Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15

The VA Office of Inspector General (OIG) evaluated the oncology service staff’s adherence to the facility’s psychosocial distress screening standard operating procedure in the care of two patients who died by suicide, and facility leaders’ response to the root cause analyses following the two patients’ deaths. Facility oncology service staff demonstrated compliance with psychosocial distress screening standard operating procedures. However, the OIG was unable to determine if a mental health evaluation completed prior to one of the patients leaving the clinic would have changed the patient’s outcome. Completion of a mental health evaluation may have identified additional risk factors and provided opportunity for suicide prevention interventions prior to the patient leaving the clinic. The National Comprehensive Cancer Network standards of care state a patient should be screened at the initial visit and ideally at every visit. Facility oncology service nursing staff were unclear about when to administer the psychosocial distress thermometer, a self-report tool that evaluates a patient’s distress level, and therefore, administered the tool at every visit. Thus, nursing practice in the facility oncology service exceeded the facility standard operating procedure requirements and provided the National Comprehensive Cancer Network ideal standard of care. The alignment of the standard operating procedure with the ideal standard and current practice is critical to ensure clear guidance to staff regarding the completion of the psychosocial Distress Thermometer. The facility’s Patient Safety Manager did not monitor progress toward root cause analysis action item completion. Following the OIG team’s expressed concern about this deficiency, the Patient Safety Manager implemented a tracking tool that same month. The OIG identified one additional concern. After a patient’s death by suicide in 2017, the Acting Suicide Prevention Coordinator did not complete a Suicide Behavior Report or Behavioral Health Autopsy, as required by Veterans Health Administration.