Zero Suicide Goes to… Washington?

press conferenceLet’s dream for a moment. It’s early 2016 and the Get Ready for Hillary campaign is storming the country. In a press conference, her running mate announces a bold and innovative healthcare initiative that will comprise an important component of the Clinton platform. It’s a call for Zero Suicide, a pledge to replicate the success of Dr. Ed Coffey’s team at the Henry Ford Health System in Detroit, Michigan. Innovative pilots in Arizona, New York, Texas, and Tennessee are cited. Within days, the Secretary of Health and Human Services echoes support and outlines a plan to implement the evidence-informed approach across the country.

CNN, USA Today, and the New York Times all feature the story repeatedly. There are no headlines that call the notion naïve or misguided. Instead, there is a rich, informed, and productive debate about the adequacy of the US healthcare system and its behavioral health capacity, and the way forward to bring a central focus to suicide care. Millions engage in the public media discussion of challenges, e.g., the difference in male and female suicide rates. The American Association of Suicidology creates a dedicated website in support of the initiative and publically calls for better training and systems for behavioral health professionals.

Fantasy, right?

Since 2010 and the formation of the public/private partnership that is the Action Alliance for Suicide Prevention, we have seen a top level U.S. government focus that is unprecedented. Instead of the hundreds that previously focused on this work, we have seen thousands become engaged. Yet, suicide is a challenge that requires the attention of millions, and that’s a level of engagement that has been restricted to other pressing issues; heart disease, cancer, HIV/AIDS, traffic and airline accidents, etc.

But not suicide.

So yes, as recently as the close of 2014, the scenario above would have seemed very farfetched, if not impossible. And yet, this is exactly what occurred last month… in the United Kingdom.

With general elections in May, the race is entering the homestretch in England. January 18 was to be a day of dueling mental health initiatives, with the Labour party suggesting more funds be allocated to child services.

downing streetUK Deputy Prime Minister Nick Clegg appeared on a BBC talk show to provide the Liberal Democrats counter, and promised to sign up the National Health Service (NHS) for a country-wide “Zero Suicide” campaign. He referenced pilot programs in organizations in Merseyside, the east of England, and the southwest that have employed the Henry Ford Health System model “where suicides were sharply reduced from 89 per 100,000 in 2001 to as low as zero among the patient population over the decade” (Guardian, “Lib Dems announce campaign for NHS to set ‘zero suicide’ goal”).

Clegg called for charities, voluntary organizations, and the NHS in “every part of England” to join in the effort to eliminate suicides. And Clegg encouraged a no-blame approach to the effort, mirroring the “just culture” performance improvement approach espoused by Dr. Ed Coffey, the pioneer behind the success at Henry Ford. “[Zero Suicide] is doing more in every area of our society to ensure that people don’t get to that point where they believe taking their own life is their only option,” said the Deputy Prime Minister.

Several pilot programs, which have already embarked on the mission, were mentioned, including:

  • Project Zero in southwest England. This program includes individuals with lived experience in its steering committee and partners behavioral health and social service organizations with local emergency services to identify and support individuals at risk, including utilization of Jeffrey Brenner’s “hot spotting” techniques.
  • Mersey Care. An NHS trust in Liverpool, this program has established a goal to eliminate suicides in its area by April 2018, with training for staff in the skills to support those at risk, such as safety planning. They have also engaged a tiger team for monitoring individuals at highest risk.
  • Stop Suicide Campaign. This program in Eastern England’s Cambridgeshire and Peterborough is providing ASIST (Applied Suicide Intervention Skills Training), and using social media and community events with public pledges.

Two days later, Norman Lamb, the UK’s Minister of State at the Department of Health, wrote about breaking the taboo on the last stigma, mental health and suicide. “We want to see this sort of approach [Zero Suicide] taken across the country.” (Read the Letter.)

