EVALUATION FRAMEWORK Zero Suicide Healthcare - Outcomes, Actions & Measures
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Zero Suicide Healthcare EVALUATION FRAMEWORK Outcomes, Actions & Measures
Acknowledgements
The Zero Suicide Institute of Australasia commissioned this work to support the
implementation of Zero Suicide Healthcare in Australia.
The principal author, Mr Alan Woodward, developed the work in consultation with a
number of experts involved in design, development and implementation of the Zero
Suicide Healthcare.
We wish to acknowledge the support and advice provided by the following people:
Dr Brian Ahmedani Henry Ford Health System, Detroit, USA
Dr Julie Goldstein-Grumet Zero Suicide Institute, Education Development
Centre Washington DC, USA
Associate Professor University of Rochester, New York State, USA
Anthony Pisani
Ms Jerneja Sveticic Gold Coast Hospital and Health Service,
Queensland Australia
Dr Kathryn Turner Gold Coast Hospital and Health Service,
Queensland Australia
Author contacts:
Mr Alan Woodward
Email: alanrwoodward@bigpond.com
Ms Sue Murray
Email: suem@zerosuicide.com.au
This work was produced by the Zero Suicide Institute of Australasia with funding provided
by the Australian Government Department of HealthContents
1. Program Theory and Evaluation...................................................................4
2. Zero Suicide Healthcare as a Program........................................................5
3. Theory of Change for Zero Suicide Healthcare............................................6
Situational Analysis..................................................................................................................... 6
Program Scope........................................................................................................................... 6
Chain of Outcomes..................................................................................................................... 7
4. Theory of Action...........................................................................................8
Assumptions............................................................................................................................... 8
External Factors.......................................................................................................................... 9
Implementation Factors........................................................................................................... 10
Outcome Chain Statement – Preparedness #1..................................................................................... 11
Outcome Chain Statement – Preparedness #2..................................................................................... 13
Outcome Chain Statement – Preparedness #3..................................................................................... 15
Outcome Chain Statement – Practice #1.............................................................................................. 17
Outcome Chain Statement – Practice #2.............................................................................................. 19
Outcome Chain Statement – Practice #3.............................................................................................. 21
Outcome Chain Statement – Pathways................................................................................................ 23
5. Data Measures...........................................................................................25
6. High Level Outcome Measures..................................................................27
EVALUATION FRAMEWORK | 31. Program Theory and Evaluation
Program Theory is used to design evaluations articulation of program purpose, rationale,
that match the purpose, intended outcomes, intended outcomes and the linkages between
scope and limitations of a program. Relevant activities to achieve these outcomes, it is
and reliable evaluation of programs needs this difficult to undertake program evaluation in
level of design. a robust and reliable way.
Clear program theory and design is essential Program Theory involves six fundamental
for evaluation and monitoring to be well- components, which are categorised within
aligned to what is intended and to test what the Theory of Change and the Theory of
is happening in the implementation and Action, as shown in the table below:
operation of a program. Without a clear
Components of Program Theory1
Theory of Change Situational Analysis: Focusing and Outcomes chain:
identification of scoping, setting the the centrepiece of
problem, causes, boundaries of the the program theory,
opportunities program, linking to linking the theory
consequences partners of change and the
theory of action
Theory of Action Desired attributes of Program features and What the program
intended outcomes, external factors that does to address key
attention to will affect outcomes program and external
unintended outcomes factors
Theory of Change is used to describe what - Outcomes: creating a chain of outcomes
change the program is seeking to achieve, to organise in a logic sequence the
for whom, and the extent to which it operates relationships between immediate,
within a context or limitations to do so. Theory intermediate and longer-term outcomes
of Change addresses the following three – the assumptions about the interactions
elements:2 between outcomes are made explicit so
that they can tested and evaluated.
- Situational Analysis; the identification of
the problem that the program is addressing, Theory of Action goes into the detail of the
its causes and the reasons why solving this results or observable attributes of program
problem generates benefits of value; outcomes, describes the program features
(delivery mechanisms and capabilities) that will
- Scoping: setting the boundaries of the support the achievement of these outcomes,
program and identifying its response to and the ways in which the program addresses
the problem(s) it is addressing; external factors or barriers to its operation,
as intended.
1
Funnell, S.C. & Rogers, P.J. 2011. Purposeful Program Theory. Jossey Bass, USA. Page 150.
2
Funnell, S and Rogers P 2011 Purposeful Program Theory. Jossey Bass. USA.
4 | ZERO SUICIDE HEALTHCARE2. Zero Suicide Healthcare as a Program
Zero Suicide Healthcare may be regarded as 3. Identify – developing a centralised,
a program. It is a multi-faceted combination consistent and systematic identification
of practice, service delivery, consumer of suicide risks
engagement and organisational change
activities that together create greater 4. Engage – developing practices and
effectiveness in healthcare settings to prevent processes for effective engagement
suicides by those in care of health services. with suicidal persons
The seven parts of Zero Suicide Healthcare 5. Treat – providing effective and proven
are as follows: treatment of suicidal ideation and
1. Lead – instilling the belief that suicide can behaviours directly
be prevented 6. Transition – transferring of persons out of
2. Train – developing the skills for a healthcare with follow up care and support
standardised approach to suicide 7. Improve – developing continuous
prevention practise improvement based on lessons learnt
Diagram provided by the US Zero Suicide Institute, Education Development Centre Washington DC
EVALUATION FRAMEWORK | 53. Theory of Change for Zero Suicide Healthcare
This identifies the problem that Zero Suicide Program Scope
Healthcare is seeking to address, the causes The core principle of Zero Suicide Healthcare
of the problem and the ways in which the is that suicide deaths for people receiving
program addresses these causes. healthcare are preventable, and the program
goal is that no deaths by suicide occur
Situational Analysis amongst persons receiving health care –
Suicidal behaviour can be difficult to detect, viewing this is an aspirational challenge
and suicidal persons similarly may be hard that health systems should accept.6
to reach. Australian research has identified
Zero Suicide addresses the above challenges in
that up to half of those who attempt to end
suicide prevention within health care systems.
