[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                     CARING FOR VETERANS IN CRISIS:
                    ENSURING A COMPREHENSIVE HEALTH
                            SYSTEM APPROACH

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, JANUARY 29, 2020

                               __________

                           Serial No. 116-52

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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                    Available via http://govinfo.gov
                    
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-957                     WASHINGTON : 2022                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York

                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         
                         C  O  N  T  E  N  T  S

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                      WEDNESDAY, JANUARY 29, 2020

                                                                   Page

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member...........................     3

                               WITNESSES

Ms. Renee Oshinski, Deputy Under Secretary for Health for 
  Operations and Management, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5

        Accompanied by:

    Dr. David Carroll, Executive Director, Office of Mental 
        Health and Suicide Prevention, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Mr. Frederick Jackson, Senior Executive Director, Office of 
        Security and Law Enforcement, U.S. Department of Veterans 
        Affairs

Dr. Julie Kroviak, Deputy Assistant Inspector General for 
  Healthcare Inspections, VA Office of Inspector General U.S. 
  Department of Veterans Affairs.................................     7

Dr. C. Edward Coffey, Affiliate Professor of Psychiatry and 
  Behavioral Sciences, Medical University of South Carolina, 
  Charleston, South Carolina.....................................     8

                                APPENDIX
                    Prepared Statements Of Witnesses

Ms. Renee Oshinski Prepared Statement............................    49
Dr. Julie Kroviak Prepared Statement.............................    57
Dr. C. Edward Coffey Prepared Statement..........................    69

                       Statements For The Record

American Legion..................................................   133
American Federation of Government Employees......................   134

 
                     CARING FOR VETERANS IN CRISIS:
            ENSURING A COMPREHENSIVE HEALTH SYSTEM APPROACH

                              ----------                              


                      WEDNESDAY, JANUARY 29, 2020

                     Committee on Veterans' Affairs
                              U.S. House of Representatives
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10 a.m., in room 
210, House Visitors Center, Hon. Mark Takano (chairman of the 
committee) presiding.
    Present: Representatives Takano, Brownley, Lamb, Levin, 
Brindisi, Rose, Pappas, Luria, Lee, Cunningham, Cisneros, 
Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, Radewagen, 
Bost, Bergman, Banks, Barr, Watkins, Roy, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good morning. I call this hearing to order. I 
am not sure whether a quorum is present, but it does not 
matter--so I am informed that a quorum is present.
    Pursuant to Committee Rule 4 and House Rule XI, Clause 2, 
the chair may postpone for the proceedings today and, without 
objection, the chair is authorized to declare a recess at any 
time.
    This committee's top priority is addressing the public 
health crisis of veteran suicide, and this is why the first 
Full Committee hearing of 2020 will explore Veterans Health 
Administration's (VHA's) adherence to policies on suicide 
prevention, care coordination, and medical facility safety and 
environment of care.
    We will also examine training for VA employees to identify 
veterans at risk of suicide, and VA Police's role in 
identifying veterans in crisis on VA campuses.
    Today's hearing is a crucial step toward a truly 
comprehensive approach to reducing veteran suicide by focusing 
on the ways VA can provide a safe, functional, and effective 
environment for veterans in crisis.
    Suicide remains a national crisis. More than 39,000 died by 
suicide in 2017 in the United States and, of these, 6,139 were 
veterans of the United States Armed Forces.
    As Ranking Member Roe astutely noted in a recent interview, 
almost as many veterans due by suicide each day in this country 
than died in combat casualties or accidents in Afghanistan over 
the course of last year. VA estimates that 20 veterans and 
servicemembers die by suicide each day. This is simply not 
acceptable. VA data indicates that of these 20 veterans and 
servicemembers, 20 had received care in the past 2 years from a 
VA--excuse me, six had received care in the past 2 years from a 
VA health care provider.
    Our focus is not only on medical staff directly treating 
veterans in crisis, we need to examine and improve how VA as a 
whole is working to create comprehensive approaches to reduce 
risk and prevent suicides among veterans in its care.
    Thousands of employees across VA work hard every day to 
provide high-quality, life-saving mental health care to 
veterans and to help them access additional supportive 
services. VHA is a leader in suicide prevention research and 
evaluation, and many of VHA's discoveries have informed better 
screening, assessment, treatment, and management for mental 
health and suicide prevention for all Americans.
    VHA has also established many policies and training 
requirements for facility-level leaders, mental health 
providers, suicide prevention coordinators, and other staff.
    These efforts are commendable and credit must be given to 
VA for its work. Yet, since the beginning of 2018, the VA 
Inspector General has published at least a dozen reports on 
facility security, environment of care, and investigations into 
a lack of care coordination at VA facilities.
    According to today's testimony, quote, ``The Office of 
Inspector General (OIG) found inadequate coordination of care 
to be an underlying theme in every one of its recently 
conducted reviews,'' end quote. Whether it was within a mental 
health treatment team, with non-mental health providers during 
the discharge process, or by care providers with patients or 
their family, there was an issue with care coordination.
    In two tragic instances in the Minneapolis VA Medical 
Center, emergency department staff failed to report one 
patient's suicidal ideation to the facility's suicide 
prevention coordinator. In a different case at this very same 
facility, the OIG determined that VA's in-patient treatment 
team failed to coordinate with the patient's out-patient 
treatment team. Both of these incidents showcase a failure in 
care coordination that could have prevented these veterans from 
completing suicide.
    The rate of suicide among veterans in VA's care has been 
steadily increasing over the past decade, despite significant 
investments by VA toward better suicide care. VA spent $64.7 
billion on mental health services in the last decade, including 
almost $9 billion just last year, but we have not moved the 
needle to stem the rate of suicide.
    We cannot tolerate any number of veteran suicides, let 
alone 20 a day. VHA's research discoveries and its policies 
must be put into practice in every VA facility for these 
policies and treatment protocols to be effective.
    I call to mind--I will depart from the script just 
slightly, but if we think about the accident rate in aviation 
and commercial airlines, it is pretty good. This is what I 
think I want this committee and this hearing today to drive at.
    The Centers for Disease Control and Prevention and VA have 
both promoted the use of an evidence-based public health 
approach. It requires VA to define the problem, identify risk 
and protective factors, and develop and test prevention 
strategies. When those strategies are found to be effective, VA 
must ensure that they are widely and systematically adopted.
    For this public health approach to work, VA must ensure its 
hospitals and clinics adhere to uniform environment-of-care 
standards; it must prioritize circumstances for suicide 
prevention coordinators at VA hospitals and clinics to 
coordinate care for veterans in crisis. All, I underscore all 
VA clinicians, along with every other VA employee in every VA 
facility must have the training to identify veterans in crisis 
and be empowered to act to save veterans' lives. VA already has 
dedicated and hard-working staff who believe in the 
organization's mission. By incentivizing staff to speak up, we 
can help VA move toward a culture of continuous quality 
improvement that works to reduce veteran suicide.
    As the Office of Inspector General noted at the West Palm 
Beach VA, the patient safety manager did the right thing and 
reported concerns to leadership about hazards in the in-patient 
mental health unit that represented, quote, ``an immediate 
threat to life,'' end quote, but the employee's concerns were 
dismissed and eventually a veteran died. No employee should be 
discouraged from reporting serious concerns about facility 
safety and, when employees raise concerns, VA leaders need to 
take them seriously.
    In another example, at the Chillicothe VA Medical Center in 
Ohio, a veteran who was supposed to be at arm's reach from a 
facility observer at all times escaped view and jumped from a 
window. The OIG determined VA staff did not adhere to the 
facility observer policy and the facility leadership failed to 
monitor staff compliance. The right policy was in place, but 
the policy was not followed.
    My hope is that today's hearing will expose what must be 
done to ensure uniform adherence to policies, treatment 
protocols, and care coordination at VA hospitals and clinics, 
and how Congress can work with VHA to enforce these standards. 
This is not about holding one single individual accountable; 
instead, our approach must be to understand why policies are 
not being followed, whether training is adequate and utilized 
correctly, and how we can mitigate hazards that represent a 
threat to patients in crisis at VA. This crisis is not new, but 
our solutions and our behavior must be.
    I now recognizing the ranking member, Dr. Roe, for 5 
minutes for any opening remarks that he may have.
    Dr. Roe.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman.
    During today's hearing, we will assess how the Department 
of Veterans Affairs coordinates care for at-risk veterans, 
examining incidences of suicide in VA medical facility, 
including two in-patient suicides at the VA medical facilities 
in West Palm Beach, Florida, as the chairman mentioned, and 
Minneapolis, Minnesota, that were subject to recent reports by 
the VA Inspector General.
    My prayers are with those of loved ones of the two veterans 
and with the loved ones of each of the 20 of their brothers and 
sisters in arms who die by suicide every day in this country. 
Every time a life is lost to suicide, it is a tragedy. When 
suicide occurs in a hospital, a place where the most vulnerable 
go for help, that loss feels particularly acute. VA is a leader 
in suicide prevention in many respects, but if the policies and 
procedures that VA has in place to screen veterans for suicide 
tendencies and ensure their safety while they are receiving VA 
care is not consistently applied, the consequences can be 
deadly.
    Led by Secretary Wilkie, the Trump administration has made 
suicide prevention VA's top clinical priority and call for a 
broad-based public health approach, in recognition of the fact 
that suicide is not solely a mental health problem and that 
preventing it will require addressing the numerous health and 
economic, relational, and other complex factors that cause an 
individual to consider ending their life.
    Mr. Chairman, as you were speaking, something occurred to 
me. We are involved and policies and procedures are important 
in preventing, but we need to move a step back before we get to 
that and prevent it before we ever get to those, if you can see 
what I mean. We are actually at the point where we should be 
preventing a person ever being in the hospital and I think that 
is one of the things we need to work on. That is the rationale 
behind President Trump's Executive Order that created the 
PREVENTS Task Force on March 5th, 2019.
    I welcomed Dr. Van Dahlen, the PREVENTS Task Force 
Executive Director, to my district last month, which we had six 
roundtables and a veterans town hall while she was in Johnson 
City, and discussed the various issues that are involved that I 
just mentioned and what the other task force members are doing 
to break down barriers that prevent at-risk individuals from 
getting the help they need and disseminate best practices for 
suicide prevention across all levels of government and the 
private sector.
    Chairman Takano announced earlier this week that the 
committee will be adopting President Trump and Secretary 
Wilkie's model by tackling the veteran suicide crisis from a 
holistic perspective and aligning our various lanes of effort 
under a single umbrella goal, preventing veteran suicide. We 
have no more important mission and I certainly support that 
effort.
    I also want to note, Mr. Chairman, as we sit here today, 
the Senate Veterans' Affairs Committee is meeting to mark up 
the companion to the Improve Act, General Bergman and 
Congresswoman Houlahan's suicide prevention bill that we spent 
so much time on last fall. Today's hearing will painfully 
illustrate once again just why the Improve Act is so necessary 
and why it must include an ability for suicidal veterans to 
receive some level of clinical care from VA's partners in the 
community, because a veteran in crisis, every door should be 
opened to having them get the help that they need.
    Finally, as we discuss the failures and missed 
opportunities in West Palm Beach and Minneapolis, and other 
locations detailed in the IG's testimony this morning, I don't 
want to underestimate how difficult this work is. Suicide is 
endlessly complex and hindsight is always 20/20.
    I am grateful to the thousands of VA staff around the 
country who do their best every day to serve the veterans who 
are struggling the most. Their work is unquestionably life-
saving. I thank them for doing it and encourage them to stay 
the course and keep fighting the good fight, just as their 
patients did in uniform.
    With that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Roe.
    This morning we will move on to--we will hear from Dr. 
Renee Oshinski, Deputy Under Secretary for Health Operations 
and Management at VA. Welcome, Dr. Oshinski. She is accompanied 
by Dr. David Carroll, Executive Director of the Office of 
Mental Health and Suicide Prevention. Good to see you, Dr. 
Carroll. Mr. Frederick Jackson, Senior Executive Director of 
the Office of Security and Law Enforcement. Welcome, Mr. 
Jackson.
    We also have Julie Kroviak, Deputy Assistant Inspector 
General for Healthcare Inspections, who offer insights about 
gaps and barriers that are plaguing VA's ability to properly 
coordinate care for at-risk veterans and abate hazards that 
represent a threat to suicidal patients on VA campuses.
    Finally, we are also joined by Dr. C. Edward Coffey, 
Affiliate Professor of Psychiatry and Behavioral Sciences at 
Medical University of South Carolina. He is a leading expert on 
achieving system-wide culture change within a health system in 
order to reduce suicide deaths.
    We will begin with Ms. Oshinski. You are recognized for 5 
minutes for your opening statement.

                  STATEMENT OF RENEE OSHINSKI

    Ms. Oshinski. Thank you. Good morning, Chairman Takano, 
Ranking Member Roe, and members of the committee. Thank you for 
the opportunity to come today to discuss the Department of 
Veterans Affairs' policies and procedures related to suicide 
risk and the environment in which we care for those veterans 
experiencing a mental health crisis.
    I am accompanied today by Dr. David Carroll and Mr. 
Frederick Jackson.
    Suicide is a complex issue with no single cause. It is a 
national public health issue that affects people from all walks 
of life. The Centers for Disease Control and Prevention (CDC) 
tells us that deaths by suicide have risen 30 percent across 
the Nation.
    VA has embarked on a journey to become a High Reliability 
Organization, an HRO, to eliminate risk to veterans who receive 
care at the VA. This journey is a long-term commitment to our 
veterans and to our workforce to continuously improve and drive 
to zero harm across VHA, drawing on lessons learned from other 
industries, other health systems, and leading VHA facilities.
    Learning from Dr. Coffey's work, we translate zero harm to 
zero suicides. We have begun a multi-prong strategy that places 
veterans at the center of care from the VA, as well as from 
State and local governments through our Governor's and Mayor's 
Challenges.
    Our Suicide Risk Identification Strategy is the most 
extensive standardized suicide risk screening and assessment 
process in any industry, but we are continuing to research and 
refine to make our tools even better.
    While we are strengthening our community network and 
proactively engaging veterans before crisis, it is imperative 
that we equip staff with the training and tools to intervene 
when veterans present in a mental health crisis. We have a 
network of over 400 suicide prevention coordinators. They 
facilitate the implementation of these strategies within their 
specific catchment areas.
    Unfortunately, there are times when our engagement and care 
coordination is not enough. In those cases, we conduct robust 
reviews of each case with the goal of learning ways to improve 
our care, as we strive to become that High Reliability 
Organization that our veterans deserve.
    An HRO promotes a just culture. We do not blame 
individuals, we generally have to focus on ways that we improve 
the systems that support those individuals. One key area has 
been the review of our physical infrastructure and 
environmental safety, with the focus on reducing hazards that 
are normally associated with suicides.
    In conjunction with our National Center for Patient Safety, 
we developed the Mental Health Environment of Care Checklist. 
This tool is used by interdisciplinary safety inspection teams 
to assess the environment for hazards and determine actions 
that need to be taken to protect our veterans. The rate of 
suicide prior to the implementation of the checklist was 4.2 
deaths per 100,000 admissions, it is now at less than 1 per 
100,000 admissions.
    VHA has recently mandated that all medical centers with an 
acute mental health unit install over-door alarms. All 
facilities are expected to be compliant by the summer of 2020; 
however, most medical centers have already finished the 
installation. This is an example of high reliability. When 
deficiencies are found, VHA has the opportunity to scale 
innovative solutions across the enterprise.
    Our Emergency Departments (ED) are another high-risk area. 
All patients are screened during the visit for suicide and 
homicide risk. The ED directive is being revised to ensure that 
all EDs have at least one psychiatric intervention room. We are 
working toward standardizing our clinical processes in these 
EDs. Many sites have made permanent police officers stationed 
in emergency departments, others patrol them as needed.
    We work with our police force to heighten awareness to 
improve surveillance of parking lots and parking structures. We 
are installing deterrent devices that inhibit self-inflicted 
harm on exposed roofs of parking garages. With increased 
rounding, we can reduce opportunities for suicides when VA 
Police are alerted and can take actions to stop veterans and 
keep them safe from harm.
    Recently, in Cincinnati, a VA police officer working a 
parking detail observed a female veteran attempting self-harm 
on the sixth floor of the garage. After attempts to verbally 
de-escalate the situation, two officers and an employee pulled 
her to safety.
    Collaboration between law enforcement and health care 
professionals is crucial when responding to veterans at risk. 
Our police officers have over 30 hours of classroom training 
specific to de-escalation and conflict management, and continue 
to focus on suicide awareness and prevention. Over the course 
of 2019, VA Police have intervened to stop veteran self-harm in 
many instances, including in Loma Linda, Murphysboro, Detroit, 
and Syracuse.
    All of us are saddened when any person attempts to take 
their life. We appreciate this committee's continued support 
and encouragement as we identify challenges, solutions, and 
opportunities to apply evidence-based practices that result in 
the reduction of death by suicide of our Nation's veterans.
    Thank you for the opportunity today. This concludes my 
testimony.

    [The Prepared Statement Of Renee Oshinski Appears In The 
Appendix]

    The Chairman. Yes. Next is Dr. Julie Kroviak, you are 
recognized for 5 minutes for your opening statement.

                   STATEMENT OF JULIE KROVIAK

    Dr. Kroviak. Thank you. Chairman Takano, Dr. Roe, and 
members of the committee, thank you for the opportunity to 
testify today on a topic that not only impacts veterans and 
their families, but the entire country: Ensuring our Nation's 
veterans receive timely access to the highest quality of mental 
health in a setting that is comfortable, safe, and respectful 
of their privacy and unique experiences.
    Prior to joining the OIG in 2014, I had the honor of 
serving veterans as their primary care physician for over a 
decade at VA. Treating veterans with complex mental health care 
needs not only requires sophisticated clinical skills, but also 
training and compliance with policies and procedures to guide 
seamless coordination of care.
    I witnessed inspirational recoveries and successful 
reintegration into civilian life, but I, like other health care 
providers, also experienced grief and loss when a patient died 
by suicide, despite receiving quality mental health care.
    The OIG shares this committee and VA's priority to improve 
VHA's mental health and suicide prevention capabilities. We 
recognize the significant work VA's dedicated mental health 
providers and other professionals are doing; however, there are 
still considerable challenges.
    VHA's effort in suicide prevention, including the Veterans 
Crisis Line, have been largely directed at crisis intervention, 
but the opportunity to intervene once a person decides on self-
harm is very short, often less than an hour before the actual 
attempt. For veterans, it is even more fraught with peril, 
because they are very likely to use firearms.
    To significantly reduce suicide and improve veterans' 
lives, prompt and effective mental health treatment must be 
paired with a wide variety of additional approaches. For 
example, VA has promoted firearm safety by urging veterans to 
secure guns with locks, remove firing pins, and store firearms 
where they are not easily accessed.
    My written statement discusses numerous reports the OIG 
published in recent years, detailing veterans' challenges in 
accessing and receiving high-quality mental health care within 
VHA. Tragic events such as suicides are the most publicized and 
are typically understood to be the result of unrecognized, 
untreated, or under-treated mental health disorders. Because of 
this, much of our work focuses on the complete health care 
journey of those veterans with a wide variety of mental health 
diagnoses and treatment needs.
    Our reports identified deficiencies in how VHA staff 
coordinated care for veterans in mental health crisis, as well 
as the quality of the environment where veterans receive that 
care.
    On the first point, we found breakdowns in communication 
between members of the mental health treatment team. We also 
found communication failures between mental health and other 
clinical providers, community resource contacts, families, and 
caregivers. Such gaps in communication and care coordination 
weaken effective management and discharge planning, and 
ultimately put patients at risk for serious complications and 
potentially devastating outcomes.
    While policies promoting effective communication may have 
been in place, staffing shortages, inconsistent training, and 
leadership failures compromised patient management.
    We also found risks in the environment where veterans 
receive their care and made many recommendations to VHA aimed 
at ensuring a safer therapeutic setting by correcting 
structural and other hazards that are unique to high-risk 
patient care. The recommendations also support staff and 
visitor safety.
    We take a proactive approach to evaluating the environment 
of care and continuously review site-specific allegations 
related to cleanliness, safety, and facility maintenance. This 
supports VHA's work to maintain a clean and safe, healing, 
recovery-oriented environment, and is even more important in 
areas often associated with high risks of harm to patients such 
as locked mental health units.
    Despite VA's efforts, there are significant challenges 
ahead. VHA must continue to focus attention on outreach 
efforts, providing all stakeholders with evidence-based tools 
that not only help identify high-risk veterans, but also 
encourage those veterans to engage in the care they need.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions you or other members of the committee 
may have.

