A #ZeroSuicide World: Interview with David W. Covington, LPC, MBA

[Episode 106] Today's episode of the Social Work Podcast is about a healthcare initiative called Zero Suicide.  In today’s episode, I spoke with David W. Covington, LPC, MBA who, along with Mike Hogan, developed the Zero Suicide initiative. We talked about how he went from clinician to health care executive, from running a crisis service to organizing Zero Suicide initiatives around the world. We talked about what Zero Suicide means for providers and health care leaders and ended with information about how you can get your healthcare organization involved in Zero Suicide.

• Zero Suicide: http://zerosuicide.sprc.org
• David's website  https://davidwcovington.com/
• Twitter
• David W. Covington: https://twitter.com/davidwcovington
• #ZeroSuicide: https://twitter.com/zerosuicide_org 
• Zero Suicide Intitute: https://twitter.com/ZSInstitute

Download MP3 [54:49]


So why should social workers care about Zero Suicide?

• Zero Suicide fits social work values. Zero suicide can only happen in a culture where people are encouraged to reach for the moon – that is no suicide, but are not punished for falling short. This idea of a “just culture” comes from Henry Ford Health System’s “Perfect Depression Care.” 
• Zero Suicide can’t happen without social workers. Social workers provide more mental health services than all other professions combined. Social workers are team players and Zero Suicide is inherently interprofessional. 
• Social workers are advocates. What if health care organizations use best practices, but those best practices haven’t been developed with diverse racial and ethnic groups, or don’t into account complex medical or trauma histories? What if Zero Suicide means that health care organizations have to spend more on training and staffing? Who will advocate for consumers if those costs are passed along to consumers rather than investors? Social workers have a professional responsibility to be involved in those conversations.   
• Social workers are trained to identify and respond to issues at the practice – the micro, and policy – the macro – level. Well guess what – ZeroSuicide is like the holy grail of micro-macro integration: it requires coordinated changes in values, beliefs, and practices at the provider- and system-level. David will talk more about this during the interview, but in plain English it means that as a social worker I have to believe that suicide is preventable, know how to assess, intervene, and coordinate care, and trust that my organization will have my back. At a systems level, health care organizations have to make a multi-year commitment of time and resources to reduce suicide deaths, train and support clinical and non-clinical staff, screen and assess everyone in the system, and use data-driven quality improvement.  It can’t work without changes at the micro and macro level.

Bio 

David and I giving the #ZeroSuicide sign at 2016
American Association of Suicidology Conference.

Transcript
Introduction 

Hey there podcast listener, Jonathan here. In today’s episode of the Social Work Podcast you and I are going to tackle the question “can healthcare make suicide a “never event?” Are their things that health care systems and the people who work in those systems like social workers, counselors, nurses, doctors, psychologists… you know the list… Are there things that can be done so that suicides don’t happen? I hear what you’re thinking… “sure we can do better, but some suicides are inevitable. I mean, at the end of the day, if someone really wants to kill themself, they’ll do it.” And that’s what I was taught. But just hold on to that thought for a while – we’ll come back to it.
Ok, so why should health care tackle the issue of suicide head on? Here are some stats: According to the World Health Organization over 800,000 people die to suicide every year. In the USA, suicide is the second leading cause of death among Americans ages 10 – 34. It used to be homicide. But now it is suicide. That’s right - during the healthiest years of life, Americans are more likely to kill themselves than be killed by someone else. So wait. That’s the answer, right? Healthy people don’t go to the doctor, so the healthcare system can’t tackle this issue. Yes and no. Yes, if we want to reduce global suicide deaths from 800,000 per year to zero we’ll have to tackle more than just health care systems. In the US there are many groups of people who don’t trust health care providers. African Americans are more likely to turn to religious leaders than health care professionals, in part because they’ve been abused and neglected by the health care industry for hundreds of years. People who have migrated to the US can’t get what they need because of language barriers and different definitions of what constitutes a problem. White people living in rural areas might not have language or cultural or historical barriers, but life in small communities can make confidentiality more difficult. When it comes to suicide, for all groups, the struggle with shame and silence is real.
But any effort to reduce suicide has to include health care systems. People across the lifespan see health care providers and people across the lifespan die by suicide.  A 2015 study by Ahmedani and colleagues looked at suicide attempts in US health care systems (Ahmedani et al., 2015). They found that nearly 65% of people who made a suicide attempt had seen their doctor within a month, and nearly 40% saw their doctor the week before they tried to kill themselves. So, what would need to change in health care so that those 65% were identified, appropriate care was provided, and the suicide attempt was prevented? As my guest David Covington explains, there would need to be changes at the individual provider and systemic levels. And the first change is that individual providers and health care systems would need to believe that suicides are preventable. In other words, they would all need to agree on the goal of Zero Suicide.

So why should social workers care about Zero Suicide?