their lives have contact with health services
in the period immediately prior.3 However, This is reflected in the four clinical elements
this contact may not be about their suicidality. of the Suicide Prevention Pathway for
Accordingly, suicide prevention faces a Zero Suicide Healthcare:
fundamental challenge: how to use the
health system to identify and engage with • Systematically identifying and assessing
those persons who may take action to end suicide risk [in all people presenting
their lives. for care]
Health and hospital service practices in • Ensuring every person [receiving care]
response to suicidal persons and those who has a suicide Care Management Plan
have presented for medical attention following
• Using effective evidence-based treatments
a suicide attempt do not always reflect
to directly target [person] suicidality
appropriate and best practice. This can result
in treatment that is not directly and effectively • Providing continuous contact and support
addressing the person’s suicidality and [to engage with suicidal persons and their
therefore fails to ensure that suicidal behaviour carers]
is prevented during the period of healthcare.
In Australia this has been recognised as a Zero Suicide Healthcare draws on the
priority policy reform to be addressed on techniques of quality management and
a national basis.4 continuous improvement in its design and
implementation. It implicitly assumes that
Those persons who have attempted suicide suicide prevention can be addressed in health
are highly vulnerable to re-attempt and care settings in the same way, and with the
to die by suicide, especially in the period same absolute improvements, as has been
immediately following a suicide attempt. done in wound management, infection control
One study estimates a 20-40 times higher and medication management.
risk of suicide for those who have previously
attempted suicide. For those suicidal persons To be effective, Zero Suicide Healthcare
who do have contact with health services requires organisational, workplace and
prior to or after a suicide attempt, attention professional cultures that support
to engagement, follow up and aftercare is continuous improvement and better practice
regarded as a high priority to facilitate in suicide prevention. The concepts of a
suicide prevention.5 Just and Learning Culture are an essential
characteristic of Zero Suicide Healthcare.
3
Shand F, Christensen H, al. E. Care After a Suicide Attempt. Sydney, Australia: National Mental Health Commission; 2015.
4
Commonwealth of Australia 2017 The Fifth National Mental Health and Suicide Prevention Plan.
Shand F, Woodward A, McGill K, Larsen M, Torok M et al. Suicide aftercare services: an Evidence Check rapid review brokered by the
5
Sax Institute (www.saxinstitute.org.au) for the NSW Ministry of Health, 2019.
Zero Suicide Multi-Site Collaborative Factsheet, Clinical Excellence Division, Queensland Health
6
6 | ZERO SUICIDE HEALTHCAREChain of Outcomes
Zero Suicide Healthcare: Theory of Change
PREPAREDNESS PRACTICE AND PATHWAYS
LEAD TRAIN IMPROVE IDENTIFY ENGAGE TREAT TRANSITION
Commitment Data is collected A person’s A collaborative A person’s
at all levels to systematically & suicidality is healthcare suicidality is
elimination of to standard for explored relationship reduced through
suicide amongst ongoing regardless of is established their treatment
persons receiving monitoring of their presenting between
healthcare healthcare health issue healthcare
operations with workers,
PHASE 1
suicidal persons a suicidal person
& their carers & their carers Suicidal persons
Data driven and their carers
performance perceive aftercare
Workforce is Data reports are Decisions on the Suicidal persons Access to lethal programs as
measurement
competent and produced & level and nature & their carers means is useful and
is adopted
confident to analysed of service and experience addressed relevant to
support people routinely within support are compassion, directly and their needs
Healthcare system at risk of suicide quality review & informed by the sensitivity, restriction
has a restorative improvement formulation of a respect in their confirmed with
just culture of cycles person’s suicide interactions with suicidal persons Suicidal persons
risk healthcare
PHASE 2
recovery, healing, and their carers
learning and services
experience
improvement smooth entry
when losing a to aftercare
person to suicide programs
Workforce is Improvements to Suicidal persons Suicidal persons
equipped to use service delivery and their carers are equipped to
Satisfaction with quality review activities are receive exercise suicide Suicidal persons
organisational and continuous made following continuous safety through and their carers
leadership improvement quality reviews. contact and self-monitoring have increased
support for processes support while in and the use of hopefulness and
suicide care of health crisis supports
PHASE 3
confidence for
prevention services recovery
HIGHER LEVEL Person-centred safety and suicide related Suicidal persons and
Organisational capability is built carers are equipped
OUTCOMES clinical improvements are achieved for recovery
IMPACT:
Suicides and suicide attempts in healthcare are reduced
3 YEARS
EVALUATION FRAMEWORK | 74. Theory of Action
Theory of Action is about the program adoptions that will achieve results. It is
execution – what is done to achieve changes through the attention to components within
the program is seeking. It is concerned the Outcome Chain Statements that a mix
with what the program will do, what it won’t of process and outcome evaluation activities
and how it will go about it. The Theory of can be designed and conducted.
Action identifies program management
choices on priorities, resource allocation The Theory of Action also incorporates
and the approach with which actions will be Assumptions and External Factors or
undertaken – characteristics, by whom and Implementation Factors that are beyond the
in what manner. program’s control that may affect both the
activities and the results for the program.