    [The Prepared Statement Of Julie Kroviak Appears In The 
Appendix]

    The Chairman. Thank you.
    Dr. Coffey, you are recognized for 5 minutes for your 
opening statement.

                 STATEMENT OF C. EDWARD COFFEY

    Dr. Coffey. Good morning, Chairman Takano, Dr. Roe, and 
members of the committee. Thank you for inviting me here today 
to participate in this very important conversation about the 
public health crisis of suicide in our country.
    You requested that I share with you our experiences at a 
non-VA health system in implementing a comprehensive suicide 
prevention strategy, and in my written comments submitted 
earlier I described the work that we began at Henry Ford Health 
System about 20 years ago known as ``perfect depression care.''
    In my comments this morning, I would like to briefly 
describe that model, and then dive into a bit of the detail 
around Zero Suicide and how it might apply as a model for other 
health systems.
    Our adventure began back in 2001 when the Institute of 
Medicine published its groundbreaking report, ``Crossing the 
Quality Chasm.'' You will recall that that report called for a 
sweeping overhaul of America's health care system. It was 
described as badly broken and not repairable; it had to be 
overhauled and transformed. The report also provided a model 
for how we might move forward to create that transformation.
    Now, in response to the report, the Robert Wood Johnson 
Foundation and the Institute for Healthcare Improvement 
launched a national collaborative called Pursuing Perfection, 
and the goal of that collaborative was to incentivize and 
support health care systems to use the Chasm report as a 
roadmap to rapid transformation and dramatically better care; 
indeed, ideal care. I emphasize the word ``ideal'' here because 
they were not looking for better care, that is not going to do 
it, and they were not even looking for best care--what does it 
mean to be the best in a mediocre industry--they were calling 
for ideal care. That was the challenge from the collaborative.
    At Henry Ford, we chose to focus our participation in this 
collaborative on our depression care system, but we struggled 
initially to create a vision for what perfect depression care 
might look like. How would we know if the care was perfect and, 
more importantly, how would our patients know if our depression 
care was perfect? We struggled with this issue for many, many 
weeks. We had focus groups involving our patients, their 
families, community leaders, our system health care leaders. 
And, finally one day, one of our staff spoke up and said, 
``Well, maybe if we were doing perfect depression care, nobody 
would die from suicide.''
    Our room was as quiet as you are now, but that moment 
transformed our department, absolutely transformed our 
department. We began a conversation wherein we recognized that 
this goal might sound unrealistic, might sound impossible, 
might be frustrating, might create problems in some scenarios, 
but we decided that if zero was not the right number for our 
goal, what number could be the right number?
    We began an initiative to transform our mental health care 
delivery system and, to make a long story short, we achieved a 
dramatic and unprecedented reduction in suicide among our 
patients, a 75 percent reduction, that was sustained for a 
decade in Detroit. This was occurring at a time when the rate 
of suicide in the State of Michigan was actually increasing, 
just as it was in the rest of the country.
    This concept of Zero Suicide has been endorsed now by the 
Joint Commission, the CDC; it is embedded in the 2012 National 
Strategy, as you probably know; and a number of organizations 
and governments across the world now are adopting at least 
iterations of this model to try and get a handle on this issue 
of suicide.
    Just now a word about the model and it is described, or 
depicted at least, in this graphic that is being shown and you 
have a copy of it in the written report. There are three 
components to this model and, starting at the base of the 
pyramid, that first component is a radical conviction that 
ideal care is possible.
    Now, this sounds sort of common sense, but, believe it or 
not, there is not a universal belief, at least in mental health 
care, that we can prevent all suicides, that belief does not 
exist. Maybe we need to look at that and challenge that issue. 
If we do not have that conviction, we do not have the energy 
needed to do the relentless work of transformation that is so 
hard and that requires attention each and every day.
    The second element of this model is a roadmap which we call 
``pursuing perfection in a just culture.'' The goal here is to 
set perfection goals, not incremental goals, which we typically 
have done forever in health care.
    For example, if your suicide rate is--I am making up a 
number--ten and your goal is zero, you commit to cutting that 
gap in half in some period of time, in our case it was 12 
months. Zero is the goal, where are we today? We are going to 
cut that in half over the next period of time and that gap we 
will then tackle in the 12 months to cut in half. That is the 
concept of pursuing perfection.
    Now, this is not possible, as Ms. Oshinski mentioned, if 
you do not have a just culture. If you expect people to go up 
to the plate and swing for the fence every time, and then turn 
around when they strike out and punish them, it is not going to 
happen, it is not going to happen. We have to transform our 
systems to look at where the defect occurred at the system 
level, not at the person level.
    We went so far, for example, to take the word ``who'' out 
of our process maps for error reviews, we have removed the word 
``who'' from the document.
    Then, lastly, every member of the team needs to be an 
expert in systems engineering. That is really health care 
today. Health care is a team sport where we work together to 
create systems that reliably produce the best quality care; 
indeed, perfect care.
    I think the model, while initially sounding audacious, has 
application to a number of health care systems, and I think it 
is worthy of further consideration and research. Fortunately, 
research is underway now, sponsored by both National Institutes 
of Health (NIH) and Substance Abuse and Mental Health Services 
Administration (SAMHSA), to look at the essential elements of 
this model and how we might make it even more effective.
    Thank you again for the opportunity to be here today, and I 
am looking forward to our comments.

    [The prepared statement of C. Edward Coffey appears in the 
Appendix]

