Speakers: Mr Peter Schmiedgen, Dr Edward Coffey, Mr Luke Lindsay and Ms Lee Wilson

Lee Wilson:
Hello, my name is Lee Wilson. I'm from the Ministry of Health, I'm a senior policy officer. I would like to express my thanks for the enthusiasm and the praise that we are so sincerely appreciative for the interest in the support, for this webinar on Zero Suicides in Care. The response to the ministry's preparation work for the toward zero suicides initiatives has been quite overwhelming and inspiring. I would like to begin today by acknowledging the Traditional Owners of our land and paying my respects to elder's past, present and emerging. Importantly, also, I would like to acknowledge the sensitive and emotionally powerful nature of the topics that we're discussing today, suicide prevention, suicide affects all members of our community in our professional lives and our personal lives, and I would like to acknowledge all those with direct experience of suicide, including those who have attempted suicide, and those who are bereaved by suicide.

The voice of people with lived experience is critical in the conversations around the development of our suicide prevention work, and we are privileged to have Peter Schmiedgen here with us today, there's a photograph of him there, with us from being to discuss it from that perspective. New South Wales is in a very unique position and we have an opportunity to be global innovators in suicide prevention. In recognition of the devastating impact of suicide, this is the strategic framework for suicide prevention in New South Wales 2018 to 2023. Was launched by the New South Wales premier, the former minister for mental health on the 17th of October 2018.

The launch was accompanied by an announcement of $87.085 million over a three-year period. And each new and expanded initiatives were announced to implement these priority areas. The priority areas include aftercare services, alternatives to emergency departments, there are many people who may not necessarily need to go to emergency if they feel suicidal ideation, there may be a better place safe space for some of those people suicides in care which is what we are all gathered here today to talk to the local health districts specifically about and the rest of the mental health sector community, improved collection and distribution of suicide data, resilience building and local communities and that has a very specific focus on our Aboriginal communities who are very much needs to be a collaborative and respectful community led response. Postvention services for those bereaved by suicide, there will be an enhancement to the rural adversity mental health program, and we are expanding the community mental health outreach teams in the assertive suicide prevention space.

This is the largest single investment in suicide prevention in any state or territory across Australia and we're very, very, very excited and privileged to be embarking on this journey. The zero suicides and care initiative reflects the Rotterdam declaration for zero suicides in care, endorsed by the Hon. Greg hunt, Minister in Parliament, Federal Minister, in April 2018, which Sue Murray, who is the managing director of Zero Suicides in Care Institute will speak to you a bit later. In line with the national and international best practice, Zero Suicides in Care will foster adjust and restorative blame free organisational culture. And strong service leadership to promote safety for patients and staff. Queensland already impressively on the journey towards zero suicides, and we are fortunate enough to have Luke Lindsay from The Gold Coast health, joining us to talk about how they have been addressing Zero Suicides in Care and their health system quite successfully. One of the key pillars of the New South Wales response will be the redesign of our system.

We're committed to ensure that no one dies by Suicide in Care. It's the public of New South Wales does not accept that anybody should die in hospital in a mental health facility in New South Wales. And the journey towards zero, we'll start with our system. One of so, the initiatives that we're here to talk about today, the Zero Suicides in Care, will have $10.2 million dedicated to it. It's an investment that will reorient the system and in order to implement or show us how this implementation is done, we have invited a very special man Dr. Edward Coffey out from the United States. He was the former director of the Henry Ford Institute in Detroit. And he has had the inspiring experience of having achieved zero suicides in his service over an 18-month period. And he will be, we're very thrilled to have him with us share how he did that, and share his journey and his insights into this seminal work. So, the program for today, we will have some time with Dr. Edward Coffey, we will be able to have questions from the audience and I believe it has been explained how you can type your questions in, and we can see them and forward them to the presenters, Sue will then speak around the international declaration.

Peter Schmiedgen will then have some words to say, Luke will then talk about the experience happening on The Gold Coast, and there will be more time for questions from the audience. And we encourage all the questions, some of this might be new, some of this, some of you might already be somewhat down the path and we are very keen to support the notions, the ideas, the goals, you'll hear Dr. Coffey talk about the audaciousness of some of the goals which is very, very, very challenging but rewarding. And we are looking forward to engaging with people about these discussions. So, without further ado, I would like to hand over to Dr. Edward Coffey, and look forward to hear what he has to say. Thank you. Thank you Edward.

Edward Coffey:
Thank you Lee, thanks for that introduction and thank you all once again for a fabulous week. I have enjoyed our time together so much, I'm even more thrilled than before to imagine the adventure that you're about ready to embark upon. And I'm very pleased to be a part of that and to help in any way that I can. So, what we're gonna do today, is I give you a brief historical overview of where the concept of Zero Suicide originated. Why it's important today more than ever, and then a talk a bit about the future of this movement and how that ties into what you hear in New South Wales are trying to accomplish.

First I'll say a word about the crisis that we have in The States. This slide shows you that, unlike most developed countries, certainly many of those in Europe and elsewhere where the rates of suicide are flat, or possibly even declining. In the United States, rates have increased by 33% in the last 16 years. The rates have increased both in men and in women, but the rate of increase appears to be greater now in women than in men, so, that gap between men and women is beginning to narrow. So, we have a problem. As you can see in this slide, all of the states are affected, some more so than others, with one notable exception. The state of Nevada, there in the white, is the only state among our 50 in which the rate of suicide is not increased over this time period. And interestingly enough, the body is the state that has gotten the most serious about handgun control.
There is variation across the United States, some states have higher rates of suicide than others, as you can see in this slide, the dark blue states, the states that we call the Mountain West states, have the highest rate of suicide, together with the state of Alaska, there in the bottom left hand corner. We don't fully understand this variation, but we know that at least in the case of Alaska, where the climate is cold, the nights are long, and rates of alcoholism and other substance use are high, those factors likely contribute to the problem in those areas. So, our journey in suicide prevention began about 20 years ago, when I was leading the mental health care delivery system at Henry Ford Health System in Detroit. And at that time, around 2001, the Institute of Medicine published this document that you see here on the right, a book called, 'Crossing the Quality Chasm.'
And that book made the point that despite a great healthcare workforce in the US, and despite tremendous advances in our research, and our knowledge of health and wellness, despite these positives, the care that patients are receiving at the bedside, and in the clinic, is mediocre at best. And so, this gap between what's possible, given the great people and the great advances in knowledge on the one hand, and what is actually occurring on the other hand, is the chasm that is referred to in the title of this report. The report goes on to say that tweaking the system is not going to work. The system is so badly broken that we really have to sort of blow it up and start all over. And to the reports credit, it provides a model for how we might start over and how we might redesign our healthcare system.

And I believe this model is applicable not just to the US, but could be a potential roadmap for you here in Australia as well. So, a key component of that roadmap, is a conceptualisation of what really perfect care would look like. It would have these six dimensions of perfection. It would be safe. We wouldn't hurt people when we're trying to provide care. It would be effective. We would use things that work, and would use them in the right way, and we wouldn't use things that don't work. The care would also be centred on the patient and their family. The patient is in charge of the care and we're there to help. The care will be timely and efficient and it will also be equitable. That is to say that every single person, every person regardless of their age, gender, IQ, zip code, socioeconomic status, religion, any demographic feature that you can mention, regardless of those features, every person gets the same ideal health care.