For a program such as Zero Suicide It is important to address these in program
Healthcare, the Theory of Action is an evaluation, as they may be pertinent to
essential translation of the broader strategic interpretation of the data and results –
intent contained in the Theory of Change no program operates in isolation.
into the operational practices, processes,
techniques and devices used to achieve The Assumptions and External Factors are
individual, organisation and systematic described for the Zero Suicide Healthcare
improvements for suicidal persons and their program as follows:
carers. It is how the ‘rubber hits the road.’
Assumptions
The Outcomes Chain Statements represent • The accountabilities of the healthcare
the Theory of Action for Zero Suicide organisation will align with the requirements
Healthcare. They expand on the Outcomes of Zero Suicide Healthcare improvements.
Chain created for the Theory of Change by
describing the specific change and practice • For the Australian context, the ‘Healthcare
to be adopted towards the achievement of System’ incorporates all services that are
each intermediate outcome, the key activities called ‘health services’ in the Fifth National
to be undertaken to generate that change or Mental Health and Suicide Prevention Plan,
practice, and the ‘inputs’ i.e. the knowledge i.e. public hospitals, community mental
and skills, the personnel, the financial, health services, allied health, funded NGOs,
intellectual and other resources required. peer support programs. That is, it does not
include primary health care services.
Accordingly, the Outcomes Chain Statements
provide an opportunity to examine more • Australian healthcare systems have quality
closely how activities relate to the stated and continuous improvement processes
program outcomes and to check for their already in place.
alignment and feasibility to deliver the
• CEO or equivalent has delegated
results intended.
authorities that will enable changes in
The Theory of Action should enable an practice with suicidal people and their
alignment to the program with operational carers for the health care system involved.
plans and budgets – to signal when, how
• Leadership from senior managers for
and with what resources program activity
the adoption of changes in practices
will occur. In doing so, the Theory of Action
to proceed (and to achieve engagement
creates the level of detail in the Evaluation
with the workforce and key stakeholders),
Framework that will support process
i.e. assumption that the people reporting
evaluations and the application of continuous
to the CEO want to make the changes.
improvement techniques to monitor the
progression towards changes and practice
8 | ZERO SUICIDE HEALTHCARE• The operating environment (budget, • Suicide safety planning and management is
cost structures, workloads, reporting widely accepted as an effective technique
arrangements, staffing, professional and a proper response by health service
development/training) will allow systems to the collaborative management
implementation of Zero Suicide in of suicide with persons.
Healthcare improvements.
External Factors
• Government requirements on systems or
other external governance on the collection • Community expectations, legitimisation and
and use of data associated with services stigma-orientation regarding health care
and practices will enable use of data for system responses to suicidal people.
quality improvement. • Consumer and carer comfort regarding
• Organisations have data systems that the privacy and ethics issues in the data
are suitable, to a standard of privacy and systems being utilised for evidence based
functionality and capable of collating and care and care transitions.
reporting data required for service and • For the Australian context, Medicare
practice improvement monitoring. items and subsidies that enable access
• Personnel at the frontline and their to suicide related treatments, especially
managers are willing and equipped with pharmacological, clinical and psychological
skills to collect data routinely and reliably. services.
• A workforce to adopt specialist suicide- • Government and organisational policies
related clinical treatments is available or that are barriers to implementation of Zero
can be developed. Suicide Healthcare, e.g. pricing structures
for services under hospital agreements.
• The workforce itself will be open to learning
and developing new skills. • Related services such as emergency
services, community mental health (NGOs)
• Organisations are culturally open and and allied health professionals interact
sufficiently responsive in their operating with the healthcare system in ways that are
processes to make continual changes for consistent with Zero Suicide Healthcare.
improvement to services and practices.
• Healthcare workers beyond the
• There is agreement among health organisation making the improvements
clinicians and key stakeholders on the are broadly supportive of Zero Suicide
evidence based and most suitable suicide Healthcare, especially in the way they
screening and assessment tools to respond to suicidal people and their carers.
enable consistency of approach across
a healthcare system. • Healthcare systems capability to collect
and transfer data through internet
• Collaborative engagement with suicidal connections and technologies – for the
persons and their carers is supported Australian context this especially applies
in principle and practice by the funders in rural and remote locations.
and operators of health service systems,
especially through critical processes such • Performance measurement and monitoring
as communication, case planning and being undertaken across multiple sites
management, information provision and being subject to standards and processes
sharing, decision making and resource set by a central review unit or similar.
allocation, and in feedback mechanisms • Financial incentives and efficiency
and service quality assurance. measures that cross or minimise quality
in service delivery.
EVALUATION FRAMEWORK | 9Implementation Factors
• Zero Suicide Healthcare is introduced to a
healthcare system as a specific program for
quality and performance improvement in
suicide prevention. It is to be incorporated
into routine or ‘business as usual’
operations following introduction.
• Zero Suicide Healthcare is to complement
and be integrated to existing quality
improvement systems for the healthcare
system.
• Consumer and carer feedback and input to
the improvement of a healthcare system for
suicide prevention is an essential element
of quality in service.
• Legal reviews of aspects of the Zero
Suicide Healthcare are undertaken to
identify potential liabilities, impacts
on existing risk profiles and mitigation
strategies, relevance to existing health
care legislation and case law.