    The Chairman. Thank you, Doctor.
    I will now recognize myself for 5 minutes for questions.
    After the release of the VA's OIG report on the veteran 
suicide at the VA Medical Center in West Palm Beach, I called 
for a VHA-wide stand-down last September. This was to ensure 
facilities were adhering to their policies and so the employees 
were trained to confidently assist veterans in crisis, and 
raised concerns with facility leadership and have those 
concerns taken seriously.
    In West Palm Beach, we learned that cameras were not 
functioning, and the patient safety coordinator's concerns 
about facility safety were not taken seriously by facility 
leadership.
    Ms. Oshinski, are the security cameras functioning in the 
in-patient unit at West Palm Beach?
    Ms. Oshinski. Thank you, Chairman. Yes, I confirmed that 
the cameras are working both in the acute mental health unit, 
as well as the emergency department.
    The Chairman. How about the door alarms?
    Ms. Oshinski. Yes.
    The Chairman. Thank you. You said in your oral testimony 
that door alarms will be installed in all VHA facilities by 
summer of 2020, but the VA's written testimony says May 2020--
excuse me, March. When will door alarms be installed in every 
VA facility? Can you clear up that discrepancy?
    Ms. Oshinski. Thank you for the opportunity to clear that 
up. One of the things that we have done as we are installing 
this across the enterprise, what we have found is that we no 
longer are able to get the appropriate equipment. The market 
could not--does not have the supply that we need in order to 
retrofit all our facilities.
    For example, places that--I saw an issue briefed just the 
other day that talked about we were supposed to be done, the 
delivery cannot be made. Instead of being done in March, it has 
to be done in May.
    We are working very hard to get this done and hoping, you 
know--and, again, I do have to say probably hoping we are done 
by summer, but it really is dependent on the ability to get the 
appropriate equipment.
    The Chairman. Again, the door alarms are part of VA's own 
standards; is that correct?
    Ms. Oshinski. That is correct. We put this on ourselves, 
because we believe it fits in exactly with what we are talking 
about, zero suicide and zero harm. If you go out to the 
community, you are not going to find as many--when we have to 
send people out, many of those places will not have over-door 
alarms, but we want to be the standard.
    The Chairman. This is an example of you know what to do, 
but we know that knowing it is not the same as being or doing 
it. It is concerning to me that there seems to be so many 
facilities without door alarms. How many facilities out of your 
150-some-odd facilities need door alarms?
    Ms. Oshinski. Every facility with an acute mental health 
unit, I am not sure if Dr. Carroll knows how many of those 
there are, and we probably have completed, I believe, 80 
percent of those now.
    If I could share just a story----
    The Chairman. Sure.
    Ms. Oshinski.--of something that came in on Friday? Is that 
there was an incident at Loma Linda, where a resident----
    The Chairman. Excuse me, I am----
    Ms. Oshinski. Okay.
    The Chairman.--I said yes to the story, but I have got 
limited time and I have got to get to a question to Dr. 
Kroviak.
    Dr. Kroviak, why do facilities continue to struggle with 
adherence to environment-of-care and care coordination 
policies?
    Dr. Kroviak. Thank you. As you have described in your 
opening comments, the policies are in place, but the actual 
work that needs to get done consistently on the front line is 
where the problem usually exists and that is what our reports 
highlight. Most of the reasons stem from staffing shortages, 
inconsistent training, and, ultimately, leadership failures at 
the local level to ensure that the policies are consistently 
played out.
    The Chairman. Staffing shortages, leadership failure, and 
inconsistent training.
    Ms. Oshinski, why are not facilities following policies, 
your own policies?
    Ms. Oshinski. I think there is an effort on the part of 
individuals to follow policies. As we talk about filling 
vacancies, oftentimes new people will come in, we need to 
ensure that we train them at that time and that we continue to 
retrain. I really believe that is a large part of the issue.
    The Chairman. Well, the Government Accountability Office 
(GAO) placed VHA on its high-risk list in part due to this 
problem. This has got to be a bigger priority. We must ensure 
that the six veterans out of the 20 veterans who commit suicide 
a day, who commit them at VA facilities or who are connected 
somehow in the VA's care--you know, I agree with Dr. Roe, we 
need to address the upstream interventions, but we definitely 
need to make sure that the public is assured that the VA is a 
safe place for a veteran who needs critical emergent care to go 
and know that the standards everywhere are at the ideal level.
    Dr. Roe, you are recognized for 5 minutes.
    Mr. Roe. Thank you, Mr. Chairman.
    On the mandatory suicide prevention training, since 1917, 
the last 3 years, all VA employees, both clinical and non-
clinical, are required to undergo mandatory annual training. 
The newly hired clinicians must complete a web-based course 
entitled, ``Suicide Risk Management Training for Clinicians,'' 
I want to take that course. If you all can get that, I want to 
go through it and see what I think about it after I get 
through.
    Dr. Coffey, I want to go over a couple of questions that I 
would like to have for you. Do you have evidence that the 
suicide prevention model that your testimony focuses on has 
been able to achieve sustained reductions in suicide in the 
health care systems where it is being used?
    Dr. Coffey. Well, to State the obvious first, its 
implementation has not been wide at this point in time. There 
are a small number of organizations, Centerstone in Tennessee 
is one, that are reporting results similar to what we saw at 
Henry Ford.
    Now, remember, ours is a quality improvement initiative, it 
is not a controlled experiment. When we talk about evidence, it 
is a different level of evidence. We are doing lots of things 
at one time to try and quickly improve the systems of care.
    It is very hard to say this particular intervention 
resulted in the particular outcome. That is the point of the 
research that is underway currently with NIH and SAMHSA.
    Then others, in addition to Centerstone, there are some 
tribes in the U.S. I think SAMHSA has testified to this 
committee before about some of the work that is being done 
there, and they are also reporting preliminary positive 
results.
    Mr. Roe. The members here have heard me say this many 
times, in the Guard in Tennessee we have a program called Guard 
Your Buddy, which has been shown to reduce suicide by almost 70 
percent, very similar to what you recognize. Given the 
opportunity that significant suicide increases in our country 
among our veterans, the supposed effectiveness of the Zero 
Suicide model that your testimony references, why is the Zero 
Suicide model not more widely known and adopted? Is it just--
and I mentioned to you before we started the committee hearing 
about Dr. Van Dahlen, who is working with the Administration 
through the VA, and they should be in contact with you.
    Dr. Coffey. Well, I do not know the answer to your 
question, obviously. I mean, I guess we could do a study and do 
a survey and find out what is going on.
    From where we sit, a lot of organizations are acknowledging 
an aspirational goal of zero suicide, and I wonder whether that 
is really--that sort of goal is really sufficient to generate 
the traction and the energy that is needed to do this kind of 
work. If we say, well, we would really like to get to zero, you 
know, if everything works out okay, that drives one set of 
behaviors. If we say, nope, we are committed to a nonevent, not 
on our watch, not today, then you have a very different set of 
behaviors that take place.
    I do think there is power in how the goal is conceptualized 
and articulated.
    Mr. Roe. I agree with you 100 percent on that. I mean, my 
goal when a patient came to me who was pregnant was to have a 
healthy baby and a healthy mother, that was my goal every 
single patient I saw.
    I think one of the most distressing statistics I heard 
during our roundtable in Tennessee was that the second-leading 
cause of death between the ages of 10 and 34 is suicide. That 
is an amazing thing. We have seen the rate go up in the 
population in general and I think our veterans are mirroring. I 
mean, we all are living in the same environment.
    When you peel the onion back, you find out it is 
relationship difficulties, it is financial difficulties, it 
could be substance abuse, which could be caused by those first 
two things I mentioned, and that is why I believe we have to 
really get back and reconstitute our mental health 
infrastructure in this country. We dismantled it in the 1970's 
and never really put a place--if you are working in an 
emergency room right now, Dr. Coffey, and you know this very 
well, if you are down there and you see a patient--and I 
applaud the VA for having a place to start the treatment and a 
coordinator that you can hand someone off to--if you are in the 
civilian sector, you are an ER guy in Union City, Tennessee, I 
picked that out, you basically have nowhere to go, and that is 
a sad situation in a country as wealthy as we are and as much 
money as we are spending.
    I think I want to give the VA a shout-out and there are 
some--obviously, we are going over some problems today that the 
VA had, but all in all I think the VA probably has the 
opportunity to be one of the best systems in the country, I 
really believe it, because the resources are there.
    My time has expired. I yield back.
    The Chairman. Thank you, Dr. Roe. Thank you for mentioning 
the dismantling of our infrastructure, mental health 
infrastructure in the 1970's, I agree with you.
    Mr. Lamb, you are recognized for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman. I will kind of pick up 
where Dr. Roe left off.
    Dr. Coffey, could you spell out maybe, what are the 
challenges you would see for a large and kind of powerful and 
distributed organization like VHA in adopting your model or 
beginning to adopt it, how would you recommend that something 
like that even gets started if it was something they were 
serious about pursuing?
    Dr. Coffey. Well, I think they are serious about it and I 
think they are beginning to adopt, as you heard, various 
elements of the model.
    The challenge for any system really begins at the 
leadership level, I think--and I am not singling out the VA 
here, I am just talking in general----
    Mr. Lamb. Right.
    Dr. Coffey.--can leaders get behind a quantitative goal of 
zero defects? I mean, can a culture stand that, can it 
withstand that kind of examination and public statement that we 
are not going to have, let me fill in the blank, a medication 
error in our organization, we are not going to have a patient 
fall in our hospitals, we are not going to have a pregnant 
woman have a problem with her delivery. Zero. I think that is 
the first step.
    Mr. Lamb. Well, and I guess on that, when you talk about 
leadership in an organization as large as VA, there are so many 
different levels of leadership. Like it would be one thing for 
the Secretary to say that at a press conference, it is a whole 
other thing for the person who is really in charge on the 
ground at an individual health center or even community 
outpatient center to be bought into that and supervising it, 
you know, on a day-to-day level. In the military they say 
``inspect what you expect,'' right? I mean, like the person 
would--that is the leader who I am thinking of, the on-the-
ground person.
    How does that change get made, how do you get that person 
bought in to what you are talking about?
    Dr. Coffey. Well, again, I think it is culture building. I 
always think back to the movie Apollo 13. That was one of my 
favorite movies, but if you remember the story there where the 
moon landing had to be canceled and they had to get the capsule 
back to Earth and there was no possible way, according to all 
the scientists, that this was going to happen. In fact, their 
power was going to be 2 days short. It is impossible, it can 
not happen. Every individual in NASA at every level 
participated in bringing that capsule back to Earth safely.
    That participation was driven by, you know, some of the 
famous quotes from the movie, ``Houston, what more can we do? 
Houston, what more can we do?'' That is Tom Hanks' character 
saying that. Of course, on the ground, failure is not an 
option----
    Mr. Lamb. Yes.
    Dr. Coffey.--failure is not an option.
    Mr. Lamb. You talked about Department-wide certification in 
cognitive behavior. What would it take to achieve that in say 
an individual hospital? I guess in terms of like how much 
training, time, and resources are we talking about, in your 
experience, to achieve something like that?
    Dr. Coffey. Right. Well, I will make a point first of all 
that, as I mentioned in my report, we end up not getting the 
grant. We got a small training grant as part of our 
participation, but we were not one of the six finalists who got 
a million bucks to do this, but we were so geeked about the 
whole thing that we decided to pursue it anyway.
    We had zero budget to do this at Henry Ford, we had no 
resources. What we had to do, it had to be----
    Mr. Lamb. Time is your resource at that point.
    Dr. Coffey. It had to be supported by taking something from 
somewhere else that was not adding value and investing that 
resource here where it did add value.
    In the case of department-wide competency in Cognitive 
Behavioral Therapy (CBT), we sent key trainers to the Beck 
Institute, the birthplace of CBT, and got them formally 
certified, and then brought them back and they became the 
trainers on the ground for our team locally. There was an 
expectation by a certain date that every member who engaged in 
the provision of psychotherapy at Henry Ford was going to be 
certified by the institute. That is the way we do it.
    Mr. Lamb. Do you have any estimate of what that means in 
terms of hours, days, weeks?
    Dr. Coffey. It is an intensive process----
    Mr. Lamb. Yes.
    Dr. Coffey.--because the supervision is very intensive. 
There are audio tapes of the session, those are sent to 
Philadelphia, they are critiqued and coached. Now, the model 
may be a little bit different today, I do not know, but it was 
intensive. But most of the staff in Georgia----
    Mr. Lamb. Thank you, sir. I hate to cut you off. Just one 
last question before my time runs out.
    Dr. Coffey. Yes.
    Mr. Lamb. Dr. Oshinski, I think we had a hearing last year 
where Dr. Franklin mentioned that there were 444 suicide 
prevention coordinators on board, but an additional 246 were on 
the way in the hiring process. Do you have any idea where we 
are on those numbers at this point?
    Ms. Oshinski. I would have to take that for the record, 
unless Dr. Carroll has----
    Mr. Lamb. If you would not mind----
    Ms. Oshinski. Yes.
    Mr. Lamb.--just getting back to us. I think we had 444 
active and 246 on the way, if you could just give us an update.
    Ms. Oshinski. Yes.
    Mr. Lamb. Thank you, Mr. Chairman. I yield back.
    The Chairman. Mr. Bilirakis, you are recognized.
    Mr. Bilirakis. Thank you very much. I appreciate it, Mr. 
Chairman. Thanks for holding this hearing.
    Ms. Oshinski, recently the VA committed to proactively 
contacting new transitional servicemembers through the Solid 
Start Program, and your testimony credits this directly to the 
President's 2018 Executive Order focused on mental health for 
transitioning servicemembers and veterans post-separation. What 
type of suicide screening is being done through this program 
and how does VA plan to track its success?
    Ms. Oshinski. Thanks for the opportunity to comment. I 
would actually like to ask Dr. Carroll, if he would, he has 
much more information about the detail of that program to 
address the question you raised.
    Mr. Bilirakis. Okay.
    Mr. Carroll. Thank you, sir. We appreciate the question. 
Solid Start is a transformative initiative that, with your 
support and that of the Administration, VA has undertaken. It 
has taken us a while to build this capability, but within the 
first year after separation from service we are calling each 
transitioning servicemember at least three times.
    To the point of your question, the contacts are checking in 
with the veteran. They are not clinical contacts, it is not a 
clinical interaction with a clinical provider screening them 
for suicide, but it is the caring support, it is making sure 
that they are connected, that they feel connected, that they 
know how to connect to either resources in the VA or the 
community. Then, if they need something or they indicate--you 
know, if there is a crisis, we will hand off, a warm handoff to 
the Crisis Line; if they need some other service from VA, there 
will be a handoff to service--but it is really to remind 
veterans that they are not alone, that the VA is there for 
them, as well as local resources.
    Mr. Bilirakis. Let me ask a question, a clarification, 
because I know we had language in the MISSION Act. Can a 
veteran, can a veteran go to a community health center, a walk-
in clinic, a what have you, to seek private care for mental 
health, mental health counseling, what have you, and would the 
VA reimburse?
    I know there is some language that I have had some 
legislation to strengthen that. Where are we on this, because I 
think it is so very important. If you can not answer the 
question now, please get back to me. You know, has this been 
implemented? How easy is it for a veteran, you know, for 
convenience purposes too, to go to their local community health 
center for mental health treatment?
    Ms. Oshinski. I believe after an initial approval it would 
be very easy, but I would like to confirm that for you for the 
record, to make sure that could someone do it without 
authorization.
    Mr. Bilirakis. Anyone else? Okay. Well, please get back to 
me on this, because I think it is very important that the 
patient, again, the veteran have access to these services.
    One more question. I just had cataract surgery, so forgive 
me, it is tough. Ms. Oshinski, what type of suicide prevention 
materials or training is provided to servicemembers as part of 
the VA's portion of the Transition Assistance Program?
    Ms. Oshinski. Again, I would like to recognize Dr. Carroll 
as our expert on these programs.
    Mr. Bilirakis. Please, Doctor.
    Mr. Carroll. Thank you. Over the last couple of years, the 
Transition Assistance Program has been remodeled or redone in 
collaboration with Department of Defense (DOD), our DOD 
partners, and I think there is an entire day that is focused on 
VA services, on VA care. There is a focus on suicide 
prevention, how to register for care. In fact, we actually ask 
them to complete an application for VA care that can be 
activated as soon as they are separated from service. There is 
information about suicide prevention and how to reach out for 
resources.
    What we are also trying to do is to include information for 
family members, so family members also have that information as 
well. Then these calls that you mentioned earlier, sir, will 
remind them of that opportunity going forward.
    If I may just circle back to your last question for a 
moment. If any veteran ever contacts us, we are going to find 
help for them today. If they come in and whether they are 
registered with us or not, if someone calls us or walks into 
one of our medical centers, we are going to find help for them 
today if they need it.
    Mr. Bilirakis. Okay, that same day?
    Mr. Carroll. Yes.
    Mr. Bilirakis. Okay, that is so very important. Time is of 
the essence in a lot of cases.
    Ms. Oshinski or whoever wants to answer the question, 
whoever is qualified to answer this question, you mentioned--
Ms. Oshinski, you mentioned briefly in your testimony about the 
Whole Health Program. As a strong advocate for this program and 
the use of a public health and whole health wraparound approach 
to suicide prevention, I want to ask, what progress is VA 
making in implementing findings for evidence-based alternative 
therapies that are otherwise outside of VA's traditional mental 
health system?
    I know that my local VA hospital is doing an outstanding 
job with this, the alternative therapies, but I want to see 
this nationwide. Can you--whoever is qualified to answer the 
question, I appreciate it.
    Ms. Oshinski. I can help with that one. Thank you for the 
question.
    Mr. Bilirakis. Okay.
    Ms. Oshinski. Whole Health is currently being expanded 
across our system. We started out with 18 flagships, each of 
the network has been asked to identify two more facilities 
within their network to be able to expand, but also to spread 
across every single facility in the country.
    In the coming year, we will be doing increasing training. I 
can tell you right now, people feel exactly the way you do. 
They can see, whether or not the evidence-based is all out 
there--and I understand we are probably close to being able to 
issue a report with research on that, I have not seen it yet, 
but I understand it is in process----
    Mr. Bilirakis. Yes----
    Ms. Oshinski.--that really shows----
    Mr. Bilirakis.--we have got to get----
    Ms. Oshinski.--that this is something----
    Mr. Bilirakis.--yes, we are waiting for it.
    Ms. Oshinski.--that makes a difference.
    Mr. Bilirakis. Yes.
    Ms. Oshinski. Everybody wants to do it, they are doing it 
whether they are identified as a flagship or not.
    Mr. Bilirakis. All right, very good. Thank you.
    I yield back. Thanks for giving me the extra time, Mr. 
Chairman----
    The Chairman. You are welcome----
    Mr. Bilirakis.--I appreciate it.
    The Chairman.--Mr. Bilirakis.
    Mr. Brindisi, you are recognized.
    Mr. Brindisi. Thank you, Mr. Chairman.
    Ms. Oshinski, just in response to Congressman Lamb's 
question, I also would like to see the numbers on the suicide 
prevention coordinators, because I know in previous testimony 
the former National Director talked about a surge in hiring. If 
you can get that to our office as well, I would love to see 
those numbers.
    Ms. Oshinski. Certainly.
    Mr. Brindisi. Then my main concern, I represent a very 
rural district in upstate New York, and I know you all know the 
challenges of serving veterans in rural communities because of 
the lack of cell phone service, the lack of Internet coverage, 
the transportation and distances to community-based out-patient 
clinics or hospitals.
    Ms. Oshinski or Dr. Kroviak, can you speak to the VA's 
efficiency in reaching veterans who live in rural communities?
    Ms. Oshinski. Thank you for the opportunity to address how 
we reach out to veterans in rural communities. I agree, we have 
tried to make sure that we have community-based out-patient 
clinics whenever we can and that we are expanding our 
telehealth network, but, as you said, we also struggle 
sometimes with the bandwidth that you may have in more rural 
communities.
    We are working with a variety of private sectors folks as 
well. One of the things I would like to highlight is we are 
trying to work with Walmart, because there are Walmarts in very 
many rural communities across the country, is there a way that 
we can do that. That is one of the areas that we are looking 
at.
    Dr. Carroll, would you like to add anything in terms of 
other alternatives?
    Mr. Carroll. One of the things that we have developed 
recently is a program called Together With Veterans. It was 
developed by our team out in Colorado and it is an evidence-
based program to go into rural communities and to help those 
communities recognize and connect and support with their 
veterans in their local communities. We have seen promising 
results from that and we are spreading that across our system, 
in addition to what Ms. Oshinski said about the importance of 
telehealth services.
    Mr. Brindisi. Dr. Kroviak.
    Dr. Kroviak. Yes, if I could add, we are also very much 
aware of the challenges associated with providing care to rural 
veterans, in particular specialty care. We have developed 
several products that are now looking--taking deep dives into 
specialty care coordination for rural vets, as well as the 
expansion and safety of telehealth.
    Mr. Brindisi. What else can we do in Congress to help VA 
reach these veterans, any ideas?
    Ms. Oshinski. Well, certainly we appreciate the support 
that we have from this group and through the funding process. I 
mean, we have worked very hard to try to expand bandwidth 
sometimes and, as you know, it can be difficult in some of 
these more rural areas, so I think the awareness.
    One of the things I think is just so important is that 
really younger veterans in particular love telehealth and I 
think we need to do everything we can to make sure that people 
understand just how effective telehealth can be.
    Dr. Carroll, anything from your standpoint? Okay.
    Mr. Carroll. Thank you.
    Mr. Brindisi. Okay. Then another question I have, Ms. 
Oshinski, you mentioned in your testimony that suicide 
prevention coordinators also do outreach to Guard and Reserve 
units, and they come to mind as one population that could be 
served by VA mental health services. I have introduced 
legislation, it is bipartisan, the Care for Reservists Act, 
that would do just that.
    If Congress decided to expand critical mental health 
services to more populations, what are the challenges you see 
in making that work?
    Ms. Oshinski. Thank you for the opportunity to address 
that. I do not think it is a secret to talk about the fact that 
sometimes the issues of trying to recruit, particularly in 
areas where it may be more--where we may have smaller 
populations, we can struggle with recruitment. I think that 
would be something that we would face. However, obviously, if 
the Congress wanted us to expand those services, we would do 
whatever we could to make sure that that occurred.
    Mr. Brindisi. Do you think that you have staff capacity at 
VA's facilities to serve more veterans?
    Ms. Oshinski. Well, I think we are serving as many veterans 
as we can, we are looking at ways that we can expand that.
    Dr. Carroll.
    Mr. Carroll. As we continue to expand our mental health 
staffing, and we have increased our net mental health staffing 
over the last 2 years, the demand also increases. I think, you 
know, we are hiring to meet the demand, but as demand 
increases, we need to continue to hire.
    Support for our training programs is an important 
component, because that is a major way that we recruit 
providers into our system.
    Mr. Brindisi. Okay.
    Dr. Kroviak. Thank you for recognizing my angst in wanting 
to participate.
    Mr. Brindisi. Thank you, Doctor.
    Dr. Kroviak. I would also really stress the importance of a 
staffing model. It is near impossible to staff up to the demand 
when you have not really measured exactly what you need and 
where you need to spend your dollars in that staffing.
    Mr. Brindisi. Thank you all.
    The Chairman. All right.
    Mr. Brindisi. I yield back.
    The Chairman. Thank you, Mr. Brindisi. Mr. Bost, you are 
recognized.
    Mr. Bost. Thank you, Mr. Chairman. Ms. Oshinski, let me ask 
this. We know that, first off, that zero number that we are 
trying for is very difficult, because so many are not even 
coming in contact with VA. The fact that we have them actually 
committing suicide at the VA is a huge problem. What is being 
done, I know you explained a little bit of it, but when Dr. 
Coffey was giving his testimony, he said that it is the mind 
set of all thinking and understanding that that zero number is 
possible. What is it that we are doing to train our frontline 
staff, and make sure that they have that same attitude?
    Ms. Oshinski. Thanks for the opportunity to address this. I 
think there are several levels of this. First, I think the kind 
of training that we do, the same training, making sure that 
people understand the very most important thing about 
recognizing suicide is the fact that, or preventing it, is 
recognizing when someone is having an issue. It is that direct 
kind of interaction that each and every one of our employees, 
whether they be in a facilities management employee or someone 
who is doing grounds maintenance, those folks sometimes are the 
ones who first run into people outside the emergency department 
or on their way in and will actually bring things to others' 
attention.
    I think we are beginning to get there, but we need to 
continue to do that kind of interaction. I will tell you that 
when a veteran commits suicide on a VA campus, or harms himself 
on a VA campus, as a network director, I used to go in and 
visit the teams, the suicide prevention coordinators and then 
some of the teams. The emotions that came out in those 
meetings, this is the most difficult thing for any provider, to 
lose someone. When you know that VA is there to do something 
good for people, and instead, they harm themselves.
    It is something that every employee at the VA is on the 
alert for.
    Mr. Bost. Dr. Kroviak, in your testimony, you actually 
talked about a particular case where someone that was a high 
risk, the red flag was removed. What are we doing to make sure 
the procedure does not go down that path again?
    Dr. Kroviak. That was a critical recommendation in the 
report you are referencing. In fact, it was the first 
recommendation. We follow up on the recommendations with data 
from VA to show that the changes have been put in place. We 
have not yet closed it. The data that we have been provided has 
not supported sustaining that. Until we see enough data to 
suggest that it has been implemented, corrected over a course 
of time, would we then close that recommendation to say it has 
been satisfied.
    Mr. Bost. Okay. As I said off the start, the worst thing we 
could have is these suicides actually occurring at our 
facilities.
    Dr. Kroviak. Yes.
    Mr. Bost. Manpower, and being informed, and communication 
is vitally important. I know that is part of what you are 
working on, but you brought up an issue that also the people of 
maintenance, it is vitally important.
    I know when reading our report, one of the suicides was the 
fact that a hallway camera was out. In my particular case with 
one of my VAs, which actually does a great job, and that is the 
St. Louis VA and Johns Hopkins, we had a person that actually 
walked into the waiting room at 4 o'clock in the morning, 
actually contacted his nephew, and said what he was going to 
do, because he was angry about the service he received from the 
VA. Laid down on the bench, committed suicide, and it was an 
hour before he was found.
    The implementation and the putting in of those proper 
cameras and making sure that our staff understands and also 
then understanding that our staff needs to be informed for that 
zero policy. These are things that this committee is wanting to 
push so hard to try to reduce this unbelievable level of 
suicide rates. The zero policy for our facilities has got to be 
met.
    I think you are trying anything, and everything that this 
committee can do, let us know. We will continue to have 
oversight of this. Thank you for being here today, and with 
that, I yield back.
    The Chairman. Thank you, Mr. Bost. I associate myself with 
your sentiment toward the end. I agree that we have to drive a 
zero policy at the facility.
    Ms. Luria, you are recognized for 5 minutes.
    Ms. Luria. Well, thank you. Thank you all for being here 
today to talk about this very important issue of veteran 
suicide. I associate myself with my colleagues' comments that 
we all focus and want to provide as much help, assistance to 
the VA to accomplish their mission as possible in this area.
    One of the things that came to my attention in the 
testimony that you provided ahead of today's hearing is that 99 
out of 140 VHA facility directors reported that they had at 
least one severe shortage area in mental healthcare providers. 
I wanted to know how that affected our community.
    I reached out to the director and the staff at the Hampton 
VA in Virginia, and I found out that the vacancy rate at the 
Hampton VA for mental health care providers is 35.5 percent. 
Whereas, the VHA rate in mental health across the country is 10 
percent, roughly. In certain areas, there are zero providers, 
so 100 percent vacancy in that specific field or type of 
provider.
    That made me think, are staffing shortages the reason that 
you are not meeting benchmarks that you feel that you are not 
necessarily able to provide the care, and the time to the 
number of people who might need the care? Just basically, what 
impact is this having on our ability to go after this problem?
    Ms. Oshinski. Thank you for that question. Definitely, the 
issue of trying to recruit the appropriate staff to staff all 
of our mental health units across the country continues to be a 
challenge. As Dr. Carroll mentioned, we have made some 
tremendous progress in the last few years. However, there are 
pockets, and you are mentioning one of those, where we still 
have difficulty trying to bring the staff onto the level that 
we need to support the demand, because you have a very high 
growing area, where we have a lot of veterans who are seeking 
care.
    It is something that we are working on. Dr. Carroll, you 
may have some additional information about that specific site.
    Ms. Luria. Well, and also, as you continue to address this 
in your response, what can we do about the hiring? I understand 
the shortage of mental health care professionals, whether I am 
in a jail, a school, the VA, anywhere in our community there is 
a shortage. But why is the VA not one of their locations of 
choice for employment?
    We have both the Hampton VA and we have two military in-
treatment facility hospitals as well, one of which is 
Portsmouth Naval Hospital. We are constantly losing providers 
between DOD, VA. It takes months to bring someone on board, 
even if they are identified. Just at the administrative level 
with the hiring process, can we not do something to make that 
more efficient? To make it a more attractive place to work? To 
be able to provide health care to these veterans?
    Ms. Oshinski. Just before I turn it to you, Dr. Carroll, a 
couple things just to say. We have an initiative to hire right, 
hire fast. We are really trying to do that, and we would target 
a particular area like Hampton, because of the vacancy rate.
    We are also trying to use all the flexibilities that we 
have in terms of, what are the kinds of incentives that we can 
offer people.
    Ms. Luria. For the hire fast, so I have been to the VA four 
times in the last year, and I hear that it takes them months. 
They have to re-credential someone. I mean, someone might 
already be working for a VA facility in another State. They 
might be working for DOD. They are already working as a health 
care provider in a Federal health care system. Why do we have 
to go back to ground zero and verify every single credential 
when there should already be standard record saying that this 
person meets the standard to be employed by us?
    It is adding months in getting people into a treatment room 
where they can treat veterans who need the care. Can we do 
anything to streamline the process and just get rid of what 
seem like true redundancies?
    Ms. Oshinski. We are taking a close look at the 
credentialing process and what are the things that we can do to 
improve that. You are exactly right. It is challenging and we 
do replicate that information. I think the issue is you never 
want anything to slip through the cracks. We need to tighten up 
our process and make sure, just like everything else, we have 
