Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities

Report Information

Issue Date
Report Number
16-03808-215
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General Office of Healthcare Inspections completed an evaluation of suicide prevention programs in Veterans Health Administration facilities. The purpose of the review was to evaluate facility compliance with selected VHA guidelines for suicide prevention programs. We conducted this review at 28 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2015, through March 31, 2016. We found that most facilities had a process for responding to referrals from the Veterans Crisis Line and a process to follow up on high-risk patients who missed appointments. Additionally, when patients died from suicide, facilities generally created issue briefs and when indicated, completed mortality reviews or behavioral autopsies and initiated root cause analyses. However, we identified system weaknesses in outreach activities, Suicide Prevention Safety Plan completion, content, and provision of copies, flagging records of high risk inpatients and notifying the Suicide Coordinator of the admission, evaluating high-risk inpatients during the 30 days after discharge, reviewing flagged high-risk outpatients every 90 days, and clinicians completing suicide risk management training within 90 days of hire. We made six recommendations.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.