And the report goes on to provide some rules for how that care might be redesigned. And I particularly like this first rule, which defines care as a relationship. Care is not an office visit with a doctor or a clinician, it's not a hospitalisation, it's not a prescription, it's not a surgical procedure, it is a relationship with the care team. The care is customised, it's centred on the patient, we share knowledge amongst the providers as well as with the patient and family, we make decisions based on fact. Not our preferences or not what we imagine might be effective. We make safety assistant priority, and we embrace transparency.

Early in our journey, we began to offer all patients the opportunity to write notes in their medical record. And we encourage patients to do so at least on a daily basis which meant that they could read the medical record. Why not? It's their information. It's their healthcare. So, when the report was published in 2001, a large philanthropic organisation in the US, Robert Wood Johnson Foundation became very excited about the possibility of a redesign of the healthcare system. And in partnership with the Institute for Healthcare Improvement, it launched an international initiative known as Pursuing Perfection. And the goal there was to try and encourage organisations to take the Chasm Report, and use it as a model for transforming their healthcare system. The only catch was, that we had to transform in two years.

The notion here was that, improvement in healthcare is proceeding way, way too slowly. And we need to find a way to accelerate that rate of improvement. So, that was part of the concept here with this notion of pursuing perfection. About 3,000 applications were downloaded, 300 applications were finally submitted, and our work at Henry Ford, was one of the 12 finalists. We elected to target depression care as our area for dramatic improvement. Now, the titling of this program pursuing perfection was very, very intentional. In healthcare for too long, we have relied upon phrases such as getting better, even being the best. But this group recognised that those aren't sufficient.

Here's some examples of what we mean by the difference between being good, even being the best on the one hand and actually pursuing perfection. If we were operating at 99.9% accuracy in healthcare, 12 babies will be given to the wrong parents today in The US. Can you imagine? And a particular relevance to my travel tomorrow two landings at an international airport would be unsafe. If 99.9% accuracy was good enough. Now, to put that number in contrast, in healthcare, we operate at levels of accuracy of around 60 to 70%. 60 to 70% versus 99.9%. That's not good enough. And that is the drive that we have for dramatic transformation and improvement. So, the initiative required that the applicant take each of those six dimensions of perfect care, safety, effectiveness, patience, centeredness, and so on, define what perfect might look like for your particular area, and then measure where you are today versus what that perfect picture would look like, and then cut that gap in half over the next six to nine months.

At which point, you begin to cut the remaining gap in half over the next six to nine months. And so, there's a progressive approximation, that is a pursuit of perfection. And so, in our case, in the instance of depression care, we set a goal for example, along safety, to eliminate when patient falls, and to eliminate medication errors. Not simply to reduce them by some percentage, but to make them go away completely. We also had a variety of other measures that were targeting 100% patient engagement around these areas that patient centred care. But as you can see, the effective care row is blank. And in early on, we had some difficulty coming up with a dramatic audacious conceptualisation of what truly effective depression care might look like. Finally, one day, one of our nurses spoke up and suggested that perhaps if we were doing truly perfect depression care, no patient would die from suicide.

No patient would kill themselves. And that moment transformed our department. We began to have a conversation wherein we realised that you know, if someone really, really, really wants to commit this act, it may be impossible to stop it. But at zero, isn't the right number for our goal. What number could be? There isn't another number. It has to be zero. So, we committed at that point to pursuing perfect depression care as defined by the elimination of suicide. And this goal was so audacious that it began to kind of overshadow all the other goals and itself become kind of the main driving force in the work that we undertook.

That's why it's shown in red here on the slide. So, we began our work of re-engineering using what's called the planned care model as the roadmap. You can learn about this model, if you Google chronic care model it's very easy to understand the resources they are ubiquitous and they're totally free. So, I encourage you to take a look. But basically, the concept here is that what you're trying to do in your healthcare system is to organise everything so that it creates productive interactions, productive interactions between a patient and a practice team. And a productive interaction is defined as, one which takes place between an informed, activated patient. One who has all the knowledge and all the information they need to optimise their health. And one who's activated who was engaged and wants to do those things to make their health better. And then on the clinical side, the practice team is prepared. They have all the information they need. They have all the knowledge and skills they need, and they're acting proactively.

They're not waiting for bad things to happen. They're anticipating two or three moves ahead and trying to ensure that they're maintaining the proper trajectory. And the idea here is that if you can create these productive interactions on a regular reliable basis, you will generate improved outcomes. So, all of the elements of your delivery system upstream are organised in such a fashion as to create and enhance these productive interactions. So, your community resources, your self-management support, the design of your delivery system, your decision support, your it systems, all are organised with that goal in mind of creating productive interactions. And what was nice about this model is that it allowed for pretty good crosstalk between the model, and the Chasm Report that I showed you earlier.

So, in the case of having an informed, activated patient, that lines up pretty well with these notions of being patient centred and having timely, efficient and equitable care. And then likewise for a prepared proactive practice team you have safe evidence-based and coordinated care. So, it made communication and translation between the two documents, much, much easier.
So, let me now shift and show you the results of our activity, this slide graphs over time, the rate of suicide, and 100,000 patients, per 100,000 patients. And at the bottom of the graph, perhaps faintly visible, should be a dotted line at about 12 per 100,000, 12 per 100,000 was the rate of suicide in the state of Michigan at the time we began the project. As I showed you earlier, those rates have now increased to anywhere between 14 and 16 per 100,000.

So, that's at the low end of the curve. At the upper end of the curve, you see that the rate of suicide in patients with a mood disorder is over 20 times the rate in the general population, a dramatically higher rate of occurrence. In fact, if we focus this initiative at only on patients in hospital, the rate approach is 600 per 100,000. So, these are very, very high rates. Now, what many people might not appreciate is that even when we take care of the mood disorder and we bring it into remission, the rate of depression, the risk of depression remains elevated. As shown by this line, those individuals whose disorders are in remission still carry as a group, a five to ten times elevated risk of suicide.

So, as you can see here, we need to focus not only on those who are acutely ill, but those who are in remission as well. And the final point here is that all major mental disorders, not just the mood disorders carry this same elevated risk of suicide. So, the thought disorders like schizophrenia, the anxiety disorders, eating disorders, certainly the substance use disorders, all of these carry about the same elevated risk of suicide. So, as we began our suicide prevention work, we don't want to mistakenly focus only on persons with mood disorders.

It's all of our patients who carry an elevated risk, even those whose illness may currently be in remission, really, really important point. Now, as we began our initiative, we were able to obtain two years of baseline data on our population. And if you take the average of those two years, you see that our baseline rate was around 90 per 100,000 population. So, certainly lower than what we see in the acute, acutely ill population, but not as low as you might see in the general population. This number of 80, 90, per 100,000, actually it's consistent with other publications in the literature that report a similar kind of a frequency and similar kinds of populations. So, we began our work. And as you can see, over the next ten years, we very rapidly achieved a reduction in suicide that was sustained over a decade period of time.