10 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Preparedness #1
Outcome – Organisational Capability is Built
Framework - Lead
Intermediate Outcome: Intermediate Outcome: Intermediate Outcome: Intermediate Outcome:
Commitment at all levels Data Driven Performance Healthcare system has a Satisfaction with
to elimination of suicide Measurement is Adopted just culture of recovery, organisational leadership
amongst persons receiving healing, learning and
healthcare improvement when losing
a person to suicide
Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted
Healthcare workers are Performance measures Just culture and learning Health system leaders
responsive to changes in aligned to the Zero Suicide processes are adopted when actively strive towards Zero
their workplace systems Healthcare Framework are losing a person to suicide in Suicide Healthcare and
and practices to eliminate in place. healthcare make decisions to enable
suicide in healthcare. its implementation.
Key Activities Key Activities Key Activities Key Activities
Case for Change – benefits ZSH Performance Measures Overhaul of Root Cause Case for Change – business
for healthcare workers are are identified – and targets Analysis procedures, case supporting this – are
presented and accepted. for local context are set. including provisions for presented and adopted.
immediate reviews of
Professionalism Appeal – Data specifications are Accountability for
critical incidents at a team
linking healthcare ethics determined for monitoring performance of the
level so recommendations
and values to the improved performance of healthcare healthcare system across
for immediate improvement
outcomes for suicidal people services within ZSH various structures and
can be made.
and their carers. Framework. leadership positions is
Training throughout the defined regarding suicide
Report formats are prepared
workforce on Just Culture prevention.
for monitoring and trend
– principles, practices and
analysis. Leader work with various
processes.
service and functional
Data reports are routinely
Provision of ‘postvention’ units to set a pace for
generated.
supports for healthcare implementation and
workers impacted by the adoption of ZSH.
loss of a person to suicide.
Implementation stages
are planned.
Communication related
to ZSH implementation
is delivered by CEO or
equivalent.
EVALUATION FRAMEWORK | 11People Involved People Involved People Involved People Involved
Frontline healthcare workers Chief Executive Officers or Chief Executive Officers or Chief Executive Officers or
equivalent equivalent (critical) equivalent
Unit Managers of healthcare
workers, e.g. DONs Senior executive team Senior executive team Senior executive team.
Support function managers, Risk managers and quality Unit Managers of healthcare Lived experience leadership
e.g. human resources, legal, assurance specialists. workers, e.g. DONs
Clinical and workforce
finance, IT, communications,
IT and Data Personnel Lead human resources leadership
facilities
(including data analysts) professional on
Representatives of workers, organisational development
Unit Managers of healthcare
e.g. unions, professional (or equivalent)
workers, e.g. DONs
associations.
Sydney Dekker (or
equivalent inspirational
coach)
Knowledge Attitude & Knowledge Attitude & Knowledge Attitude & Knowledge Attitude &
Skills Skills Skills Skills
Healthcare workers Knowledge of the basis for Knowledge about just Leadership reinforces that
believe that they can performance measures for culture principles and their evidence based treatments,
achieve elimination of ZSHC. translation into healthcare clear clinical pathways
suicide through continual operations and practices. and collaborative care
Knowledge of related
improvement. management for suicide
external requirements on Skills in leading
care is consistent with
Knowledge of relevant performance measurement, organisational development
standards of care for other
system and practices in e.g. Health Safety and and culture change.
health conditions.
their role that will make Quality Standards.
Skills to apply just culture,
a difference towards Knowledge of what works
Skills in specifying data e.g. analytical skills,
elimination of suicide in for suicide prevention in
requirements and definitions technical translation of
health care. healthcare settings.
against performance improvements, interpersonal
Skills in safer suicide care measures. skills for shared learning, Skills in communicating the
communication skills. benefits, the sustainability
Knowledge of technology
and the results of ZSH.
required to fulfil data Cultural attributes are based
requirements and reporting on learning and opportunity
capabilities. instead of blame and
retribution.
Resources Resources Resources Resources
Data on the case for change; ZSHC suite of standardised Just Culture Principles and Local data for the Case for
examples of achievements performance measures. Theory. Change.
with the changes (peer or
IT Systems (operations Funding for training – skills Financial modelling for local
like organisations); feedback
support). development. situation - applied to local
from lived experience.
budget.
Budget for data system Budgets for time-related
Key positions are given
refinements, e.g. integration, activities to implement Just Evidence surrounding
work-time and ‘licence’ to
linkages. Culture. suicide prevention in a
participate in the changes
hospital and health care
being introduced.
setting.
Lived experience insights
on service provision.
Pathways and protocols are
embedded in clinical care as
routine practice.
12 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Preparedness #2
Outcome – Organisational Capability is Built
Framework - Train
Intermediate Outcome: Intermediate Outcome:
Workforce is competent and confident to support people at Workforce is equipped to use quality review and continuous
risk of suicide improvement processes
Change/Practice Adopted Change/Practice Adopted
All members of the workforce are assessed for their All members of the workforce understand how they can
knowledge, skill and attitudes commensurate with the roles contribute to processes of continuous improvement of
and responsibilities that they will perform in supporting services for suicidal persons and their carers.
people at risk of suicide.
Key Activities Key Activities
Specifications on the level and nature of competency for all Guidelines for service provision to suicidal people and
job roles their carers are integrated to existing quality improvement
processes.
Workforce survey to quantify current workforce status
regarding competency levels and degrees of confidence and Liaison with Centre for Clinical Excellence and other
comfort with regard to services for suicidal people and their agencies to set training for quality improvement managers
carers. to incorporate suicide prevention.
Health service staff are trained, in line with their roles and Just Culture training delivered widely to the workforce.
responsibilities, and are competent and confident to work
with suicidal persons and their carers.
Workforce development plan that identifies areas of need for
training and development.
People Involved People Involved
Senior Human Resources Management professional, with Healthcare service Quality Improvement Manager, or
expertise in workforce learning and development. equivalent.
