St. Joseph’s Healthcare Hamilton Suicide Prevention .

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendation2.7Processes should be adoptedthat require a re-assessment ofsuicide risk be completed anddocumented with each changein the patient’s level ofobservation.Work PlanStrategies In Placemeans prior to passes and discharge.being built as part of EHR. Within the written assessmentprocess include any informationprovided by the family about accessto means. Existing practice is to reassess For inpatient care, the RAI is triggeredpatients when significant changeswhen there is significant change inoccur, the goal of the workplan is forstatus, this will revise the various selfreassessment of suicide risks asharm scales.outlined in the processes described in Some outpatient services also have2.7methods to update risk assessments Re-assessment of suicide risk will beand safety plans.aligned with and included in These strategies will be reviewedprocesses described in 2.1. It willagainst best practice and appliedaddress ongoing follow-up andacross MHAP.“triggers” for re-assessment andputative change in risk level duringtreatment. The working group addressing thesuicide risk/mitigation algorithm willensure that a standard process forchange in status is in place. With the addition of the ElectronicHealth Record (EHR) auditing andcompliance rates of the processes willbe shared at all levels including withpoint of care staff and with theJuly 14, 2017UPDATE SEPT. 30 2017Timelines for Implementation A small working workwhich addressesrecommendation 2.1 hasa draft plan for triggeringrepeat Columbia SuicideSeverity Rating Scale toolquestions to observationlevel changes to befinalized and shared withthe Action Committee forSuicide Prevention.6 Page

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendationWork PlanStrategies In PlaceJuly 14, 2017UPDATE SEPT. 30 2017Timelines for ImplementationPatient and Family Advisory Council.E. Rec F. Clinical Services, Care Management and Safety Planning: SJHH should take the approach that most suicides are preventable, recognizing that suicide prevention#33.1requires a collaborative approach that involves patients, families and care teams.Complete a needs assessmentsurvey regarding staff’seducational needs to ensurethat they feel confident andcompetent to deal withpatients at risk for suicide. A small group will be formed toformulate comprehensive needsassessment related to suicide riskassessment and treatment. In parallel, a series of focus groupswill be held with patients and familiesto ascertain their experiences ofstaffs’ interventions and perceivedgaps in knowledge, skills and attitude. The needs assessment will beadministered electronically. Results will be tabulated andanalyzed for themes. Concurrently with the above, thegroup will review best practiceeducational offerings and determinethe most feasible alternatives. Staff needs as identified by theassessment will be matched toavailable training opportunities. Education will be offered to all staffwith a view toward sustainability (i.e.onboarding new staff in future) Education on suicide risk assessmentand management is provided to newclinical staff as part of clinicalorientation. Various clinics and services have hadstaff engage in a variety of trainingopportunities when these have arisenin the past. Managers and directors havecompleted some environmental scansand are aware of training opportunities(e.g. ASSIST) that might be scaled up. We have adapted a staffneeds assessment fromZero Suicide initiative. Thiswill be electronicallydistributed in Octoberprioritizing inpatient staff.The results will informfuture education.7 Page

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review Recommendations3.2July 14, 2017UPDATE SEPT. 30 2017RecommendationWork PlanStrategies In PlaceTimelines for ImplementationConcurrent Disorders Programshould develop and implementan algorithm for decisionmaking and intervention forpatients with a specific riskprofile related to suicide, e.g.the algorithm should includerisk profiles, substance use,care pathways, familyengagement, observationlevels, an environmentalevaluation and rapid responsesrelated to emerginginformation. Develop a synthesis of the literatureon Concurrent Disorder andAddictions on specific risk factors forsuicide, and evidence-informedinterventions. Complete an environmental scan ofpractices utilized in similar peerorganizations. Develop, implement and evaluate acompressive algorithm that outlinescare pathways, and clear treatmentprotocols based on identified riskfactors. Engage the MHAP Patient and FamilyAdvisory Council to ensure thepatient and family voice is clearlycaptured throughout the admissionprocess. Considerable work has beencompleted to date to incorporate bestpractices in the assessment andmanagement of Concurrent Disorders. Currently, M1 utilizes an electronicbattery of validated screening andassessment measures to assesssubstance use, mental healthsymptoms and risk factors. An environmental scanning processtitled “Red, Yellow, Green” iscompleted and in place to identifyenvironmental risks on the unit daily. An Addiction Counselor meets witheach patient to develop an initializedassessment and treatment plan thatincludes risk. A monthly family group for families ofpatients with Concurrent Disorders isfacilitated at the West 5th Campus. Current screening practices includestandardized tools for symptoms ofsubstance use and withdrawal, whichcan impact risk levels. Work is well underway foralgorithm development andwill reflect aninterdisciplinary approach tocare.8 Page

