| 1. Suicide prevention policy on organizational level |
No actual suicide prevention policy Policy < 5 years; contains 0–2 guideline recommendations Ibid 2 & >3 guideline recommendations Ibid 3 & reflects patients’ perspective Ibid 4 & part of general patient safety policy; clear prevention ambition |
| 2. Monitoring suicide numbers |
Incomplete monitoring of suicides, no analysis of trends Complete monitoring, no analysis of trends Complete monitoring, with analysis of trends & recommendations to improve Ibid 3 & Improvement plan across service after sharing w. patient advocacy Ibid 4 & transparent publication of trends, recommendations and plans |
| 3. Evaluation & improvement after suicide |
<75% of suicides are evaluated in a multidisciplinary team >75% evaluated by a multidisciplinary team using a guideline-based method or instrument Ibid 2 & Significant Others involved & requested to identify issues to improve Ibid 3 & at least 1 improvement plan completed & shared across service Ibid 4 & >25% of evaluations is based on extensive root cause analysis |
| 4. Collaborative care |
No written collaborative care agreements with regional partners Written agreements with partners, describing responsibilities Ibid 2 & including at least 2 healthcare partners (e.g., General Practitioners, Emergency Departments, Addiction Care) Ibid 3 & including at least 2 partners other than healthcare (e.g., police) Ibid 4 & including annual evaluation & update of agreement. |
| 5. Multi-annual workforce training plan |
There is no plan or a plan in development Plan is in development but not in effect. Complete, multi-annual plan leading to a competent present workforce Ibid 3 & Compulsory training for new employees Ibid 4 & Compulsory booster training for all employees |
| 6. Suicide prevention training of clinicians |
<1% of clinicians trained in the last 2 years 1–10% of clinicians trained in the last 2 years 11–40% of clinicians trained in the last 2 years 41–80% of clinicians trained in the last 2 years 81–100% of clinicians trained in the last 2 years |
| Added Domains Measurement 3–6 |
Level of Implementation |
| 7. Recording of suicide attempts in Electronic Health Record (EHR) |
<20% of known attempts are recorded 21–50% of known attempts are recorded 51–80% of known attempts 81–99% of known attempts recorded in a dedicated Electronic Health Record field or by Alert Ibid 4 & All attempts with serious medical consequences are evaluated |
| 8. Assessment of suicidality |
<20% of all patients assessed in course of treatment 20–50% of all patients assessed in course of treatment 51–80% assessed using systematic interview & reported in Electronic Health Record Ibid 3 & Alert in Electronic Health Record Ibid 4 100% of patients |
| 9. Involving family/carers |
<20% of suicidal patients has family/carers registered & involved at 1st contact Ibid 1 20–50% Ibid 2 51–80% & agreement on active involvement Ibid 3 81–99% Ibid 4 100% and actual involvement during entire treatment trajectory |
| 10. Safety planning & Continuity of Care |
Suicidal patients have no safety plan; continuity of care is not guaranteed Suicidal patients have a safety plan; continuity of care is not guaranteed Suicidal patient have a safety plan & guaranteed continuity & warm handoffs Ibid 3: safety plan has prominent place in Electronic Health Record Ibid 4: carers are actively involved in safety & continuity |