After these events, the dialogue exploded and it was rich.

bbc news ukThe BBC featured an article, “New strategy to cut suicides ‘achievable’, says Clegg.” The Guardian reported “Zero suicides is an admirable aim but it requires all-out change.” It also addressed the disparity between male and female suicide rates (read here). Allied non-profit organizations like theSamaritans and Contact NI weighed in with support. Professional associations immediately took notice, addressing “‘Zero suicide’s goal risks blame culture if applied ‘clumsily.’” The Telegraph argued the first step in the ambitious plan would be to reject euthanasia and “assisted dying.”

Twitter traffic soared on the topic of Zero Suicide in the 30 days since Clegg’s proclamation.

Just yesterday, in an article on the suicide deaths of adults detained while in psychiatric inpatient, jail or prison, the BBC reported the Department of Health for England is calling on every part of the NHS to commit to a new “zero suicide” ambition, again referencing the “perfect depression care” program at Henry Ford.

It’s a dream come true to see the political will at play in the UK in the spring of 2015. However, some might be concerned about the translation 4,000 miles away on the other side of the pond. As the mission spreads, will there be fidelity to the model?

The catalyst for success at Henry Ford was inspired in large measure by Don Berwick and the Institute for Healthcare Improvement, authors of Crossing the Quality Chasm and the 100,000 lives campaign for increased patient safety in hospitals. Studying these efforts yields four essential bold ideas, and they were all front and center in the January dialogue in the UK.

What distinguishes a Zero Suicide initiative?

  • First, the goal of Zero Suicide must emanate from the leader. When it’s the stated objective of the CEO, Health Commissioner, or Deputy Prime Minister Clegg, one can be confident the resources of the full enterprise will follow (Bold Idea #1).
  • Second, Zero Suicide starts the goal from the other end. It was clear from their language that Clegg and Lamb eschew the potential for incremental change in favor of a bold declaration (Bold Idea #2).
  • Third, Zero Suicide includes individuals with lived experience in the leadership and design(Bold Idea #3).
  • Finally, Zero Suicide reject the myths. It believes suicide is not inevitable; not a choice. Aspire for Zero (Bold Idea #4).

As Minister of State Lamb stated, “Different regions will find different ways of targeting ‘zero suicides’… But as much as anything else, we need a change of mindset in our health system and in our society to understand that suicide is something that we can prevent and that we can talk about openly without shame.”

That’s a great vision for the Zero Suicide in Healthcare mission… not just in the United Kingdom, but for the world.

*Note: David Covington co-authored this blog with Fergus Cumiskey, the Managing Director with Contact, Northern Ireland, which operates the regional crisis counseling service and 24/7 crisis helpline, under license from the Public Health Agency.

Assembling the Team

x-menRecovery Innovations is hiring senior executives!

Hannibal Smith’s favorite catch phrase was, “I love it when a plan comes together.” But, the plan only got figured out in each and every episode of The A-Team because first, there was a great group putting their minds and efforts together.

Today’s equivalent is the super hero team. In the juggernaut Marvel series The Avengers,an unlikely group of individuals with a diverse set of special skills come together for a bigger purpose. It’s a tried and true formula. In the blockbuster movie, they form. They norm. They storm. And, ultimately, they kick alien butt. Together.

I’ve had the enormous privilege in my career to participate in and/or lead a number of great teams. We have created exciting innovations that have been widely recognized, and are as diverse as suicide care models and clinical algorithms, recovery pathways and online dashboards, and integrated care linkages and interactive software technologies.

The common themes of these teams:

  • We believed the work and mission were very important.
  • We were collectively committed to creating something special and each of our opinions counted.
  • We were empowered to run and the pace was fast; it felt like a “live fire” range at times.
  • We were pressed to the limits, but the result was rich personal growth and development.
  • We celebrated success.
  • We made great friends in the process. To borrow another First Break All the Rules-ism, there was always a best friend at work and the time flew.

I’m looking for new members to join our team.

