Complexities and Promise of Suicide Prevention in the Military Context: Implementing a Zero Suicide Systems Approach in the Air Force

Introduction: Suicides among military service members continue to rise with approximately 100 active duty Air Force members dying by suicide each year. Zero Suicide Systems Approach (ZSSA) is a set of organized activities, processes, and procedures designed to close common healthcare gaps through which those who die by suicide often fall (e.g., lack of suicide risk screening, poor care transitions, underuse of evidence-based treatments). ZSSA has significantly decreased suicides in several large civilian healthcare organizations. The U.S. Air Force recently began a pilot implementation of ZSSA at five bases. From an implementation perspective, ZSSA in a military context presents a number of complex challenges (e.g., stigma, rigid clinical processes). This presentation will describe the implementation approach, challenges encountered, early successes, and lessons learned. Methods: Semi-structured interviews with healthcare leaders, who had successfully implemented ZSSA, and pre-implementation readiness assessments at each base were conducted using an adapted version of the Suicide Prevention Resource Center’s Zero Suicide Organizational Self-Study. Numerous suicide screening and assessment approaches were examined for best fit within the Air Force. More than 1,500 providers and non-providers were trained on a new suicide screening and assessment protocol. Monthly community of practice and local pilot site implementation support meetings, and quarterly in-person site visits occur to address implementation challenges, reduce barriers, and share successes. Both qualitative (e.g., results from pre-implementation site visits) and quantitative data (e.g., participant ratings of training) analyses were conducted. Results: While it is too early to know if suicide rates have been impacted, several early implementation "wins" have been documented. Post-training, participants reported a high degree of confidence in their ability to screen and assess for suicide and follow the evidence-informed pathway to care steps. Across the pilot bases, the new healthcare system-wide screening protocol has already identified numerous Airmen at risk for suicide who would have been missed using the old protocol. Providers report that they conduct fewer full risk assessments because the new screening approach yields a lower false positive rate. Waivers of Air Force policy were also obtained from leadership to decrease paper work and increase time for patient care. Conclusions: Implementing a system-wide suicide prevention approach in a military context is an ambitious and complex undertaking. Although early in the process, there are several indicators that ZSSA is already yielding some positive results. Within the next year, a formal evaluation of the ZSSA will be conducted.