zero defects when we do this as well as anything else.
    Dr. Carroll, anything else?
    Mr. Carroll. I would just highlight, we have a mental 
health sustainability initiative going on currently, where we 
are looking at not just bringing on new providers, as we want 
to do and we have had success with that, but we are also 
looking at retaining our providers. We have a national program 
to conduct stay interviews, because want to minimize our losses 
and generally speaking, we do fairly well in that regard.
    We are also looking at things like open and continuous 
recruitment for these critical vacancies that you mention.
    Ms. Luria. Well, I will just bring something up about 
retention, and I have found that providers like to work at the 
VA. They like to provide that care. The environment for 
employees at the VA right now is very tense and very stressed, 
especially due to the fact that a lot of them feel like they 
have no recourse as far as some of the executive orders that 
have been passed; the fact that employees are being disciplined 
without the ability to repeal those specific actions; the fact 
that unions basically that represent them, and represent their 
rights, are being kicked out of VA facilities; that time is not 
allowed for the people who represent them.
    I hear this over and over again from long time VA employees 
who want to continue to work there, but they really feel like 
their rights are being infringed on. How do you address that 
with your workforce to make them feel like they can have fair 
representation and fair recourse in employment decisions?
    The Chairman. You may answer the question. Go ahead.
    Ms. Oshinski. Well, I think one of the things that is very 
important to all of us is that people have the opportunity to 
be able to respond to, or raise any concerns that they have. 
That is why we established the Office of Accountability, so 
that there are places for people to go. There are hotlines, 
anything, if they are worried about things that happened.
    I have to say that my preference is----
    Ms. Luria. When you say, ``People,'' is this for employees?
    Ms. Oshinski. For staff, I am sorry. Yes, for staff. I 
apologize for using that terminology. For any of our employees 
to go. I mean, I am hopeful that our leadership is listening 
and that one of the ways that we can learn to better ourselves 
is by listening to our employees and reacting to what they tell 
us to make the environment a better place.
    That is the expectation that I would have of anyone who 
works in our environment.
    Mr. Carroll. Within mental health, we conduct an annual 
mental health staff survey every year, and that is part of our 
metric in terms of how we look at the experience of care. It is 
not just from the veteran's perspective. That, of course, is 
the most important thing. We need to find out from our 
providers, and we do, whether or not they can schedule 
appointments as frequently as they feel that they should, 
whether they feel supported by leadership.
    We ask that annually and we use that in our oversight 
process.
    Ms. Luria. I appreciate the feedback on that. I will just 
tell you from what I hear, from employees at the VA, in our 
region, is they do not necessarily feel that they have that 
outlet. We have new leadership. I am very encouraged by our new 
director and I know that he is working very hard to improve 
that morale, but just as one VA around the country, I just 
wanted to make you aware that there is a significant amount of 
concern amongst the VA employees.
    The Chairman. Ms. Luria. Ms. Luria, we have to move on. 
Thank you. I associate myself with your frustration with the 
hiring process and climate, but we need to move on.
    Ms. Radewagen, you are recognized. By the way, thank you 
for that lovely shirt you sent me. Thank you.
    Ms. Radewagen. Thank you, Mr. Chairman and Dr. Roe. Thank 
you to the panel for appearing today. My question is for Dr. 
Coffey. The suicide prevention approach that you highlight in 
your testimony centers on achieving ideal health care delivery 
and zero incidents of suicide, rates of perfection that I am 
sure many would say are impossible, particularly in a health 
care system as large and complex as VA. In what ways does your 
approach to preventing suicide differ from the suicide 
prevention approach occurring in VA right now? Why do you think 
your approach is not only possible but preferable for our 
Nation's veterans?
    Dr. Coffey. Well, I can not answer the question about what 
is happening in the VA right now, because I do not know. I am 
not privy to the detail of those operations. As I said earlier, 
I firmly believe that everyone that works in the VA is 
committed to eliminating suicide. I have no question about 
that.
    Stepping back, in general in health care, we have the same 
story. Hardworking people, smart people, dedicated to doing the 
right thing. What is getting in the way is terrible, broken 
systems. That is the general issue. That was the issue that was 
called out 20 years ago in the Kazim (phonetic) report. I am 
sad to say that I don't think we are a whole lot further along 
today in fixing some of those fundamental systems issues.
    I think that is the starting point. We have to step back, 
look at these systems, and begin to think about, okay, what 
adds value and what does not. If I may just tag on a question 
that came earlier, which was a wonderful question, and it was 
what could this committee do to help the VA. I thought that was 
fabulous. I get goosebumps thinking about it.
    My boss at Henry Ford asked me the same thing when we 
started our work and when we did not get the grant. I had to 
beg for some time. I went back and thought about it. Then I 
went back to her and said, ``Help us with the bureaucracy. Let 
me bring to you a list of issues that we do not think are 
adding value. We could be wrong, and we may not understand it 
completely based on your perspective. Let us bring you a list. 
If you agree, can we take some of these off the plate? Can we 
stop doing things that, in our view, at the front line, do not 
add value to the care of the patient?''
    That was a blessing from heaven. She stood by that, allowed 
us to make those changes. Perhaps there is some opportunity 
there for the VA.
    I have worked in the VA and I know the challenges that 
bureaucracy in such a system. It is all well-intentioned. It is 
there to try to make things better, but maybe it is a time to 
look at some of that and say, okay, this has outlived its 
usefulness. Let us let the sun set and move on to processes 
that add more value.
    Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you, Ms. Radewagen. Ms. Brownley, you 
are recognized.
    Ms. Brownley. Thank you, Mr. Chairman. I wanted to ask, 
with the way VHA is set up and organized, the medical centers 
have a lot of autonomy. When we are talking about this grave 
issue of suicide and solving that, and you are talking about a 
lot of different programs, different directives, expectations, 
and the like. We know from OIG reports that we have different 
medical facilities who may be out of compliance and not 
fulfilling all of those requests and requirements.
    In an organization as big as VHA is, who has the 
accountability? How do you ensure that each one of those 
medical facilities are in compliance and who are doing what you 
are asking them to do? They even have large controls over their 
budgets. How are you ensuring that they are investing in their 
facilities to meet some of these goals that we are trying to 
attain and reach by actually really reducing the suicide rate?
    Ms. Oshinski. Thank you for that question. One of the ways 
that we do that, obviously, you are right. Each individual 
medical center operates on its own. We have the network 
directors. The Veterans Integrated Service Networks (VISN) 
directors are really responsible for ensuring that we reduce 
the variation and that we, then, make sure that facilities 
across that entire network are complying with what they need to 
do in each of these areas.
    We have a lot of conference calls. We have a lot of 
information that is shared. We have a mental health lead, for 
example, in each network, who will visit each of the medical 
centers and make sure that the things that are happening there 
are consistent with what the policy is across VHA.
    We also have things at the national level. Dr. Carroll's 
office in mental health also looks at the consistency of what 
we are doing across the country.
    Ms. Brownley. The next question I have is in direct 
opposition to Dr. Coffey's philosophy in terms of a new 
approach to all of this. What are the consequences for a 
medical center that is not putting their resources where we 
want them to put them in relationship to suicide prevention?
    Ms. Oshinski. One of the things that I really believe is 
that everybody that--the idea of Zero Suicides and that 
preventing suicide is the VA's No. 1 priority, I believe, is 
shared by every executive across our country.
    I think the issues are less with not doing it, but how is 
it they prioritize some of those things. That is what the job 
of the network and the mental health office is that we need to 
make sure they prioritize that.
    The consequences, the way I would look at it is 
accountability is all about making sure that you have the best 
outcomes for your patients. That if that does not happen, that 
is something that we will be discussing in our evaluation 
process.
    Ms. Brownley. Well, with suicide, we have not moved the 
dial. We are not getting good outcomes. It is--and, I mean, I 
think that is why we are having this hearing and why there is 
such a focus on this. It just seems to me that the system, the 
way it is built right now, is not working the way we would like 
it to. It may be a general patient care, general mental health 
care and the like, but with regard to suicide, we are still 
dealing with the issues.
    I do not have that much more time, and I wanted to ask 
another question. I do not think that we can really solve this 
problem without understanding where the problems lie. I think 
we have, over the last couple of years, we have really started 
to break down of the 20, 21 suicides per day, who are those 
people and what are the demographics?
    I know in the staff report we are saying of that number, it 
is about 16.8 are veterans and 6.3 of those have used the VHA 
facilities. Do we know, of that population, how many are--who 
are women? Who are native veterans? I just visited the Dakotas 
the last couple of days, and suicide in tribal lands is 
disproportional to the rest of the country.
    Do we know who they are, because I believe that we 
probably--well, with native veterans, we are not getting the 
programs that the VA has that are good programs to the tribal 
lands, one. I do believe that there are different ways to 
address suicide, depending on who the population is. I have run 
out of time, so if----
    The Chairman. Witness will answer the question.
    Mr. Carroll. Thank you, ma'am. I will try and do this 
briefly. The Together With Veterans program that I mentioned a 
moment ago will address tribal veterans, and I think that is 
one of the focus of that program.
    In terms of women veterans, we have the programs that you 
know and that you are supporting us on. One of the things that 
we saw in our data report between 2016 and 2017, there was no 
increase among suicide deaths for women who were engaged in VA 
care. Unfortunately, there was no decrease. I think that was a 
point that caught our attention. I think we feel that we may be 
taking steps in the right direction for women veterans in our 
care. We need to see that number, of course, decrease.
    In terms of the question that you asked about other 
veterans. We know, for example, that of those 11 who die by 
suicide everyday, who have not been in recent VA care, at least 
two of them have been previously, and we are putting together a 
program to help them reengage in VA care. We are also looking 
at what we can do more broadly in the population through our 
mayors and Governor's challenge.
    I am happy to talk more about it with you.
    Ms. Brownley. Thank you. I yield back. Thanks for the extra 
time, Mr. Chairman.
    The Chairman. You are welcome, Ms. Brownley. Mr. Bergman, 
you are recognized. General Bergman.
    Mr. Bergman. Thank you, Mr. Chairman. I will just get to 
the point right away. There is nothing more radical than a 
Marine in the fight. Okay? I thank you, Dr. Coffey, for giving 
radical a positive definition, because sometimes when we hear 
terms that it will pop up either a negative or a positive, 
normally when you think of the term radical, it tends to have a 
negative connotation on the front end. I applaud you, because 
if there is one phrase that we have is that we never leave a 
Marine behind, whether it be on the battlefield, or here back 
in the States in their personal environment, because we are 
looking out for him and making every effort to look out for him 
at all times.
    This is a question to the panel. The Improve Well-being For 
Veterans Act is legislation that I introduced to help the VA 
reach out into the community and provide life saving services 
to veterans who do not always make it to the VA or are just not 
within the VA system.
    As originally written, a merit of this legislation was that 
we would not only touch the veterans we were not previously 
reaching, but we would learn from them, and use metrics and 
information gathered, sharing to help the VA and other 
communities understand the many complex factors that lead to 
suicidal ideations. In your view, what is the value of reaching 
veterans in our communities who do not use the VA often or at 
all, or maybe were in it and are out of it, as you just 
referenced, Doctor? Would you agree that the learning that we 
get from these veterans' interactions would assist the VA to 
improve the environment of care, and therefore the results, on 
its own campuses and VA facilities? Anybody want to make a 
comment on that?
    Mr. Carroll. Thank you, sir, for the question and for the 
opportunity to talk about that. We believe that we do need to 
know about veterans in the community. Our commitment in VA 
healthcare, and certainly in mental health and suicide 
prevention in particular, is to serve all of American veterans. 
That is out mission. That is our commitment. It is absolute.
    We need to understand there may be veterans who choose not 
to receive care or services from VA, and we respect that. We 
want to make sure that they are well-connected in their 
community. And we have seen models for----
    Mr. Bergman. It is okay to have other entities that maybe 
are not employees of the VA to actually make those connections?
    Mr. Carroll. We partner with external organizations all the 
time. Yes.
    Mr. Bergman. Anybody else?
    Dr. Kroviak. I would just add from the oversight 
perspective, we are typically focused on the sick veterans that 
are engaged in care, and measuring and monitoring the quality 
of care they receive. We do support outreach efforts, and are 
targeting products that will hopefully be able to support VA in 
their expansion of vet centers, which I think, and we as an 
organization think, will be critical in serving those veterans 
who have not, for whatever reason, chosen not to engage in 
facility care.
    Mr. Bergman. Basically, the overall goal is to engage those 
veterans, who are not engaging with the VA. In some cases, you 
are going to be able to bring them in, because that is going to 
be the right answer for them. In other cases, they are going to 
be outliers, if you will, through tele-health or whatever it 
happens to be. The goal is 100 percent outreach. Whatever we do 
to get that is the VA--it is the right answer, because the VA 
is the valuable partner. You are the big dog here. You are the 
St. Bernard, if you will, in this that is, in the end, going to 
have the overall responsibility.
    Dr. Carroll and Dr. Coffey. Dr. Coffey, you talked about 
the Henry Ford effort. Dr. Carroll, you talked about the 
Colorado effort. What I do not know is the timeframe of those 
efforts. Has there been any, if you will, after action, 
collaborative exchange of data and/or results or lessons 
learned between those two efforts?
    Dr. Coffey. Not that I have been involved in.
    Mr. Carroll. Not those two efforts specifically. I think, 
too, we respect and appreciate so much Dr. Coffey's work. In 
our suicide prevention strategy that was published last year, 
we have tried to incorporate. There are several principles in 
Dr. Coffey's work to incorporate those.
    Together With Veterans program is relatively new. We have 
not been able to crosswalk it yet.
    Mr. Bergman. Okay. Well, again, I see my time is almost up. 
The point is when we look at military operations, we talk about 
intelligence sharing. That comes across all spectrums. Think of 
you two as entities, all of you as different entities, whatever 
that might mean, to share than intelligence, to share that data 
collected. Because sometimes the best example of something 
being done, we just do not see it.
    I will just conclude by an--Dr. Coffey, you said stop doing 
things that do not add value. Okay. Jim Collins, good to great, 
101. Stop doing the things that no longer add value to your 
business model.
    I enjoin VA, like any other entity, do everything you can 
to stop doing the things that do not add value. Identifying--
break a few China bowls, if you will, in the process, because 
there are rice bowls that people love to protect. It is about 
the veteran and it is about the outcome. Mr. Chairman, I yield 
back.
    The Chairman. Thank you, General. Mr. Cisneros, you are 
recognized.
    Mr. Cisneros. Thank you, Mr. Chairman, and thank you all 
for being here today.
    Ms. Oshinski, on May 29th of last year, I led a bipartisan 
letter with my House Veterans' Affairs Committee (HVAC) 
colleagues, Rev. Banks and Rev. Bergman, requesting the VA 
elaborate on DOD and VA's responsibilities for carrying out a 
warm handover of service members from DOD to VA care.
    As you are well aware, the time period after separation 
from service is critical period for service members, especially 
as it relates to the risk for wellness. This is exactly why I 
founded the Military Transition Assistance Pathway Caucus, with 
Rep. Bergman, to build a bipartisan coalition of members 
engages with the Veteran Service Officers (VSOs), veterans, 
service members, and stakeholders to solve and improve.
    Although I appreciate the VA's response to our letter 
highlighting the president's executive order on veteran 
suicide, however, it did not elaborate in detail what is being 
done for a warm handover.
    I ask you today, what exactly is the VA doing specifically 
to this critical period between when a service member leaves 
active duty and transfers to the VA to make sure that those 
that are suffering from maybe suicidal tendencies while they 
were on active duty, get the VA care that they need and it is 
done quickly?
    Ms. Oshinski. Thank you. One of the things that we have 
done, and we mentioned a little earlier, but I think it is 
certainly worth continuing to talk about is the new solid start 
initiative, where we are contacting every service member as 
they leave the service, that they are contacted three times 
during the year that they return to civilian life.
    Each of those, it is really meant to be, as you said, a 
warm handoff. Let us find out what is going on in your life. If 
there are issues, let us connect you. Again, to make sure that 
they understand that VA, and that is all of VA, is there to 
support them.
    They would also be able to refer them to community 
resources. Dr. Carroll, would you like to add anything to that?
    Mr. Carroll. I would highlight two other things. One, for 
certainly the most critically ill people, that we often will do 
a warm handoff between DOD and VA to our trauma centers, our 
Traumatic Brain Injury (TBI) centers. In addition, there is a 
program called, ``In Transition,'' that will hand off 
individuals who are receiving mental health care within DOD, 
directly either to VA or set up a community care appointment 
for them, to make sure that those individuals do not fall 
through the cracks.
    Mr. Cisneros. Right. Where there is also situations where 
service members do not want to self-report that they are having 
any problems, because it might take them out of status, whether 
it be flying or anything else, while on active duty. What is 
the VA doing to help identify those individuals, to give them a 
comfortable place so they can self-report when they come to the 
VA after they leave active duty?
    Mr. Carroll. I would highlight our vet center program is a 
particular resource for those individuals. It has a completely 
separate record system. And at vet centers, many of the 
counselors are veterans themselves. They really have an 
expertise in dealing with combat veterans. Many individuals, 
like the situation you described, find that a welcoming and 
good place to go. We work closely with our vet center partners 
in the health care.
    Mr. Cisneros. I would ask, as Members of Congress, and 
members of this committee, how can we help you out to make sure 
that you have the ability to go out and contact these veterans, 
because most veterans are not going to the VA once they are--I 
should say, once they leave active duty, are not going to the 
VA initially. How do we create that and make it more welcoming 
for them so that they can do this? How can we help in that 
process?
    Mr. Carroll. Sure. We appreciate your support. We 
appreciate opportunities like this hearing and other 
opportunities to talk about that. We talked earlier about 
support for our education, training, and research programs. 
That helps us.
    I think to the point of ensuring--using all of the 
platforms that you have to inform veterans that VA is there for 
them. We are committed to do that. If they contact us, we are 
going to find help either in our system or in their community. 
We need to change together the conversation in America, that 
there is always hope. There is always a way forward for 
someone. That no one is ever alone.
    To Dr. Coffey's point, zero is the right answer and we are 
committed to that. We need to infuse that, not only within our 
health care system, but within the population of veterans that 
we serve.
    Mr. Cisneros. All right. Well, thank you for your answers 
today and use us as a resource in how we can help, because this 
is an issue that we all need to solve and we need to work on so 
that we can get this through and make sure that these veterans 
are taken care of. With that, I yield back.
    The Chairman. Thank you, Mr. Cisneros. Mr. Banks, you are 
recognized.
    Mr. Banks. Thank you, Mr. Chairman. Thanks to each of you 
for being here today to talk about a very important subject.
    It is safe to say that the Suicide Prevention Coordinators 
(SPC) are the face of the VA's efforts to combat veteran 
suicide. Yet, this committee has found that many SPCs report 
being overworked and unable to keep up with any of their 
responsibilities. Late last year, President Trump signed into 
law a piece of legislation that this committee supported that 
required the GAO to review the training, workload, and staffing 
at the VA to ensure that our SPCs have the tools and resources 
they need to assist veterans in crisis. I look forward to 
reviewing those findings in the coming year.
    Dr. Kroviak, in your testimony regarding the incident at 
the Minneapolis VA, you stated that the ``suicide prevention 
coordinator did not collaborate with the inpatient 
interdisciplinary treatment team during the admission.'' Is it 
possible that the SPC at Minneapolis was too overworked to have 
a thorough collaboration with the treatment team?
    Dr. Kroviak. It is certainly possible that that is the case 
and not just unique to that facility. I would also add that 
suicide prevention coordinators are important team members in 
serving as the face of suicide prevention, but we can not 
disregard the other providers and support staff that are also 
critical in combating suicide.
    Mr. Banks. Okay. That is fair and I appreciate that 
feedback, but are there any enforcement mechanisms that exist 
to ensure that staff are informing the SPCs?
    Dr. Kroviak. There are policies in place that guide these 
coordinators, but I would have to defer to VA in terms of 
holding up those policies and recognizing accountability in 
those situations.
    Mr. Banks. I know we do not want to minimize the efforts of 
the SPC.
    Dr. Kroviak. Not at all. We cite many short--or in the 
reports that we found shortcomings, we are very careful to 
assign accountability to those, as well as those that supervise 
and run the facility. It is certainly not belittling their 
role, but recognizing it as part of an important team.
    Mr. Banks. I would prefer you to defer to Dr. Carroll. I 
mean, do SPCs have any responsibilities to double check and 
make sure that nothing is overlooked? I mean, what are some of 
the rules that are governed about how the SPCs operate within 
the team structure?
    Mr. Carroll. Yes. The SPCs are an important part of our 
health care situation. As Dr. Kroviak said, we do not place the 
entire responsibility for suicide prevention on these 450 
individuals. It has to be a team effort. They are the leader 
around suicide prevention, and so they have the responsibility 
to communicate with the team, and the team has the 
responsibility to communicate with them. It is a team based--
that is one of the strengths of our organization is our team 
based structure, both within primary care and mental health.
    Mr. Banks. I get it. I do not want to walk away thinking 
that either of you are minimizing the SPC. What 
responsibilities do they do have? What responsibilities exist 
within the team structure to keep them informed to ensure that 
they are doing their job?
    Mr. Carroll. One of the key responsibilities that the SPC 
has, and they have many, but I will highlight this one, because 
I think it is relevant, is to ensure that any veteran who has a 
high risk flag for suicide on their electronic health record, 
to make sure that that flag gets reviewed every 90 days.
    I think that is a critical responsibility. That helps us 
keep track of individuals who are at highest risk perhaps among 
our population. That is a function that they have. They need to 
make sure that that staff training takes place. They do have 
this outreach responsibility that we talked about as well, to 
interact across the system.
    Mr. Banks. I want to stay on the same subject. I see heads 
nodding, so I wonder if there are others on the panel that want 
to weigh in about how the SPCs can--what responsibilities the 
team has to informing the SPCs? Anybody else?
    Dr. Kroviak. My nod was not specific to that. I would also 
want to recognize, the SPCs play a role in management at a 
later time in the management of the patients. Recognizing the 
care that is required up until the point where they would 
intervene.
    Mr. Banks. Thank you. I have got 30 seconds left. At the 
end of----
    Ms. Oshinski. I just would like to also, and Dr. Carroll 
talked about the outreach. They do have internal things that 
they are doing, but we have been talking about rural health 
care. The SPCs, and I am going to speak particularly to General 
Bergman's area, I have been up there visiting those folks. They 
are out there across the upper peninsula. I think we can not 
minimize the fact, they are part of our public health outreach. 
That is part of their job.
    I think that is going to become more important as we move 
to this multi-pronged approach to try and look at how do we get 
our word out to those 14 who are not seen in the VA, it is 
through those SPCs.
    Mr. Banks. Thank you. My time has expired.
    The Chairman. Thanks. Mr. Levin, you are recognized.
    Mr. Levin. Thank you, Mr. Chairman. I appreciate you 
holding this hearing on this critically important issue to all 
of us.
    I have the honor of serving as the chair of the 
Subcommittee on Economic Opportunity, so I want to focus my 
questions on that intersection.
    Assistant Secretary Oshinski, in your written testimony, 
you emphasize the importance of social determinants of health, 
which, as you note, include economic factors, such as 
employment and housing. The CDC includes strengthening economic 
support as one of its seven core strategies for suicide 
prevention.
    As far as I can tell, none of the goals or objectives in 
VA's national strategy for preventing veteran suicide address 
economic opportunity specifically. I am concerned that perhaps 
you are being too siloed within VHA, so I wanted to ask how you 
can work better together; specifically, how can you connect 
veterans at VHA with the VBA-provided benefits, such as the 
G.I. Bill, vocational training, home loans, and housing 
vouchers.
    In general, can you address how is VHA going to better 
collaborate with VBA on suicide prevention.
    Ms. Oshinski. Thank you for that opportunity.
    I think, again, that Solid Start is the first place that we 
are looking at because VBA is really a key driver in making 
this happen and they are going to be ensuring that we connect 
people right away when they begin to leave the service and 
enter civilian life. I think that is certainly one item.
    We do understand that the economic factors in a veteran's 
life can be a big determinant of what happens in their mental 
health status, so we obviously cannot ignore that. I think we 
are looking at, you know, making sure that veterans have 
housing. We do get involved in helping them with job 
placements.
    Dr. Carroll, would you like to elaborate on some of those?
    Mr. Carroll. If I could mention two things, sir, I think 
within our mental health programs are Compensated Work Therapy 
program and Supported Employment. We want to help veterans, 
particularly those with mental health challenges, find and 
sustain, you know, competitive employment in the community.
    VA is working with, through our Office of Strategic 
Partnership, through our office, working with the Chamber of 
Commerce, also looking at what we can do to support employers 
to hire veterans and to recognize and support veterans within 
their workforce. We are looking beyond just working within our 
own organization--certainly, our partnership with VBA is 
important--but what we can do with the larger community.
    Mr. Levin. Thank you. If there is anything that we can do 
on the policy level to help you better collaborate, we would 
obviously like to entertain that.
    Dr. Kroviak and Dr. Coffey, VHA has set forth several 
policies to identify and mitigate suicide risks, but multiple 
OIG reports have found that those policies are not being 
consistently followed. What can VHA leadership do differently 
to promote policy compliance manage facility staff?
    Dr. Kroviak. Much of our recommendations are focused on 
filling leadership vacancies and other staff vacancies to 
promote consistent training and consistent caring out of those 
policies.
    We have also talked about culture to where we have 
identified in several high-profile reports where staff members 
will complain, will speak up, will say, This is not right, This 
has been consistently not practiced. The culture was such that 
after they complained 5 or 6 times, they stopped because there 
was no action in place.
    Really, supporting, effective leadership responding to 
leadership vacancies and staff vacancies, and, again, I point 
to a staffing model: understanding what you need so you can 
design it to work.
    Mr. Levin. One of the local feedback from local veterans is 
VA, as whole, is doing a good job, but local VA facilities are 
not being held, perhaps, to the metrics or accountability that 
is necessary. Looking at ways to address that, I think, is 
helpful.
    Finally, I want to turn to VA police officers, who I think 
are generally doing a great job playing a key role in de-
escalating difficult situations on VA campuses.
    Mr. Jackson, how many of the 400 hours of training that VA 
police officers receive are specifically focused on suicide 
prevention?
    Mr. Jackson. Yes, sir. Thirty and a half hours are 
definitely focused on suicide prevention and then 24 hours on 
doing scenario-based, because we want to evaluate that you are 
doing the right things in terms of recognizing, de-escalating, 
and identifying.
    As Ms. Oshinski mentioned earlier about the saves that the 
police have done, that is just a few; it has been quite a few.
    Mr. Levin. Mr. Chairman, my last question.
    We have heard a bit about security cameras and the issues 
there, where in one instance, cameras had not been operational 
for 3 years. Who is responsible for maintaining security 
cameras on VA premises and what are we doing to fix these 
issues in the future?
    Ms. Oshinski. Thank you for the opportunity to mention 
that. The facilities director is responsible for making sure 
that the equipment on the site works.
    I think that it is one of the items that the Office of 
Security and Law Enforcement reviews during their reviews, 
whether those be yearly, bi-yearly, or every third year. They 
will oversee to make sure that we are doing that, but it should 
be a facility director responsibility.
    Mr. Levin. Is that something we could do a better job of, 
though?
    Ms. Oshinski. Yes, we certainly can, and I think we are 
working on trying to do that. We have started an initiative to 
look and make sure that our cameras are operational and that 
they are able to be viewed.
    Mr. Levin. I look forward to following up with you.
    I thank the chairman and I thank the colleagues on both 
sides of the aisle. I look forward to working together to 
continue to address this crisis in our country.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Levin.
    Mr. Watkins, you are recognized.
    Mr. Watkins. All right. Thank you, Mr. Chairman.
    Thanks to the panel for being here.
    This question will be for anybody who would like to 
respond. The 22 per day is a raw number. Can someone comment on 
what percent that is--I understand there is somewhere in the 
neighborhood of 21 million veterans--and how that percent 
compares to the general population.
    Mr. Carroll. Yes. Thank you, sir. I am happy to talk about 
that.
    Actually, the daily number that is typically reported is 20 
a day and that includes about one active-duty servicemember, 2 
or so Guard and Reserve, and then 17 individuals who are 
veterans; of those, 6 have been engaged in VA healthcare in the 
year or two prior to their death and 2 of the 11 have been 
engaged in healthcare at some point, and the other 9, not 
engaged with VA. That is how it breaks down.
    What we see in terms of the rate in the population, it is 
about 31 per 100,000. What we have seen between 2005 and 2017 
is there was a significant increase in the American population 
rate of suicide. There were somewhere in the neighborhood of 86 
deaths per 100,000 among American adults in 2005 and it went up 
to 124 in 2017.
    During that period of time there was an increase among 
veterans, the rate, but I do not recall what it was in 2005. As 
I said in 2017, it is 31.
    What happened, though, is that the population of veterans 
went down. The veterans are about 1.5 times more likely to die 
by suicide than individuals in the population.
    Mr. Watkins. All right. Forgive me.
    Just looking at 2017----
    Mr. Carroll. Yep.
    Mr. Watkins.--124 per 100,000 at the national level?
    Mr. Carroll. Yes, Americans.
    Mr. Watkins. Americans, correct.
    But veterans, 31 per 100,000?
    Mr. Carroll. Correct.
    Mr. Watkins. Why is it one and a half more times likely to 
kill yourself if you are a veteran? The numbers do not add up.
    Mr. Carroll. It has to do with the size of the population.
    Mr. Watkins. We are taking the size by taking the 
denominator of 100,000.
    Mr. Carroll. Yes----
    Mr. Watkins. You are----