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review Recommendations3.3July 14, 2017UPDATE SEPT. 30 2017RecommendationWork PlanStrategies In PlaceTimelines for ImplementationExpand on collaborativeapproaches that includefamilies and significant othersin suicide prevention such as:Therapeutic alliance, collaboration andtrust are foundational to care ofpatients and in the relationshipbetween clinicians and patients andtheir families. This is already reflectedin professional standards, quality andaccreditation standards and manypolicies and procedures. The followingwill be done to strengthen theimportance of therapeutic alliance andcollaboration: Emphasis on the importance oftherapeutic alliance in orientation ofall clinical staff Implementation of a consistentsafety/crisis tool with consultationfrom the MHAP Peer Advisory andFamily Advisory Councils Implementation of emerging newtools in empathy training Ensure consistent family engagementin discharge planning byimplementing Key Steps to DischargeProcess across all Mental Health andAddiction Program inpatient unitsand thereby engaging families insafety/crisis planning MHAP has already identifiedpartnerships with families as one oftheir strategic directions and multiplestrategies have been developed andimplemented to foster collaborativerelationships with families. Key Steps to Discharge is currently inplace in Schizophrenia Community &Integration Service and MoodDisorders Service. “Guidelines for Communicating withFamily Members” has been developedwith training sessions held in Fall 2016. Process for consultations with FamilyAdvisory Council and Peer AdvisoryCouncil is in place. Fostering collaborativesafety planning,Joint interventions toremove access to means,Clear procedures torespond to a family’sconcerns about thepatient’s risk for suicide The action for suicideprevention committee hasbeen engaged in theimplementation of thisrecommendation.Key steps to dischargeprocess plan forimplementation isscheduled to expand inJanuary 2018.Family charter of rights isbeing developed inpartnership with MentalHealth and AddictionProgram Family Advisorycouncil.9 Page

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendationWork PlanJuly 14, 2017UPDATE SEPT. 30 2017Strategies In PlaceTimelines for Implementation SJHH is deeply committed to a personcentred approach to care which placesstrong emphasis on therapeuticalliance with patients we serve. Key Steps to Discharge is currentlyfirmly established in the Schizophreniaand Mood Disorders Services. Safewards’ Modules are in process ofbeing implemented across MHAPinpatient units. Comfort Plans are in use on allinpatient units. Clinical Monitoring process is in placeand it fosters patient engagement anddevelopment of therapeutic alliance. Guidelines have already been3.4Staff should continue to focuson developing therapeuticalliances and support thepatient in telling their story. implemented called “Guidelines forCommunicating with FamilyMembers” and will be amended, inlight of these recommendations toemphasize the therapeutic alliance,collaborative safety/crisis planningand will consistently include opendiscussion of suicide risk.The practice of engaging patients intheir plan of care will continue withstrong emphasis on the importanceof the therapeutic alliance.This is already reflected inprofessional standards, quality andaccreditation standards and manypolicies and procedures.The importance of the therapeuticalliance is foundational toSafewards, currently in process ofimplementation across the MentalHealth and Addiction Program; KeySteps to Discharge which includesstrong elements for patient andfamily engagement; and otherpatient-first strategies that areimplemented across the ProgramSafewards training isproceeding well and ontarget for completion inSpring 2018 and strategiesfor sustaining are beingconsidered10 P a g e