• Zero Suicide fits social work values. Zero suicide can only happen in a culture where people are encouraged to reach for the moon – that is no suicide, but are not punished for falling short. This idea of a “just culture” comes from Henry Ford Health System’s “Perfect Depression Care.” 
• Zero Suicide can’t happen without social workers. Social workers provide more mental health services than all other professions combined. Social workers are team players and Zero Suicide is inherently interprofessional. 
• Social workers are advocates. What if health care organizations use best practices, but those best practices haven’t been developed with diverse racial and ethnic groups, or don’t into account complex medical or trauma histories? What if Zero Suicide means that health care organizations have to spend more on training and staffing? Who will advocate for consumers if those costs are passed along to consumers rather than investors? Social workers have a professional responsibility to be involved in those conversations.   
• Social workers are trained to identify and respond to issues at the practice – the micro, and policy – the macro – level. Well guess what – ZeroSuicide is like the holy grail of micro-macro integration: it requires coordinated changes in values, beliefs, and practices at the provider- and system-level. David will talk more about this during the interview, but in plain English it means that as a social worker I have to believe that suicide is preventable, know how to assess, intervene, and coordinate care, and trust that my organization will have my back. At a systems level, health care organizations have to make a multi-year commitment of time and resources to reduce suicide deaths, train and support clinical and non-clinical staff, screen and assess everyone in the system, and use data-driven quality improvement.  It can’t work without changes at the micro and macro level.

In today’s episode, I spoke with David W. Covington, LPC, MBA who, along with Mike Hogan, developed the Zero Suicide initiative. We talked about how he went from clinician to health care executive, from running a crisis service to organizing Zero Suicide initiatives around the world. We talked about what Zero Suicide means for providers and health care leaders and ended with information about how you can get your healthcare organization involved in Zero Suicide.
But, before we get into it, I’d like to ask you three things – and no, I’m not asking for money. First, I know there are tens of thousands of people who listen to the podcast, but I don’t know much about you. I would be so grateful if you took a minute to fill out an audience survey. You can find the survey link in the “info” section of this episode, and on the top right corner of the Social Work Podcast website. Second, if you like what you hear, please leave a review on iTunes. The more reviews, the easier it is for folks to find the podcast. Finally, I’ve had several requests for transcripts. I’d love to be able to provide transcripts for every episode. Many are, but some aren’t. So, if you have an interest in transcribing an episode in exchange for an shout out in the next episode, send me email.
And now, without further ado, on to episode 106 of the Social Work Podcast: A #ZeroSuicide World: Interview with David W. Covington, LPC, MBA

But, before we get into it, I’d like to ask you three things – and no, I’m not asking for money. First, please take a minute to fill out the Audience Survey: http://survey.podtrac.com/start-survey.aspx?pubid=Iqglf8oKcaQi&ver=standard. I know there are tens of thousands of people who listen to the podcast, but I don’t know much about you. You can find the survey link in the “info” section of this episode, and on the top right of the Social Work Podcast website. Second, if you like what you hear, please leave a review on iTunes. It helps folks find the podcast. Finally, I’ve had several requests for transcripts. I’d love to be able to provide transcripts for every episode. So, if you have an interest in transcribing an episode, send email. Ok, that wasn’t so bad was it?

And now, without further ado, on to episode 106 of the Social Work Podcast: A #ZeroSuicide World: Interview with David W. Covington, LPC, MBA

Interview 
[08:00]
Jonathan Singer:  David – thanks so much for being here on the Social Work Podcast and talking with us about Zero Suicide. What got you passionate about suicide and about this idea of Zero Suicide?

David Covington:  Thank you Jonathan.   You know my very first experience was back in 1995 and it was the week I was graduating with my community agency counseling degree.  I had gone through, took me four years to complete that degree. I was working part-time, it was a 60 hour CACREP accredited program at the University of Memphis. That Saturday I took the four-hour national counselor exam which they were using as the exit for licensed professional counselors.  I came out of that exam that Saturday really on top of the world, I was a master counselor! Because I was about to graduate and thought I knew what I needed to know and it had great training.  And I walked into our townhouse and my wife at the time handed me the phone as I walked in, tears are running down her face and she had just received a call from someone, who I didn't really know that well, who was a church member.  He was calling someone, anyone, just to say 'goodbye.' So the very first thought that went through my mind was not "what can I do to help this individual?", my very first thought was "Are you kidding me?" I had just spent four years through multiple video tapes, practicums, internships, all kinds of great training but not even five minutes of preparation for this moment.  I spent the next ten hours trying to figure out what in the world do I do?  I didn't know where this individual lived, there was some good, there was some bad, there was some ugly that went on during that next ten hours.  I relied on the collaboration and engagement, the good things that I had been trained.  So there were some things that I think I did well.  A few hours later law enforcement was outside the Walmart in Jackson, Tennessee and he, the individual, myself were in the McDonald's portion of that Walmart in the back.  Later, law enforcement asked me if it was such a great idea to get the guy, he had a shotgun and was wanting to shoot himself, if it was such a great idea to get the guy with the firearm to go to a public place. So that probably wasn't my greatest moment. But, the pastor's wife was pushing her shopping cart around the Walmart pretending like she was a customer, I had law enforcement outside and it was trying to persuade this individual to get an assessment.  He agreed to go out once he understood law enforcement was outside, he agreed to go in for an in-patient evaluation if I would go with him.  We went in, the psychiatrist, this was I think a great thing this was 21 years ago, you know?  He said "look David, I'm willing to admit this person but I'm going to need you to go out and secure the shotgun so that when he is ready to be discharged that weapon won't be in play."  I had to go find this weapon.  I get home at 5 or 6 in the morning, none of that partying that I mentioned was going to happen.  Years later when I'm responsible for managing programs with literally thousands of clinicians underneath our responsibility, I realized that their preparation and training really wasn't that much better than mine had been when I had first ran into that moment.