    Mr. Carroll.--the experts to review the statistics with 
you, sir, but----
    Mr. Watkins. Yes, because it looks to me like it is three 
times more likely if you are a citizen, as opposed to a 
veteran.
    Mr. Carroll. That is--Okay.
    Mr. Watkins. Okay. Thirty-one veterans out of 100,000----
    Mr. Carroll. Yes. In----
    Mr. Watkins.--but 124 citizens out of 100,000.
    Mr. Carroll. Uh-huh.
    Mr. Watkins. There is a denominator, so there is a percent 
there.
    Mr. Carroll. Right. Right.
    The reality is in 2017, 6,139 veterans died by suicide and 
that is the number that we need to get to zero, per Dr. Coffey 
and we would agree with that.
    Mr. Watkins. I just--I understand.
    Mr. Carroll. We would be happy to sit down and walk through 
our whole day report if that would be helpful.
    Mr. Watkins. Sure. I just want to make sure I know what I 
am talking about when I go and look at percentages----
    Mr. Carroll. Yes.
    Mr. Watkins.--because what you just cited me is it is 
roughly three times more likely to kill yourself if you are a 
citizen. That is literally what you just cited.
    I mean, maybe somebody can pull me aside after this, but 31 
out of 100,000----
    Mr. Carroll. We will have to go back, and I may have 
misspoke, sir----
    Mr. Watkins. Okay.
    Mr. Carroll.--so, let me--I will own that. I will go back 
and look at that, but let me----
    Mr. Watkins. All right.
    Mr. Carroll. You are right, that does not make sense.
    Mr. Watkins. The reason is, as a veteran and as somebody 
who has buried friends, I mean I have people approaching me and 
saying, Hey, walk me through this 22 per day, and so I am 
turning to you and asking you to walk me through it. These 
percentages--because I am hearing pushback and what you just 
said is consistent with the pushback.
    You do not need to scramble to find the answer for me right 
now. It is just, I want to----
    Mr. Carroll. I apologize to you and the committee if I 
misspoke----
    Mr. Watkins. That is Okay.
    Mr. Carroll.--on that, sir. We are happy to get that 
right----
    Mr. Watkins. Well, politicians never misspeak, so----
    Mr. Carroll. Well----
    Mr. Watkins.--do not worry about it. We will get to the 
bottom of the numbers. I just eventually want to know what I am 
talking about.
    Mr. Carroll. Yes. We want to make sure you have that 
information and we appreciate your support.
    Mr. Watkins. Of course.
    Yes. Ms. Oshinski, the death of a patient in a VA facility 
is a never event, which means exactly what you think--it should 
never happen--but when it does, what sort of internal review of 
the systems and procedures take place?
    Ms. Oshinski. Thank you. We have a root-cause analysis that 
takes place, which looks at exactly what happened and what are 
the ways--what are the reasons behind that and what are the 
things that need to be done to correct it. That is kind of from 
the investigation side. If we think there is something more 
that needs to be done, an administrative board of investigation 
may be chartered; it depends on what we find as we are looking 
at the situation as we collect the facts.
    However, I think one of the other important things we can 
talk about is the work that we do when this happens with the 
staff or with veterans who may have interacted with those 
individuals. One of the things you find is that veterans 
participate in these groups and when we have one veteran who 
may lose his life, it affects greatly those individuals who 
interact with that veteran. We work on, also, on inventions 
with the staff, as well as veterans who worked together with 
that individual.
    Mr. Watkins. Thanks.
    I am out of time. I yield.
    The Chairman. Thank you, Mr. Watkins.
    Ms. Underwood, you are recognized.
    Ms. Underwood. Thank you, Mr. Chairman.
    As a public health nurse, I know just how important it is 
to advance solutions to the veteran suicide crisis that are 
data-driven and that are evidence-based. Identifying strengths 
and weaknesses in VA care allows us to focus on those areas 
that require the most immediate attention.
    One of those areas is mental health and suicide prevention 
workforce. I understand that vacancy rates among mental health 
clinical staff are critical challenges facing many of our 
communities, including some at VA facilities, so, at the 
outset, I will say that I know that just in a community-based 
setting, this is a problem, okay.
    What actions, Ms. Oshinski, is VA taking to retain staff 
and fill vacancies in the mental health and suicide-prevention 
space?
    Ms. Oshinski. Thank you for that question.
    One of the things that we try to do, again, is make sure 
that people are very well oriented so that they understand 
exactly what--how they are going to interact in that 
situation----
    Ms. Underwood. Oh, yes, ma'am.
    I am sorry. We have limited time, so just, honestly, what 
are you doing to fill the vacancies, if you can?
    Ms. Oshinski. What are we doing to fill vacancies? We have 
open and continuous hiring so that we never close a vacancy. We 
continually put that out there so that anytime anybody wants to 
apply for a job, they have that opportunity--it does not mean 
that a vacancy has to exist--so that we would constantly have 
people able to step in, that they would already be qualified 
and we could hire them--overhire them--and that is something 
that we do on a routine basis when we can do it.
    Unfortunately, as you know, often, there is a gap and we do 
not have those, but open and continuous is certainly one of the 
things that we have done to improve hiring.
    Ms. Underwood. Okay. Thank you.
    Another area is lethal means training.
    Ms. Oshinski. Uh-huh.
    Ms. Underwood. Research backs up the life-saving benefits 
of creating additional space and barriers between a veteran who 
may be experiencing suicidal thoughts or ideations and the 
lethal means for them to complete any suicidal action.
    It is my understanding that VA has implemented lethal means 
training for all VA mental health-care clinicians who interact 
directly with the veterans.
    Dr. Carroll, is that correct, and can you confirm exactly 
which categories of VA staff are currently receiving the lethal 
means safety training.
    Mr. Carroll. I will have to get back to you about which 
categories of employees across the board, but, yes, all mental 
health providers would be required to receive that training.
    Ms. Underwood. Okay. In that response, can you please 
outline, like, clinical and if there is any non-clinical staff 
that are receiving that training----
    Mr. Carroll. Yes, ma'am.
    Ms. Underwood.--and whether it is voluntarily offered or a 
requirement----
    Mr. Carroll. Yes.
    Ms. Underwood.--and sort of some of the details around that 
training would be very helpful.
    Can you also tell us more about the training that the VA 
has developed, like, how often does staff have to receive it--
things like that.
    Mr. Carroll. Yes, the lethal means training is not 
currently an annual requirement, but I think the frequency of 
training, we will get back in our response to you.
    Ms. Underwood. Okay.
    Mr. Carroll. We have also developed a lethal means training 
that is available widely in the community in partnership with 
the American Foundation for Suicide Prevention----
    Ms. Underwood. Uh-huh.
    Mr. Carroll.--as well as the National Shooting Sports 
Foundation.
    Ms. Underwood. Then, to develop that training, was that 
something internal to VA or did you work with outside experts?
    Mr. Carroll. We worked with outside experts.
    Ms. Underwood. Was it just the Sports Foundation or others?
    Mr. Carroll. The American Foundation for Suicide 
Prevention.
    Ms. Underwood. Okay. Then what is your understanding of the 
lethal means safety training that contractors receive and would 
you say that it is equivalent to what the staff receives?
    Mr. Carroll. I would like to take that for the record----
    Ms. Underwood. Okay.
    Mr. Carroll.--so we can make sure we get you the correct 
information.
    Ms. Underwood. Thank you.
    In some instances, some of the veterans in crisis no longer 
require inpatient care supervision by the medical staff at the 
VHA centers. This requires a handoff to another responsible 
party--it might be the veteran's family or other members of 
that veteran's support care network--so, Dr. Carroll, what 
resources are available to families and the support networks 
for the veterans that are at risk for suicide and are they able 
to coordinate with the veteran's clinicians? Are they able to 
access trainings or any other educational resources provided by 
the VA?
    Mr. Carroll. Certainly, family members are part of the team 
that cares for veterans and we respect veterans' wishes in 
terms of having family members engaged in their care----
    Ms. Underwood. Uh-huh.
    Mr. Carroll.--but to the extent that they are a support of 
that, we welcome them to our--into the care process. We also 
have resources available to family members, just like they are 
to veterans, such as the Veterans Crisis Line. We also have a 
program called Coaching Into Care, which is a specific resource 
for families to call, in particular, if their veteran may be 
hesitant or reluctant. It will help----
    Ms. Underwood. Right.
    Mr. Carroll.--the family kind of understand what some of 
the resources are and how they can maybe help that person 
toward getting into care.
    Ms. Underwood. Well, I appreciate that, but that is on the 
front end. I am talking about after someone has already 
received care----
    Mr. Carroll. Oh, Okay.
    Ms. Underwood.--at the VA, they have completed an inpatient 
stay and they need to be discharged. There needs be some kind 
of handoff----
    Mr. Carroll. Yes.
    Ms. Underwood.--to, likely, a community provider.
    What we are seeking to understand is the type of 
coordination that is offered in that handoff and information 
that is being shared to both, family and other clinicians in 
the community or support networks, of which there are plenty--
--
    Mr. Carroll. Right.
    Ms. Underwood.--in many communities around our country.
    Can you speak a little bit about that--I know I am out of 
time--so, maybe you can take that for the record if the 
chairman would allow him to answer?
    The Chairman. Okay.
    Ms. Underwood. Okay. If you would answer?
    Mr. Carroll. Yes, so families--there should be a warm 
handoff when someone leaves an inpatient unit to make sure that 
they have an appointment, you know, for follow up and they 
understand, and in many cases, the provider, if it is within 
our facility, may come on to the unit and may see that patient 
already or have an existing relationship, and the family 
members should be involved. If they are going to the community, 
the community provider needs to acknowledge that they have an 
appointment, and then we would need to follow up to make sure 
that that handoff actually occurred.
    Ms. Underwood. Okay. Then for the record, we will probably 
submit a question, because I think I heard you say that the 
community clinician is allowed in before that handoff occurs to 
the VA facility, so I just want to really drill down on that, 
along with the other questions that we had.
    Thank you so much to our witnesses for being here, I 
appreciate it.
    Mr. Carroll. Thank you.
    Ms. Underwood. Thank you, Mr. Chairman.
    The Chairman. Thank you, Ms. Underwood; as always, you are 
very prepared and I admire your questioning.
    Mr. Barr, you are recognized.
    Mr. Barr. Thank you, Mr. Chairman, and I appreciate you 
holding this hearing on this very important topic.
    I appreciate all of our witnesses for your work on 
preventing veteran suicide, which is just an absolute tragedy 
in our country. As we all agree, it is essential that the VA 
take every step possible to identify and address suicidal risk 
factors for veterans, especially in the care of the VA.
    Before getting to my questioning, Mr. Chairman, I do want 
to raise a concern. On December 12th of last year, I sent a 
letter to you requesting a field hearing in Lexington in our 
district on the topic of equine-assisted therapy; a topic that 
you know I have been passionate about and advocating for 
Congress since--and this has received bipartisan support in 
this committee. Since then, though, my office has not received 
a response on this and our office was told last Friday to be 
expecting a call from your staff regarding the request, and 
despite multiple emails and calls, we have not received an 
answer. Ranking Member Roe has replied in support of the 
hearing, but we are awaiting your support.
    At the VA Medical Center in our district, the veterans 
using equine therapy at the VA are in the Mental Health 
Residential Rehabilitation Treatment Program and I know, Mr. 
Chairman, you have equine-assisted therapy facilities in your 
own district that serve veterans.
    I do think a field hearing on this therapy is in line with 
our suicide-prevention goals in this committee and I would just 
ask, Mr. Chairman--and I will yield to you--can we get a 
commitment that we will get an answer on that.
    The Chairman. Mr. Barr, field hearings, in terms of our 
committee travel budget and our staffing, have been restricted 
to the chairman of committees and the ranking member. We have 
had--we usually have a reciprocal agreement among the chairman 
and the ranking member on top, if they want to choose. I am 
going to have to adhere to that tradition and precedent; 
however, as--so, I cannot support a field hearing.
    I am interested in equine therapy, and I will look at my 
schedule and I will look at--you know, short of a field 
hearing, I can, perhaps, work with you on a visit.
    Mr. Barr. Well, I know you are, Mr. Chairman. I appreciate 
that. I know Chairwoman Brownley is, as well, and I appreciate 
both of you all expressing interest in working with me on that, 
whether we have a field hearing or not.
    Ms. Oshinski, I would like to welcome you and your 
colleagues this morning, and, again, thank you for your work to 
counter veteran suicide.
    I am heartened to hear that since 2017, all VHA employees 
are getting training both, clinical and non-clinical, mandatory 
annual suicide-prevention training. I think it is important 
that we are giving veterans every opportunity to talk about 
suicidal ideations and get the help that they need.
    I have heard, however, from veterans in my district that 
veterans are more hesitant to talk to staff at the VA because 
of a lack of shared experience if those staff are not veterans, 
themselves, and so my question is, would you or any of your 
colleagues see the benefit of a peer-support program enfolded 
within the VA where veterans can process their experiences with 
other veterans?
    Ms. Oshinski. Thank you for that question.
    About a third of our employees currently are veterans, so I 
think there is some possibility there, but we certainly 
recognize and are beginning to incorporate more and more peers 
within our treatment areas. I think, in particular, in mental 
health, we have made a huge effort there, as well as in that 
whole health initiative where we have peer-led groups for folks 
who come and are veterans who want to participate in some of 
those areas.
    Dr. Carroll, would you like to expound on what we are doing 
with peers in mental health.
    Mr. Carroll. Sure. Within mental health we have over 1,100 
peer-support specialists. These are veterans with the lived 
experience of mental health experience, themselves, as well as 
being certified, and we are also incorporating them into our 
primary care----
    Mr. Barr. Well, that is great, and the more the better of 
that; that is the feedback from folks in the Sixth District 
Veterans Coalition.
    Dr. Kroviak, kind of an overview, as the Inspector 
General's Office--overview--you know, I read about this 
terrible tragedy at West Palm Beach--are we getting better 
overall or are we getting worse? What is the trend line?
    Dr. Kroviak. Oversight gives you an incredible perspective 
in terms of how care is being delivered and the consistency 
with which policies are being carried out.
    I think what our work highlights, as it did in West Palm, 
is that there are consistency issues with staff carrying out 
relatively understandable policies and procedures. We fault 
much of that or hold accountable, leadership in those 
situations--the multiple layers: the service line managers, the 
facility directors, up through the VISNs.
    Looking at leadership vacancies, instability of leadership 
and other staff vacancies; it is ripe for issues like we report 
on.
    Mr. Barr. Well, my time has expired.
    Ms. Oshinski, I did just want to commend my friend Mr. 
Levin from California bringing up the VBA and interaction. Some 
of my veterans who are in difficult situations, they--their 
frustrations and their vulnerabilities are compounded by the 
difficulties that they have with their interactions with the 
VBA. I think we need to watch those veterans, particularly, 
that are having trouble interacting with the VBA. Thank you.
    I yield back.
    The Chairman. Thank you, Mr. Barr.
    Mrs. Lee, you are recognized.
    Mrs. Lee. Thank you, Chairman, and thanks for your 
leadership on this incredibly important topic, and thank you 
all for being here.
    As I have sat here and listened to all of your testimony 
and the questions, Dr. Coffey, I have one question for you. The 
Henry Ford Health System--how many hospitals, patients did that 
encompass?
    Dr. Coffey. I can not give you the number of patients. It 
is a very, very large, vertically integrated healthcare system 
in the Midwest. It owns and operates its own Health Maintenance 
Organization (HMO), which is sort of the test tube in which we 
did our measurement for the rates of suicide, but--and that was 
about a half a million people--but the system----
    Mrs. Lee. Half a million people, population?
    Dr. Coffey. In that membership in the HMO----
    Mrs. Lee. HMO, Okay.
    Dr. Coffey.--at one time. The system serves many, many more 
individuals who are not members of the HMO, so----
    Mrs. Lee. Okay. Yes, I just--my question is really around 
sort of the complexity of the VA and the medical centers. We 
have 170 medical centers, 1,400 community-based clinics serving 
9 million vets, and I certainly love the radical idea of 
perfect--a goal of perfect care, and I think that is certainly 
a goal that we should have when we are talking about men and 
women who have served this country to make sure that we are 
getting to a point of zero suicides a day. I certainly believe 
that that should be the goal.
    My question is, as I sit here and listen to all of our 
members ask questions on oversight--we have the OIG--clearly, 
we hear our constituents with their frustration, whether it is 
with the VBA, the VHA, et cetera, and my question to you is 
when you talk about your roadmap, I imagine you were invited 
here because we are intrigued by this concept and are hoping 
that, potentially, we can implement this concept within the VA, 
especially as it pertains to suicides.
    My question is, really, when you think about your roadmap, 
to me, the most part of it is your Just Culture and making sure 
you are asking why and how, instead of who?
    Dr. Coffey. Yes.
    Mrs. Lee. The question I have to you is based on just the 
general concept of how the VA is run, how we provided oversight 
as Members of Congress, do you think that is possible?
    Dr. Coffey. Absolutely.
    Mrs. Lee. Okay.
    Dr. Coffey. Of course it is, absolutely.
    Mrs. Lee. I am glad to hear that. Now, my next question 
is--you know, basically, we have 6 veterans a day who are in 
care of the VA who commit suicide. When you talk about a 
roadmap--when we talk--I feel like this is such an overwhelming 
problem for us, because we are not only dealing with the 6 in 
our care, we are dealing with the 10 who are not in our care, 
and we are looking at the handoff between the DoD and us and 
then those men and women who we failed at the handoff who are 
now in the population who are counting for that, as well.
    I guess my question is, if you were to establish a roadmap, 
would your recommendation be to focus first on the 6 in our 
care and then if we can get to a 75 percent reduction or a 100 
percent reduction, then look at the how do we get those 16 into 
our care----
    Dr. Coffey. Sure.
    Mrs. Lee.--and, you know, I am just trying to wrap my head 
around a roadmap, because I sat here today and listened to the 
suicide-prevention strategy, the mental health sustainability 
initiative, the Solid Start. I mean, it is just so--I feel like 
we continue to pile on and on and on initiatives and yet, 
people who are running these facilities and people who are 
providing the care, and then the culture of when we ask who and 
the accountability and what we are doing about that, I just 
feel like we are on a hamster wheel here.
    If we are, in fact, going to adopt a zero-tolerance, you 
know, a perfect-care policy, I would like to see us look at how 
we are putting that roadmap into place. You know, I am just 
more of a, what steps do we need to take to get to where we 
need to be going?
    I think my question, I guess for Ms. Oshinski would be, 
what is it that this body can do to help promote the type of 
culture that would be needed to implement this type of perfect-
care scenario?
    Ms. Oshinski. Thank you. It is a challenge, and I agree 
with you, we are trying to do very many things.
    I think what we heard today about supporting the Just 
Culture, that this is not about an individual failure; this is 
about how we need to change and work the system. As I said 
before, I can assure you, in terms of accountability, any 
provider or any person who has any interaction with a veteran 
who harms himself is forever remembering what happened.
    I think this committee helping to spread that word that we 
need to make sure that we have a Just Culture, and that when we 
fix things, we are fixing things so that individuals are not 
the issue; the issue is, how do we make the system work for the 
betterment of the most number of veterans that we can?
    I think by having this hearing, this is exactly what we 
need.
    Mrs. Lee. Okay. Any recommendations, Dr. Coffey?
    I am sorry, I am over my time.
    Dr. Coffey. Well, no. I feel you and I agree with all that 
you have said about complexity.
    I can't specifically advise VA on this matter, but as the 
general strategy and what I would recommend is, where is the 
low-hanging fruit? Where is the biggest opportunity?
    You know, I tell my team, There are a thousand things we 
could do this year. There are a hundred things we need to do 
this year. There are three things that we are going to be able 
to do this year, and our job as leaders is to make sure that we 
have identified the correct three things. You just go through 
your priority setting at that point and then go from there.
    But I do think there is a balance between where is the low-
hanging fruit--some quick wins--and then where is the big 
problem that we can begin to sort of chip away at.
    Mrs. Lee. I yield back.
    The Chairman. Thank you, Ms. Lee.
    The Just Culture, that term, I think is very important. I 
want to mention it in light of the fact that we have some 
issues with the VA's Office of Whistleblower Protection. Making 
sure whistleblowers are protected is definitely a part of 
making sure that we have a Just Culture and it is about the 
culture.
    Before we wrap this up, Dr. Roe--and I will also ask him to 
ask questions along the line if I do not get it completely 
answered--but Ms. Oshinski, to the extent possible--and I am 
throwing a curve ball at you because it is a--but I have to 
tell you that 213 passengers who were evacuated from Wuhan 
will--have already landed in the heart of my congressional 
district.
    I did appreciate my chat last night--I had a briefing with 
the under secretary at U.S. Department of Health and Human 
Services (HHS) and an individual at the CDC--but here is what I 
think is of concern for this committee in this jurisdiction. In 
light of a grave public health concern, and I would say even 
threat, what plans are the VA--have the VA begun a planning 
process for taking care of our veterans?
    As you know, we have a fourth mission at the VA, which is 
also disaster preparedness and operating the emergency caches. 
I want to know your thinking in terms of what sort of planning 
is starting to occur already with our primary role of providing 
healthcare to veterans and then we also have a community 
responsibility through our fourth mission.
    Ms. Oshinski. Thank you. Actually, as I left for this 
meeting, I had to leave a planning process for how we are 
dealing with the coronavirus; however, I will tell you that we 
have been monitoring this on open-source, as well as in 
collaboration with HHS, since the initial reports began from 
China.
    We have been identifying what are the requirements that we 
need to have in terms of laboratory testing as these cases 
present themselves. We have widely shared and had a conference 
call yesterday with chiefs of staff across the networks about 
how do we proactively deal with--what are things you need to 
make sure all the providers across your site know.
    We shared last night making sure that all the modules from 
the CDC in regards to education and how we train people were 
distributed to all the medical centers all across the country.
    We are likely going to--as things get closer, we will be 
giving--we are giving out more information and that was part of 
the meeting that I left today--what do we do, as you have said, 
when we have, now, people who are coming back from that part of 
the country?
    Some of them may be providers. Some may be people who are 
within our system. We need to make sure that we are giving out 
the appropriate guidance.
    We have--like I said, we are collaborating daily with HHS 
to find out what is going on and making sure that we are 
following everything that they are putting out and telling that 
to our folks. I think we are being very proactive. I would 
likely see an incident command being set up if we see a more 
significant spread.
    The Chairman. Well, as you know, we have numerous veterans 
in the Philippines, American veterans that utilize the Foreign 
Medical Program, and we also operate a clinic attached to the 
embassy there. We also, in the region, of course, have veterans 
on Guam and the Northern Mariana Islands, so closer in 
proximity to the epicenter of this epidemic.
    Are you plans also taking account of our exposures there?
    Ms. Oshinski. Yes, thank you.
    We are--actually, we have been monitoring the Philippines 
very closely recently with the volcanic activities on that 
island and in our morning meeting, we have been looking at that 
situation on a daily basis for the last 2 weeks. We do continue 
to have monitoring with them.
    The difficulty there with the change in time zones, but we 
have daily interaction with them about where we stand both, on 
the environmental situation there, as well as, what is 
happening with the coronavirus.
    The Chairman. Dr. Roe, do you have anything that you want 
to ask?
    Mr. Roe. Yes, we were--I mentioned this to the chairman 
during this that I hoped the VA--because we have already had in 
our local community, a shortage of gowns and that occurred 
before the coronavirus outbreak. We had to delay some elective 
surgery because of just sterilized paper gowns, a shortage of 
those already.
    This reminded me of a couple of things that occurred that 
was sort of funny. There was a flight from Hong Kong or 
somewhere when the bird flu was going on--maybe it was Ebola--I 
can not remember which of the outbreaks it was--but this guy 
sitting in the airplane said, Well, I think I have this. What 
the airline did with this highly contagious disease is kept him 
on the airplane, but let all the other vectors go that had been 
exposed to it, which could have exposed the whole country to 
this problem. I think educating the public about this is 
extremely important and then being prepared for this, if it 
does.
    What I always did when I went into the operating room was 
prepared for the worst disaster that I could think of, you 
know, a train wreck, and hope I went on a train ride, and I 
think that is what we need to do in this situation.
    Ms. Oshinski. Thank you. You know, one of the things that 
we are doing is we are pulling out the things that we had put 
in place when the last pandemic flu outbreak came around and 
are looking at what we can quickly put into place; again, we 
have the procedures and processes from the last time around and 
I think we can quickly implement the things that we need to do.
    Mr. Roe. This one is a little bit confusing because we do 
not know how it spread, quite frankly, yet. We do not have 
rapid turnaround testing. The CDC has got a nice test, but it 
will take a couple of days to get the results back. That is--
those are the things that we need to beef up.
    Can I just finish my statement and then I will turn it over 
to you?
    The Chairman. Go ahead, sir. Go ahead.
    Mr. Roe. Dr. Coffey, I wanted to compliment you, once 
again, on broken systems. They are a deterrent to us providing 
quality of care, and also what does not bring value.
    I remember as a young doctor, I learned how to do a 
laparoscopy when I was in the Army and I came to Johnson City, 
Tennessee, and I was ready to do my first laparoscopic exam and 
I went in to see this patient before she went in and she had 
been shaved from here to her knees--I mean, there was not a 
hair--and I said, Well, why did we do that?
    They said, Well, that is the way we have always done it.
    I am afraid in healthcare that is a lot of what we do 
because of how we have always done something and never ask 
ourselves: Does this bring any value? Does this added step 
improve quality of care, outcomes, all that?
    We need to step back and look at the whole system--I could 
not agree with you more on that.
    I think the thing, also, that has disturbed me so much is 
that suicide is a national tragedy. It is not just the VA; it 
is a national tragedy for us. We lost--when you hear the 
number--50,000 people died of self-inflicted--either by--
whatever method they chose to utilize to end their life--that 
is bigger than all but two towns in my whole district. I do not 
have a town, but two, that are that large, and I think about 
that when I drive through them, about how many people in 
America have done this.
    Prostate cancer--31,000 people died of it. We have spent, 
you know, billions of dollars trying to cure that.
    Breast cancer--42,000, same thing.
    Colorectal cancer--less than the number of suicides.
    It is a national tragedy and it is going to take--not at 
the thirty-thousand-foot level where we are--but I think you 
are going to have to solve this at the individual and the 
local, grassroots level, just like you did, Dr. Coffey, like 
the VA is trying to do.
    I do believe the public health approach--when Dr. Vandell 
and I were in Johnson City we remembered--you remember the old 
thing, Smokey Bear: Only you can prevent forest fires; we 
taught everybody how to cough; ``Friends Don't Let Friends 
Drive Drunk''--I mean, all those things that are catchy, but we 
need to do that for suicide so that you can look after your 
neighbor and your friend if they are having problems. That is 
where we are really going to have to really reduce the level. 
All these things we are doing are good, but it has got to be 
more organic than that.
    I, personally, am agnostic about where someone gets care. 
When they are extremists and in trouble, I just want them to 
get the best care they can get wherever it may be, and I think 
you all feel the same way.
    We mentioned facilities. I visited the new--of all the 
bumbles and stumbles that it had--out in Denver. They have a 
great inpatient facility there for psychiatric patients that 
really look at how to prevent.
    I think what the VA should do is go to those places that 
have the best practices. Instead of trying to reinvent the 
wheel, take those best practices to each facility--here, this 
is what actually works; do this--and then hold people 
accountable, as I think many of our colleagues have asked.
    Then I do applaud the VA for trying to contact--Dr. 
Carroll, you mentioned this--that is amazing when you put a 
touch on 3 veterans who leave every day. I know when I left the 
military, I just left the military; there was not any touch, 
there was not anything. I applaud the VA for that, but also, I 
will mention that patients share some responsibility to reach 
out to you.
    The VA can not do everything. You have to have the patient 
reach out and then we have to have rapid access to care that 
they need. I think that is one of the things that when the 
patient does reach out that we do not just blow them off--here, 
call 9-1-1 or call the suicide hotline--and leave them hanging.
    I applaud, and I want to thank--the last person I talked to 
when I left was a fellow who was painting my house inside when 
I left and he said, Doc, I just want to tell you, I really get 
great care at the VA.
    I hear that a lot. Through all of its misgivings, I hear 
that a lot, and I want to thank you all for that and everything 
that you are trying to do and all the panel members for being 
here, because I know you are all committed to the same thing 
that we are.
    I yield back.
    The Chairman. Thank you, Dr. Roe.
    Ms. Oshinski, just before I launch into my closing 
statement, Dr. Roe reminded me when he said something about the 
shortage of paper gowns, one of the reasons why there was a 
decision to evacuate Americans and other nationals in Wuhan was 
an understanding that the medical system was highly stressed 
and that if these individuals did get sick, they would be 
facing an overwhelmed system.
    This overwhelm is part of what I am concerned about, the 
ripple effect. The beyond the shortage of these gowns, my 
understanding is that China produces a huge share of our 
medicines and that the production facilities are not far from 
Wuhan, and the VA, as we know, is a major purchaser, a large 
purchaser of these medications and it would be helpful to know 
whether there is a concern of the VA leadership about our 
inventory of important medications, you know, in the planning 
process--if you could get back to the committee with some 
assessment of where we stand with that.
    Ms. Oshinski. Yes, Congressman. I will do that.
    The Chairman. Thank you.
    Again, I would like to thank----
    Mr. Roe. Mr. Chairman, I just referred to my friend Dr. 
Google and it said the FDA estimates that 13 percent of the 
world's Application Programming Interface (API) production 
facilities are in China, compared to 28 percent in the United 
States. It is a huge percentage.
    The Chairman. It is a huge percentage.
    Mr. Roe. Yes.
    The Chairman. I would like to thank the witnesses for their 
appearances today and their testimony.
    The crisis of veteran suicide is not new, but our solutions 
must be, and that is why I introduced the Veterans' Acute 
Crisis Care for Emergent Suicide Symptoms Act, or Veterans' 
ACCESS Act, that will mandate VA cover the costs of emergency 
mental health care for all veterans, regardless of their 
eligibility for VA history or level of service connection.
    No veteran experiencing a mental health crisis should be 
deterred from seeking critical treatment because they fear a 
medical bill. By removing this significant Bayer to care, my 
hope is that veterans can now focus on getting the help they 
need. I look forward to working with all my colleagues, the 
VSOs, and VA, to make this hope a reality for our veterans.
    All members will have 5 legislative days to revise and 
extend their remarks and include extraneous material.
    Again, I thank you for appearing before us today, and this 
hearing is now adjourned.
    [Whereupon, at 12:25 p.m., the committee was adjourned.]