And as Lee mentioned in the introduction, for 18 months for that year, 2009, we actually achieved zero deaths in our HMO patient population. Unprecedented reductions that were maintained over a decade. And I will say that if we can do it, you can do it. This is eminently achievable. It can be done by any organisation or group. Now we do see a blip here at 2010, an uptake. We don't fully understand why that uptake occurred. Although we do know that this is the time when the great recession began to impact Detroit in a big way. And many of our members, many of our population for that matter were being laid off, were losing their job. And many of our members had healthcare coverage on January 1, but the next day on January 2, lost that coverage. So, they were without healthcare, even that, if that was the case, we still counted those deaths, if we, once we learned about them. So, that we could be sure to gain the opportunity to learn from that those errors and improve our system.

So, over the next five years, and we began to describe these results to be published and to gain recognition for the work being done. This is very important because this is hard work and you need to look for opportunities to celebrate the successes with your team. And so I encourage all to make sure, to look for those opportunities to apply for awards, you're certainly most deserving when you do this kind of work. I think the big breakthrough moment for our work came in around 2010 when the US began an update of its national suicide prevention plan.

And that committee charged with that update spent some time at Henry Ford reviewing our work and essentially endorsed that model as a key component and recommendation of the national plan. So, it's now referenced in that plan. And some description of that work has provided a net plan for those who are interested. Since then, this entire movement has gone international. You'll be hearing more about that in a moment from Ms Marie. But international summits are now taking place almost every two years, Australia hosted one of those summits a few years ago, and the next one is scheduled for 2020 in Liverpool, England.

So, what are the key elements of this brand's formation? What are the key things, the key pillars that we need to think about as we begin to roll out such an enterprise here in New South Wales, I believe this pyramid provides our current understanding of how to approach this kind of work. At the base of the pyramid is foundational belief, what I would call a radical conviction that ideal healthcare is attainable. We have to be all in on this notion that we can approach zero. We can dramatically improve and dramatically reduce errors in our healthcare system. This sounds obvious, and it sounds like common sense, but this conviction is not widespread in healthcare today. And so we'll need to work at a leadership level to create the environment that says, yeah, we can do this, we believe we can bring it down to zero.

The second key foundational element is having a roadmap. And I believe this roadmap outlined by the Chasm Report is one potential viable model. Set your perfection goals, take stock of where you are currently, and then aim to try and cut that gap in half as quickly as you can. It's been, healthcare improvement has been proceeding at a rate that's way too slow. We have to accelerate that rate, and in order to bring about the improvement that our patients deserve. Now to pursue perfection, we have to, at the same time be building a just culture, a just culture is one in which we don't punish people when mistakes happen. Instead, we assume that the mistakes are the result of a system or a process breakdown. So, when a mistake occurs in a just culture, we don't ask who did it, we ask instead, what happened? How did it happen? What can we learn from the mistake and how can we incorporate that learning into improvement in our process going forward.

That's a just culture. And it's going to be absolutely fundamental to any sort of aggressive pursuing perfection goals that you might be setting. And then finally, we've heard about the importance of systems and if systems are broken, they need leaders to help fix them. Which means in turn that we need to have skills around systems design and systems engineering. Unfortunately, we don't get taught these skills in medical school by and large. So, we're going to have to provide opportunities for our teammates to learn the skills and to become themselves experts at designing and continually improving systems of healthcare delivery as we've seen here. So, that concludes our brief summary. I again, thank you all for the opportunity to be a part of the adventure that you're undertaking. And I look forward to helping in any way that I can going forward.

Lee Wilson:
Thank you so much Ed, that, and I would like to invite Peter Schmiedgen now to make any comments on what you've just heard or your perspectives.

Peter Schmiedgen:
I'll just make a couple of scripted comments, so...

Lee Wilson:
Sure, sure.

Peter Schmiedgen:
Is that OK. So, being welcomed to the commitment that new South Wales has made to provide the funding for this program. So of course, that's a very positive thing, and we also welcome the diverse range of projects that have been embraced both in times of emergency and people exiting inpatient. And it's particularly positive to see the notion that culture change is a basic requisite of this. And I think that's very much in line with what's been seen already in seclusion and restraint process which being has also been involved in.

And it's great of course, to hear from Ed and from Luke as we will in a moment. OK. The thing that I'd like to share, I think from our consumers is that so some can, the experience of some consumers, some consumers would prefer to see consumer run services. And that's one thing that we haven't seen in this funding, despite the fact that it very positively integrates co-design and the peer workforce. So, because some people say that, you know, they turn up to emergency and they worry about being hospitalised and people don't necessarily wish to be hospitalised.

And so the kinds of services they'd like to see would be either consumer run or even crisis centres where they could drop in and go and talk through what they're experiencing. Versus going to emergency where they'll be assessed for being hospitalised or not, or even put into the PECC unit. So, I think that's a really interesting, I think that's the issue I'd like to share, I just want to share.

Lee Wilson:
Do you see a scope for that in the suicide cafes or the safe haven sort of model?

Peter Schmiedgen:
I think the concern that people still have around say the safe haven model is that it's still essentially a clinician centred model.
So, this is kind of the concern I think, sometimes people feel fear of psychiatrists actually, you know. Because they feel that, Oh, well, if I go, and seek the help for psychiatrist then you know, what's going to happen is I'll just be hospitalised again. And so I suppose this is a question of debate, is it good to be hospitalised or not? I mean, but clearly some consumers don't always believe so. And probably at times that's correct.

So, I think that's kind of the core issue that we hear about in relation to this. And suicidality is obviously one of those issues where this particularly happens, you know. Because often people arrive at emergency and there'll be put in overnight observation and then they're gone the next day. You know, they arrive in emergency and they spend six hours sitting there and then they're told, Oh, well, no, you're OK. Go home.

You know, and I recognise some of the plans that you have in these funding commitments already addressing that. You know, to provide people with, you know, direction after they'd been to emergency, to have ongoing support. So, I certainly recognise some of those issues are going to be addressed. But I think this is just something to share that this is still what we hear from people. And I mean, it'll be, it's interesting to hear maybe from Ed, what his thoughts are around that. You know, whether... you know, because not everyone avoids services because they're unwell. Sometimes people avoid services because they're unwell, but they still understand that they don't want to be in hospital.

Edward Coffey:
And I think the suggestions that you make line up perfectly with this notion of patient centred care. Although, we had, we used many auto metaphors in Detroit. And one of those was the patient has the car keys. So, it's your healthcare, you're driving the car. I might be in the front seat with you helping navigate. But at the end of the day, you're making the decisions. And those decisions include not only what medicine you are willing to take, but how do you want to organise the care? Where should it be delivered, whom should deliver it? And everything in between. So, I think we should be, as a system, we should be absolutely open to every option that a patient or family suggest as an, you know, an alternative to traditional treatment. Now we might not be able to do all of those right at the very beginning, but we can certainly listen and be open and move whenever we can.

Peter Schmiedgen:
I suppose I think what we'd like to see would be, you know, because some of these services exist already. Book read Queensland experiments is an experiment with this, with the idea of like consumer run services. I think we just like to see those kinds of services being utilised to see how they work as well. I mean, obviously the services you provide are very successful, clearly. So, but I think we'd like to see those, kinds of alternatives part of it too. I think that's the sense that we have.