Senior clinician, who can define the levels of clinical Frontline healthcare workers across the workforce, including
knowledge, skill and attitudes (competency) required for peer workers.
specific clinical services for suicide prevention.
Unit Managers of healthcare workers, e.g. DONs
Providers of training (internal and external), including
trainers and persons with lived experience as facilitators of
learning.
Clinical mentors and coaches as appropriate.
Frontline healthcare workers across the workforce, including
peer workers.
Unit Managers of healthcare workers, e.g. DONs
Representatives of workers, e.g. unions, professional
associations.
EVALUATION FRAMEWORK | 13Knowledge Attitude & Skills Knowledge Attitude & Skills
Workforce planning knowledge Knowledge of the principles and techniques of quality and
improvement – as applied to the healthcare system context
Knowledge of the availability and relevance of workforce
and services provided for suicidal persons and their carers –
training programs
commensurate with job roles and responsibilities.
Skills in designing and administering assessments of
Skills in the selection and/or design of quality improvement
competency (knowledge skills and attitudes) across a
education programs for the healthcare workforce.
workforce with different roles and structures.
Attitudinal acceptance across the organisation of the
Skills in observing and analysing comfort and confidence
relationship between Just Culture practices and quality
levels about providing services to suicidal persons and their
improvement for services provided for suicidal persons and
carers.
their carers.
Resources Resources
Budget for workforce planning activities and subsequent Just Culture theory and principles.
training.
Quality Improvement Program as utilised by the
organisation.
Budget for training development and delivery.
14 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Preparedness #3
Outcome – Organisational Capability is Built
Framework - Improve
Intermediate Outcome: Intermediate Outcome: Intermediate Outcome:
Data is collected systematically to a Data reports are produced and Improvements to service delivery
standard for ongoing monitoring of analysed routinely within quality review activities are made following quality
healthcare operations with suicidal and improvement cycles reviews
persons and their carers
Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted
Continuous improvement systems have Data reporting is included in meetings, Decisions are taken and acted upon to
data that allows monitoring of quality quality review processes and decision implement improvements arising from
and performance. making on service and practice quality reviews.
improvements.
Key Activities Key Activities Key Activities
Data specifications are determined for Data reports are compiled to meet Recommendations for service and
monitoring quality and performance the needs of those involved in their practice improvements are prepared
of healthcare services for suicidal analysis with presentation of data with reference to data results and
persons and their carers. results relating to the measures reports.
of service performance, variation
Data is routinely collected, collated Appropriate decision-making and
indicators and quality standards.
and analysed, on an automated or governance processes within an
procedural basis. Meeting agendas, information organisation are used to consider
for reviews, management reports the recommendations and make
Data custodianship and accountability
incorporate the data reports. determinations.
for data use is determined.
Meeting minutes, notes and Implementation of decisions includes
documentation records the consideration of the resources, budget,
interpretation and implications of personnel and change management
the data reports to feed into decision factors required to achieve successful
processes. change.
Accountability for the service and
practice improvements being
effectively implemented is assigned
and progress is monitored.
People Involved People Involved People Involved
Chief Operating Officer (or equivalent) Chief Operating Officer (or equivalent) Chief Operating Officer (or equivalent)
IT and Data Personnel (including data Quality Improvement Officer (or Risk manager and legal officers.
analysts) equivalent)
Quality Improvement Officer (or
Frontline healthcare workers Unit Managers of healthcare workers, equivalent)
e.g. DONs
Unit Managers of healthcare workers, Unit Managers of healthcare workers,
e.g. DONs Clinical specialists e.g. DONs
Clinical specialists
Frontline healthcare workers
EVALUATION FRAMEWORK | 15Knowledge Attitude and Skills Knowledge Attitude and Skills Knowledge Attitude and Skills
Knowledge of data needs/skills in Knowledge of data analysis and Knowledge of the dynamics of burnout,
specifying data requirements. performance measures for services compassion fatigue and vicarious
and practices relating to suicide trauma as they can affect service
Knowledge of technology required to
prevention in healthcare. performance.
fulfil data requirements and reporting
capabilities. Skills in translation of data results into Skills in decision making and
improvement techniques for services implementation of service
Skills in data collection, standards and
and practices. improvements in organisational
data management.
settings, depending on job roles and
Attitude towards data-informed service
Skills in data analysis and reporting. responsibilities.
improvement.
Attitudes generally towards positive
improvements to services and
practices.
Resources Resources Resources
IT Systems (operations support) IT Systems (operations support) Budget for service and practice
improvements.
Data ethics and standards relevant to Data reporting formats and
healthcare provision configuration that relates to user Authorisation of personnel to make
needs/specifications changes and to implement decisions.
Budget for data system refinements,
e.g. integration, linkages Distribution of data reports in a routine Knowledge of implementation
way within organisational systems. practices by key personnel.
16 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Practice #1
Outcome – Person Safety and Suicide Related Clinical Improvements are Achieved
Framework - Identify
Intermediate Outcome: Intermediate Outcome:
The suicidality of people is explored regardless of their Decisions on the level and nature of service and support are
presenting health issues. informed by the formulation of a person’s suicide risk.
Change/Practice Adopted Change/Practice Adopted
Screening tools for suicidality are consistently utilised with Suicide risk formulation tools are utilised alongside clinical
all persons in healthcare services. judgement with people at risk of suicide.
Key Activities Key Activities
Selection of screening tools for the health care services and Selection of suicide risk formulation tools e.g. SafeSide, or
facilities – relevant to context. Screening Tool for Assessing Risk of Suicide (STARS); or
Chronological Assessment of Suicide Events (CASE).
