Report Summary

Title: Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities
Report Number: 16-03808-215 Download
Issue Date: 5/18/2017
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Healthcare Inspection Report
Release Type: Unrestricted

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.