11:42
Jonathan Singer: So you had just graduated, you are a Master level provider, and you really got thrown into the fire. It sounded like it really disrupted your sense of "I know what I'm doing."

David Covington: Immediately, right? (laughs). It was the real final exam, but I had not been prepared for the questions and had to kind of make it up as I went along.  I'm not saying that I didn't have great training, but I didn't have training for this issue.  Richard McKeon who is the Branch Chief for Suicide Prevention at SAMSA, years later in one of our meetings which really formed the platform for Zero Suicide, made a statement that has really gone with me.  He said that over the decades individual clinicians have made heroic efforts to save lives, but systems of care have done very little.  I'm not sure that they've done anything.  So that's ultimately where I found an opportunity- that clinicians can be better equipped, and they would be within the learning environment organization to help them do what they love and do it better.

12:51
Jonathan Singer: So how did you go from this individual clinician experience to thinking system-wide, to thinking Zero Suicide as systemic thing?

David Covington: Yes, there really were some intermediate steps for us.  In 2009 I was a CEO of a crisis services company in the state of Georgia and with the recession, the Great Recession, it wasn't really clear where everything was going.  I ended up interviewing and receiving a job at Magellan Health in Phoenix, Arizona.  We were responsible for the health plan contract with the state of Arizona, Medicaid, and the Department of Health.  It was a 750 million dollar a year contract responsible for about 100,000 people receiving active services. Underneath that was a network of providers with about 7-10 thousand clinicians, social workers, counselors, physicians, etc.  When I came to that program the CEO of that contract went home one weekend and he had about eight records that he was reviewing to understand better the risk-management, the compliance, the quality review process.  He came in on Monday morning, just distraught.  For all but one of those, they were young men between the ages of 25 and 35 who had died by suicide. Their risk was known to the system, there was nothing in the charts that would suggest way out of practice kinds of activities going on and yet this is the worst outcome possible.  He challenged our team to begin to take this issue on in a way that it had not been taken on.   The first thing that I did was pull together a focus group of about 70 professionals and asked them so very basic questions.  Several questions that were just cultural, statistics about suicide, that kind of thing, but the key questions I was looking for were what was their self-report of their preparedness?  Again, thinking back to this experience of when I didn't know what to do.  Just on a Likert scale, how would you report that you were trained?  Where are your skills?  The thing that came out of that day that I will never forget is the frustration and anger from many in that group.  They wanted another question; they wanted a question about the support and supervision of their organization to do this work.  I determined that we needed more data.  We ended up doing a SurveyMonkey-style approach. We had about 1700 responses to that first survey.  Subsequently, we just kept doing the survey.  We re-did it after a year in Arizona, but I had relationships in other states, and we began to repeat it.  We ultimately have done that survey in nine states and had over 30,000 people participate.  We've done a couple of published papers with researchers out of Dr. Thomas Joiner's group at Florida State.  The bottom line sort of finding of that survey is that for professionals, (clinicians, social workers, counselors, psychiatric nurses) for them there is about a coin-toss chance that they will at least agree to three questions: " I have the skills to engage those at risk.", "I have the training.", and "I have the supports and supervision."  Imagine going in for a heart procedure or a cancer treatment and your physician is saying, "Wow! I haven't done this before, I'm not really trained for it, I don't have the skills but let's give it our best, best shot."  Now that data, while not surprising, it fit with my own experience it fit with the other clinicians that we had seen.  The one other question we asked was, "have you had someone under your care, under your responsibility, on your caseload, die by suicide?"  For that nationwide survey it was 27%.  It did differ a little bit by state because of the differences of rate by state, but about half of that group had said that it happened to them more than once.  During that process we looked into, there's a small amount of research, about the impact upon clinicians when someone dies by suicide.  We clinicians are not robots, we're human beings and about 1/3 have a very acute reaction, like we would have for a co-worker, a friend, or a loved one.  A small percentage leave the workforce, they decide I'm going to do something else.  That was really a core impetus for us to do something really different.  The other thing, there was a very significant portion of our effort that was about the clinicians, the staff that do this work day-to-day.  We also realized that a very significant number of people with serious mental illness were dying by suicide. In 2010, the National Action Alliance for Suicide Prevention was formed, and they launched a number of task-forces for high risk groups: veterans and military, LGBT youth, Native Americans/American Indians, elder white males.  All groups that are at elevated risk in comparison with the general population.  In our work what we discovered was the relative risk, or the hazard ratio if you will, for people with serious mental illness- schizophrenia, bipolar disorder, major depression, is you almost have to stack those four other groups I just mentioned together to achieve the same rate of risk.  Healthcare systems have just not focused on these individuals in that way.  Now I was working in a 3-billion-dollar company at the time, I was very cautious and thoughtful how we proceeded with this initiative because we were really trying to do something very different.  There was a hypothesis among some executive staff about an increased focus on suicide would yield higher in-patient admissions and thereby a higher medical loss ratio, we were going to run into trouble from an expense standpoint. But others of us on the team had a different hypothesis and that was, would a clinical workforce who is afraid of this issue, I'll give one example.  We had a social worker she had a team of ten underneath her (para-professionals, peer support staff) and the physician came in to her team and said, "I need you guys to really get down in the hole of pain with a person before you just come to me and look for them to be admitted.  I'm going to give you some guidance on that."  Now I don't know what happened to the para-professionals on her team but I know what happened to her.  She went to human resources two weeks later and said, "I can't eat, I'm not sleeping, he had placed this burden on me that I don't want, and I'm not prepared for it."  So we had the hypothesis that if we equipped a workforce that we would actually see reductions in cost, we'd see safer and more effective care, and we thought that there would be cascading effects of if we could get to the heart of what clinical staff do and help them to feel confident, competent, and their caring can really come out, then we were going to get all kinds of benefits.  This was way before we begin thinking of the word "zero."