In late 2014, RI shifted its organizational structure to better support its five business lines. Three key leadership roles are being added:

  • Chief Operating Officer
  • Chief Recovery and Clinical Officer
  • Regional Director for the West Coast

The Regional Director for the West Coast will report to the COO and will support RI’s customer relationships with Optum Health in Pierce County, Washington State and behavioral health departments across six California counties (Alameda, Contra Costa, Kern, Riverside, San Diego and Ventura). This position will ideally be based in the Seattle metropolitan area or the greater Riverside, California area.

The Chief Operating Officer will be responsible for recovery and outpatient programs nationwide with direct reports including the Regional Directors: Marleigh O’Meara, Arizona; Willard Heuser, Delaware; and Ann Holland, North Carolina. While the operations of the crisis facilities will fall under the Chief of Recovery and Crisis Facilities, the Chief Operating Officer and his/her team will also be responsible for all Customer relations, working closely with State, County, and Health Plan leaders across the country. The Chief Operating Officer will also coordinate with new business implementations, risk management, and corporate compliance functions. This position will be based in Phoenix, AZ.

The Chief Recovery and Clinical Officer will lead a consolidated group of learning departments, which currently operate separately. The Recovery Opportunity Center provides recovery and peer supports consultation and training worldwide; The Recovery Education Center equips RI’s citizens; and the RI Learning Team orients new employees who join our nearly 800 strong work force. In addition, this individual will lead the Quality Support Department, who will be tasked with strengthening the integration of recovery, clinical/medical, and programmatic requirements. The Chief Recovery and Clinical Officer will also evaluate how best to introduce a Zero Suicide in Healthcare initiative at RI. This position will be based in Phoenix, AZ.

The Chief Recovery and Clinical Officer will support a team including: Scott Palluck, Chief Quality Support Officer; Marie Gagnon, Chief of Nursing; Arrow Foster, RSA; Lisa St. George, Director of Recovery Practices; Chris Martin, Chief Learning Officer; and Marianne Long, Recovery Champion.

These individuals will join the following exceptional team members who report to me:

  • Leon Boyko. As Chief of Recovery and Crisis Facilities, Leon leads the Recovery Response Center programs (what funders refer to as “Crisis Stabilization Programs”), which are 24/7 programs across six states. These programs are experiencing significant growth and we expect to double the number of facilities in 2015.
  • Vernon Barksdale, M.D. He is the Chief Medical Officer for the Company.

In addition, Susan Dess, a consultant with Crestline Advisors, advises RI on special projects. These include the selection of an Electronic Health Record, the facilitation of an RFP to sub-contract medical services at the Recovery Response Center in Peoria, new program implementations and a comprehensive, enterprise-wide corporate compliance review using the Marguerite Casey Foundation Organizational Capacity Assessment Tool.

ri teamDownload the new RI organizational structure here. In 2015, RI will complete a formal vision and strategic planning process alongside the comprehensive corporate compliance review, and these activities may offer additional structural recommendations.

If you are interested in learning more about these leadership opportunities at Recovery Innovations, please

About Recovery Innovations: With recovery programs in six states, including Arizona, California, Delaware, North Carolina, Texas and Washington, Recovery Innovations mission is to create opportunities and environments that empower people to recover, to succeed in accomplishing their goals, and to reconnect to themselves, others, and to meaning and purpose in life. With projected 2015 revenues of $60 million, the Company’s health programs are grouped into advanced crisis, transition management, integrated outpatient and peer supports, and consulting and training.

Improving Performance with the Balanced Scorecard (and the King)

elvis stampIt’s been said that frameworks are a dime a dozen… but you have to have one. Prior to 1990, many businesses focused their measurement on finance alone, which tended to discourage continuous improvement and innovation. These companies lacked a systemic model.

In 1992, the Harvard Business School devised the four quadrant Balanced Scorecard, “a fast but comprehensive view.” Instead of isolating a single issue to the potential detriment of other important factors, the Balanced Scorecard sought to integrate four key perspectives: the customer, internal business, innovation and learning, and finance.

