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

The purpose of this review was to re-evaluate the extent Veterans Health Administration (VHA) mental health (MH) providers consistently developed suicide prevention safety plans (SPSPs) for patients assessed to be at high risk for suicide. We 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.