21:07
Jonathan Singer: So, you're talking about identifying gaps in provider knowledge, their confidence, all that sort of stuff.  At the same time there is the issue of, "well how much is this going to cost?"  I know a perpetual question for providers is, "are these decisions made by insurance companies really about patient care?  or are they about the bottom line?"


David Covington: My basic responsibility was, "is the care safe?  is it effective? and is it cost efficient?"  We had to address all three of those, all of the time.  But again, I think the issue here is that we saw a workforce that despite professional degrees and licensure, half of them could not even self-report on an anonymous survey that they had the skills, the training, or the supports to do the work.  We believe this was one of those opportunities where it's really a win-win. I remember a meeting where I was, myself, cautious because the CEO, not of the contract but of the entire enterprise responsible for 5,000 employees nationwide, a publicly traded company, was in the room.  I was talking about the number of staff we had trained, the surveys we had done, some of the process improvements we had made, and Renee Lair at the time, the CEO of Magellan Health, said, "I don't want to hear any more about process.  Are we saving more lives?"  It's not an either-or question, it’s a both/and.  Ultimately, our responsibility was to keep people safe.  I've co-led this Zero Suicide initiative in the US with Dr. Michael Hogan, really grandfather of mental health, long-time state Mental Health Commissioner, the chairman of the Precious New Freedom Report on Mental Health and he has made the statement that we have got to work to make suicide to be a never event in our care.  At the end of the day, we at the health plan were responsible for services in partnership with the state, with providers, and with the clinical staff that work for them.  We could no longer accept the sort of myth that suicide is the natural course of many of these diseases.  We had to take ownership for our backyard, and we had to provide care better.

23:32
Jonathan Singer: So you use the phrase "never event," what did you mean by that?