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendation3.53.6Work Plansuch as the Comfort Plan. The Patient Story is integrated intothe new electronic health record.Policies regarding passes – The In light of these recommendations,program may consider creatingthe Mental Health and Addictiona policy about allowing passesProgram policy addressingto patients on Forms 1, 3 and 4.Therapeutic Passes will be reviewedand updated. Upon completion ofthis, the policy will be distributed andimplemented. Continue ongoing environmentalscan of peer organizations’ policiesand procedures related to passes andintegrate improvements into theMental Health and AddictionProgram policy on an ongoing basis. Review integration of applicablepolicy elements into the newelectronic health record.Clinical Monitoring Policy: Review and amend the ClinicalWithin the policy, the sectionMonitoring Policy (031-MHA) toon documentation shouldreflect this recommendation.specifically indicate that a newassessment of suicide riskshould be documented withany change in the level ofmonitoring for patientsStrategies In Place 042-MHA (Mental Health andAddictions) policy is drafted and nearcompletion Clinical Monitoring policy wasdeveloped in 2015. This policy supportsa culture that fosters person-centredcare and places greater emphasis ontherapeutic engagement, andreduction of emotional distress. Clinical staff conducts clinicalmonitoring rounding at least hourlyJuly 14, 2017UPDATE SEPT. 30 2017Timelines for Implementation Process amendments arein process.COMPLETED11 P a g e

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendationWork Planconsidered at risk of suicide.3.73.8Suicide Risk Assessment and The Suicide Risk Assessment andMonitoring Policy: The GuidingMonitoring Policy (040-MHA) will bePrinciples should include thatrevised immediately to include themost suicides are preventable;guiding principles outlined in thissuicide prevention requires arecommendation.collaborative approach Subsequently a much broaderinvolving patient, family, etc.revision of this policy will be carriedAlthough the document is quiteout as work on 2.1 and 2.7 willcomplete, the policy shouldnecessarily change the actions calledinclude doing safety planningfor in that policy.with each patient at risk anddocumenting that removingaccess to means has beenaddressed.Contracting for safety is not an The implementation of thiseffective suicide preventionrecommendation will be aligned withmethod and focusing primarilyneeds assessment and education planon the presence or absence ofdescribed in 3.1suicide ideation is not an A component of the education planadequate means to determinewill reflect a shift from contractingsuicide risk. Both thesefor safety to more evidence-informedapproaches should not be usedstrategies.to replace a well-documentedsuicide risk assessment,Strategies In Placeand this intervention contributes to thebroader assessment of patient’s wellbeing and plan of care. The current policy has been in placesince 2011 and is widely known andadhered to. The lack of evidence for contracting isgenerally known and accepted by staff.July 14, 2017UPDATE SEPT. 30 2017Timelines for Implementation This policy will be revisedin line withrecommendations 2.1 and2.7 Contracting and its lack ofefficacy and effectivenesswill be directly targetedby education effortsbased on the newalgorithm, safety plans aswell as results from theneeds assessment.12 P a g e

