Two Patient Suicides, a Patient Self-Harm Event, and Mental Health Services Administrative Deficiencies at the Alaska VA Healthcare System, Anchorage, Alaska

The VA Office of Inspector General (OIG) conducted a healthcare inspection to review allegations of deficiencies in quality of care and administrative processes that contributed to two patient deaths by suicide and one patient’s self-harm behavior at the Alaska VA Healthcare System’s (facility) outpatient Social and Behavioral Health Services. Facility staff failed to follow missing patient policies and patients did not have follow-up appointments scheduled. However, the OIG was unable to determine that this contributed directly to adverse patient outcomes. The OIG team substantiated that a patient was evaluated by multiple providers; however, the care provided was adequate. The Same Day Access Clinic had gaps in triage staff coverage, lacked morning psychiatric coverage, and providers were sometimes double booked. The OIG did not identify adverse patient events related to coverage or double booking. Facility medical support assistant staff closed scheduling orders without contacting patients and completing proper documentation. Further, the OIG learned that facility leaders identified a backlog of outstanding scheduling orders and did not report scheduling non-compliance to the Veterans Integrated Service Network. Following an OIG request, facility leaders completed a clinical review of all unresolved scheduling orders. The OIG team substantiated that the facility did not have a missed appointment policy and that facility leaders did not implement Behavioral Health Interdisciplinary Program teams. The OIG team did not substantiate that facility leaders failed to implement an electronic wait list or that an unlicensed social worker provided care to a patient. The facility lacked a Mental Health Treatment Coordinator policy as required and leaders established a policy on February 1, 2019, subsequent to an OIG request. Facility staff did not express concerns about personal safety; however, the facility lacked a behavioral health emergency policy and there were opportunities for improved culture of safety. The OIG made 11 recommendations.