Northumberland Hills Hospital Community Mental Health Services (NHHCMHS) identified that clients accessing the community walk-in clinic were not being screened for suicide risk using a formalized screening practice. They recognized that this was resulting in inconsistent documentation and the potential for clients contemplating suicide to not receive the proper level of care needed.
NHHCMHS participated in the IDEAS Program to find ways to improve suicide screening for clients at the walk-in clinic.
They used Health Quality Ontario’s Quality Standard for Major Depression and focused on Quality Statement 2: Suicide Risk Assessment and Intervention
“People with major depression who are at considerable risk to themselves or others, or who show psychotic symptoms, receive immediate access to suicide risk assessment and preventive intervention.”
As a result, the average suicide screening rose to 85.2% from 16%, almost meeting their target of 90%.
After reviewing their data, NHHCMHS discovered that, at times, clients who expressed having suicide thoughts via the screening paperwork they filled out at the walk-in clinic were not being assessed for suicide risk during screening with therapists and case managers. The team questioned if face-to-face screening allowed for conversations that exposed suicide risk better than a single question on paperwork.
For those identified as being at risk of suicide, few (17%) were being offered an opportunity to complete a safety plan during the screening session.
NHHCMHS participated in the IDEAS Program to learn QI skills, knowledge and tools that would enable them to implement a solution.
NHHCMHS set an aim that 90% of people attending the walk-in clinic would be screened for suicide risk and, for those who are identified as having thoughts of suicide, 90% would be offered the opportunity to formulate a safety plan that would be taken home by the client and documented in the file.
The team identified several change ideas, including:
- Conducting staff meetings to discuss clinicians’ skill and comfort to assess suicide
- Educating clinicians about Health Quality Ontario’s Quality Standard for Major Depression
- Creating a process map of the current state
- Creating formalized tools to assess suicide risk and complete safety plans
- Working with the EMR vendor to create a customized form and report to capture data
- Developing a formal policy on how and when to assess for suicide and document the results of assessment
- Obtaining client feedback on the new assessment process
View the full project summary here.
NHHCMHS achieved significant results and plans to spread their efforts across all outpatient programs in the agency to meet Health Quality Ontario’s Quality Standard for Major Depression.
How do you support
clients with mental health needs? Share your experiences by clicking on “Add a
This post is part of a series about how quality standards can be used to support quality improvement together with others who are working on adopting the quality standards. The introductory post can be found here.