Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020

Report Information

Issue Date
Report Number
21-01506-76
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Report Topic
Suicide Prevention
Major Management Challenges
Healthcare Services
Recommendations
4
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ selected mental health program requirements. This evaluation focused on suicide prevention coordinator processes, provision of suicide prevention care, and suicide prevention training. This report describes mental health-related findings from healthcare inspections that were initiated at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020, and electronic health record review at five additional facilities. Each inspection involved interviews with facility leaders and staff, and reviews of clinical and administrative processes. The results in this report are a snapshot of Veterans Health Administration performance at the time of the fiscal year 2020 OIG reviews. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key mental health-related processes and issued four recommendations related to: • completion of four follow-up visits within the required time frame, • appropriate follow-up of veterans with high-risk patient record flags who do not attend mental health appointments, • suicide prevention training, and • completion of five monthly outreach activities.

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)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers conduct four follow-up visits, either face-to-face or telephonic with documented patient preference, within the required time frame.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures providers collaborate with suicide prevention coordinators when follow-up contact is unsuccessful for high-risk patients.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that employees complete initial suicide risk and intervention training within 90 days of hire and annual suicide prevention refresher training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all facility suicide prevention coordinators complete at least five outreach activities per facility each month.