Edward Coffey:
Great. Great suggestion.

Peter Schmiedgen:
Yeah. Yeah.

Lee Wilson:
Noted.

Peter Schmiedgen:
OK. So, I think that's kind of core issue, I think that we hear from people when we speak to them about suicidality and their experience of the system here. And it may well be to do with culture, right? Like, I mean, it may be the case that the culture has to change. And if the culture or the system changes, then people won't have that experience anymore as consumers. So, you know, it's interesting to say that's right, quite how that works. But nevertheless, that's the kind of experience that people reflect to us. Some people anyway.

Lee Wilson:
Which of course is valid.

Peter Schmiedgen:
That's right. Lee Wilson: Right now. That's right. Thank you.

Lee Wilson:
Thank you Peter. We have a question from Michael, what needs to change with medical practitioner culture in hospitals and how does it need to change? So, I could throw that open to either Ed or Luke. Luke, I guess you haven't spoken as of yet. Would you like to cut your teeth on this one or.

Luke Lindsay:
So, in terms of medical practitioner culture, I can say in emergency...

Lee Wilson:
Does not give a setting.

Luke Lindsay:
OK. Look, I guess I can talk from the emergency perspective. And in terms of culture we know, and certainly the experience of consumers teller from the research is very clear that often the culture of
Our emergency department colleagues is around confidence, competence and skill level; around providing care to consumers in an emergency department setting because we know the setting is not an appropriate setting for most consumers that present to an emergency department, with suicidality often in crisis looking for care. So, in terms of cultural change within the medical workforce, in particular within the emergency department.

Certainly, at the Gold Coast, we have really invested quite heavily in very targeted education around our peer workforce, our nurse, emergency department, nursing colleagues, allied health and medical staff, particularly around a core set of skills around interacting and providing care for highly distressed, vulnerable and often suicidal consumers in that department. And the way we kind of provide that education is during the care has been a real collaboration between our consumers with lived experience our emergency department colleagues and our mental health staff, So, that it is kind of co-designed and co-delivered in that kind of education space.

And we've seen some really significant changes around culture, particularly, they're not changes we've necessarily measured as such. But in terms of experience and feedback we get, we have seen some quite significant changes in that space.

Lee Wilson:
Thank you. Ed, would you have anything to add to that?

Edward Coffey:
Well, I think all of the issues that were just pointed out are opportunities for us as clinicians to relook at the culture. And I believe the starting point for all of these redesigns is a conversation with the patient and the family. What are you looking for in your care? And then how do you want that care to be delivered? What works for you? And then can we work together? Can we get you connected to the system and can this system work with you in some way to try and approach that ideal model for your healthcare?

I think that, in its essence, is what is meant by patient centred care. That's what the report was trying to get at. Right now, frankly, as Peter points out, and he's absolutely right. The care, for the most part, is not centred on the patient. It's centred on us, as providers. Our schedules dominate when patients get seen when they don't get seen. Our systems determine what treatment is provided where and when. And we understand how that emerged, how that system kind of developed, but now it's time to say OK, maybe we're ready for the next iteration, you know? Let's have a conversation with the customer. And then let's see what we can do to deliver on those requests from the customer. I thank Peter for that feedback.

Lee Wilson:
OK. Well, hopefully that answers Michael's question. We have time for one more question. What are some practical steps that frontline staff and executives can take right now? So, I think Ed might be best placed to answer that.

Edward Coffey:
We've actually had this conversation all week with a number of teams here in New South Wales.

Our answer is, what's stopping us right now from taking a look at how we feel about this idea of Vision Zero? Pursuing perfection, could we really get behind the notion that suicide is a potential never event that we should be able to eliminate? Now, it's interesting when I share this triangle with our outpatient advisory groups back home, they're astonished that you have to call out this first pillar. What do you mean you guys don't believe that ideal healthcare is possible? I mean, they're astonished. And yet, you know, I don't think we do believe that across the board. Understandably so. So I think what's stopping us now from trying to look at that belief and try and look at that culture, and begin to change it?

What's stopping us from beginning to work on a just culture? If we really believe that most of the mistakes that are taking place and the evidence for this is clear, it's correct. The belief is correct. If most of the mistakes taking place are system failures, not personnel failures, why can't we begin to work on a culture that's going to allow us to redesign systems? Get past the blaming, and get to the fixing, and repairing. So, don't get me wrong. I think we need some help and some resource to get started. That's always good. But I don't think there's any barrier to changing those sorts of cultural beliefs right now. At least to start the conversation.

Lee Wilson:
Thank you. I actually had a question for both clinicians around the... gauging any sort of reticence or willingness to actually talk about suicide from the people that come into your systems.

Just wanted to hear a little bit about how they've responded when suicide's been put at the front and centre their care.

Edward Coffey:
Well, I can tee it up and then welcome Luke's comments here. It's interesting when we began this work, we realised early on that a key lever in the safety enterprise was going to be the safety plan. A formal conversation. Not just a document, but an ongoing conversation around how do we ensure a safe environment for our patient and their families, regardless of what the condition might be? And that obviously, and very quickly goes right into a conversation around suicide. That's one of the major safety factors for our patients. And there was initial reluctance to have this conversation among our clinicians. The fear was that, you know, we might trigger an idea or trigger an impulse. And just the opposite was the case.

The patients and their families were desperate to have a conversation about this. The resistance and the anxiety was more in us. Right? And it came across of course. If we were nervous, the patient picked up on it, and that that inhibited any kind of conversation, right? So, we had to get over our own anxiety to begin the conversation. And once we did - and you can train for that. Practice, you know, and roleplay all these things; and get patients to help us. Get a patient advisory group and their families to help us with this. How would you like us to talk about it with you? You know, not assume that we know how to talk about it with you. But once that barrier was addressed and removed, I think it was almost smooth sailing at that point. This conversation evolves very naturally. But there were some challenges up front. Luke, I'd be curious what your experience has been.

Luke Lindsay:
We've actually had very similar experiences. And, and I'll talk a little bit about this later, but certainly as part of our suicide prevention pathway, and the particular questioning techniques we use around the idea of suicide; and we talk a lot. We use the kind of case approach within that. So, a lot of that was around building confidence in our clinicians to explore suicide beyond that superficial initial denial. And you know, looking at real intent, stated intent, reflected intent and having a really good basis of understanding around that. And we've found it's been incredibly positive in terms of consumers really engaging in the conversation, rather than it being a "yes, no" response.

Lee Wilson:
Fabulous. Thank you. Well, I might move us along to our next speaker. It's my pleasure to introduce Sue Murray. She will talk about the international declaration to local implementation.

