Five-Year Implementation of Zero Suicide: Lessons Learnt From an Academic Health System

The rising rates of suicide in the United States have motivated several interventions, including among health systems. A leading quality improvement approach for health systems is the Zero Suicide (ZS) model. Despite its well-recognized nature, implementation of ZS initiatives across health systems remains underutilized and understudied. We evaluated a 5 year-long real-world implementation of the ZS initiative in a behavioral health inpatient setting to understand strategies and challenges.

Electronic medical record (EMR) data were used over a period of 5 years between January 2020, and June 2024, to study implementation of 3 clinician-delivered domains of the zero-suicide model, identify, engage, and transition. For each domain, we evaluated implementation rates and then stratified by demographic characteristics. We also estimated a logit model with individual-level data to examine whether implementation rates varied by demographic characteristic.

During the implementation period, 8810 individuals were hospitalized and included 5703 unique individuals. For each domain, attrition was noted. Racial and gender disparities were observed in all domains. While 100% of individuals were screened and stratified for risk level, approximately 80% of individuals identified as high risk received safety planning, and 53.3% accepted the proposed transition intervention. Refusal reasons ranged from having enough resources to feeling overwhelmed.

Our study provides useful insights for behavioral health settings planning to implement the ZS initiative and discusses strategies including EMR integration.

For clinical systems incorporating ZS as a quality improvement implementation, this study provides suggestions about potential challenges, particularly related to sociodemographic disparities.