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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                  Prepared Statement of Renee Oshinski

    Good afternoon Chairman Takano, Ranking Member Roe, and Members of 
the Committee. I appreciate the opportunity to discuss the critical 
work VA is undertaking to prevent suicide among our Nation's Veterans. 
I am pleased to be in attendance with Dr. David Carroll, Executive 
Director, Office of Mental Health and Suicide Prevention, and Frederick 
Jackson, Deputy Assistant Secretary, Office of Security and Law 
Enforcement.

Introduction

    Suicide is a complex issue with no single cause. It is a national 
public health issue that affects people from all walks of life, not 
just Veterans. Suicide is often the result of a multifaceted 
interaction of risk and protective factors at the individual, 
community, and societal levels. All of us at VA are saddened by suicide 
among Veterans, and we are committed to ensuring the safety of our 
Veterans, especially when they are in crisis. Losing one Veteran to 
suicide shatters his or her family, loved ones, and caregivers. 
Veterans who are at risk or reach out for help must receive assistance 
when and where they need it in terms they value.
    Thus, VA has made suicide prevention our top clinical priority and 
is implementing a comprehensive public health approach to reach all 
Veterans--including those who do not receive VA benefits or health 
services.
    These efforts are guided by the National Strategy for Preventing 
Veteran Suicide. This 10-year strategy, published in June 2018, 
provides a framework for identifying priorities, organizing efforts, 
and focusing national attention and community resources to prevent 
suicide among Veterans through a broad public health approach with an 
emphasis on comprehensive, community-based engagement. This approach is 
grounded in four key focus areas as follows:

      Primary prevention that focuses on preventing suicidal 
behavior before it occurs;

      Whole Health offerings that consider factors beyond 
mental health, such as physical health, social connectedness, and life 
events;

      Application of data and research that emphasizes 
evidence-based approaches that can be tailored to fit the needs of 
Veterans in local communities; and

      Collaboration that educates and empowers diverse 
communities to participate in suicide prevention efforts through 
coordination.

    Through the National Strategy, we are implementing broad, 
community-based prevention initiatives and clinical intervention driven 
by data to connect Veterans in and outside our system with care and 
support at both the national and local facility levels.

                   Clinical Intervention Strategies:

           Care Coordination Across the Continuum of Services

    VA provides a full continuum of care from crisis intervention 
services, screening, same day access to mental health care, outpatient, 
residential, and inpatient mental health services across the country. A 
2019 RAND study i shows that VA is providing high-quality 
mental health care and that this care can improve recovery rates and is 
cost-effective. Points of access to care span VA Medical Centers 
(VAMC), community-based outpatient clinics (CBOC), Vet Centers, mobile 
Vet Centers, the Veterans Crisis Line (VCL), and through the network of 
Suicide Prevention Coordinators (SPC) and team members available at all 
VAMCs. Veterans and their family members can connect with support 
through in-person appointments at local VA facilities, telehealth 
sessions, and online resources.
---------------------------------------------------------------------------
    i High-Quality Mental Health Care for Veterans: What It 
Means and Why It Matters. Santa Monica, CA: RAND Corporation, 2019. 
https://www.rand.org/pubs/research_briefs/RB10088.html.

VA-Department of Defense (DoD) Collaboration for Suicide Prevention 
---------------------------------------------------------------------------
Care Coordination Among Servicemembers in Transition

    VA collaborates closely with DoD to provide a single system of 
lifetime services for the men and women who volunteer to serve in the 
Armed Forces. Our partnership with DoD and the Department of Homeland 
Security (DHS) is exemplified by the successful implementation of 
Executive Order (EO) 13822, Supporting Our Veterans During Their 
Transition from Uniformed Service to Civilian Life. EO 13822 was signed 
by President Trump on January 9, 2018, and focused on transitioning 
Servicemembers (TSM) and Veterans in the first 12 months after 
separation from service, a critical period marked by a high risk for 
suicide.
    The EO mandated the creation of a Joint Action Plan by DoD, DHS, 
and VA that provides TSMs and Veterans with seamless access to mental 
health treatment and suicide prevention resources in the year following 
discharge, separation, or retirement. VA provides several outreach 
programs and services that facilitate enrollment of Veterans who may be 
at risk for mental health needs, to include VA Liaisons stationed at 21 
military medical treatment facilities as well as multiple outreach 
programs to support engagment in mental health services at VA or in the 
community. Some of our early data collection efforts point toward an 
increase in TSM and Veteran awareness and knowledge about mental health 
resources, increased facilitated health care enrollment, and increased 
engagement with peers and community resources through the Transition 
Assistance Program (TAP) and Whole Health offerings. TAP curriculum 
additions and facilitated enrollment have shown that in the third 
quarter of Fiscal Year (FY) 2019, 86 percent of 11,226 TSM respondents 
on the TAP exit survey reported being informed about mental health 
services.
    VA and DoD are committed to delivering compassionate support and 
care, whenever and wherever a Servicemember or Veteran needs it. This 
includes collaborating to implement programs that facilitate enrollment 
and transition to VA health care; increasing availability and access to 
mental health resources; and decreasing negative perceptions of mental 
health problems and treatment for Servicemembers, Veterans, and 
providers. The most recent coordinated effort under EO 13822 began in 
December 2019, when VA launched the Solid Start call center, which 
proactively contacts all newly separated Servicemembers at least three 
times during their first year of transition from the military.
    Although EO 13822 was established to assist in preventing suicide 
in the first-year post-transition, the completed and ongoing work of 
the EO effects suicide prevention efforts in the years following a 
Servicemember's transition. These efforts are demonstrated through 
increased coordinated outreach, improving monitoring, and increasing 
access to care beyond the first year. VA is working diligently to 
promote wellness, increase protection, reduce mental health risks, and 
promote effective treatment and recovery as part of a holistic approach 
to suicide prevention.