Sue Murray:
Thanks very much, Lee. And good afternoon. This statement that you see on the screen, it is really the foundational statement that has galvanised the Zero Suicide global movement. And it's fantastic that New South Wales health is now a part of that movement. And as Ed has shared with people as we've talked around the state, this is probably, if not, the largest scaled implementation of zero suicides anywhere in the world. So, we're delighted that New South Wales health has bitten the bullet on this. The declaration that you see there on the right-hand side, that was developed at the fourth international summit on Zero Suicide that was held in Rotterdam last September. More than 100 healthcare leaders, those with lived experience clinicians, academics, NGOs, private providers and governments from some 20 countries came together to explore the development of this initiative; and also to write the international declaration. And participants included those from UK, US the Netherlands, China, Malaysia, obviously Australia and New Zealand.

And the purpose of the declaration is really to provide a simple, consistent flow for understanding and implementing Zero Suicide healthcare. I think it's important though to emphasise that we do not see this as the only answer. Zero suicides healthcare has to be seen as a complement to other community based initiatives that are seeking to reduce the impact of suicide on individuals, families, and communities. I want to share a couple of examples of the international arena. This is a US institution, and they have been implementing Zero Suicide now for some years.

And as you can clearly see, there was a definite decline in suicides commencing around the beginning of 2016. 18 months later, though, you can see that that downward trend was reversing. They had fully implemented the model. they were constantly looking at the data. And so, what they were able to do was to identify those individuals who took their own life; and then analyse, if anything, what was different. What they did find out was that these individuals were presenting at outpatients to only collect their medications. They were not seeking any psychosocial support while they were there, even though this was available to them. So, the institution was able to then implement strategies to change this. And the result, as you see, the downward trend has returned.

Across in the UK, Mersey Care has been working to implement the or bring a refocus to their organisational culture and bring in approaches that embrace recovery, healing, learning and improvement. And that's the just culture that Ed was talking about. It asks who is hurt? What do they need? And whose obligation is it to provide for those needs?

Rather than what many would currently be experiencing of what rule is broken? How bad is the breach? And what are the consequences going to be? You will, I'm sure, hear more from the Mersey care example as our Zero Suicides and care initiative rolls out. But there at the bottom of the slide, you can see a couple of metrics that just show the benefits in one area of their business that they've experienced as a result of this implementation.

I want to talk a little bit about what's happening around Australia, just in terms of Zero Suicide healthcare. We've seen on the Gold Coast, as you've heard, they're just About three years into their journey, being led by Dr. Catherine Turner. And Queensland Health was spurred on by the success of that Gold Coast initiative to support another 11 sites to implement the initiative within their healthcare settings. That's now about 18 months underway.

So, it'll be interesting to hear from them sometime in the near future, what they've learned and how they've been effective in rolling out the initiative. Over in South Australia, they're soon to be releasing a mental health services plan. And within that plan, they're also exploring the Towards Zero initiative. There are a number of individual institutions that are around Australia at the moment. They have linked in to the Gold Coast and learned from them as they've tried to implement the approach. And what this means is as New South Wales rolls out the Zero Suicides in Care, there will be ample opportunity for us to develop an active community of practice that can share learnings both across districts and across states.

And this graph really just starkly shows us why we need to implement Zero Suicides in Care in Australia. Over the last few decades, we've seen a very encouraging downward trend in some of those common causes of death. Generally, this is the result of taking research knowledge, applying it into practice; and our health professionals putting in place protocols that have improved patient outcomes. It's clear that the same cannot be said of suicide.

As the leading cause of death for those under the age of 44 years, Suicide takes the lives of people in their most productive years. We certainly recognise that Zero Suicides in Care is not going to change this entirely. But the literature does show that between 15 and 30% of suicides are people who have been into our healthcare system. So, Zero Suicides in Care is for these individuals. It is about how our system receives, manages, treats and supports those who are suicidal and seek help from our healthcare system.

I also want to share with you some of the resources that we are putting into place to support the rollout of the Zero Suicides in care initiative. Certainly the international declaration identifies these four pillars or these four drivers as being important to the implementation of Zero Suicide healthcare. Leadership. As we know, it's a critically important factor, and the leaders must be able to foster a culture in which there is a fundamental belief that suicide or an attempted suicide is an avoidable outcome of care in a modern health setting.

We need to know that our teams are trained to care for and manage those who are suicidal. People enter our healthcare system from many different avenues. They don't all come through the formal mental health structures. So, training needs to be provided to all staff, so that wherever a person is within the system, they encounter staff who are confident and competent to manage suicidality. Active participation between the person, the clinician and their family members and/or carers. This is a critical path. It also means that we have to have communication, both across the hospital system and within the wider community based services that will wrap around the individual once they leave the hospital system. And then finally, the fourth driver is data.
This provides the basis for continuous improvement and for sharing our learnings with others as our programs progress. So, there are a number of policy areas that will also support the rollout of the zero suicides in care initiative. The fifth mental health and suicide prevention plan in priority area two, which is specific to suicide prevention, It clearly states, all health services should strive to achieve zero suicides. So, we should expect to see, with the implementation plan, that there are initiatives and activities that will support services to achieve that outcome. The National Safety and Quality Health Service Standards, it clearly has a standard that's directly related to suicide and self harm, but there are other standards that also align with the elements of zero suicides in care.

Specific to New South Wales is the strategic framework for suicide prevention. It's the guiding focus for and specifically, the zero suicides in case is addressing priority action area, three which is supporting excellence in clinical services and care. To support health service leadership, respond to the call for implementing this initiative, New South Wales Health will be looking at the current policy on clinical care for people who may be suicidal. We need to look at whether that requires updating, does it require reframing, or are there additional needs or additional inclusions which need to be made to that particular policy.

And more recently, we've seen the recommendations being put in to place from the review on seclusion and restraint, and the ministry teams are working together to ensure that we can develop mutually supportive policies. Zero suicides in care is complementary to many of the recommendations that come from that review, and then finally, we already have the proud spirit declaration to support Aboriginal and Torres Strait Islander people, these are all designed to support local health services as they roll through their implementation of zero suicides in care.

In this website, I want you to have a look at this website, it provides a vey solid toolkit that is a wonderful foundation for you to design your approach to zero suicides in care. It is a US based website but within it, the, for each of the seven elements of the model, there are tools which are available to help you understand and design your approach for each of those elements, there are webinars, there are videos, written materials, sample documents, everything you need to support the implementation.
It was developed by the education development centre which also supports the suicide prevention resource centre and it continues to be funded by the federal government in the US. The resources are US developed, but the important thing is they are all evidence based, and they provide a very solid foundation to get started. The good thing about the ongoing funding from the US government means that all of these resources are regularly reviewed and they are done so in the most up to date international evidence.

Here in Australia, to complement the US resources as part of the roll out we plan to produce our own commentary from Australian experts and develop some videos, some podcasts, some other webinars, these are going to be able to complement what you can find on the US website, and as I've mentioned earlier, we'll also establish a community of practice so that we can share learnings about the program, and its implementation in the Australian context. This is just a quick snapshot of the sort of things that you might need to get started. I'm not going to go into any detail over this because Luke is able to, is going to be able to tell you how it's really done on the ground. So thanks everyone, I look forward to working with you on this exciting initiative.

Lee Wilson:
Thank you, Sue. Again I would like to invite Peter to make any comments.

