The relative unavailability and inability to easily collect data related to suicide risk assessment present challenges to the development and ongoing monitoring of quality indicators associated with suicide risk assessment. As one example of this problem, Mahal et al. (2009) had to use a manual chart review for scoring 19 process quality indicators among 141 persons who received services at one emergency mental health setting. Requiring that organizations undergo this kind of data collection exercise for all persons under care would be onerous and the potential cost, high. While the accreditation process involves site visits and random chart review to audit these practices, this process is carried out at broad intervals.
Mork, Mehlum, Fadum, and Rossow, (2010) suggest that evaluating the quality of one’s suicide risk assessment can be done by referring to clearly defined standards written in organizational guidelines and policies. Without systematic ways to efficiently track the completion of risk assessment (e.g. electronic medical records), organizations wanting to monitor the quality of their risk assessment process, may have to rely on their demonstrated adherence to suicide risk assessment-related policies. These policies may include the principles for high-quality risk assessment outlined in this and other guides, as well as policies for the timing of risk assessments and the processes for following up on risk identification.
While future research is needed on their validity and effectiveness, other indicators of high quality organizational suicide risk assessment processes may include policies that:
• Use a specific suicide risk screening tool as part of the risk assessment process;
• Use standard guidelines and specific care planning interventions for persons identified at different risk levels;
• Detail timelines for ongoing risk assessment based on low, moderate, or high risk;
– Include processes for reporting and reviewing adverse events, including post-suicide debriefing (for post-suicide debriefing, the policy includes steps for reviewing and acting on findings from the review and plans to mitigate risk in future); and
• Have mandatory competency-based education and training in suicide risk assessment.
More broadly, in terms of outcome, the rate of suicide has been examined as an indicator of mental health service quality. Desai, Dausey, and Rosenheck (2005) examined the use of suicide rates as a quality measure for mental health services delivered through Veterans’ Affairs hospitals in the United States. In a sample of over 120,000 persons who received services, 481 suicides occurred. While suicide rates did vary across facilities, no association was found between the differences in suicide rates and other quality of care measures such as length of stay, continuity of care, timeliness of outpatient visits, rehospitalization, or hospital funding.
Desai and colleagues recommend against the use of suicide rates as a quality measure because:
• Rates are highly unstable (due to low rates);
• The difficulty in obtaining death data post-discharge; and
• The lack of association between suicide rates and other indicators of facility quality.
It is clear that designing process indicators (i.e., indicators about the how the risk assessment was completed) to specifically identify poor suicide risk assessment is a challenge due to the qualitative nature of risk assessment processes. Outcome quality indicators measuring the incidence of suicide ideation, plans, or behaviours while a person is receiving care from a service
Further, the rate of suicide does not directly reflect the quality of the risk assessment process itself. It may be that a high rate of suicide is indicative of poor intervention planning or a lack of services for persons who are successfully identified as being at high risk for suicide.
provider (e.g., admitted to a hospital) may be easier to develop. However, these indicators may reflect poor quality of care in terms of the organization, delivery, or responsiveness to treatment, rather than poor suicide risk assessment. In other words, despite having conducted a high quality suicide risk assessment, an adverse event could still occur. That fact notwithstanding, what is certain is that if the quality of the risk assessment process is not ensured, the likelihood of an adverse event occurring is exponentially higher. Thus, however challenging, specific indicators need to be developed to monitor the quality of suicide risk assessment.
Further research should examine the potential development and validity of indicators for quality suicide risk assessment. Examples of potential indicators include:
• Prevalence of suicide behaviours while in care among persons designated as low risk upon initial assessment;
• Rate of suicide attempt or death by suicide within one week of discharge; • Rate of persons discharged as high-risk for suicide;
• Rates of change in dynamic risk factors or warning signs related to suicide risk;
• Documentation between identification of specific dynamic risk factors and implementation of a care plan specific to those factors;
• Increase in number of identified protective factors such as resiliency and coping strategies while in care;
• Incidence of environmental hazards identified in care environment; • Number of hazards remaining in the care environmental since
prior assessment;
• Person/family perception of the risk assessment process; and • Staff perceptions of the risk assessment process.