Care Training (ASIST)
PC

51. 2012 Survey
81% of Agency Staff
Report Specific Suicide
Care Training (ASIST)
PC

52. Comparing Two Cultures
2009 - Non-ASIST
86%
2012 - ASIST
1) Training
2) Skills
3) Supervision/Support
36%
37%
27%
12%
2%
Agree or Greater x3
Don't Know/ Mixed
Disagree or Greater x3

53. How to Become
Suicide Safer
Care Center

54. The Survey Results
38%
24%
4%
• 2,792 / 13%
I have the _________ to engage and
assist those who are suicidal.
One/Three
23%
More
than once
Supports
12%
• 3,314 / 15%
Training
6x
4x
3x
2x
1x
Once
Skills
Role
#
Counselor
2,421
Social Worker
2,361
Physician
416
Nurse
1,371
Case Manager
3,312
Para-professionals
826
Certified Peer Staff
479
Administrator
2,640
Support Staff
3,409
SMI Suicide Rate vs. General
Population
Over 6,000 report a patient has died
by suicide (27%).
39% 44% 30% 53%
Endorsed Don’t Know, Disagree, or Completely Disagree

55. Two Day ASIST Training
Supports
One/Three
1,407
Skills
Without Specific
Suicide Training
Training
I have the _________ to engage and assist those who are suicidal.
57% 48% 31% 63%
Endorsed Don’t Know, Disagree, or Completely Disagree
6%
One/Three
8%
Supports
1,324
Training
ASIST Trained
Skills
I have the _________ to engage and assist those who are suicidal.
10% 15%
One/Three
Endorsed Don’t Know, Disagree, or Completely Disagree
15%
Overall
Clinician
70%
12%
Administrator
Physician/Nurse
80%
17%
Case Manager
Certified Peer Staff
63%
18%
Support Staff
66%
9%
62%
10%
37%
15%
33%
ASIST Trained
No Suicide Training

56. zerosuicide.com

57. Eduardo Vega, MHA of
San Francisco
“Suicide prevention has not been
informed by peers who have
experienced the agony and
decision-making. They can
provide support that can be
magic”

58. Forest Rogers
“I have long felt that the word of
survivors/sufferers is considered
somehow suspect by many medical
professionals. So long as that is so,
or perceived to be so, there will be a
silencing fear -- much like the fear
that can silence a victim of rape.”

59. Contact Us
Zero Suicide Advisory Group Co-Leads
david.covington@crisisaccess-co.com
dr.m.hogan@gmail.com
Social Networking
http://www.linkedin.com/in/davidwcovington
https://twitter.com/davidwcovington
https://www.facebook.com/david.covington
http://www.youtube.com/davidcovington
crisisaccess.com