Peter Schmiedgen:
Well I think it was great to see in the Rotterdam declaration that this has clear link with human rights, and I think that's another issue which is going to be really important for consumers in terms of the implementation of the zero suicide framework because you know, really health care should be about balancing individual consumer rights or lived experienced rights with the imperatives of the system and it kind of goes back a bit to what Ed was saying, but you know, you want a system that doesn't just centre itself on clinician needs, but which sees itself as always balancing between the needs of clinicians and the needs of the system and I think suicidality is one of those other issues that you often encounter this, I mean, because you do sometimes, you are sometimes subject to involuntary hospitalisation as a result of suicidality, and that's a clear rights issues depending, you know, or an issue where rights should be considered carefully.

So I suppose I think that's what I like to say and I certainly know many, many, many consumers we speak to are very concerned about sort of the need for the health system, and I think this came out very strongly from the seclusion and restraint process which you mentioned, the importance of making sure we don't forget rights, you know, when we implement health care systems, the importance of ensuring that consumer rights are heard, and to some extent, of course, that's already in the package of funding because co-design, you know, the work, this is part of that, but it's still important for it to be, I think going back to continuously...

Lee Wilson:
Do you feel as the consumers that you are in contact with will, that fear will be allayed during the co-design process because the co-design process will be quite rigorous for the initiatives that are being developed now.

Peter Schmiedgen:
I think it wouldn't be fair for me to say.

Lee Wilson:
Sure, sure.

Peter Schmiedgen:
One would hope that the co-design process will allay those kinds of fears, yes, and hope that it will move towards the system where people no longer feel that sense of, oh gosh, you know, my rights will be trampled over, or I'll have something done to me which I don't want done to me, but of course I can't, I can't.

Lee Wilson:
No, no, no, no.

Peter Schmiedgen:
And it wouldn't really be appropriate for me to say, oh I know what they'll say, but I know it's a strong, it's a cool concern, people are worried about their rights being respected. And I think it's because in mental health, there's the sense that, there are very few areas of medicine where you can be involuntarily subject to treatment, so there's that sense of that, I think, and I think that's what raises this issue for a lot of consumers as well, you know, it's not like someone gets told, gosh you got cancer, there you are, you're in hospital now, for the next months in order to have treatment it's radically different as an experience, so anyway, yeah I think that's something I think that's brought up, and it's actually good, the declaration seems to be like moving towards the idea of like human rights as kind of something that's got to be a core issue when it comes to suicidality, yeah.

Lee Wilson:
As it should.

Edward Coffey:
I wonder if and maybe this is not a confusion but perhaps in the minds of some, co design could mean that my involvement is really just at the beginning.

Lee Wilson:
And that's not what it's...

Edward Coffey:
And that's what's intended to be sure. So...

Peter Schmiedgen:
That's right.

Edward Coffey:
I think perhaps we as a system may have an opportunity here to do some work to ensure and make consumers aware of a review and observation and monitoring of the process throughout the length of the episode of care. What do you think about that?

Peter Schmiedgen:
Well one which is of course the process, if you think about co design, the process of moving away from consultation which the system does do already, you know, government in Australia consults widely, that's not quite the same as co design, and yeah, that's what I think, I think that's the distinction here in Australia, you know, we have a system which consults widely, but that's not co-design because often it's the process of saying, oh here's the framework, what do you think? Rather than saying what are your problems here right at the very beginning? We're not gonna give you the framework, what are the problems that you have when you, you know, you come to the system.

Lee Wilson:
I think that will be part of the re-orientation.

Peter Schmiedgen:
Yes.

Lee Wilson:
That we're talking about.

Peter Schmiedgen:
Yeah, correct, correct. It's not a comfortable, I understand it's not a comfortable process because it's kind of giving up a bit of power, I think, you know. Not every, not all your power, but a bit of power.

Lee Wilson:
It's necessary for a person centred approach.

Peter Schmiedgen:
Yes, yes.

Edward Coffey:
Our power comes from the patients belief that we're gonna help them. And if we don't have that, if we're not acting in that good faith, then we don't really have any power, and we shouldn't have any power.

Peter Schmiedgen:
Of course, but also from the law, so that's kind of, but anyway, yeah, yeah, but you're right, yeah.

Lee Wilson:
Very interesting. I would now like to formally introduce Luke Lindsey from the Gold Coast Mental Health Specialist Services and you'd like to tell us, give us a bit of a case study on where you're up to.

Luke Lindsay:
Thank you, and thank you for invitation today as well.

Lee Wilson:
Thank you for being here.

Luke Lindsay:
So I am conscious of time and I'm a little content heavy, but I'll do my best to move through.

Lee Wilson:
That's fine.

Luke Lindsay:
So look, today I wanna really talk about the Gold Coast journey to suicide, to zero suicide and particularly looking at our suicide prevention pathway which really underpins the work we're doing around the journey to zero suicide. So I'm gonna talk through the pathway today and particularly through the different elements of the pathway and how it looks in real life and how it looks on the ground with clinicians in a public clinical service. So the pathway itself is essentially made up of seven kind of key essential elements with a number of key actions. Without going to a great amount of detail around this, the first essential element around the leadership really is around that kind of, that leadership level driving cultural transformation, that really changes the concept and allow clinicians to conceptualise, you know, the true and very genuine beliefs that the idea of zero suicide and suicide reduction is possible in mainstream, in mainstream care today.

Now the training aspect for us is a really important element of this, so we did really invest heavily in targeted training to provide an evidence based for our clinicians to ensure there's a standardised consistency in practice, and that it's not reliant on particular individual clinicians' level of experience and confidence and competence. Now the identify, engage, and treat, these three elements are very much around looking at systems and procedures and ensuring they're in place to identify respond, in a real, a real timely way to help support people that are at risk of suicide, and ensuring they are very consumer focused and patient centred. The transition, the transition element really is around again looking at systems and procedures and resources, ensuring that there is intensive support throughout the periods of the process, and throughout the transition points of the care and particularly of the pathway. And the final element really is around looking at data driven quality improvement approaches to system changes that will lead to improved consumer outcomes, and better care for those at risk.

So the pathway itself really, there are four kind of primary components of it, so the identified component really is around taking a systematic approach, and systematically identifying and assessing suicide risk amongst people presenting to our services and receiving care around suicidality. The engagement component is around every individual consumer having a pathway to care that is timely and adequate to meet their needs, and two of the keys of that component that I'll touch on shortly is around the collaborative safety planning and the restriction to lethal means within the pathway.

The treat element really is around using effective evidence-based treatments that directly target the drivers behind the suicidality, behind the suicidal thoughts, and the behaviour and the transition component is especially important particularly around providing continuous contact to support especially after acute care. So not looking at a fragmented system where there is a period of care provided around suicidality, and then when there is a perception of crisis is over, that's where the care ends. So really moving beyond that.

So who gets on to the pathway, so essentially who's offered the suicide prevention pathway at the Gold Coast. So we've set four criteria for the pathway. So a consumer who presents to our mental health services with a recent suicide attempt, a consumer who presents with a past history of a suicide attempt, and currently presenting crisis with suicidality, any consumers admitted to our inpatient units with the risk of suicide and the fourth criteria we kept at clinician's discretion, and this was very deliberate and very conscious decision and this was around ensuring that our clinicians at the ground level, at the call phase were still able to use clinical discretion and clinical judgement that if they were working with a consumer who may not neatly fit into any of these three elements but they had a, they had a feeling that, you know, there was something not right here, and this consumer was in need of support. Sorry. There we go.

