Combined Assessment Program: Summary Report Re-Evaluation of Suicide Prevention Safety Plan Practices in Veterans Health Administration Facilities

摘要

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 VHAs 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.