Protocol on universal application of suicide screening tools
across health care services and with people of all ages, Selection of imminent suicide risk tools, e.g. brief and crisis
cultures and circumstances. interventions.
Training in the administration of and interpretation of Selection of suicide safety planning tools, e.g. BeyondNow.
screening tool data.
Selection of tools to Prevent Access to Lethal Means.
Integration of screening tools and data collection to existing
Communication and engagement with personnel and
care data systems and health care planning or case
stakeholders including persons with lived experience of
management.
suicide and carers in co-design comprehensive assessment
Guidelines and examples of how screening tool results are protocols.
to be utilised in health care responses and referrals for
Formalisation and budgetary allocations to support service
suicidal persons.
and support responses based on a person’s need – with
associated decision making delegations and authorisations.
Training in the administration, purpose and interpretation
of comprehensive suicide risk formulation assessments,
alongside clinical judgement.
Training in related suicide safety planning, prevention of
access to lethal means and crisis or brief interventions.
Training in discussing results/formulation of risk/level of
care with patient and carers to engage with a suicidal
person around use of services.
EVALUATION FRAMEWORK | 17People Involved People Involved
Front line health service personnel. Qualified health professionals, i.e. nurses, doctors, social
workers, psychologists, allied health workers.
Qualified health professionals, i.e. nurses, doctors, social
workers, psychologists, allied health workers. Related health and social services, notably Alcohol and
Other Drugs, Psychosocial Support Services.
Related health and social services, notably Alcohol and
Other Drugs, Psychosocial Support Services. Peer workers.
Nursing Unit Managers, team leaders, clinical leads/ Families, carers, spiritual & support workers.
directors.
Nursing Unit Managers, team leaders, clinical leads/
Service improvement and quality assurance managers. directors.
Service improvement and quality assurance managers.
Senior managers and finance managers in a health care
system.
Health system funding managers.
Knowledge Attitude & Skills Knowledge Attitude & Skills
Knowledge of validated and reliable suicide screening tools Knowledge of the distinction between suicide risk
to be used in different settings. formulation and suicide risk prediction including crisis or
imminent risk assessment.
Skills in the use of suicide screening tools in a way that
engages with the person to obtain accurate data. Skills in the use of suicide risk formulation – comprehensive
suicide assessment tools – in a way that collaboratively and
Attitude towards the use of screening tools to maximise
respectfully engages with the person and their carers.
person benefit and improved care.
Attitude towards service response decisions based on
identified need.
Resources Resources
Licence fees for selected screening tools. Licence fees for selected assessment tools and related
intervention and safety planning tools.
Training for personnel in the administration, interpretation
and use of screening data. Training for personnel in the administration, interpretation
and use of assessment data and decision making on service
IT Systems for integration of screening data.
and support responses.
Training for personnel is the use of related intervention and
safety planning tools.
IT Systems for integration of assessment tools and data
collection and for integration of comprehensive assessments
into service responses, care plans and case management.
18 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Practice #2
Outcome – Person Safety and Suicide Related Clinical Improvements are Achieved
Framework - Engage
Intermediate Outcome: Intermediate Outcome: Intermediate Outcome:
A collaborative health care relationship Suicidal persons and their carers Suicidal persons and their carers
is established between healthcare experience compassion, sensitivity, receive continuous contact and support
workers, a suicidal person and their respect in their interactions with health while with health care services.
carers. care services.
Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted
Trust in the health care relationship Clinicians and other health workers hold Follow up contacts are made routinely
is enabled through development of a beliefs and understandings of suicidal and at key points such as when
Care Management Plan through open behaviour that underpin compassionate appointments are missed or a referral
exchange of information, continuous health care. to another service is made.
communication and participative
decision making.
Key Activities Key Activities Key Activities
Adoption of tools such as the Frontline and professional health Operationalisation of routine and ‘key
Collaborative Assessment and workers who are treating suicidal points’ follow up contacts with all
Management of Suicide (CAMS) or persons and their carers are recruited suicidal persons including protocols
similar as the basis for engagement with suitable attitudes and personal for responses to identified changes in
and treatment planning with all attributes for the roles that they will needs and suicidal status.
suicidal persons and their carers. perform.
Creation of a service directory and
Training for all key personnel, such as Frontline and professional health referral protocols to a range of
care coordinators and clinicians in the workers are trained in values based ‘aftercare’ and support services for
skills required to build collaborative engagement with suicidal persons suicidal persons and their carers,
health care relationships. and their carers, e.g. Connecting With including lived experience and peer
People. support programs.
Preparation of the Care Management
Plan includes education of person and Clinical supervision and wellbeing Integration of support service referrals
carer on suicidality and its causes, and support programs monitor for staff and follow up contact activities to the
the health care services that relate to showing signs of burnout, compassion care management plans and clinical
treatment and recovery. fatigue and vicarious trauma to review processes for a person.
intervene earlier and prevent impacts
on services.
People Involved People Involved People Involved
Care coordinators/case managers. Care coordinators/case managers. Care coordinators/case managers.
Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses,
psychologists, psychiatrists. psychologists, psychiatrists. psychologists, psychiatrists.
Related health and social services, Related health and social services, Related health and social services,
notably social workers, alcohol and notably social workers, alcohol and notably social workers, alcohol and
other drugs workers, counsellors and other drugs workers, counsellors and other drugs workers, counsellors and
psychosocial support coordinators. psychosocial support coordinators. psychosocial support coordinators.
Nursing Unit Managers, team leaders, Nursing Unit Managers, team leaders, Nursing Unit Managers, team leaders,
clinical leads/directors. clinical leads/directors. clinical leads/directors.