So this is an overview of the actual suicide prevention pathway. So essentially, the first element of the pathway is around the consumer presenting to services and having a standardised consistent screening process, the way we screen for suicide. The second element is around the assessment, the assessment component, so this is, this is where we look at using the (UNKNOWN) case approach, which I'll talk about in a minute. Again and this is very much around questioning techniques and the way we actually engage the consumer in a consumer around the suicidality to truly tease our real intent around that.


The risk formulation element is based on the risk formulation, which really is around the way we synthesise the risk, to look at the risk formulation quite globally. The brief interaction element of the pathway moves on to a collaborative safety plan, now this is a two-paged document that we, that the clinician and the consumer, and the consumer's identified significant others are involved in a very collaborative process of looking to work and develop a safety plan. Now this stage, this is identifying consumers that may be going into our in patient unit, or that maybe going into community based care.

Now the idea of this really is that it is around collaboration, and that this in itself is an intervention, that we use this opportunity to sit with the consumers and to sit with their loved ones to really use this element as a brief intervention. The idea of prevention to access of lethal means, this is a really important element, and again it's done in collaboration with carers, with the consumer or with their significant other, and some very targeted and specifically designed patient resources for both the carers or the significant others, and the consumer to actually, to take with them. Now at the decision point, here along the pathway, the consumer in this, in this pathway will go on to admission in our inpatient unit, or will go into community based mental health support and care.

So for those consumers being discharged from the service at the point going into a community phase of care, these elements are very important, and this is our rapid referral component of the pathway. So this means that when the consumer leaves the emergency department or leaves the service to go home that they leave with a scheduled rapid referral so that within the next 24 to 48 hours, they will be seen face to face by the mental health clinician and they will be provided with very structured follow up that will really address the drivers behind the suicide, so that structured follow up may happen over a period of time, and over a number of sessions, but it is a very specific structured follow up and it is very much focused around the drivers behind the suicidality, and also built into the training that we provide to the staff.

At the transition of care which is final element of the pathway, this is very much focused around that warm transition of care. Now for us, we've been very fortunate in commissioning an NGO service that provides up to four weeks of psychosocial support that we've co-located with us in our public mental health community clinic.

So, the CASE Approach I mentioned briefly when talking through the pathway around the assessment stage is using the Chronological Assessment of Suicide Events, the Shawn Shea CASE Approach. It's built in to the pathway so that it provides our clinicians with the tools to be able to truly look and engage in the consumer in an assessment around suicidality focused on the idea of stated intent, reflected and withheld intent really equalling through real intent. And the idea of this is to move past that initial superficial the consumer denied they felt suicidal and really allowing our clinicians to actually understand real intent and to embed that into the assessment process and make that part of that conversation around the pathway. Now, the CASE Approach is very much focused around the a chronological oversight or view of suicide events. So, looking, initially, the first the previous 48 hours, moving on to looking at recent - so, the 2 months beyond that, moving into beyond that 2 months and then, coming back to the immediate suicide events that may have led to the presentation or being a contributing factor.

And part of the training we provide around the CASE Approach is looking at the particular question intent mix clinicians use in this space. So, looking at the idea of things like normalisation, gentle assumption symptom amplification, shame attenuation behavioural and in denial of the specific. Now, the... A really significant component of this pathway is the idea of moving away from risk prediction and away from risk stratification, the traditional low, medium, high to the idea and the notion of suicide's risk prevention. And part of that is the way we look at how do we formulate our risk process. And we look at the work and we've based a lot of this process around the work of Anthony Pisani, looking at a prevention-oriented risk formulation.

And so, the training we provide to our staff with the online and the face-to-face training is very focused around what we can see on this slide which is the idea of the risk status combined with the risk state. And then, we look at the available resources - so, whether that be internal supports, external supports and foreseeable changes. So, the foreseeable changes is a really crucial part of the way we formulate risk and certainly part of the training - so, looking at, you know, if foreseeable changes are likely or unpredictable or avoidable, that we look at our specific contingency planning around that risk mitigation and that coming back to that safety planning element of the intervention of the pathway, making sure that it is very collaborative and that it works to address some of the elements raised within the risk formulation.

So, we know that the brief interventions - so, we know that the safety planning intervention and we know that the conversation around the prevention of access to lethal means and the resources that we provide within that intervention - we know that they are designed for patients who will be discharged from the emergency department into community-based care. We know that they are designed specifically for BCED department and for BC Emergency Department Staff. And we know that we get best results from when they are used in conjunction within the emergency department. So, the safety plan itself and the safety plan intervention - it's made up of seven stages. Now, this is a document that is driven and formulated through a collaboration between the consumer, the clinician and their identified significant other within this interaction.

It involved or it includes the rep response follow-up appointment the following day and it addresses the immediate safety planning that's done within that intervention. So, essentially, so everybody's on the same page. Everybody gets a copy of this including the community mental health team that will be coming out the following day to see them. And everybody's working toward the same process and the same common goals within the safety planning intervention.

So... Within the transition of care element, a lot of the linkage work we do, we've been associated with being very fortunate in that we do or we have been able to commission psychosocial NGO provider who is co-located with us to really help with that transition of care when the suicidality has reduced and essentially, the consumer and the clinician and the carers feel that the crisis has resolved or is resolving and that the consumer's at a stage where they can move in to a non-clinical support service that we utilise our NGO partners within this space.

Part of this process, as well, is that we've trained over 100 private practitioners within the Gold Coast around our suicide prevention pathway which has been really important around that transition phase. So, the training element of this - we've really invested quite heavily in - it's been incredibly important part of this. So, the Queensland Centre for Mental Health Learning have three existing SRAM-ED Modules, online educational modules, around suicide and particularly around the emergency department. The Gold Coast Mental Health and Specialist Services have developed a fourth model, particularly around zero suicide and the suicide prevention pathway.

So, all of our clinicians across our mental health service had to complete these four modules before they attended their eight hour face-to-face training day around the pathway. Initially, we targeted our community staff and we've now trained all of our in-patient staff as well. So, that's our lived experience team. That's our nursing, our allied health and medical workforce. So, there's almost 700 staff across the service that have been trained in this. And we've really looked to make this a sustainable training program. We've built it into our mandatory orientation program.