Last fall, Recovery Innovations (RI) adapted this tool for its own improvement efforts, and in January 2015 we recognized our first recipient for outstanding performance related to its four domains. This RI team member has led measurable performance above and beyond normal expectations, and the success has been comprehensive.

What does comprehensive success mean according to RI’s Balanced Scorecard? (Click to download.)

For RI, the framework is simple. It outlines four major domains and specifies how to measure the baseline and improve performance.

Each program/team leader rates their program by circling the most accurate description in each of four quadrants using a simple Likert scale.

Domain 1 – Customer Perspective: How well does your team and program reflect RI’s recovery principles and practices to customers?

  1. Inadequately reflected by both team and program.
  2. The team is cordial and friendly to the customer (which RI refers to as guests, students, citizens) but privately reveals a lack of respect and hope; the program has gaps.
  3. The team is no better or worse than teams in other traditional Behavioral Health Agencies; the program is also the same.
  4. The RI Mission Statement is sporadically reflected by team members and program – varies per team member and issue.
  5. The RI Mission statement is consistently reflected by all team members and the program to all customers.

Domain 2 – Finance & Productivity: How well does your program and team use your available daily capacity (staffing, space, and resources) to optimize your services?

  1. We experience insufficient daily capacity usage (under 50%) in staffing, space, and resources.
  2. Our daily capacity varies by never falling under 50% and occasionally getting close to 95% in 1 or 2 of the 3 areas.
  3. Our daily capacity is generally close to 95% or greater in 1 area but usually remains significantly under in 2 areas.
  4. Our daily capacity is at 95% or greater in at least two of the areas and usually remains significantly under in 1 area.
  5. We have consistent optimal use (>95%) of capacity in all three areas.

Domain 3 – Internal Business: How well do you know your business, i.e., demonstrable data, outcomes, and real time performance compared to goals?

  1. Inadequate due to time-consuming, paper tracking process with outdated information.
  2. Somewhat, but I acknowledge gaps in what I need to know in real-time.
  3. Adequate due to workarounds using paper and system for information.
  4. Above average knowledge, but not fully real-time and not fully paperless.
  5. Excellent knowledge due to collaborative team review and a paperless process.

Domain 4 – System Leadership: How high would your local System of Care (SOC) such as Law Enforcement, Emergency Responders, and Mental Health Funders rate your program and team’s relevance to the SOC’s mission and purpose for people with behavioral health challenges? (their perception)

  1. Not relevant
  2. Relevant as one option among many
  3. Very relevant for folks with lower needs, but no impact for majority of people with highest needs
  4. Highly relevant much of the time for people with high needs
  5. Indispensable for people with high needs (the SOC’s “go to” place for getting people to the best service)

chalkboardThe goal is not exemplary performance on one or two of the four domains, but “balanced” optimization across all four. The total score is calculated by summing the answers across the domains.

RI and many organizations have a strong mission and values, but the Balanced Scorecard helps with the strategic vision, bringing a vital view to the organization’s effectiveness as observed from 30,000 feet. Otherwise, we can falsely assume success based upon an incomplete analysis. For example:

  • The services are exemplary from the customer’s perspective (recovery-oriented, hopeful, and engaging), but the program benefits far too few for the capacity in which the county, state, or health plan leadership have invested.
  • The crisis program is full and engaging, but the individuals served are largely self-referrals, those with substance abuse issues, and not primarily those with the highest psychiatric needs or those where law enforcement and emergency departments are involved
  • The services are full, engaging, and fit the target population highest in need, but the program cannot document the effectiveness through readmission and/or escalation data (limited to anecdotal stories)

You get what you measure, and RI has a new way of celebrating success based on its Balanced Scorecard: The Velvet Elvis.

You’re probably wondering “Why a Velvet Elvis?”

