Department of Veterans Affairs
 

Office of Inspector General
 

Combined Assessment Program
 

Summary Report
 

Re-Evaluation of Suicide Prevention
 

Safety Plan Practices in
 

Veterans Health Administration Facilities
 

Report No. 11-01380-128 March 22, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

Executive Summary
 

The VA Office of Inspector General, Office of Healthcare Inspections completed a

re-evaluation of Veterans Health Administration (VHA) facilities’ suicide prevention

safety plan (SPSP) practices. The purpose was to evaluate the extent VHA mental health

(MH) providers consistently developed SPSPs for patients assessed to be at high risk for

suicide.

Inspectors evaluated SPSP practices at 45 facilities during Combined Assessment

Program reviews conducted from January 1 through September 30, 2010.

VHA facilities recognized the importance of developing comprehensive, timely SPSPs

for high-risk patients. Additionally, VHA issued appropriate timeframes for initiating

SPSPs. However, despite VHA’s efforts to comply with suicide prevention program

requirements, problems with SPSP development continue to occur. We recommended

that the Under Secretary for Health, in conjunction with Veterans Integrated Service

Network and facility senior managers, ensure that MH providers develop and document

timely SPSPs that meet all applicable criteria.

The Under Secretary for Health concurred with the finding and recommendation. The

implementation plan is acceptable, and we will follow up until all actions are complete.

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Under Secretary for Health (10)

SUBJECT: Combined Assessment Program Summary Report – Re-Evaluation of

Suicide Prevention Safety Plan Practices in Veterans Health

Administration Facilities

Purpose

The VA Office of Inspector General, Office of Healthcare Inspections (OHI) evaluated

Veterans Health Administration (VHA) facilities’ practices related to suicide prevention

safety plans (SPSPs). The purpose was to evaluate the extent VHA mental health (MH)

providers consistently developed SPSPs for patients assessed to be at high risk for

suicide.

Background

VHA MH officials estimate that there are approximately 1,600–1,800 suicides per year

among veterans receiving care within VHA and as many as 6,400 per year among all

veterans. VHA and the Centers for Disease Control and Prevention state that a major

predictor for increased risk of suicide is a history of a prior suicide attempt. In

November 2004, VHA implemented the MH Strategic Plan. One of the major goals of

the plan was to reduce suicides among veterans. Since 2006, VHA has implemented

several initiatives aimed at suicide prevention, including establishing the National

Suicide Prevention Center of Excellence, appointing a National Suicide Prevention

Coordinator (SPC), establishing a suicide prevention hotline, developing a distinct patient

record flagging system, and establishing suicide prevention programs in each facility.

In April 2008, the Principal Deputy Under Secretary for Health and the Deputy Under

Secretary for Health for Operations and Management (DUSHOM) issued a memorandum

further outlining actions required for patients identified to be at high risk for suicide.

Among the requirements were that there be a written safety plan, that the plan and the

VA Office of Inspector General 1 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

process for developing it be included in the medical record, and that the patient be given

a copy of the plan.1

In April 2008, VHA requested that OHI evaluate compliance with implementation of

suicide prevention programs during Combined Assessment Program (CAP) reviews. We

reviewed 24 facilities during the period January–June 2009. We reported that although

all 24 facilities had implemented suicide prevention programs that generally met VHA

requirements, program effectiveness could be strengthened by improving documented

collaboration between MH providers and SPCs and by developing comprehensive and

timely safety plans.2 The review showed that 178 (74 percent) of 239 medical records

had documented evidence of safety plans. In August 2009, VHA asked OHI to review

SPSP practices during another cycle of CAP reviews.

At the time of this review, VHA directives did not address an acceptable timeframe for

initiating an SPSP once a patient was designated as high risk for suicide. In July 2010,

VHA issued guidance that SPSPs should be completed prior to discharge from an

inpatient facility or at the next scheduled appointment for those patients seen at

community facilities or followed as outpatients.

Scope and Methodology

We performed this evaluation at 45 facilities during CAP reviews conducted from

January 1 through September 30, 2010. The facilities reviewed represented a mix of size,

affiliation, geographic location, and Veterans Integrated Service Networks (VISNs). We

interviewed selected program managers and reviewed documents, including the medical

records of patients placed on high risk for suicide lists.

We generated an individual CAP report for each facility. For this report, we analyzed the

data from the individual facility CAP reviews to identify system-wide trends. We used

an expectation of 95 percent as our threshold for making recommendations.

Inspectors conducted the reviews in accordance with Quality Standards for Inspection 

and Evaluation published by the Council of Inspectors General on Integrity and

Efficiency.

Inspection Results

Comprehensive safety planning is a clinical intervention that can serve as a valuable

adjunct to suicide risk assessment. “A safety plan is a prioritized written list of coping

strategies and support sources that patients can use during or preceding suicidal crises.

The intent of safety planning is to provide a pre-determined list of potential coping

1 DUSHOM, “Patients at High-Risk for Suicide,” memorandum, April 24, 2008. 2 Healthcare Inspection – Evaluation of Suicide Prevention Program Implementation in Veterans Health 

Administration Facilities January–June, 2009; Report No. 09-00326-223 September 22, 2009.

VA Office of Inspector General 2 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

strategies as well as a list of individuals or agencies that veterans can contact in order to

help them lower their imminent risk of suicidal behavior.”3 The basic components of a

safety plan include:

 Recognizing warning signs that are proximal to an impending suicidal crisis.