Care Coordination for Veterans at Risk of Suicide Across the Continuum 
of Care: The Role of Suicide Prevention Coordinators

    Within the VA system, there is currently a network of over 400 
SPCs. Overall, SPCs facilitate the implementation of suicide prevention 
strategies within their respective VAMCs and catchment areas to ensure 
that all appropriate measures are being taken to prevent suicide in the 
Veteran population, particularly Veterans identified to be at high risk 
for suicidal behavior. As an integral part of Veterans' care teams 
implementing VA suicide prevention programs, SPCs are experts on 
suicide prevention best practices. SPCs work closely with other 
providers to ensure that Veterans living with mental health conditions 
and experiencing difficult life events receive specialized care and 
support for their suicide risk.
    SPCs also plan, develop, implement, and evaluate their facility's 
Suicide Prevention Program to ensure continual quality improvement and 
excellence in customer service. This work affects a wide range of 
agency activities and operations and directly affects the health and 
well-being of the Veterans served and relationships with community 
organizations and stakeholders.
    An essential role of SPCs is to participate in outreach activities 
in local communities to increase awareness of suicide prevention and 
the resources available in the local community (a minimum of five 
events per month with increased efforts during September's Suicide 
Prevention month). These outreach activities include: (1) community 
suicide prevention trainings and other educational programs; (2) 
exhibits and material distribution to a wide variety of organizations 
and populations; (3) meetings with State and local suicide prevention 
groups, collaborations with Vet Centers, local Veterans of Foreign Wars 
(VFW) and American Legion branches; and (4) suicide prevention work 
with Active Duty/Guard/Reserve units, college campuses, and American 
Indian/Alaska Native groups.

Suicide Prevention Crisis Services and Follow-up Care Coordination: VCL 
and Emergency Department

    Established in 2007, VCL provides confidential support to Veterans 
in crisis. Veterans, as well as their family and friends, can call, 
text, or chat online with a caring, qualified responder, regardless of 
eligibility or enrollment for VA care. VA is dedicated to providing 
free and confidential crisis support to Veterans 24 hours a day, 7 days 
a week. VA has streamlined and standardized how crisis calls from other 
locations within VA reach VCL, including full implementation of the 
automatic transfer function that directly connects Veterans who call 
their local VAMC to VCL by pressing a single digit (7) during the 
initial automated phone greeting. SPCs also assist in coordination of 
follow-up referrals for Veterans after they call the VCL by assisting 
Veterans with accessing VHA care and assisting with evaluation, 
treatment, and or referrals to community-based care for those who 
decline VA services or are ineligible for services.
    Veterans in crisis not only present to the VCL but also present in 
VA emergency departments (ED). Suicide Prevention in Emergency 
Departments (SPED) is an evidence-based strategy currently being 
deployed in VA. Veterans presenting to the ED, or for VA urgent care, 
who have been assessed as at risk of suicide, but are safe to be 
discharged home, receive suicide safety planning intervention prior to 
discharge and follow-up outreach to facilitate engagement in outpatient 
mental health care. Safety planning interventions (SPI) in EDs provide 
safety planning and lethal means counseling prior to discharge and 
follow-up contact after discharge with the Veteran to offer support 
until he/she has connected with outpatient mental health providers. 
Implementing an SPI and follow-up phone call for patients who visited 
participating VA EDs for suicide-related concerns reduces suicidal 
behaviors by almost half (45 percent) in the 6 months following the ED 
visit.ii
---------------------------------------------------------------------------
    ii Stanley, Brown, Brenner, Galfalvy, Currier, Knox, 
Chaudhury, Bush, and Green 2018. Comparison of the Safety Planning 
Intervention With Follow-up vs Usual Care of Suicidal Patients Treated 
in the Emergency Department. Journal of the American Medical 
Association, 75(9):894-900. Published online July 11, 2018.

Suicide Risk Identification Process: Screening to Enhance Access to 
---------------------------------------------------------------------------
Treatment and Care Coordination

    In addition to providing suicide prevention services during the 
time of crisis, VA provides proactive methods for identifying 
individuals at high risk for suicide. VA has implemented a standardized 
suicide risk screening and assessment process, providing Veterans with 
a high standard in preventive care. This process, known as the Suicide 
Risk Identification Strategy (Suicide Risk ID), was introduced in May 
2018. The Suicide Risk ID is for all Veterans receiving VA care. The 
strategy is comprised of three components and implements population-
based mental health screening for those with unrecognized risk 
(universal screening), for those who may be at risk (selected 
screening), and for those at elevated risk (indicated screening). The 
components include standardized primary and secondary screens specific 
to risk of suicide and a comprehensive suicide risk evaluation for 
Veterans with a positive secondary screen. Screenings occur at every ED 
and urgent care visit across VA. For Veterans presenting for other VHA 
services, VA has setting-specific guidance for screening and 
assessment.
    The Suicide Risk ID integrates the recently published (2019) VA/DoD 
Clinical Practice Guideline for the Assessment and Management of 
Patients at Risk for Suicide (CPG). CPG is an update to the 2013 
guideline and outlines five recommendations on screening and 
evaluation; the Suicide Risk ID uses part of the CPG's recommendations, 
including comprehensive screening, specifically:

      The use of a validated screening tool for universal 
screening to identify individuals at risk for suicide-related behavior;

      The use of the Patient Health Questionnaire-item 9, and

      An assessment of risk factors as part of a comprehensive 
evaluation of suicide risk.

    From October 1, 2018, through December 4, 2019, more than 4.1 
million Veterans have received a standardized risk screening.

Same Day Access: Getting to Care when Care is Needed

    A critical part of suicide prevention is ensuring same day access 
to mental health services. VA launched the My VA Access Initiative in 
2016. This initiative provides same day access to primary care and 
mental health services. In mental health care clinics, the number of 
same-day scheduled appointments increased from 796,242 in Fiscal Year 
2017 to 824,276 in Fiscal Year 2018. The percentage of new patients 
with same-day appointments increased from 29.5 percent (FY 2017) to 
33.2 percent (FY 2018).

Suicide Prevention in Primary Care: Reaching Veterans through Early 
Identification

    VA's Primary Care Mental Health Integration (PCMHI) is an 
initiative that provides collaborative care with embedded mental health 
providers within primary care clinics and collaborative care 
management. Through PCMHI, primary care providers are critical partners 
in VA suicide prevention strategies. The PCMHI model provides open 
access to Veterans, as well as mental health consultative advice to 
Primary Care staff, assessment, and brief interventions in a stepped 
approach within the Veteran's local health care clinic. Early 
identification, accurate diagnosis, and effective treatment of mental 
health conditions improves the chances for recovery.
    As a result, VA primary care providers screen Veterans for 
depression, posttraumatic stress disorder (PTSD), problematic alcohol 
use, and difficulties related to military sexual trauma. It also 
provides an opportunity to deliver mental health services to those who 
may otherwise not seek them and identify, prevent, and treat mental 
health conditions at the earliest opportunity. Making mental health 
care a routine part of primary care helps reduce stigma and provides 
the right intensity of care to the Veteran as quickly as possible.

Suicide Prevention and Care Coordination through Outpatient Mental 
Health Services

    Each Veteran receiving ongoing VA specialty mental health care is 
assigned a Mental Health Treatment Coordinator (MHTC) who ensures 
continuity of care and provides the Veteran with a consistent and 
reliable point of contact, especially during times of care transitions. 
The MHTC serves as a clinical resource for the Veteran and staff, 
generally as part of the Veteran's assigned mental health care team.
    In addition, VA facilities throughout the country are utilizing 
teams to promote Veteran-centered, coordinated care to support 
recovery. One model for this team-based care is the Behavioral Health 
Interdisciplinary Program (BHIP), which coordinates collaborative, 
evidence-based, Veteran-centered care by an interdisciplinary team of 
providers and clerical staff in outpatient mental health clinics at all 
VAMCs. BHIP is guided by the evidence-based Collaborative Care Model, 
which focuses on six core elements: providing organizational and 
leadership support, anticipating care needs through process redesign, 
enhancing Veteran self-management skills, offering decision support for 
providers, managing clinical information about Veterans, and accessing 
support for Veterans in the community. Through its emphasis on team 
building, communication, and coordination, BHIP is demonstrating a 
meaningful, positive impact on patient care and teamwork--including 
improved staff relationships, job satisfaction, and Veteran access to 
care. Early data show that, compared to non-BHIP patients, patients who 
had depression, PTSD, and serious mental illness, who were seen by BHIP 
teams, were more likely to engage in three treatments over 6 weeks.

Suicide Prevention and Care Coordination Related to Inpatient and 
Residential Services

    VA's most intensive services for mental health and suicide 
prevention are delivered through residential treatment and inpatient 
mental health programs, either the Mental Health Residential 
Rehabilitation Treatment Programs (MH RRTP) or the Domiciliary Care 
Program, which is VA's oldest program--established in 1865, at the 
National Home for Disabled Volunteer Soldiers. Today, MH RRTPs provide 
intensive specialty treatment for mental health and Substance Use 
Disorders, as well as for co-occurring medical needs, homelessness, and 
unemployment. MH RRTPs are staffed 24 hours a day, 7 days per week, and 
provide access to both professional and peer support services. MH RRTPs 
identify and address Veterans' goals for rehabilitation, recovery, 
health maintenance, quality of life, and community integration. VA 
provides inpatient mental health care for Veterans at risk of harming 
themselves or others, or who require hospitalization to stabilize their 
condition and to facilitate recovery. Nationwide, 113 VA facilities 
offer acute inpatient psychiatry programs, and in Fiscal Year 2018, 
those programs served approximately 57,000 Veterans.
    VA has several policies and guidance that require care 
coordination, and a clinical care team member follows up or provides 
caring communications across all VA medical facilities for Veterans 
after an inpatient mental health stay or hospitalization for suicide 
related concerns. According to VHA policies for post-discharge follow-
up and enhanced care for patients at high risk of suicide, the type and 
frequency of the contact varies depending on inpatient stay setting 
(residential vs. inpatient mental health), type of discharge (regular 
or against medical advice), and the severity of suicide risk 
presentation. Follow-up contact may include phone calls, letters, and 
clinical visits and can be as soon as 24 hours or 7 days post-
discharge, with potential subsequent clinical contacts weekly for the 
next 30 days or longer.

Mental Health Safety and Environment of Care on VA Campuses

    Providing a safe environment of care is a critical part of suicide 
prevention. In a 2018 study, Williams and Schmaltz completed a study of 
Joint Commission Accredited Hospitals who voluntarily reported 505 
suicide deaths to The Joint Commission between 2010 and 2016, including 
VHA. The data in The Joint Commission's possession may not reflect the 
actual occurrence of suicides in all U.S. hospitals; however, data 
collected included inpatient suicides, suicides in emergency 
departments, suicides that occurred post-discharge, and suicides in 
which the victim may not have been directly receiving treatment at the 
hospital. Based on this report, VA has been able to reduce the number 
of in-hospital suicides from 4.2 per 100,000 admissions to 0.74 per 
100,000 admissions on mental health units, an 82.4-percent reduction, 
suggesting that well-designed quality improvement and safety 
initiatives can lead to a reduction in the occurrence of these tragic 
events.iii
---------------------------------------------------------------------------
    iii Williams SC, Schmaltz SP, Castro GM, Baker DW, 2018. 
Incidence and Method of Suicide in Hospitals in the United States. 
https://www.jointcommissionjournal.com/article/S1553-7250(18)30253-8/
fulltext.
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    One example of VA's safety initiatives is the requirement that each 
VAMC review its inpatient mental health units' environment every 6 
months by using the Mental Health Environment of Care Checklist. To 
perform this task, facilities are expected to create Interdisciplinary 
Safety Inspection Teams (ISIT). ISITs are expected to provide their 
subject matter expertise on the environmental risks that facilities may 
face regarding suicide. ISITs use a risk assessment matrix to help 
determine the actions that need to be taken to improve facilities' 
mental health environments in accordance with Joint Commission 
Standards. In May 2019, VHA mandated that all VAMCs with an acute 
mental health unit install door top alarms. Door top alarms installed 
on swinging corridor doors of patient rooms in VA mental health 
inpatient units have proven to be effective in providing timely 
notification to staff and preventing completion of suicide attempts. As 
of August 2019, approximately 50 percent of VHA inpatient mental health 
facilities reported having door top alarms installed. Projects are 
underway to install door top alarms on the remainder of the inpatient 
mental health units, with a targeted completion date of March 1, 2020.
    As part of its efforts to ensure all facilities are safe for both 
Veterans and employees, VA also requires all MH RRTPs to ``stand down'' 
or suspend clinical operations for 1 day each year to focus on safety, 
security, and quality of care. MH RRTP clinicians are required to 
undergo documented annual competency reviews for assessing risk for 
suicide. MH RRTPs are required to complete Annual Safety and Security 
Assessments of their environments before each Stand Down. SPCs are 
required to participate in both the Stand Down and the pre-Stand Down 
assessment of facility environments to assist with addressing suicide 
prevention content.

Responding to On-Campus Suicidal Behavior

    VHA policy requires that all VHA employees must complete their 
required suicide risk and intervention training module (either Suicide 
Risk Management Training for Clinicians or Signs, Ask, Validate, and 
Encourage and Expedite (S.A.V.E.) training for non-clinicians) and, for 
providers/clinicians, pass the post-module test within 90 days of 
entering their position. VHA has also developed a Suicide Risk 
Management Training for registered nurses that may be assigned annually 
as an alternative training option to Suicide Risk Management Training 
for Clinicians, understanding that the roles may be different in some 
cases. Local facilities may assign training to appropriate staff and 
track this training through the Talent Management System. VA supports 
employees as well as external community providers by providing the VA 
Suicide Risk Management Consultation Program to consult on a specific 
case or talk about suicide risk management strategies more generally.
    VA Police Officers receive specialized training at the VA Law 
Enforcement Training Center (LETC). LETC is accredited by the Federal 
Law Enforcement Training Accreditation Board, which emphasizes the use 
of non-physical techniques and is recognized as meeting the highest 
standards in Federal law enforcement training. All VA Police Officers 
go through a 10-week basic course at LETC. They receive 30 hours of 
training specific to de-escalation and conflict management, with a 
special focus on suicide awareness and prevention. Officers also 
complete nearly 24 hours of de-escalation training in which they learn 
skills to affect positive outcomes in real-life scenarios.
    Collaboration between law enforcement and health care professionals 
is crucial when responding to violent incidents, police calls for 
service in the field, or Veterans in suicidal crisis. VA Police and all 
VA employees work every day to recognize Veterans who may be in crisis 
and expedite getting them the help they need. Their diligence and 
specialized training have saved lives across the country on VA campuses 
when they have interrupted or responded quickly to Veterans in suicidal 
crisis. VA began tracking on-campus suicidal behavior in October 2017; 
as of January 2020, there have been a total of 566 incidents of 
suicidal attempts, of which 49 were suicide deaths.

                    Community Prevention Strategies

Communication Strategies

    Preventing suicide among all of the Nation's 20 million Veterans 
cannot be the sole responsibility of VA; it requires a nation-wide 
effort. Suicide prevention requires a combination of programming and 
the implementation of strategies and initiatives at the universal, 
selective, and indicated levels. This ``All-Some-Few'' strategic 
framework allows VA to design effective programs and interventions 
appropriate for each group's level of risk. Not all Veterans at risk 
for suicide will present with a mental health diagnosis, and the 
strategies below employ a variety of tactics to reach all Veterans, 
which may include:

      Universal strategies that aim to reach all Veterans in 
the United States. These include public awareness and education 
campaigns about the availability of mental health and suicide 
prevention resources for Veterans, promoting responsible coverage of 
suicide by the news media, and creating barriers or limiting access to 
hotspots for suicide, such as bridges and train tracks;

      Selective strategies are intended for some Veterans who 
fall into subgroups that may be at increased risk for suicidal 
behaviors. These include outreach targeted to women Veterans or 
Veterans with substance use disorders, gatekeeper training for 
intermediaries who may be able to identify Veterans at high-risk, and 
programs for Veterans who have recently transitioned from military 
service; and

      Indicated strategies designed for the relatively few 
individual Veterans identified as having a high risk for suicidal 
behaviors, including some who have made a suicide attempt.

    Guided by this framework and the National Strategy, VA is creating 
and executing a targeted communications strategy to reach a wide 
variety of audiences. VA uses an integrated mix of outreach and 
communications strategies to reach audiences. VA relies on proven 
tactics to achieve broad exposure and outreach while also connecting 
with hard-to-reach targeted populations. Our target audiences include, 
but are not limited to, women Veterans; male Veterans age 18-34; former 
Servicemembers; men age 55 and older; Veterans' loved ones, friends, 
and family; organizations that regularly interact with Veterans where 
they live and thrive; and the media and entertainment industry, who 
have the ability to shape the public's understanding of suicide, 
promote help-seeking behaviors, and reduce suicide contagion among 
vulnerable individuals.
    VA proactively engages others to help share our messages and 
content, including Public Service Announcements (PSA) and educational 
videos. For example, in collaboration with Johnson & Johnson, VA 
released through social media a PSA titled ``No Veteran Left Behind,'' 
featuring Tom Hanks. VA continues to use the #BeThere Campaign to raise 
awareness about mental health and suicide prevention and educate 
Veterans, their families, and communities about the suicide prevention 
resources available to them. During Suicide Prevention Month 2019, VA's 
#BeThere campaign reminded audiences that everyone has a role to play 
in preventing Veteran suicide. It also emphasized that even small 
actions of support can make a big difference for someone going through 
a challenging time and can ultimately help save a life. Through 
shareable content and graphics, VA reached over 200 entities through a 
news bulletin and quarterly newsletter emails. In collaboration with 
Twitter, a custom icon--an orange awareness ribbon--was linked to the 
#BeThere hashtag in tweets. This positioned Veterans as part of the 
global Twitter conversation about Suicide Prevention Month. Veteran-
specific posts that used the #BeThere hashtag had almost 84 million 
potential impressions.
    We are leveraging new technologies and working with others on 
social media events while continuing our digital outreach through 
online advertising. VA also utilizes its Make the Connection resource 
(www.MakeTheConnection.net) to highlight Veterans' true and inspiring 
stories of mental health recovery, connecting Veterans and their family 
members with local VA and community mental health resources. Over 600 
videos from Veterans of all eras, genders, and backgrounds are at the 
heart of the Make the Connection campaign. The resource was founded to 
encourage Veterans and their families to seek mental health services 
(if necessary), educate Veterans and their families about the signs and 
symptoms of mental health issues, and promote help-seeking behavior in 
Veterans and the general public. Finally, VA continues to rely on 
Veterans Service Organizations, non-profit organizations, and private 
companies to help us spread the word through their person-to-person and 
online networks.

Working with Communities

    VA is working with Federal partners, as well as State and local 
governments, to implement the National Strategy to reach all Veterans 
through community prevention. Community Prevention focuses on 
``upstream strategies'' to address social determinants of health 
outside the VHA health care system to promote early awareness and 
prevention prior to times of crisis, while also expanding collaboration 
and coordination of services across all Veterans, families, non-VHA 
health care systems, other community partners, and VA. In March 2018, 
VA, in collaboration with the Department of Health and Human Services, 
introduced the Mayor's Challenge with a community-level focus, and in 
2019, debuted the Governor's Challenge to take those efforts in Veteran 
suicide prevention to the State level. The Mayor's and Governor's 
Challenges promote VA's suicide prevention efforts by working with 7 
Governors (from Arizona, Colorado, Kansas, Montana, New Hampshire, 
Texas, and Virginia) and 24 local governments; locations were chosen 
based on Veteran population data, suicide prevalence rates, and 
capacity of the city or State to develop plans to prevent Veteran 
suicide, again with a focus on all Veterans at risk of suicide, not 
just those who engage with VA. We will be expanding to 28 additional 
states in Fiscal Year 2020 with a goal of engaging all 50 states and 
the territories by the end of Fiscal Year 2022.
    In addition to the Challenges, VA is developing models of 
community-based approaches for suicide prevention, including a pilot in 
Veterans Integrated Service Network 23, focused on community coalition-
building and ``Together with Veterans,'' a VA program focused on 
community coalition-building specifically in rural settings. The goal 
of ``Together with Veterans'' is to build and sustain local capacity to 
implement multiple coordinated suicide prevention strategies, following 
a science-based implementation toolkit. As part of these strategies, 
technical assistance is available to provide data reporting, 
evaluation, and consultation in support of local communities 
implementation of strategic plans to address Veteran suicide.
    In addition to the proactive work by VA Police on campus, VA Police 
are actively involved in training other first responders in the 
community in life saving strategies. The VA National First Responder 
Outreach and Training Program is an innovative, common-sense, and cost-
effective public health approach that addresses the Veteran community, 
spefically prioritizing Veteran suicide. At its foundation, the program 
utilizes community outreach engagements to facilitate collaboration 
with emergency first responders at the local, State, and Federal 
levels. To date, this program has trained over 3,500 community 
emergency first responders across the country. The feedback from the 
first responder community has been resoundingly positive, noting that 
the information is relevant and presented in a way that has direct 
practical application.