David Covington: So "never event" really comes from the quality field.  I had the opportunity to briefly Dr. Don Berwick after a presentation he gave several years ago at a National Counsel conference.  He was the architect behind crossing the quality chasm, the leader for the Institute for Healthcare Improvement, and went on to become the leader of the Medicare and Medicaid system in the United States.  I asked Dr. Berwick, "wow, I bet you're not aware of dramatic impact you've had on suicide prevention from your work of bringing quality to healthcare."  He said, "oh no, I'm absolutely aware of what Dr. Ed and what Dr. Justin Coffey have done at the Henry Ford health system."  The thing that struck me the most was that he, within a very natural and quick way, moved from talking about suicide prevention to talking about hand washing.  I've referenced this story to people over the course of time about what that meant and it's hard for most folks to get their brains around it but this is what I took from it: to Dr. Berwick suicide was not a problem in a box off by itself, it was like other complex, intractable, challenging issue that human beings have tackled.  Hand washing is one of the major interventions that has been done to address hospital acquired infections.  If we go back 15, 20 years ago especially before the Institute for Healthcare Improvement started, the Saving 100,000 lives Campaign, we will find that a view that they were just going to happen.  When you put a lot of sick people together in a building there are going to be infections and you can't do anything about it.  Well, that's not the approach the Institute for Healthcare Improvement took.  They said let’s save lives, let’s look at what the data suggests are the major ways people die in healthcare.  Hospital acquired infections was one of the top ones.  They begin to compile data and use quality initiative techniques and practices robust performance improvement, big data, standardized protocols to begin to tackle it.  So, for him, he didn't see suicide as this inevitable consequence of a disease.  He saw it as a challenge that we needed to face with the most robust quality improvement.  Now, quality improvement is not something that started in the last decade.  This is a 70-75 year old that goes all the way back to the 50s with Demming (?) that has been perfected by companies like Motorola and Toyota, but also as being used in healthcare all of the time for in-patient falls, medications, wrong patient, wrong site surgeries.  "Never event" is about us beginning to address suicide the same way.  I was in the UK a couple of years ago and one of the international leaders of suicide prevention said, "wow, here's another one of those zero tolerance movements."  And I said, "not zero tolerance, this is really around the opposite."  We're not about creating more stress for clinicians, I think what you're hearing from us Jonathan is, I'm a clinician and I'm really focused on, how do we equip people to be in a better place?  We love what we do, how do we do it better? And what I said to him is, "I wish we were really pioneers and innovators, but all we're really doing is, and I reference that I had been on one of those big red buses the day previous in  London riding around with Dr. Jerry Reid (SP?) who is a national leader in suicide prevention in the US.  He and I took a picture of a construction site with a gigantic crane and a huge banner that said, "all harm is preventable" and it had a big diamond in the middle that said, "target zero."  So, perfect care, perfect processes, "never-events," target zero - all of these are, instead of us incrementally improving from where we are, let's do the opposite.  Let's think about from the other end.  If we go to where we want to be, what would that look like?  It's really the same kind of work but it presses us to think harder, to think more creatively, and to tackle this in a much more focused way.  I think those efforts of calling it out and owning it is how we're going to really change this from something where we accept.  At the end of the day other diseases that people have tackled - heart disease, cancer, HIV and AIDS, leukemia- those diseases if you look at where their peak was all of them have made reductions from the height of 25% as in the case of HIV and AIDS all the way to 75% as it relates to ALL.  Suicide is either flat or slightly rising in the US and I think the reality is as a country if we go back five years ago, it's not fair to say we even dabbled it in it.  The people doing that work were doing heroic work.  At the end of the day our society was not engaging the resources, the supports, and the quality improvement to tackle it.  That’s what we're talking about with "never event."  What if you and I traveling back from here were on an airline that promised 98 out of 100 safe flights.  Or a hospital that said no more than one baby a month is going to be that we can't really find where it went.  Or mail that 99% of the time it is going to go to the right person.  Aviation has brought us a level of safety, I mean even in our lifetime, you were anxious getting on a plane.  When that flight clipped the runway in San Francisco, a year a year and a half ago now, and three individuals died it was the first time in 13 years that we had had a fatality on a commercial airline in the United States despite 30,000 flights a day.  They did that from saying "we want a never event."  Now you have to do that in the context of a "just culture", Henry Ford health system talks about a "just culture" where it isn't blame when near misses or fatal outcomes occur, but it is everybody learning together as a team.  When somebody learns in that environment it cascades throughout the organization.  When something happens or a near miss occurs, we are learning from it because we are owning this together.  That is what we mean by never event.


30:24

Jonathan Singer: So all the things that you've been talking about, quality improvement and provider education and all that sort, is that what you mean by "zero suicide"?


David Covington: Yes, absolutely.  So, stated simply: "Zero Suicide" is a focus by healthcare organizations to bring a central bullseye to this issue.  Forbes magazine back in 2010 did an article, The Forgotten Patient. On the cover they had a microscope table with the light shining down- the love, the best practice, the clinical soul if you will, was shining on this group of individuals.  Those are the individuals who are receiving care for depression, anxiety, addiction, serious mental illness, etc.  Out on the edge of the table, not off, but sitting with their feet draped over the edge well outside of the light was the person who mentioned the word "suicide."  Their scathing critique was for the entirety of the mental health and addiction system in the US: researchers, pharmacology providers, etc.  This is about no, the person at the bullseye and the core of our care ought to be the person most at risk with suicide.  Now I've focused on the organizational, the quality improvement, the data, the bringing of learning environment together.  There is a clinical heart to this as well that says that suicide is inevitable for some people is a myth and that collaboratively we can keep people safe.  Tragedies do occur, like they do with auto accidents.  When auto accidents occur, they are needless, they're preventable and we are constantly as a society working together and we can start to see it in our own lifetimes, we're probably going to reach a time when deaths by car accident are almost never, like we see in aviation.  That's coming.  We've made huge gains.  So, there is a clinical belief that that can occur with suicide as well.  One of the seminal moments in this national movement was a task force, in this task force that Dr. Mike Hogan and I led with consensus experts from across the country - we were on a phone call with Dr. Ed Coffey from Henry Ford and he was talking about how their perfect depression care initiative started.  Over the course of time they saw the suicide rate reduce dramatically among those that they were responsible for, even with several quarters of zero deaths occurring.  In that story they were applying for an Institute for Healthcare Improvement grant which they made the finals on and Dr. Don Berwick came out and explained to them what they were doing was probably very revolutionary for mental health but was not going to cut it in the context of the "never event" environment they were looking for, and "perfect care."  So, Ed Coffey and his team went back to the drawing board and they were just a little bit, you know, "Oh my goodness, how did we so mess this up?" and they, "what is he looking for?" A nurse, just speaking sort of brainstorming out loud said, "I don't know, perfect care, perfect care... I guess that would mean that a perfect depression care would mean that nobody would die by suicide." A physician in the room stood to his feet and said, "That is the damn dumbest idea I've ever heard.  If a person is intent on killing themselves, they are going to kill themselves."  Then there was this little sort of war that went on within Henry Ford for a moment about clinically, which of those two ideas was going to dominate?  They went with the nurse.

