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Emeryville: Improved Clinic Workflow for Suicidal Ideation Patients

An improvement project sparked by an Action Request Form (ARF)

Submitted by Hazel Kelly, BSN, RN, PCCN, CMSRN, Clinical Nurse IV, Cardiovascular Diagnostic Lab

and Stephanie Orozco, MS, RN, AMB-BC, PGMT-BC, Clinical Nurse II, EHC Multispecialty Clinic

Goals: Identification and coordination of care for patients endorsing suicidal ideation (SI) including:

  • To provide a referral tool for clinic staff to use when patient expresses SI or has a self harm attempt during and/or outside of a clinic visit

  • Implementation of evidence-based and validated mental health screening tools to guide patients to appropriate providers and resources

  • Partner with social services to create a clinical guideline or decision tree to support the management of crisis, such as SI or recent history of suicidal attempt


As the pandemic continued, the Emeryville specialty clinics saw an increase in patients who needed additional screening for suicidal ideation, as well as resources and a comprehensive follow up plan. The Emeryville providers, nurses, and other healthcare personnel needed guidance on how to provide standardized care and resources for these patients in crisis. Though policies existed regarding the screening and management of patients at-risk for suicide, there was not sufficient guidance for remote suicidal patients. To combat this concern, Emeryville's Ambulatory Shared Leadership Council (ASLC) created a user-friendly workflow for effectively managing suicidal patients who are located in a variety of settings, including off-site. The ASLC also partnered with the organization-wide Suicide & Self Harm Risk Steering Committee to enhance their protocols for patients with SI.


  • Reviewed the policy for Non-Psychiatric Settings: Assessment Screening and Safe Management of Patients At-Risk for Suicide. This team worked to separate the inpatient policy for managing SI from the outpatient policy for ease of access.

  • Created specific protocols for managing patients who express SI in each of the following settings:


1.) In-person outpatient visit

2.) Telephone encounter 

3.) Video visit 

4.) MyHealth message

These protocols included the use of SmartPhrases when documenting the Suicide Assessment and Suicide Safety Plan.​

  • Per the Suicide & Self Harm Risk Steering Committee's recommendations, this group shifted from using the Columbia Suicide Severity Rating Scale to the more accurate ASQ (ASK Suicide-Screening Questions) questionnaire as the standard tool for screening patients who express SI. The ASQ, a validated tool for both youth and adults, was developed by the National Institute of Mental Health and consists of four brief suicide screening questions that only take about 20 seconds to administer.

  • Consulted the Emergency Department (ED) Social Work Team for additional resources to leverage, including local county Crisis Support Hotlines, the Mobile Crisis Response Team, the Mental Health Emergency Response Teams, and Alameda County Behavioral Health Services, in addition to creating a safety plan with the patient and their family.

    • Additionally, the ASLC team compiled a list of Mobile Crisis Units and their contact information per county.​


Hazel Kelly, RN, Clinical Nurse IV & Stephanie Orozco, Clinical Nurse II

"Special thanks to Cindy Tse, Director, Clinic Operations and Services Lines for Psychiatry, Sleep Medicine, Integrative Medicine and Dermatology. She included Hazel and I in the taskforce for Suicidal Ideation and Self-harm and has been a key ally in guiding our Emeryville pilot project."

-Stephanie Orozco

Emeryville Ambulatory SLC Members:

  • Laura Moreno, PCC III; ASLC Emeryville Chair-elect

  • Rida Chaloeicheep, PCC II

  • Alicia Flor, RN, Clinical Nurse II

  • Catherine (Cat) Mendes, RN, Clinical Nurse IV

  • Diana Gamino, PCC III

  • Uriel Barraza, PCC II

  • Brie'Onna Spencer, PCC II

  • Rachelle Cabilatazan, PCC IV

  • Georgina Quintana, PCC IV, Alternate

  • Michael Stevens, PCM EHC Multispecialty Clinics; Advisor

  • Kristi Carnahan, APCM EHC Multispecialty Clinics; Advisor

  • Franco Herrera, Director of Clinic Operations; Advisor

The Results

With the goal of improving the health and safety of their patients, Hazel, Stephanie, and the ASLC workgroup successfully created a resource tool for ambulatory staff to utilize when assessing a patient with emotional distress. They also established workflows for when patients express SI via a telephone call, MyHealth message, or in person at a clinic.

Kudos to this team who designed a patient-centered and impactful patient safety project that is strategically aligned to Our Customer: Patient Experience as well as Our Care: Operational Optimization and Value. Stephanie and Hazel's leadership as this project's Task Force Leads has led to meaningful workflow changes that positively impact the lives and safety of SHC's patients.

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