EVALUATION FRAMEWORK | 19Knowledge Attitude & Skills Knowledge Attitude & Skills Knowledge Attitude & Skills
Knowledge of comprehensive Knowledge of the concepts of Knowledge of the personal and social
psychosocial suicide risk assessment psychological pain as it relates to factors of a non-health nature that
and management tools, such as suicide and suicidal behaviour. affect a person’s suicidality and
Collaborative Assessment and recovery.
Non-judgemental and empathic
Management of Suicide (CAMS)
attitudes towards a person Knowledge of support services outside
or similar.
experiencing suicidality and/or of the health care system.
Attitudes that uphold participative attempting to take their lives.
Skills in use of care planning with
and partnership-based treatments
Knowledge of the impacts of another’s persons and carers to promote support
of suicidality, based on respect for a
suicidality on carers/families. services.
person’s ability to recover.
Listening skills. Skills in the use of brief follow up
Skills in the creation of collaborative
contacts to ascertain changes in
health care relationships through
person need or suicidal status.
personal rapport generation,
communication and negotiation. Attitudes that embrace total person
care beyond health care system
boundaries and enable productive
interaction with other services.
Resources Resources Resources
Licence fees for use of CAMS or Human resource management: Education and training for key
equivalent. recruitment, retention and clinical personnel.
supervision protocols.
Education and training for key Service and system development to
personnel. Education and training for key support operationalisation of follow up
personnel. brief contacts.
Education materials and programs
for carers. Investments in creation and
maintenance of support service
Technology – integration of
directories.
comprehensive psychosocial
assessments to care management
systems.
20 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Practice #3
Outcome – Safety and Suicide Related Clinical Improvements are Achieved with
Suicidal Persons
Framework - Treat
Intermediate Outcome: Intermediate Outcome: Intermediate Outcome:
A person’s suicidality is reduced Access to lethal means is addressed Suicidal persons are equipped to
through their treatment. directly and restriction confirmed with exercise suicide safety through
suicidal persons. self-monitoring and the use of crisis
supports.
Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted
Interventions that specifically address Lethal means counselling is offered Suicide safety plans are formulated
a person’s suicidality are adopted routinely, with due consent, and with all persons.
in care and treatment plans as the integrated with suicide safety planning.
primary course of action.
People Involved People Involved People Involved
Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses,
psychologists, psychiatrists. psychologists, psychiatrists. psychologists, psychiatrists.
Nursing Unit Managers, team leaders, Nursing Unit Managers, team leaders, Nursing Unit Managers, team leaders,
clinical leads/directors. clinical leads/directors. clinical leads/directors.
Key Activities Key Activities Key Activities
Psychotherapy; psychology; psychiatric Selection of counselling and consent Selection of suicide safety planning
interventions that directly address techniques on lethal means restrictions techniques, e.g. Beyond Now –
suicidality are utilised, e.g. – informed by expertise. informed by expertise.
- CBT Training relevant staff in the use of Training relevant staff in the use of
these interventions. these techniques.
- SP
Legal review of aspects of lethal Legal review of aspects of suicide
- DBT
means restrictions to address potential safety planning to address potential
- Psychotherapy liabilities. liabilities.
- Psychoeducation
- Pharmacotherapy
- Psychiatric care
- ECT
- Chemical dependency treatment
(substance abuse)
Clinical governance and oversight of
treatments for suicidality is exercised
by expertise in suicide.
Intersections between primary health
care (GPs), community mental health
and health system mental health and
psychiatry are formed through care
plans for suicidal persons.
EVALUATION FRAMEWORK | 21Knowledge Attitude & Skills Knowledge Attitude & Skills Knowledge Attitude & Skills
Clinical expertise and research Expert knowledge of techniques for Expert knowledge of techniques for
evidence to inform the selection of requesting consent and use of lethal developing suicide safety plans with
interventions in treatment plans. means restriction protocols. suicidal persons.
Clinical and health care skills in Skills in the performance of lethal Skills in the development of suicide
identification of interventions and mix means counselling. safety plans.
of treatments for suicidal persons.
Attitudinal acceptance of ethical Attitudinal acceptance of a suicidal
Clinical workforce with skills to deliver dilemmas arising in discussions on person’s ability to self-monitor and
treatments for suicidality. lethal means. address elevations in their suicidal
state.
Attitudinal acceptance of suicidology
as a discrete body of knowledge Attitudinal acceptance that person’s
with specialist clinical and health suicidal state may wax and wane and
treatments. that these cycles may be manageable
rather than resolvable.
Resources Resources Resources
Public health subsidies or provision Licence rights to counselling programs Licence rights to suicide safety
of treatments, pharmaceutics and on lethal means. planning tools and techniques.
programs to support treatment of
Training for key personnel. Training for key personnel.
suicidality.
Data systems and technology supports Data systems and technology supports
Licence rights for treatment programs.
for the operationalisation and review of for the operationalisation and review of
Workforce acquisition and professional lethal means restriction programs. suicide safety planning.
development.
Data systems and technology supports
for the operationalisation and clinical
review of treatment programs.
22 | ZERO SUICIDE HEALTHCAREOutcome Chain Statement – Pathways
Outcome – Suicidal Persons and Carers are Equipped for Recovery
Framework - Transition
Intermediate Outcome: Intermediate Outcome: Intermediate Outcome:
Suicidal persons and their carers Suicidal persons and their carers Suicidal persons and their carers have
perceive aftercare programs as useful experience smooth entry to aftercare increased hopefulness and confidence
and relevant to their needs programs for recovery
Change/Practice Adopted Change/Practice Adopted Change/Practice Adopted
Aftercare programs are integrated with Care transitions for suicidal persons The provision of healthcare instils
hospital-based health care for suicidal and their carers occur in a planned a recovery outlook within suicidal
persons. way. persons and their carers.
