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t m c » p u l s e | d e c e m b e r 2 0 1 5 11 taking care of patients with a psychiat- ric disturbance that is somehow related to an underlying neurological problem. It might be a person with a stroke who is now depressed. It might be a person with a head injury who now has a per- sonality change. It could be a person with Alzheimer's disease who is now hearing voices. At Duke, I became director of the neuropsychiatry/electroconvulsive therapy program before being recruited to the Allegheny System in Pittsburgh by Dr. Stuart Yudofsky, who is now at Baylor. Dr. Yudofsky convinced the leadership at Allegheny to buy a free-standing, 94-bed, neuropsychia- try facility and then hired me to run it. After being in Philadelphia for six years, the Henry Ford Health System in Detroit had a position open and I knew many, many people there, including the former chair who had risen to the dean's position. The leaders were and are phenomenal—Henry Ford is an incredible, world-class health care system. I thought I would only be there five years, but my family and I fell in love with Detroit and there were plenty of great learning opportunities there. We created an integrated mental health service line for the system—it was a $4 billion system and we had the oppor- tunity to create this notion of Perfect Depression Care and Zero Suicide. Q | I know the Perfect Depression Care and Zero Suicide program was a Malcolm Bladridge Award-winning program. What was the standard of care before and after the program? A | A couple years after I arrived in Detroit, health care financing under- went a major change. Our system, like many others, was struggling. We had to recalibrate after a round of layoffs that sank morale. At the same time, the Institute of Medicine convened a committee to evaluate the American health care system. What resulted was an Institute of Medicine Report called Crossing the Quality Chasm. I was tasked with studying the report and presenting findings that were applica- ble to Henry Ford. The report revealed that despite the great people in the American health care system, despite the advances in knowledge in this coun- try, the care that people are getting at bedside is mediocre. The gap that exists between what is possible with health care professionals and what is happen- ing at bedside is the chasm. The report also yielded a model of how to fix the chasm. When this was published, the Robert Wood Johnson Foundation got behind the report and partnered with Don Berwick at the Institute for Healthcare Improvement to launch the 'pursuing perfect initia- tive.' The idea was, if you can take this document as a road map to transform your system, they would give you a few million dollars to get started. I spearheaded Henry Ford Health System's application to the 'pursuing perfection initiative.' There were about 3,000 applications downloaded, 25 semifinalists and eventually 12 final- ists. We were one of the 12 finalists and the only mental health application in the group. Our application was Perfect Depression Care. Each applicant was required to outline six dimensions of care—safe, effective, patient-centered, timely, efficient and equitable—and define how to achieve perfection in all six dimensions. We had five of the six nailed, but we couldn't get something around effective care. We initially thought we'd do the same thing that the FDA does to approve drugs and say effective care is lowering depression scores by 50 percent with our treatment. While this was good enough for the FDA, it did not meet the standards for this initiative. We regrouped around a conference table, and a nurse raised her hand to suggest that doing perfect depression care would mean that people wouldn't kill themselves. The room went still and no one said anything for what seemed like an hour. Her idea was met with resistance as some clinicians were under the impression that we couldn't stop people from killing themselves if that's what they wanted to do. To be honest, that was kind of the attitude back then in psychiatry—suicide is inevitable and you can't do anything about it. That nurse's suggestion, however, transformed our department. We went back and forth among our team, asking ourselves if zero isn't the right number for our goal, what is? Is it 12 suicides a year? Does that include my sister? Your mother? What does our billboard say? 'Come to Henry Ford, only 12 of you will commit suicide this year.' No, it has to be zero. You would think that is common sense, but even today, this is still very difficult for people to embrace. That is how we got into Perfect Depression Care. We drove the suicide rate down in two years and maintained it for over a decade. It was unprecedented. People around the world told me that we were crazy for doing this, and that I was going to embarrass myself and ruin my career. As my senior leadership team at Menninger now knows, I am stubborn and hardheaded and so I said, 'We're going to do it.' What is neat about this notion of perfection is that it is abso- lutely galvanizing. Most people don't want to get up in the morning, go to work and be average. Most people have the notion of doing something spec- tacular, but it is not for everybody. You have to adjust an organization's culture. Now others have signed on to this movement—Great Britain, Northern Ireland and other states here in the U.S. Q | In the perfect care model, what was the difference? Was there more intense communication with the patient? Was it the focus on the patient to not let them wander off alone and feel lost within the spiral of depression that leads to suicide? A | You are absolutely right. There are two evidence-based approaches to reducing suicide: rapid access to definitive diagnosis and treatment of the underlying disorder—depression, anxiety disorder, substance abuse, etc. The other is 'means restriction'—you make it hard for the person to carry out the act. Patients who have survived suicide attempts will tell you that it is purely impulsive. The thought is maybe always there, but most of the time it is in the background. But when the person is experiencing stress or maybe when they are drinking, the impulse bubbles to the top. If it is easy to do it right then—if you have a gun that is loaded in your car's glove box and it doesn't take any thought or planning to do it, then it happens. Means restriction means getting rid of that stuff. We had very intentional conversa- tions every time we interacted with the patient, not just in person, but on the phone, email whatever and every inter- action began and ended with, 'What is the status of your gun at home? Your plan?' If it wasn't a gun, but hanging, 'Tell me about how you have thought this would happen? What do you imag- ine is the means?' If the patient told us they were planning to hang themselves in the garage using a ladder and a cord, we would tell them to go home and get rid of the ladder and the cord. The most incredible thing we learned from doing this is that the patient will not go buy a new ladder. Another fascinating thing is people who have chosen the ladder and cord in their suicide plan don't typically go and replace those with a gun after they've gotten rid of them. The goal here is to put some time between the impulse, so that the impulse will sub- side. Michigan is a big gun state like Texas, so we negotiated with patients to have them put the ammunition in one safe on one side of the house and the gun in another safe on the other side of the house. We also got the gun clubs in Michigan to get on board with this. A lot of patients didn't want to give up their guns, so the gun clubs said, 'We'll hold it for you. Whenever you want to come practice you can, but we will keep it here.' We got really good at means restriction. Q | What was the driving force behind you taking the CEO position at Menninger? A | There are several factors. My family is from the South, so there was an appeal to get back to our cultural roots. I've since learned that there's the South and then there's Texas, and those aren't identical. I'm not saying there's anything negative here. I'm just saying they're different, and I didn't fully appreciate that. And we love Texas. Additionally, there is no brand in mental health like Menninger. It is just an amazing brand. That's, of course, due to leaders here in Houston and people like Dr. Yudofsky who were so keen on bringing Menninger here over a decade ago. They knew it had the potential to be the MD Anderson of mental health. In fact, I think that analogy has been used by many here in the Texas Medical Center. The tagline: 'Advancing treatment and transforming lives.' That isn't just talk. It really is what goes on here. It's incredible.