Five years ago, longtime Maricopa County behavioral health leader Chris Damle and I were brainstorming a fun way to celebrate individual performance on our teams, and one of his prior employers had used a tacky portrait of a velvet Elvis. His wife found an appropriate replica and the rest is history. (You might be surprised how many current leaders across Phoenix have written their name on his frame at some point over the past several years.)

It was awarded based on nominations, which anyone could provide, but only my direct reports chose the final winners. We developed a couple simple rules for the holders:

  • We didn’t talk about the why. (It’s self-evident we would joke.)
  • Elvis must be proudly and prominently displayed.
  • There were no time frames associated with possession. Some individuals kept the King for weeks, and occasionally, some held him for mere hours.

sarah blanka velvet elvisSo, after a well-deserved year’s vacation, the Velvet Elvis reemerged in January at Recovery Innovations. Sarah Blanka (pictured below) leads the Recovery Response Center in Peoria, Arizona, which features a West Valley Retreat and Living Room (RI language for 23-hour observation and sub-acute inpatient, respectively) and is the first recipient at RI of the Velvet Elvis (“V.E.”) Award.

Sarah, Irma Stewart, Elizabeth Timko, and the RRC team have demonstrated material improvements across the board and were recognized with the Balanced Scorecard “V.E.” as a result. Their achievements:

  • System Leadership Perspective:Responsiveness with local law enforcement yielded a positive letter from Phoenix Police Department’s Nick Margiotta to local West Valley precincts encouraging higher utilization of the facility.
  • Internal Business Perspective: Nearly 100% increase in the number of individuals transported to the facility by local law enforcement over the last year.
  • Finance & Productivity Perspective: Improved “throughput,” faster referral access times, and stronger coordination with partner organizations Community Bridges, ConnectionsAZ and CPR.
  • Customer Perspective: Overall better experience, less likely to be holed up in Emergency Department, faster access to care, better engagement, and collaboration with peers focused on hope and recovery.

Congrats to Sarah and the RRC team, and I’m hoping another success story quickly ferries the Velvet King of Rock ‘n Roll to another RI location!

Reference: The Balanced Scorecard – Measures that Drive Performance (Harvard Business Review, 1992.) Special acknowledgment to Chris Martin and the RI Learning Team, my collaborators on adapting the tool for RI.

Velvet Elvis Fact: At some point, individuals began adding their own mark to this coveted prize (click below), and the 2015 King barely resembles his original 2010 self. He now has actual hair on his head… and chest, as well as a guitar pick, blue cape, and more.

elvis 2010

Avoid Crisis Not Top Ten… Join #NatCon15

10In the last few years, nearly a dozen US states have determined it was time to end the “Not Top Ten.” This decision is leading to an investment of hundreds of millions with a new level of expectation for psychiatric crisis services; crisis stabilization facilities, crisis respite, mobile crisis and high-tech crisis call centers.

What is the “Not Top Ten?” On Super Bowl Sunday, it’s easy to think about the plays that made SportsCenter for the wrong reasons.Seattle is playing today in part because their last minute onside kick against the Packers in the NFC Championship slipped through a tight end’s hands and bounced off his head and away. Ouch.

We have our own “Not Top Ten” when it comes to crisis services and their coordination. What does it look like? SportsCenter… roll the tape.

Coming in at #10 – Shotgun Referrals…

Individuals who need more intensive residential care are referred by fax to multiple facilities all at the same time, because the crisis center/ER knows that most agencies will deny and/or not respond in a timely fashion

#9 – Who’s on First?

The first facility giving acceptance is where the individual goes without regard to the person’s preference, how far away the facility is from family supports, etc.

#8 – I’m Stuck!

There’s no way to really know if someone is stuck in an Emergency Department unless the staff make noise (squeakiest gets grease)

#7 – Cherries for Everyone

Receiving facility staff may sift through all referrals, and pick out the ones that will be easier in their milieu

#6 – Through the Cracks

No one knows how many are being sent home without care and/or walk out of the ED against medical advice

#5 – Calling & Waiting

Communication depends on numerous phone calls and faxes. ED staff and crisis facility staff make and field numerous phone calls about each case.  If nurses at either facility are busy, the other must wait for call backs. No time frames are set for receiving facilities to give referral decisions

#4 – Just Following Protocol

Costly, invasive and time consuming medical tests are often required unnecessarily.

