The VA Office of Inspector General (OIG) conducted a national review to evaluate the Veterans Health Administration’s (VHA’s) suicide risk screening and evaluation training, adherence, and oversight procedures. VHA’s standardized Suicide Risk Identification Strategy (Risk ID) process requires annual screening using the Columbia-Suicide Severity Rating Scale (screening) and comprehensive suicide risk evaluation (evaluation) in response to a positive screening. VHA also recognized the need for screening beyond annual screening and implemented setting-specific Risk ID requirements in 10 clinical settings.
The OIG found that VHA’s required suicide prevention training does not include Risk ID processes or requirements. Training related to Risk ID responsibilities is available. However, the training is optional and not monitored.
VHA has not established annual or setting-specific Risk ID performance benchmarks and has conveyed inconsistent expectations to facility leaders and staff. In fiscal year 2023, annual screening and evaluation adherence was 55 and 82 percent, respectively. In a November 2020 memorandum, VHA expected 100 percent adherence, while other VHA documents reference expectations ranging from 81 to 95 percent. Furthermore, except for emergency department and urgent care settings, VHA does not monitor setting-specific Risk ID adherence.
The OIG determined that staff encountered barriers to completing Risk ID screening and evaluation, which included (1) limited engagement of facility clinical staff, (2) lack of facility leaders’ support, (3) limitations of performance data, and (4) unclear delineation of responsibilities.
The OIG made six recommendations to the Under Secretary for Health related to suicide risk and intervention training, suicide screening and evaluation performance benchmarks, setting-specific Risk ID monitoring, effectively addressing barriers to Risk ID non-adherence, non-mental health clinical specialty leaders’ awareness of Risk ID requirements, and clear identification of Risk ID monitoring and oversight responsibilities.