Jonathan Singer: I love that for so many reasons.

David Covington: (Laughs) That was the trajectory that they went forward with.  They weren't saddled with an idea that this is inevitable for some.  Harkening back to the US Airforce's initiative in the late 90s where they saw 30+% reduction in suicide deaths, those individuals that were leading that program actually bypassed the clinicians because they were fearful that the myths of clinicians would sabotage the work they were trying to do.  There's a clinical component to this as well, we don't believe suicide is a choice, we believe people succumb when their strength, their resources, their supports, and their hope utterly fails.  And we've got to do better collaborating and engaging with them in a learning environment to tackle what is a wicked problem.  But humans tackle wicked problems all the time and we make gains.  We ought to do that here.

35:12
Jonathan Singer: So why only in healthcare?

David Covington: Jonathan, if I was in another industry, I'd be telling you about that industry.  There are Zero Suicide-like initiatives, Jorgen Gullestrup with Mates and Construction in Australia.  They are tackling with a very similar approach for individuals who are in the construction industry where there are high rates of suicide.  I started this initiative with partners at Magellan Health in Phoenix, Arizona because we were healthcare executives.  At the end of the day, think about it this way:  we historically have had an approach before the US Air Force Initiative, there was very little to show actual progress with suicide deaths.  I think that's partially because we were looking at the entire population with a very rare event and we just couldn't get our arms around it.  What they did was narrow down a defined population, began to use interventions, they took responsibility for their backyard.  Now the Golden Gate Bridge for 70+ years has been a place where there were lives saved. Kevin Briggs and a host of trained law enforcement were supportive of individuals on that bridge and they save lives.  There are telephones, crisis phones on that bridge and yet it was also an unsafe place where usually about twice a month someone would die.  That occurred year, over year, over year to be one of the most unsafe places we've had.  The view of San Francisco and the Golden Gate Bridge Authority for most of that time was: this is something, we can do something about it, we're making a difference, but at the end of the day if someone is going to kill themselves, they're going to kill themselves.  If we stop them here, they'll go someplace else.  They'll go to the Bay Bridge or they'll do something different, they'll take a different method.  All that changed after the movie, "The Bridge" came out and it showed the impact of deaths.  It showed an interview with Kevin Hines who survived a fall from the Golden Gate Bridge.  They made a decision, OK, not enough. No more half-measures.  We need to fully take responsibility for this bridge. Yes, at the end of the day, our business is number one: transportation, number two: tourism.  We didn't want to be in the suicide prevention business but we're going to have to be.  We're going to make this a core priority for us and we're going to undergird the entirety of this bridge, the whole thing with a plastic coat and steel safety net which is essentially going to drive that number to zero for our bridge.  We're going to do what the Empire State Building and others have done. They took responsibility, they don't own the Bay Bridge, they took responsibility for theirs.  What we did in our health plan contract is we begin to tackle this.  Then we ran into Henry Ford Health system and we saw what could be done.  Healthcare and especially those, any system in the United States or worldwide that is delivering mental health and or addiction services is working with individuals who face a risk 12-15x higher than the general population.  We've seen suicide as an essential part of the disease of schizophrenia, or bipolar disorder, of major depression, of individuals who have borderline personality, or those with eating disorders.  At the end of the day, in addition to that, and maybe even more fundamentally these individuals are not unlike all the others at risk we're talking about. They're diagnosed with a disease and they see a path for themselves in life, they don't feel like they're going to make a contribution to society, they feel like a burden to others, they become disengaged.  They're facing the risk of suicide for the same types of reasons that older white males or LGBGT youth, or others are facing.  We believe there's a paramount responsibility for healthcare to own this.  This isn't about only in healthcare, it's about that healthcare must take on that mantle.  We must shine that light on this as a bullseye target and own that.  Should construction do it? Should universities? The Jed Foundation is doing similar work with universities, but healthcare has got to do that too.  That’s where we're starting because that’s who we are.

39:52
Jonathan Singer: If I were to be looking at leaders in organizations that are implementing Zero Suicide, how would I know that I'm looking at a leader that is doing it right?

David Covington: The leaders that inspire me are real people, they're real like Becky Stoll that leads the Zero Suicide initiative at Centerstone, one of the largest community mental health centers in the United States.  The passion and clinical savvy that she has been able to bring to this in activating her workforce.  Virna Little at the Institute for Family Health in New York, a series of 29+ federally qualified health centers, and the way she has utilized their epic electronic health record platform to integrate and bake in clinical protocols that are being used across the organization.  Leadership like Jan Mokkenstorm who has imported some of these ideas into Amsterdam at 113 online and In Haste, which is one of the largest community mental health providers in the Netherlands, of making that cultural interpretation and he's really begun to enhance our view around a mindset, a new culture around Zero Suicide.  And people like Julie Goldstein Grumet from the Suicide Prevention Resource Center, who has been major architect behind a national learning community for Zero Suicide.  And our website Zerosuicide.com, which has a fidelity toolkit and resources.  Those are the real examples of the leaders of this movement and it's growing.