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendation3.9management plan and pathwayof care.Patients seen in ED because ofthe risk of suicide should havefollow-up contact.3.10 Leadership action should betaken on search and seizurepolicies to prevent patientsfrom having access to means.July 14, 2017UPDATE SEPT. 30 2017Work PlanStrategies In PlaceTimelines for Implementation Identify and implement specificinterventions based on the suiciderisk assessment and clinicalpresentation, to ensure immediatesafety, psychiatric assessment,support and follow-up. Interventions have been identified andthe process is being implemented. For patients who are underthe care of the EmergencyRoom physician, follow-uparranged with PrimaryCare and/or psychiatry asrequired (process alreadyin place and patientspecific). Patients who areseen in PsychiatricEmergency services have acrisis plan build into theirplan Updated search proceduredistributed to all inpatientmanagers on August 16.An instructional video forstaff training has beendeveloped.To date 93 per cent of theinpatient staff hascompleted the training. In light of the recommendations, the Patient Search Procedure includingthe Contraband/Restricted items list will be reviewed and updated toinclude risks for self-harm that havearisen from these completed suicides.Update recently established PatientSearch Procedure to include risk for self-harm. Include all relevantprograms (beyond MHAP) whereapplicable. Include review ofContraband/Restricted items list.Considerable work has beencompleted to date.All inpatient clinical staff at the W5thcampus has reviewed Patient SearchProcedure with a consistentContraband/Restricted listestablished for all MHAP units.Training plan for staff is underdevelopment and will include aninstructional video. 13 P a g e

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendationWork PlanStrategies In PlaceJuly 14, 2017UPDATE SEPT. 30 2017Timelines for Implementation Continue ongoing environmentalscan of peer organizations’ policiesand procedures related to searchesand integrate improvements intoMHAP as appropriate. Develop communication,implementation and training plan forall inpatient staff.Rec G. Leadership: St. Joes should undertake a review of its leadership structure in the Mental Health and Addiction Program that positions the organization to be a regional#4leader in suicide prevention and Concurrent Disorders. Leadership should work to encourage increased engagement of psychiatric staff in the leadership of theConcurrent Disorders Program. This review will be completed by theChief of Psychiatry in collaborationwith the Chief of Staff.4.2Review the medical leadershipstructure of the “GeneralPsychiatry and AddictionsServices” and the ConcurrentDisorders Inpatient Program.The Medical Leadershipstructure should encouragemore engagement of thepsychiatric staff in theoperations of the ConcurrentDisorders Inpatient Service.4.3It is suggested that the A distinct report document will be4.1 Increase standardization ofpsychiatric care for this specializedpopulation Recruit addictions lead for thisprogram Recommendationsdeveloped and a searchcommencing for anaddictions concurrentdisorders medical lead.COMPLETED Monthly meetings with Head of Serviceof the General Psychiatry andAddiction Services and the physicianswithin this service are already in place Physicians participate in teammeetings and safety huddles on theunit Monthly complex care reviews areestablished SJHH has been a longstanding member We are committed to14 P a g e

St. Joseph’s Healthcare Hamilton Suicide Prevention Workplan for Implementationof External Review RecommendationsRecommendationWork PlanStrategies In Placeorganization and its healthcareprofessionals consider sharingrelevant issues arising from thisreview with other psychiatricfacilities and professionals inthe province and the OntarioHospital Association (as itrelates to the SuicidePrevention Standards TaskForce) with the specific goal ofcreating an appropriate meansof collecting data to refine themost effective policies,procedures and practices inorder to approach the zerosuicide objective.developed that describes thecircumstances that led to thereview, recommendations resultingand organizational response. The report will also contain alessons learned component to helppeers with practices that wereeffective, feasible, and sustainable. That document will be shared withthe MHAQI members and discussedat regular meetings so as tomaximize the opportunity for peerinstitutions to learn from ourexperience. The report will serve as a basis forwebinar or online learning withexecutive teams at other OntarioMental Health Programsof the Mental Health and AddictionQuality Initiative (MHAQI), whichinvolves almost 30 mental healthfacilities in Ontario. MHAQI already discusses similar issuesthat arise and can be updated on ourwork in progress.July 14, 2017UPDATE SEPT. 30 2017Timelines for Implementationsharing the work with ourpeers and will look foropportunities to do so.15 P a g e

suicide risk in the Emergency Department (ED). of suicide risk in the ED Implement a standardized screening and assessment process for suicide risk in ED. Review the screening process for Urgent Care. discuss mental health Align the screening process with 2.1 and implement Columbia Suicide Severity Rating Scale built into the new EHR.