Pursuing Perfection in Healthcare to Reduce Suicides to Zero Requires More Than Tweaking

For C. Edward Coffey, MD, affiliate professor of psychiatry and behavioral sciences at the Medical University of South Carolina, the pursuit of perfection in healthcare is not only necessary, it is attainable. But it can’t be achieved by “tweaking at the margins,” as he put it at a recent meeting of mental healthcare professionals, where he discussed one of the most successful initiatives ever to dramattically lower a suicide rate within a health system, and actually hit the goal one year of having zero suicides.

To illustrate, he used the example of any system pursuing 99.9% accuracy instead of 100%: It would mean that 12 infants are handed over to the wrong parents, or 2 unsafe plane landings at the closest airport.

In 2001, he was head of the behavioral health services division of the Henry Ford Health System. And it was 2 years after the then—Institute of Medicine (IOM) landmark report, Crossing the Quality Chasm, was released, detailing, Coffey said, the “dismal care at the bedside.”

Morale was down after a series of layoffs and the staff was looking for an all-encompassing, transformative project.

The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement launched the pursuing perfection challenge, seeking to implement the findings from the IOM report by challenging healthcare systems to dramatically improve patient outcomes by redesigning all care processes in order to deliver perfect care.

Henry Ford Health System applied, but was not chosen as a finalist. Regardless, the staff decided to move forward with the project. The roadmap for transformation seized on the IOM’s report 6 dimensions of perfect care: safety, timeliness, effectiveness, efficiency, equity, and patient centeredness—standards that still have not been met today, Coffey said.

In addition, the report set 10 rules for ideal care: care equals relationships, for example. “The old guys knew this,” said Coffey, referring to doctors from decades ago or fictionalized television characters. Customized care, patient-centered care, sharing of knowledge, managing by fact, making safety a priority, embracing transparency, anticipating patient needs, continually reduce waste, and having all professionals cooperate rounded out the list.

Using the idea of patient centeredness as an example, Coffey asked, “Who is the care centered on right now? It’s not centered on the patient.”

To that end, in 2 years, Henry Ford rapidly redesigned mental health services to implement the IOM report as well as the goals set by Robert Wood Johnson University Hospital, such as same-day appointments as part of improving access to care so as to enable rapid diagnosis and treatment. The other action that clinicians started doing was talking openly about the risk of suicide with patients and their families and then working to remove access to lethal means of suicide (eg, guns).

In other words, he said, “Environmental safety was a major focus.”

The initiative worked: Suicide dropped 80% in their patient population, and in 2009, there were no suicides, an achievement considered remarkable when one considers that the recession started in 2008 and hit Michigan particularly hard.

The idea that zero suicides are possible must begin with “the radical conviction that ideal healthcare is attainable,” he said. The roadmap to change must encompass the value of pursuing conviction in a just culture. That means that “you have to look at mistakes not as a personal one, but as a problem with systems. In a just culture you don’t ask ‘who did it?’ You ask, ‘what happened?'”

And then you bring that learning and understanding into the next design of the system with engineering expertise, he said.

“If you don’t do that you can’t expect your teammates to swing for the fences,” he said.