 Identifying and employing internal coping strategies without needing to contact

another person.

 Utilizing contacts with people as a means of distraction from suicidal thoughts and

urges.

 Contacting family members or friends who may help to resolve the crisis.

 Contacting MH professionals or agencies.

 Reducing the potential for use of lethal means.

The patient should have input into each step of the plan and should be given a copy of the

agreed upon plan. The plan should be maintained in the patient’s medical record.

Inpatients and outpatients placed on the high risk for suicide list must have a current

SPSP. We reviewed the medical records of 469 inpatients and outpatients placed on the

high risk for suicide list. We found that 412 (88 percent) of 469 medical records had

documented SPSPs. These results indicate improvement compared with 74 percent in

our previous report.

Of the 412 SPSPs, we found that 389 (94 percent) fully addressed the components listed

above. For the remaining records, SPSPs did not contain all the essential elements, such

as contact numbers for family and professionals. In almost all the medical records

reviewed, we found that the patient and/or family members participated in development

of the SPSP. However, we only found documented evidence in 310 (75 percent) of the

412 medical records with SPSPs that the patient and/or family members received a copy

of the plan as required.

Conclusions

VHA facilities recognized the importance of developing comprehensive, timely SPSPs

for high-risk patients. We acknowledge VHA’s issuance of clear timeliness expectations

as a positive action. The SPSPs created were generally comprehensive. However,

completion of SPSPs for all patients on the high-risk list needs improvement.

Recommendation

We recommended that the Under Secretary for Health, in conjunction with VISN and

facility senior managers, ensure that MH providers develop and document timely SPSPs

that meet all applicable criteria.

3 Barbara Stanley and Gregory K. Brown, Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version,

August 20, 2008.

VA Office of Inspector General 3 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

Comments

The Under Secretary for Health concurred with the finding and recommendation. (See

Appendix A, pages 5–6 for the full text of the comments.) The implementation plan is

acceptable, and we will follow up until all actions are complete.

 (original signed by:)

JOHN D. DAIGH, JR., M.D.

Assistant Inspector General for

Healthcare Inspections

VA Office of Inspector General 4 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

Appendix A

Under Secretary for Health Comments
 

Department of

Veterans Affairs Memorandum

Date: March 4, 2011

From: Under Secretary for Health (10)

Subject: OIG Combined Assessment Program Summary Draft 

Report – Re-Evaluation of Suicide Prevention Safety Plan 

Practices in Veterans Health Administration Facilities 

(Project No. 2011-01380-HI-0066) (VAIQ 7080527) 

To: Assistant Inspector General for Healthcare Inspections (54)

1. I have reviewed the draft report and concur with the report’s

recommendation. Attached is the Veterans Health Administration’s corrective

action plan for the report’s recommendation.

2. Thank you for the opportunity to review the draft report. If you have any

questions, please contact Linda H. Lutes, Director, Management Review

Service (10B5) at (202) 461-7014.

(original signed by:) 

Robert A. Petzel, M.D.

Attachment

VA Office of Inspector General 5 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA)

Action Plan

OIG Draft Report, Re-Evaluation of Suicide Prevention Safety Plan 

Practices in Veterans Health Administration Facilities (Project 

No. 2011-01380-HI-0066, VAIQ 7080527) 

Date of Draft Report: February 2, 2011 

Recommendations/ Status Completion 

Actions Date 

Recommendation 

We recommended that the Under Secretary for Health, in conjunction with

VISN and facility senior managers, ensure that MH providers develop and

document timely SPSPs that meet all applicable criteria.

VHA Comments

Concur

The Office of Mental Health Services (OMHS) will identify facilities that

have a safety plan completion below 95 percent. Once the facilities have

been identified, OMHS will forward the list of these facilities to the Office

of the DUSHOM. The DUSHOM will issue a memorandum to those facility

directors requesting each facility to submit an action plan outlining steps to

ensure that mental health providers develop and document timely SPSPs that

meet established criteria. Once the action plans have been received, the

DUSHOM will work with OMHS to ensure that action plans meet

established criteria. After OMHS has approved the action plans, the

DUSHOM will return the action plans to the facility directors and require

the facility directors to certify to the DUSHOM that the actions have been

implemented.

In Process August 30, 2011

VA Office of Inspector General 6 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

Appendix B

OIG Contact and Staff Acknowledgments
 

OIG Contact Christa Sisterhen

Director, Bay Pines Office of Healthcare Inspections

Acknowledgments	 Daisy Arugay

Gail Bozzelli

Vickie Coates

Darlene Conde-Nadeau

Linda DeLong

Dorothy Duncan

Kathy Gudgell

Stephanie Hensel

Frank Keslof

Glen Pickens

Kimberly Pugh

Jennifer Reed

Wilma Reyes

Clarissa Reynolds

Kathleen Shimoda

Barry Simon

Laura Tovar

VA Office of Inspector General 7 
Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities 

Appendix C

Report Distribution
 

VA Distribution

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

National Center for Patient Safety

Office of General Counsel

Office of Medical Inspector

VISN Directors (1–23)

Non-VA Distribution

House Committee on Veterans’ Affairs

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies

House Committee on Oversight and Government Reform

Senate Committee on Veterans’ Affairs

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies

Senate Committee on Homeland Security and Governmental Affairs

National Veterans Service Organizations

Government Accountability Office

Office of Management and Budget

This report is available at http://www.va.gov/oig/publications/reports-list.asp.

VA Office of Inspector General 8