To the Editor
Drs Sisti and Joffe1 described challenges in conducting research on suicide. We agree that such research should include individuals with suicidal behavior and that suicide attempts and death are appropriate outcomes for trials. We also agree that conceptualizing the outcome of suicide as an adverse event might trigger objections by regulatory bodies that jeopardize the feasibility of such investigations.
We disagree, however, that the zero suicide model might “paradoxically constrain” research.1 As previously described,2,3 the zero suicide model is a comprehensive quality improvement approach that organizations can use to improve health care delivery. The zero suicide model consists of 3 essential components: a conviction that ideal health care is attainable, a road map to achieve that vision, and requisite expertise in systems engineering to rapidly achieve zero suicides.
Following its introduction in 1966,4 the concept of zero defects spread to industries throughout the world, and recently, innovating to zero was called 1 of 10 megatrends for innovation.5 High-reliability organizations aggressively pursue perfection, an approach that has driven commercial aviation to achieve remarkable levels of safety. Twenty years ago, the Henry Ford Health System adopted this approach, setting goals for mental health care and achieving an 80% reduction in suicides, which was maintained over a decade.3
In our view, the success of the zero suicide model depends on a just culture, one that views errors or near misses as system failures from which to learn and rapidly improve. In response to defects, a just culture asks “What happened and how?”, not “Who did it?”A just culture seeks recovery, restoration, and improvement, not blame, punishment, or retribution.
Thus, we disagree that a corollary of the zero suicide model “is that every suicide represents a culpable failure on the part of health professionals.”1 Quite the contrary, the zero suicide model views a suicide as a system defect that provides an essential opportunity for learning and rapid improvement. This approach is constructive and productive and will not only improve care but enable clinical research. The Substance Abuse and Mental Health Services Administration and the National Institute of Mental Health have recently provided funding to study the effectiveness of the zero suicide model.
Footnotes
Conflict of Interest Disclosures: Dr Ahmedani reported receiving a grant from the National Institutes of Health. Dr M. J. Coffey reported receiving authorship royalties from UpToDate and MedLink Neurology. No other disclosures were reported.
Contributor Information
C. Edward Coffey, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston.
Brian K. Ahmedani, Department of Psychiatry, Henry Ford Health System, Detroit, Michigan.
M. Justin Coffey, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas.
References
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