41:29
Jonathan Singer: So you've mentioned so many benefits of Zero Suicide. Everything from the most obvious which is, suicide being a "never event" to supporting clinicians, leaders in healthcare, but in any initiative,  there are risks.  So what are the risks of a Zero Suicide initiative?

David Covington: Yeah.  I'm not sure I'd call it a risk, weakness but I'll tell you one of the challenges we've faced.  I give presentations about the initiative around the country and it's not uncommon that in the presentation I'll have a kind of a multi-choice question of, is suicide preventable?  And everybody basically believes yes to that answer but what they mean by that varies.  From the lowest level being, "yes in some cases" to "in every case, up until the last moment of life."  It's not uncommon for a mother or a father or a family member to come to me after and say, "really love what you're trying to do, but could you just not say it's preventable every time?"

Jonathan Singer: Because that's a tough thing to hear if you've lost someone to suicide, you know, this was preventable.  Not just even this was preventable, and your healthcare providers didn't do enough, but there's the personalization which is and you, the loved one, could have done something else.

David Covington: Yeah, I mean the bottom line is these are tragic deaths.  If some suicides were inevitable, they would be tragic.  But what if they're not?  Kevin Hines (SP?) talks about that last five seconds at the Golden Gate Bridge.  The one second where he's on the bridge, he'd do anything to end his pain.  The next second where he's in the air and he would wait a second, he'd do anything to be back on that bridge.  I think if we look back at the 1500 people plus that have died there, that was the experience of all of them.  That makes looking back actually in some ways feel more tragic and yet the hope of us being able to save lives going forward.  So what I say to family members is, "wow, it is the last thing to heap more guilt on someone." But, I think in healthcare we've had this blanket around us to try to keep us warm from this idea and that blanket said that some of these deaths were just going to happen.  As we've surveyed clinicians about after an event has occurred, being blamed is not an uncommon event in organizations that don't have a just culture and don't have a zero-suicide initiative.  But, maybe even more frequently what happens is, they're patted on the head and they're told, "look, this is going to happen.  there's nothing really for us to learn about it, we just need to keep going and doing our work."  At the end of the day when we're part of something bad that happens we want, the family wants, that something good comes of that, that we learn something, that we incorporate it in, that it benefitted others going forward.  We've included family members in our steering committees and our leadership events, but it’s still a challenge for people who the idea that suicide was inevitable for some is some part of the comfort that they have had.  I don't know how to get around that.  There are also family members that are thankful that we're working to create a new healthcare system that takes this challenge on but it’s hard.

45:29
Jonathan Singer: So that was a great illustration of a challenge around the concept of Zero Society, what would be a challenge for an organization around the Zero Suicide Initiative?

David Covington: When we first started the initiative in Phoenix at Magellan Health, I invited the CEOs of the top largest ten organizations like, Terros,  Southwest Behavioral Health and others to come together.  The CEOs as we talked about the clinical rationale and the hope and possibility, they got that fire quickly.  The next round of people that I ended up sitting down with were chief operations officers, people who were beginning to think about the time, energy, risks, etc.  I'm such a believer in this, I don't think there are anything but upsides to equipping your staff around something as powerful as, again harkening back to that social worker couldn't eat, couldn't sleep from doing this work.  I think the impact and the discussions we would have with those chief operations officers had to do with the retention of staff, being a great place to work, and we had to put ROI on...

Jonathan Singer: Return on investments

David Covington: We had to put return on investment to those initiatives because I'm not saying the chief operations officers were robots with no inner soul that I could touch with that fire, but I had to go through the process of answering their programmatic, financial, HR questions.  And again, think about a workforce 50% of who cannot just agree, not strongly agree, just simply agree to a question "I'm equipped to do work within individuals that I'm going to face almost on a daily basis."  So I think the upsides from a programmatic, from a financial, from a clinical one here at multiple levels in the system are enormous.  We've created a society where we're afraid of this topic. One other challenge is, I think there will be positive gains that occur immediately but the real outcomes that Henry Ford Health system saw took 7-8 years to get to.  This requires a multi-year commitment and Henry Ford, with Dr. Ed Coffey and Dr. Justin Coffey being there for 15 years, being able to perfect and improve and take this.  And then having the luck that when they left and went to Menninger and Dr. Brian Amidani took over at Henry Ford that he is fully behind it and driving it forward.  The Henry Ford Health System has made a multi-year commitment and long-term focus on a central bullseye effort here.  That organizations have to be willing to accept. It's not going to happen overnight.

48:12
Jonathan Singer: Which I know is a huge challenge.  In social services, in health care, you have things that are on 3-year grants, 2 year grants that are the brain child of one person and they then they leave and then it's gone.  You're saying Zero Suicide, while it might have some benefits in the short term, we're really looking at the long game.

