Spotlight on the Standards

Suicide Prevention: Variations on a Theme

Think of a suicide prevention program as a musical composition. The revised G-05 Suicide Prevention Program standard has 258 more “notes,” or words, than the 2003 edition. The intent of this essential standard, as recorded in the first lines of the Discussion section, is identical in both editions: “... to ensure that suicides are prevented if at all possible. When suicides do occur, appropriate corrective action is identified and implemented to prevent recurrences.” The standard is identical in the jail and prison versions.

Can 258 words make a significant difference? Why bother to change such a strong and useful standard?

The Overture
Listen to the tone of the opening lines of this standard as presented in 2003: “The facility has a program that identifies and responds to suicidal inmates.” Compare this to the impact of the 2008 wording: “The facility identifies suicidal inmates and intervenes appropriately.” The first places emphasis on the program, the second on the outcomes: identification and intervention.

The Theme
As before, the Compliance Indicators delineate the key elements of a successful suicide prevention program. In the 2008 update, however, the first CI now articulates specific outcomes of the program, stated as follows:

a. facility staff identify suicidal inmates and immediately initiate precautions
b. suicidal inmates are evaluated promptly by the designated clinician, who directs the intervention and assures follow-up as needed
c. actively suicidal inmates are placed on constant observation
d. monitoring takes place on an irregular schedule with a frequency of no more than 15 minutes between checks
e. suicidal inmates in isolated housing are placed on constant observation

13 Movements
The foundations of a successful program are enumerated in CI #2, and now number 13 elements instead of the former 12 (see box above).

Were you able to identify the new element? It is treatment. Always implicit in the concept of evaluation (why evaluate if not to intervene and treat?), treatment refers to “strategies and services to address the underlying reasons for the inmate’s suicide ideation (e.g., depression, auditory commands) that are to be considered. The strategies include treatment needs when the patient is at heightened risk of suicide as well as follow up treatment interventions and monitoring strategies to reduce the likelihood of relapse.”

The debriefing element has been renamed (previously it was critical incident debriefing), and this step is clarified in the Discussion, which cautions: “There are different approaches to the debriefing process, some include highly confrontational or ‘forced interventions’ methods. Such methods are not intended under this standard.”

New clinical information that is of value to any facility housing adolescents, whether or not they are adjudicated as adults, has been added to the Discussion: “Recent research also points out that adolescent suicides in correctional settings have different ‘high-risk’ periods than do the adults.”

Orchestrations
There are now six Compliance Indicators instead of three. We have already discussed the first (expected outcomes) and second (program elements). The requirement for the written policy and procedure remains, but it has been listed last to emphasize the outcome as the primary focus.

The third CI remains the same: The use of other inmates in any way (e.g., companions, suicide-prevention aides) is not a substitute for staff supervision.

The fourth CI addresses elements of the clinical interventions: Treatment plans addressing suicidal ideation and its recurrence are developed, and patient follow-up occurs as clinically indicated.

The fifth highlights the importance of health staff leadership in suicide prevention and of specific trainings: The responsible health authority approves the facility’s suicide prevention plan; training curriculum for staff, including development of intake screening for suicide potential and referral protocols; and training for staff providing the suicide screening at intake.

Postlude
The changes in this standard clearly illustrate the move toward a greater focus on outcome rather than process. This shift in focus will result in better care for patients and greater flexibility for facilities.

[This article first appeared in the Winter 2008 issue of CorrectCare.]

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