So, every new clinician coming in to the service undergoes this training before they actually start working within their teams. Now, the data, I will move quite quickly but essentially, we've seen over 3,000 patients come through on our suicide prevention pathway and in the bottom left-hand corner here in the safety planning, you can see that the idea of safety planning pre-implementation of this self prevention pathway was very low and post had a significant improvement around formalised and collaborative safety planning as part of the intervention within the services with us. We've seen a significant move away from the idea and the notion of risk stratification - away from that low, medium, high risk pre and post the implementation of the pathway. We've seen a significant increase in formalised counselling on access to local means which are all really positive things.
Some of this data - I'll move through very quickly - but essentially, in relation to you know, to the different elements of the pathway and the clinician kind of adherence with those elements, so particularly, looking at the Pisani Risk Formulation, the safety planning elements, the counselling on access to local means and the face-to-face rapid response follow-up within 48 hours, we've seen a significant increase across all four of those areas. Again, this just shows us... We've seen an increase around the risk formulation from our clinicians again, for safety planning since implementation, access to local means and questions already. [laughs]

I just wanted to, just before I wrap up, say that from our perspective, certainly feedback from clinicians on the floor really like this and really see a lot of value in this. It standardises that approach. It moves away from that old school risk stratification and that we're seeing an emergency department presentation around our crisis - a consumer, you know, presenting with suicidality in crisis being able to use that emergency department interaction as an intervention through these different stages of the pathway. And the results, in terms of, some of the data we've looked at and some of the data around what we're seeing have been really positive, so far.

Lee Wilson:
Brilliant. Thank you. Thank you very much. Lots of insights there.

Luke Lindsay:
Yeah. Really rushed through that. [laughs]

Lee Wilson:
Yeah. Yeah. But you did very well. Thank you.

White:
There's a question for you Luke. Would the private practitioner training for those working in the Gold Coast Area, would you please provide more information about how you know, do they still select... did you select them?

Luke Lindsay:
So, we put out a general invitation through our PR chain. So, through our primary health plan work to all private providers within the Gold Coast that we're interested in knowing more about the idea of zero suicide, knowing more about the idea of our suicide prevention pathway, particularly, that transition phase, you know, when the care moves from us, you know, into the NGO and to the private sector. And we had... We ran a number of sessions. We had over 100 private practitioners attend. So, it was definitely coordinated and the invite went out through the PR chain.

Lee Wilson:
Fabulous. And this leads... There's another question around the scope of what in care means? At the moment for us, it's you know public acute in-patient sort of out-patient facilities, but how did you go from... OK. We're just going to do, you know, the publicly funded mental health to engaging, you know, community managed organisations you know, the primary health network, you know. Let's talk a bit about that.

Luke Lindsay:
Yeah. So, initially, the idea or the notion was that the pathway was going to be... For consumer to come on to the pathway and get a formalised structured intervention and care, that would happen within any part of our mental health organisation. So, whether you're an in-patient, whether you were seen in the emergency department and discharged with carers, whether you're seen through our community mental health clinic, you know, there was no discrimination around where you were seen, whether you could come on to the pathway or not, we didn't want to select only particular components of our service. We want it to be all-encompassing.

So, regardless of the way you sat within our mental health service, whether you were sitting with our CCT, with our case management teams you are open to that. The idea of the involving particularly private providers and NGOS and community providers was very much around that transitional phase. If we did all these amazing work whilst they're in care, they got to the transition phase and nothing changed and you know, their usual primary care providers have no witness of what had happened or the work that had been done or what work is still needed to be done that it was just not going to work, you know. So, we... Part of the implementation was very much focusing around that transitional phase as well.

Lee Wilson:
And the wrap-arounds.

Luke Lindsay:
Yeah. Absolutely.

Lee Wilson:
OK. Thank you.

Luke Lindsay:
No worries.

Lee Wilson:
Is there anything you'd like to add or... no? No. OK. Alright.

White:
Alright. There's more of a comment than a question but I found the concept of a just and restorative culture that Ed and Sue mentioned interesting. What did that look like for the Gold Coast Mental Health Services? And how is that fostered?

Luke Lindsay:
Yeah. So, in terms of the just culture element of this, it was certainly right from the get-go, it was a focus that if we want a system-wide approach and if we want this to work across the systems, then we have to look at where the flaws in the system are. That if we don't embed this system-wide, then nothing's gonna change essentially. The cultural change around that - it took some time to be truthful, not as much time as we anticipated.

You know, there are always gonna be you know, staff that will be slightly sceptical at the time of the idea of just culture but actually putting it into practice and demonstrating it, you know, throughout the systemic changes we make is another thing. You know, so, the idea of bringing everybody on board with this was an overwhelming thought, you know. But the more training and the more education and the more it's being used and the positive outcomes that we're continually sharing with our clinicians and with our staffing group reinforces that this is making a difference and reinforces that this is not just talk and conversation, that it's being embedded, it's being acted on and that, you know, they're kind of seeing the fruits of their work essentially, you know.

Lee Wilson:
Yeah. There's a question there about how do you share your successes and celebrate your successes and keep the momentum going within your team?

Luke Lindsay:
So, from our perspective, we're really very transparent with the data. So, the data - we're very transparent across the service. We share that with regular communications with staff. We present at different forums and all different staff meetings and our lived experience colleagues are very involved in that process, as well. So, they're involved in, you know, getting the word out, literally, going to staff meetings, you know, talking to staff about it, sharing the data and looking at some of the positive, kind of outcomes, you know.

So, it's important to be consistent with that and not take your eyes off the ball, you know. Once you get past implementation phase and you think, "OK. We've got past the most difficult part." To not take your eye off the ball, but to continue that. And three years down the track, we are still continuing that, to keep the momentum going, but it's become second nature to the staff now. It's just become the default option. I think when you speak to staff, some staff don't even remember pre-suicide prevention pathway, the idea of, you know, stratifying risk and saying somebody's low risk, discharging them home back to their GP, the idea of that wrap around service.

Sue Murray:
I think there's an important point that Luke has talked about and that is that training is embedded in induction. So, the sustainability is built in to the system. The other thing I'm aware of, in regard to the Gold Coast, is that the benefits of this are shifting into other areas of the hospital's business. Am I correct in that?

Luke Lindsay:
Yes. Yeah. I think so. [laughs]
Yes. I think what we're seeing is we're seeing other elements of our wider hospital also getting onboard with this, outside of the mainstream mental health service - so, our trauma colleagues and our general health psychology colleagues and yeah. It's beyond just in the health service.

Sue Murray:
So, I think that's similar to the sort of experience you've been talking about as we've gone around this week, Ed.

Edward Coffey:
It is indeed and Luke, congratulations on the fantastic accomplishment on a relatively short period of time. Remarkable. And our experience was the same, as Sue knows. Improving performance improved performance. The rising tide lifted all of those boats. And I mean, even our financial performance got better in part because we began getting better at recognising what's not working, recognising where we're wasteful in our resources, agreeing that we don't need to do those any longer even if some of them are sacred cows and then, focusing our newly found resources on those evidence-based approaches that we know are making a difference.

So, you can just see there's waste reduction improves and performance across the board, morale improves, people are engaged and excited about coming to work. We're kind of removing the barriers that had been present to people wanting to do what we wanted them to do. Now, they can do what they want to do which is a good job. And have a personal relationship, you know, with the patient and family. So, I think it's great and exciting. Congratulations again, Luke.

Lee Wilson:
On that note, we are unfortunately gonna have to finish. I'd like to continue the discussion but thank you very much Dr. Ed Coffey, Peter Schmiedgen, Sue Marie and Luke Lindsey for your time and your expertise. It's been invaluable. Thank you very much.

Sue Murray:
Thank you.

Lee Wilson:
Thank you.​

Current as at: Thursday 10 September 2020
Contact page owner: Mental Health Branch