David Covington: Absolutely, the investments that are made, the changes that are going to occur in culture and in baking in protocols and supporting staff and learning together.  Now, you know, I think Henry Ford operated in somewhat of a vacuum. We're starting to see a national and even international learning environment occur where people can support one another.  I'm hopeful that will mitigate some of that challenge we just talked about.

48:59
Jonathan Singer: It sounds like Zero Suicide is not just a US thing, so where is it happening?

David Covington: I've referenced earlier the meeting in Oxford a few years ago.  Last September in Atlanta we brought together the second international gathering of Zero Suicide and we had representatives about 50 policy makers, healthcare leaders, family members, people who have lived experience and expertise from 13 countries, 50 individuals come together.  The pioneers that are out there right now, the ones that are most established, there are three initiatives in the UK, in southwest England in Liverpool, in Cambridgeshire, and Peterborough.  There's also an initiative that looks like it's going to be launched in the Yorkshire area, so there's a number of initiatives from the UK.  Again, I reference Dr. Jan Mokkenstorm and his group in Amsterdam, Within Haste.  And Dr. Steve Duffy in Christ Church New Zealand, at Hal Morton Hospital, has been looking at developing a similar program after visiting with Henry Ford and a number of folks in the US.  So we are seeing this cascade.  One of the things we did at the international summit last September, we had Professor Jo Smith, she is one of the pioneers behind early intervention services for first break psychosis.  We're seeing a worldwide phenomenon around early intervention services now, but that really began with a small group of pioneers back over a decade ago.  They used an international declaration as a platform for that, again think "never event," blue-skying what could be, they stole/pirated that idea from a group of diabetes pioneers of co-management from ten years earlier than them when the idea of the person owning their care didn't exist.  And again, blue-skying what could be.  So, she came, facilitated, and we have this document - the International Declaration for Better Healthcare - that's available for download at zerosuicide.org.  But that, we're hoping that this becomes the basis for continuing to see this initiative expand into the other countries that we're a part of, of that summit.

51:43
Jonathan Singer: David, I really appreciate you spending all the time to talk with us.  This has been really inspiring and encouraging.  For those who are listening to this right now and are thinking, "wait a minute, I want to do this."  What are the next steps for starting a Zero Suicide initiative?

David Covington: Thank you so much Jonathan for the opportunity. Zero Suicide is an organizational effort, it's a strong component of leadership, but the seeds of all that are planted with individuals.  I think the first step, I'm a clinician, you're a clinician, we're - the first step is to make a personal commitment to this.  I made a personal commitment that night when I got that phone call that I was going to figure that out.  It seemed to me to somehow, just I knew that that went to the heart of being a clinician. That's where this is going to grow into the leadership.  The second thing is organizations in order to do this have to establish steering committees to make it happen.  That multi-year commitment we talked about, the changes in culture and mindset, the efforts and activities are going to have to be in place to support staff to do what they love and do it better, requires a group that's going to own that, that's going to develop and implementation and work plan.  The resources I mentioned earlier, The International Declaration as well as the work the Suicide Prevention Resource Center has done and the tools and resources at zerosuicide.com.  Dr. Julie Goldstein-Grommet leads a learning community on a monthly basis, they have a national list serve.  So, a steering committee.  That steering committee ought to have clinicians in it, it ought to have leadership in it, it ought to have some outside folks and the magic isn't really going to occur unless there are people with lived experience of suicide on it.  Not just family members or people who have had someone die, people with personal experience.  They have made a serious suicide attempt and they now want to translate that into helping others.  That’s what is going to make that steering committee definitely.  And then the third and final thing is, I would, this is a social movement.  This is more than a healthcare improvement; this is more than robust quality improvement.  If you track out in the Twittersphere the hashtag #zerosuicide, it is spreading worldwide.  There is a ownership of it from not only clinical and healthcare leaders, but again people with their own life expertise that is forging new ground.

Jonathan Singer: Great, well thank you so much.

David Covington: Thank you so much, Jonathan.


Transcription generously provided by: Francesca Haley, MSW Student, Stonybrook University

References and resources

• Ahmedani, B. K., Stewart, C., Simon, G. E., Lynch, F., Lu, C. Y., Waitzfelder, B. E., … Williams, K. (2015). Racial/Ethnic differences in health care visits made before suicide attempt across the United States. Medical Care, 53, 430–435. http://doi.org/10.1097/MLR.0000000000000335
• Zero Suicide: http://zerosuicide.sprc.org
• David's website  https://davidwcovington.com/
• Zero Suicide: An International Declaration for Better Healthcare (2015) http://www.slideshare.net/davidwcovington/zero-suicide-international-declaration-draft-01-september-2015
• David's research publications: https://davidwcovington.com/research-papers/
• Twitter
• David W. Covington: https://twitter.com/davidwcovington
• #ZeroSuicide: https://twitter.com/zerosuicide_org 
• Zero Suicide Intitute: https://twitter.com/ZSInstitute

 

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APA (6th ed) citation for this podcast:

Singer, J. B. (Producer). (2016, September 4). #106 - A #ZeroSuicide World: Interview with David W. Covington, LPC, MBA [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2016/09/zerosuicide.html