Key Activities Key Activities Key Activities
Creation of service directories and Formulation of checklists, guides and Recovery objectives are developed for
referral protocols to aftercare services, authorisations for discharge plans every suicidal person as part of the
e.g. Beyondblue The Way Back Support relating to suicidal person. clinical care planning process.
Service; Eclipse Suicide Survivor
Training for key personnel in use of Training for key personnel in positive
Support Groups, Life Clinic.
templates for discharge planning communication and messages to
Education and training for key relating to suicidal person. encourage a recovery outlook.
personnel in the benefits of and
Discharge plans for suicidal persons Use of peer workers and informal
facilitation of suicide aftercare
are finalised ahead of actual departure supports to enable recovery
programs.
from the hospital and specialist health orientation.
Carers are routinely educated about care environment.
the care, safety management and
support that is available for them
during healthcare periods and prior
to transitions out of healthcare.
Systematic referrals for aftercare
programs occur for every suicidal
person.
People Involved People Involved People Involved
Care coordinators/case managers. Care coordinators/case managers. Care coordinators/case managers.
Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses, Clinicians, i.e. mental health nurses,
psychologists, psychiatrists. psychologists, psychiatrists. psychologists, psychiatrists.
Related health and social services, Related health and social services, Related health and social services,
notably social workers, alcohol and notably social workers, alcohol and notably social workers, alcohol and
other drugs workers, counsellors and other drugs workers, counsellors and other drugs workers, counsellors and
psychosocial support coordinators. psychosocial support coordinators. psychosocial support coordinators.
Nursing Unit Managers, team leaders, Nursing Unit Managers, team leaders, Peer workers, carers, informal and
clinical leads/directors. clinical leads/directors. volunteer support people
EVALUATION FRAMEWORK | 23Knowledge Attitude & Skills Knowledge Attitude & Skills Knowledge Attitude & Skills
Knowledge of available aftercare Knowledge of discharge planning Knowledge of principles and practice
programs and their type, purpose and techniques and use of templates. of recovery in suicide prevention
application for suitable participants.
Skills in engagement with persons and Skills in engagement with persons and
Knowledge of referral processes carers on discharge actions. carers on a recovery orientation
including information and assessment
Attitudinal acceptance of Skills in motivation and problem
provision to facilitate entry to aftercare
responsibilities within hospital and solving through incidental contact
programs.
specialised health care services to with others
Skills in collaboratively developing complete discharge planning properly
Attitudinal embrace of positive and
plans for aftercare programs with prior to person release.
constructive provision of supports for
persons and carers.
those recovering from suicidal crisis
Skills in negotiating placements and
Attitudinal acceptance of the potential
referral pathways for persons to enter
for recovery from suicidal crisis
aftercare programs.
Attitudinal acceptance of concepts
of total person care that includes
attention to the post-specialist service
care arrangements.
Resources Resources Resources
Training for key personnel. Training for key personnel. Education and professional
development for key personnel
Education and information resources Operationalisation of discharge plans
for suicidal persons and carers. for suicidal persons through IT and Education and information resources
systems technologies. for suicidal persons and carers.
24 | ZERO SUICIDE HEALTHCARE5. Data Measures
The Evaluation Framework for Zero Suicide Healthcare outlines the outcome chains across
the framework for adoption of a comprehensive approach to suicide prevention in healthcare
systems. These outcomes relate to practice changes, processes and workforce development.
Data measures as outlined below will support data collection within the Evaluation Framework
across these levels of operation and results monitoring. These data measures will also feed quality
review and continuous improvement processes.
The Data Toolkit available online through the US Zero Suicide Institute contains some data
measures – the Evaluation Framework extends these. Those data measures that are from the Data
Toolkit are shown in green highlight.
Processes marked with ** are listed on the US data elements worksheet found here:
http://zerosuicide.edc.org/sites/default/files/ZS%20Data%20Elements%20Worksheet.TS_.pdf
Lead
Outcomes Practice and Change Processes
% Healthcare workforce holding Feedback from healthcare workers % Healthcare workforce is familiar
commitment to elimination of suicide shows support for changes to eliminate with the Case for Change
suicides
Extent to which healthcare Data for performance measurement
performance measures align to Zero Corporate and individual performance is collected and reported on.
Suicide Healthcare reviews apply measures from Zero
Workforce training in Just Culture
Suicide Healthcare
Culture review confirms existence of is completed.
values of recovery, healing, learning Corporate policy and procedure align
Executives/leaders performance
and improvement to principles and practice of Just and
agreements contain measures on
Learning Culture
Organisational wide feedback shows suicide prevention.
satisfaction with leadership Implementation decisions on Zero
Suicide Healthcare are made in a
timely manner
Train
Outcomes Practice and Change Processes
Measured levels of knowledge, Extent to which healthcare workforce Workforce competency reviews
skill and confidence of healthcare meets standards of knowledge, skill completed
workforce in providing support to and attitudes on working with people
Workforce training completed
people at risk of suicide at risk of suicide
Guidelines and practice notes on
Extent to which healthcare workforce Extent to which healthcare workforce
continuous improvement for service
is utilising quality and continuous applies continuous improvement
provision to suicidal persons and their
improvement processes across practices in routine service delivery
carers are adopted.
discrete operational units
EVALUATION FRAMEWORK | 25You can also read