Interested in learning #3, #2 and #1 in the Not Top Ten list of crisis coordination? Join us at the National Council Conference in Orlando, April 20 – 22 and participate in our second annual Crisis Track. More importantly than revealing the bottom three, we’ll be highlighting superstar programs and showing you how to achieve similar success, with services that quantify both their outcomes and cost-avoidance.

We are in the process of confirming invited speakers for the preliminary agenda below. Also, keep on the lookout for a crisis services survey, the results of which will be shared in Orlando. Space is limited in the preconference, so reserve your slot today!

Half-Day Preconference (Sunday Afternoon, April 19)

“Supercharge Your Crisis Services to Next Generation Status in 90 Days.” Join us for the #NatCon15 crisis services pre-conference university where you will build your own rapid action plan, build your business case and improve your results quickly and inexpensively while meeting funding expectations

  • National expert leadership David Covington, Vijay Ganju and Richard McKeon will partner with crisis systems leaders to give a how-to on measuring and reporting cost-avoidance
  • County, state and health plan leaders will share success stories and give an inside view of what they are looking for with investments in crisis, including Larry Goldman from Value Options and Gabriella Guerra from Mercy Maricopa Integrated Care

Crisis Track Lunch & Learn

  • “Where Addiction, Recovery and Crisis Services Meet Together.” John Hogeboom and Community Bridges began crisis services in 2002 with the LARC detox (Local Alcohol Reception Program), but have evolved into an industry leader with 24/7 outpatient, co-located short-term residential, a strong peer workforce and fully integrated care.

Crisis Track Town Hall

  • Crisis Responders Town Hall (Moderated by David Covington and Cheryl Sharpe, with Becky Stoll). Join colleagues from around the country who are committed to improving crisis services for people with mental illnesses and substance use disorders to review a national survey of crisis services and plan next steps. Lunch provided in the room.

Crisis Track Workshops

  • “Suturing in the Field: Innovative Mobile Crisis Partnerships with First Responders.” Three creative upstream collaborations with first responders and crisis systems: Tom McSherry on CPR, Inc. with Mesa Fire in Arizona, Wendy Schneider on Behavioral Health Link with Grady Memorial Hospital in Georgia and Lorraine Chamberlain with AMHC on crisis collaborations in Maine.
  • “Fascinating. Star Trek’s Mr. Spock on the New Crisis Services Technologies.” With today’s advances in the area of technology Americans have come to rely on the use of smart phones, tablets, and computers to make their lives easier. Centerstone America’s Becky Stoll and @crisistextline’s Jen James will moderate a look at next generation tools for crisis systems to better serve those experiencing behavioral health emergencies.
  • “Transformational Crisis Services: Peers Bring Unique Mix of New Approaches.” Sera Davidow, Western Massachusetts Recovery Learning Community and Thomas Lane, Magellan Health will overview peer-run respite, warm lines, and wellness centers as trauma-informed alternatives to hospitalization. Will include outcomes and lessons learned at Afiya House, a peer-run respite program in Massachusetts. Presenters will also discuss financing strategies and training options.
  • “We’re Not the Only State with a ‘Boarding’ Problem: Community Connections and Solutions from Washington State.” Harbor View Medical Center’s Laura Collins on methods to avoid having people stay long periods in EDs, including electronic bed inventory solutions, and how to create your own plan for these community connections.
  • “Here There Be Dragons: New Voices in Suicide.” Suicide Attempt Survivors Dese’Rae Stage, DeQuincy Lezine and Craig Miller who have been published and featured in the New York Times on how they lived through suicide. Moderated by David Covington.

Note: Read about the National Council’s first-ever crisis track in 2014: Time for Crisis is Now