Partnerships with Organizations for Suicide Prevention

    The National Strategy is a call to action to every community, 
organization, and system interested in preventing Veteran suicide to 
help do this work where we cannot. For this reason, VA is leveraging a 
network of more than 60 partners in the public, private, and non-profit 
sectors to help us reach Veterans, and our network is growing weekly. 
For example, VA and PsychArmor Institute have a non-monetary 
partnership focused on creating online educational content that 
advances health initiatives to better serve Veterans. Our partnership 
with PsychArmor Institute resulted in the development of the free, 
online S.A.V.E. training course that enables those who interact with 
Veterans to identify signs that might indicate a Veteran is in crisis 
and how to safely respond to and support a Veteran to facilitate care 
and intervention. Since its launch in May 2018, S.A.V.E. training has 
been viewed more than 18,000 times through PsychArmor's internal and 
social media system and 385 times on PsychArmor's YouTube channel.

         VA and DoD Veteran Suicide Data Tracking and Reporting

    While implementing both clinical and community strategies for 
suicide prevention, VA aims to provide the most accurate report on the 
status of Veteran suicide in the Nation. Each year, VA and DoD produce 
separate annual reports on Veteran and current Servicemember suicide 
mortality, respectively. VA and DoD partner in preventing suicide for 
all current and former Servicemembers, but do not use the same data 
sources for suicide surveillance reporting, with VA reporting on 
Veterans and former Servicemembers, and DoD reporting on current 
Servicemembers. This allows VA's report to focus on former 
Servicemembers who most closely meet the official definition of Veteran 
status that is used by VA and other Federal agencies. For this report, 
a Veteran is defined as someone who had been activated for Federal 
military service and was not currently serving. In addition, the report 
includes information in a separate section on suicide among former 
National Guard or Reserve members who were never federally activated.
    For VA suicide surveillance reporting, VA and DoD partner to submit 
a search list of all identified current and former Servicemembers to 
the Centers for Disease Control and Prevention's (CDC) National Death 
Index (NDI) each fall. After processing, which can take several months, 
NDI returns all potentially matching mortality information. 
Additionally, internal processing and coordination occurs between VA 
and DoD to identify Veteran and Servicemember deaths, finalize 
mortality information, conduct statistical analyses, and interpret 
results.
    Due to the different data sources, DoD data on mortality among 
current Servicemembers are available in a timelier fashion. DoD uses 
the Armed Forces Medical Examiner System (AFMES) as its data source for 
current active duty Servicemember suicide mortality information. A data 
source similar to AFMES is not available to VA. VA relies on national 
reporting to identify dates and causes of death per State death 
certificates, through NDI, which are reported up through local medical 
examiners and coroners to respective states and territories.

VA 2019 National Veteran Suicide Prevention Annual Report

    The 2019 National Veteran Suicide Prevention Annual Report is VA's 
most recent analysis of Veteran suicide data from 2005 to 2017. It 
reflects the most current national data available through CDC's 2017 
NDI.
    One of the key ways in which this year's report is different is 
that it sets Veteran suicide in the broader context of suicide deaths 
in America and the complex cultural context of suicide. From the 
report, we know the average number of suicides per day among U.S. 
adults rose from 86.6 in 2005 to 124.4 in 2017. These numbers included 
15.9 Veteran suicides per day in 2005 and 16.8 in 2017. The report 
highlights suicide as a national problem affecting Veterans and non-
Veterans, and VA calls upon all Americans to come together to take 
actions to prevent suicide.
    The data presented in the report are an integral part of VA's 
comprehensive public health strategy and enables VA to use tailored 
suicide prevention initiatives to reach various Veteran populations. 
The report includes a section on key initiatives that have been 
developed since 2017 to reach all Veterans. The report is designed for 
action based upon a stratification with the public health 
classification of universal (all), selective (some), and indicated 
(few) population framework as noted in the National Strategy.
    When we look at our data, there are indicators that trends among 
Veterans in VA care that offer anchors of hope upon which we can 
continue to build. For example, suicide rates among Veterans in recent 
VHA care (Veterans who had a VHA health encounter in the calendar year 
of interest or in the prior calendar year) with a diagnosis of 
depression have decreased from 70.2 per 100,000 in 2005 to 63.4 per 
100,000 in 2017. After adjusting for age and sex, between 2016 and 
2017, the suicide rate among Veterans in recent VHA care increased by 
1.3 percent while increasing by 11.8 percent among Veterans who did not 
use VHA care. We have seen a notable increase in women Veterans coming 
to us for care. Women are the fastest-growing Veteran group, comprising 
about 9 percent of the U.S. Veteran population, and that number is 
expected to rise to 15 percent by 2035. Although women Veteran suicide 
counts and rates decreased from 2015 to 2016 and did not increase for 
women Veterans in VHA care between 2016 and 2017, women Veterans are 
still more likely to die by suicide than non-Veteran women. These data 
underscore the importance of our programs for this population. VA is 
working to tailor services to meet their unique needs and has put a 
national network of Women's Mental Health Champions in place to share 
information, facilitate consultations, and develop local resources in 
support of gender-sensitive mental health care. Efforts are already 
underway to better understand this population and other groups that are 
at elevated risk, such as never federally activated Guard and Reserve 
members, recently separated Veterans, and former Servicemembers with 
Other Than Honorable (OTH) discharges.
    We need to consider the social determinants of health, defined 
broadly as well-being (economic disparities, homelessness, and social 
isolation), and how these issues, may create a context that markedly 
increases someone's risk of suicide. Veterans who are employed, have a 
stable place to live, and are affiliated with a community of Veterans 
and others for support are more likely to be optimistic about their 
future. While there is still much to learn, there are some things that 
we know for sure: suicide is preventable, treatment works, and there is 
hope.

Update Progress and Challenges Toward Addressing VA OIG Recommendations

    In collaboration with the Office of Security and Law Enforcement, a 
staffing model was developed. The new staffing model is currently under 
review. In addition, VHA has modernized the position descriptions for 
all of the Police Chiefs in the field. This is part of a larger 
workforce modernization effort underway for the VA Police force. This 
was a major accomplishment as it helps ensure our Police Chiefs are 
paid equitably. VA is in the process of continuing to develop 
modernized positions for all of our law enforcement professionals. The 
intent of the modernized positions is to create uniformity in the way 
work is distributed and carried out, thereby raising the technical 
standard of each position to ensure the best services are provided to 
our Veterans.

Conclusion

    On March 5, 2019, EO 13861, National Roadmap to Empower Veterans 
and End Suicide, was signed to improve the quality of life of our 
Nation's Veterans and develop a national public health roadmap to lower 
the Veteran suicide rate. EO 13861 mandated the establishment of the 
Veteran Wellness, Empowerment, and Suicide Prevention Task Force to 
develop the President's Roadmap to Empower Veterans and End a National 
Tragedy of Suicide and the development of a legislative proposal to 
establish a program for making grants to local communities to enable 
them to increase their capacity to collaborate with each other to 
integrate service delivery to Veterans and to coordinate resources for 
Veterans. The focus of these efforts is to provide Veterans at risk of 
suicide support services, such as employment, health, housing, 
education, social connection, and to develop a national research 
strategy for the prevention of Veteran suicide.
    This EO implementation will further VA's efforts to collaborate 
with partners and communities nationwide to use the best available 
information and practices to support all Veterans, whether or not they 
are engaging with VA. This EO, in addition to VA's National Strategy, 
further advances the public health approach to suicide prevention by 
leveraging synergies and clearly identifying best practices across the 
Federal Government that can be used to save Veterans' lives.
    VA's goal is to meet Veterans where they live, work, and thrive to 
ensure they can achieve their goals, teaching them skills, connecting 
them to resources, and providing the care they need along the way. 
Through open access, community-based and mobile Vet Centers, app-based 
care, tele-mental health, more than 400 Suicide Prevention 
Coordinators, and more, VA is providing care to Veterans when and how 
they need it. We want to empower and energize communities to do the 
same for Veterans who do not use VA services. We are committed to 
advancing our outreach, prevention, empowerment, and treatment efforts, 
to further restore the trust of our Veterans every day and continue to 
improve access to care. Our objective is to give our Nation's Veterans 
the top-quality experience and care they have earned and deserve. We 
appreciate this Committee's continued support and encouragement as we 
identify challenges and create innovative solutions to address the 
needs of Veterans.
    This concludes my testimony. I am prepared to answer any questions 
you may have.
    Thank you.
                                 ______
                                 

                  Prepared Statement of Julie Kroviak

    Chairman Takano, Ranking Member Roe, and members of the Committee, 
thank you for the opportunity to discuss the Office of Inspector 
General's (OIG's) oversight of the mental health care and services 
provided by the Department of Veterans Affairs (VA) at Veterans Health 
Administration (VHA) facilities. The mission of the OIG is to oversee 
the efficiency and effectiveness of VA's programs and operations 
through independent audits, inspections, evaluations, reviews, and 
investigations. For many years, the OIG has conducted reviews and 
inspections that have identified concerns with veterans' access to 
quality health care, including mental health care, provided at VHA 
facilities. Recent reports have identified ongoing concerns with the 
timeliness and delivery of quality mental health care, the challenges 
associated with the coordination of that care, the proactive measures 
that could reduce suicides, and the physical environment in which 
veterans receive mental health care.
    Although veterans are a tremendously diverse community, they have a 
culture, set of experiences, and sense of duty associated with military 
service that can differ dramatically from civilians. Some veteran 
experiences can contribute to and challenge the management of often 
complex mental health needs. According to research, veterans experience 
mental health and substance abuse disorders, posttraumatic stress, and 
traumatic brain injury at rates disproportionately high when compared 
to their civilian counterparts.\1\ This underscores the magnitude of 
responsibility VHA assumes in supporting the needs of this population. 
Responding effectively to their needs requires a holistic approach 
focused on each veteran's successful reintegration into civilian life. 
A truly integrated approach, while veteran-centric in design, can be 
effective only if families, caregivers, healthcare providers, and 
communities work together to support veterans' whole health. Perhaps 
most urgent is the need to mitigate the risk of suicide. VHA must 
continue to focus attention on outreach efforts that educate and 
provide all stakeholders with evidence-based tools that not only help 
identify high-risk veterans, but also encourage those veterans to 
engage in the care they need.
---------------------------------------------------------------------------
    \1\ Terri Tanielian et al., ``Invisible Wounds: Mental Health and 
Cognitive Care Needs of America's Returning Veterans,'' (Santa Monica, 
CA: RAND Corporation, 2008), https://www.rand.org/pubs/research_briefs/
RB9336.html; National Alliance on Mental Illness, ``You Are Not 
Alone,'' https://nami.org/mhstats, accessed on January 27, 2020.
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    VHA has implemented several initiatives aimed at reducing the 
stigma surrounding mental health conditions, providing access to mental 
health services, and promoting public awareness of suicide. The focus 
on suicide prevention has included appointing a National Suicide 
Prevention Coordinator, establishing the Veterans Crisis Line, 
developing a patient record system to identify high-risk patients, and 
creating suicide prevention programs in each facility. In addition, VHA 
expanded facility suicide prevention coordinator roles, requiring them 
to participate in community outreach activities.
    VHA's efforts in suicide prevention, including the Veterans Crisis 
Line, have been largely directed at crisis intervention. According to 
the medical literature, the opportunity for intervention between the 
decision to complete suicide and the attempt itself is extremely 
narrow, as short as 1 hour in over 70 percent of all suicide 
attempts.\2\ Additionally, 69 percent of veteran suicide deaths are by 
the more likely lethal means of firearms, compared to 48 percent of 
civilian suicide deaths.\3\ To significantly reduce suicide and improve 
the lives of veterans, prompt and effective behavioral health treatment 
must be paired with a wide range of additional approaches. For example, 
VA has promoted firearm safety by urging veterans to secure guns with 
locks, removing firing pins, or storing firearms where they are not 
easily and quickly accessed. The VA Suicide Prevention Program's Acting 
Director was recently quoted as saying, ``The safety measures can slow 
a person's ability to follow through on suicidal thoughts and preempt 
an irrevocable choice.'' \4\ It is being presented as just one element 
of a plan, in the hope that clinicians can include this topic as an 
aspect of self-care. Lethal-means safety counseling offers clinicians 
an evidence-based opportunity to erect a barrier to suicidal 
impulsivity. VHA has several current projects that address lethal-means 
safety, but each project requires additional resources to develop their 
concepts and evaluate effectiveness in the veteran community. VHA must 
take every opportunity--from the time of a servicemembers' transition 
to the community and throughout the veterans' life--to identify and 
address behavioral health conditions.
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    \2\ E.A. Deisenhammer et al., ``The Duration of the Suicidal 
Process: How Much Time Is Left for Intervention Between Consideration 
and Accomplishment of a Suicide Attempt?'' Journal of Clinical 
Psychiatry, 70(1), 19-24.
    \3\ Department of Veterans Affairs, ``VA National Suicide Data 
Report 2005-2016,'' VA Office of Mental Health and Suicide Prevention, 
September 2018.
    \4\ Martin Kuz, ``Can Veterans Lead the Way on Preventing 
Suicide,'' Christian Science Monitor, December 31, 2019, https://
www.csmonitor.com/USA/Military/2019/1231/Can-veterans-lead-the-way-on-
preventing-suicide.
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    Despite VHA's recent efforts, there are significant challenges 
ahead. The OIG has published numerous reports in recent years that 
detail veterans' experiences with obstacles accessing and receiving 
high-quality mental health care within VHA. Tragic events such as 
suicides are the most publicized and typically understood to be the 
result of unrecognized, untreated, or undertreated mental health 
disorders. The OIG's focus, however, has also included the timely care 
and management of the wide variety of mental health needs for which 
veterans seek care. Report recommendations are meant to assist VHA in 
its efforts to be responsive at all levels to addressing the complex 
mental health care needs of veterans. The goal, ultimately, is to 
improve veterans' quality of life (as well as the lives of their 
families and caregivers) and to reduce the rate of veteran suicide.
    Recognizing the importance of suicide prevention as VA's--and this 
Committee's--top clinical priority, the OIG has focused significant 
resources on conducting oversight of VHA's mental health treatment 
programs and other suicide prevention efforts.\5\ This statement 
focuses on some of the more recent OIG reviews highlighting 
opportunities where VHA can strengthen its efforts to improve the 
quality and coordination of care as well as the environment in which 
veterans receive that care.
---------------------------------------------------------------------------
    \5\ Department of Veterans Affairs, ``The VA is Making Real 
Progress on Suicide Prevention for Veterans,'' January 14, 2019, 
https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=5177; House 
Veterans Affairs Committee, ``Chairman Takano Announces New Compromise 
on Legislation to Address Veteran Suicide,'' December 3, 2019, https:/
veterans.house.gov/news/press-releases/_chairman-takano-announces-new-
compromise-on-legislation-to-address-veteran-suicide.

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DEFICIENCIES IN VHA MENTAL HEALTH COORDINATION OF CARE

    The OIG has reviewed a number of reported suicides and mental 
healthcare-related concerns that occurred on VA campuses. These 
involved veterans who were receiving, seeking, or may have needed 
mental health care from VHA providers. These reviews found deficiencies 
in care delivery that resulted in negative outcomes for patients 
experiencing a mental health crisis. The OIG's findings in this area 
can be categorized as deficiencies in coordination of care in the 
following contexts:

      Within a mental health treatment team

      With non-mental health providers

      During the discharge process

      By care providers with the patients or their family/
surrogate

    The OIG found inadequate coordination of care to be an underlying 
theme in every one of its recently conducted reviews. Relevant examples 
from these reports are discussed below.

Coordination of Care Within a Mental Health Treatment Team

    Typically, a mental health treatment team is multidisciplinary and 
may involve a psychiatrist, a psychologist, mental health nurses, 
mental health social workers, mental health clinical pharmacists, and 
suicide prevention coordinators. Coordination within the team is vital 
to provide the patient with synchronized and complementary services. 
Failures in communication could result in conflicting information or 
gaps in care that may result in harm to the patient. The following 
reports involve deficiencies in coordination of care within a mental 
health team.

Alleged Deficiencies in Mental Health Care Prior to a Death by Suicide 
at the VA San Diego Healthcare System

    The OIG conducted a healthcare inspection in response to 
allegations that staff failed to provide mental health care to a 
patient who subsequently died by suicide.\6\ The OIG did not 
substantiate that the system failed to provide mental health care when 
the patient sought help. However, the OIG team found deficits in the 
decisionmaking process to deactivate a patient's High Risk for Suicide 
Patient Record Flag (PRF).\7\ The assigned suicide prevention 
coordinator chose to deactivate the patient's PRF in spring 2018 
without consulting the treatment team. In addition, the patient did not 
have any scheduled future appointments and had not been engaged in any 
mental health services for more than 2 months. VHA does not have 
clearly delineated requirements for the decisionmaking process to 
deactivate the High Risk for Suicide PRF; however, the then Executive 
Director of the Suicide Prevention Program told the OIG that there is 
an expectation that the suicide prevention coordinator will consult 
with the patient's treatment team, provide evidence of decreased 
suicide risk factors, and document rationale for clinical judgment 
about mental health conditions and behaviors. The OIG recommended the 
Under Secretary for Health expedite the development of a National 
Suicide Prevention Program policy and procedure to delineate the 
deactivation process of High Risk for Suicide PRFs and monitor 
compliance.\8\ The VHA action plan projected completion date was 
December 2019. OIG staff will monitor VA's progress until the proposed 
action is complete.\9\
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    \6\  Alleged Deficiencies in Mental Health Care Prior to a Death by 
Suicide at the VA San Diego Healthcare System, California, August 7, 
2019.
    \7\ VHA established the High Risk for Suicide Patient Record Flag 
to alert staff to patients with immediate clinical safety concerns and 
is therefore only activated for those patients assessed at high risk 
for suicide and only for the duration of the increased risk. The 
suicide prevention coordinator works with the patient's clinicians to 
determine if the flag is needed, monitors its continued application, 
and deactivates the flag when the patient no longer has an elevated 
risk.
    \8\ The recommendations directed to the Under Secretary for Health 
are submitted to the Executive in Charge, who has the authority to 
perform those functions and duties.
    \9\ VA provides implementation plans and determines their projected 
dates for implementation when providing comments on OIG draft reports. 
At quarterly intervals starting 90 days after report issuance, OIG 
staff requests the VA office provide an accounting of actions taken to 
implement open recommendations, as well as whether the VA office 
believes a recommendation may be closed. After receiving the VA 
office's report, OIG staff reviews the materials and provides a final 
determination whether any recommendations have been satisfactorily 
implemented and can be closed. The decision to close a recommendation 
is based on a review of VA's supporting documentation or independent 
information obtained by OIG that indicates the corrective action has 
occurred and is sustained or progressed enough to show recommendation 
implementation.

The September 2018 Review of Mental Health Care Provided Prior to a 
---------------------------------------------------------------------------
Veteran's Death by Suicide in the Minneapolis VA Health Care System

    In September 2018, the OIG reported on the care of a patient who 
was admitted to the inpatient mental health unit and subsequently died 
from a self-inflicted gunshot wound less than 24 hours after 
discharge.\10\ The OIG determined that the inpatient interdisciplinary 
treatment team failed to appropriately coordinate with the patient's 
outpatient treatment team. Specifically, inpatient mental health staff 
did not identify an outpatient prescriber and schedule an outpatient 
medication management follow-up appointment. Additionally, the system's 
suicide prevention coordinator did not collaborate with the inpatient 
interdisciplinary treatment team during admission. The OIG was unable 
to determine that identified deficits, alone or in combination, were a 
causal factor in the patient's death. However, the OIG did make 
recommendations related to interdisciplinary team collaboration, which 
are now closed.
---------------------------------------------------------------------------
    \10\ Review of Mental Health Care Provided Prior to a Veteran's 
Death by Suicide, Minneapolis VA Health Care System, Minnesota, 
September 25, 2018.

Review of Two Mental Health Patients Who Died by Suicide at the William 
---------------------------------------------------------------------------
S. Middleton Memorial Veterans Hospital in Madison, Wisconsin

    The review team assessed the care of a patient who committed 
suicide less than 48 hours after being discharged from the VA 
facility.\11\ The OIG found that the mental health clinical pharmacists 
informally collaborated with facility psychiatrists but did not 
appropriately refer patients with complex mental health issues whose 
treatment was beyond the pharmacists' scope of practice. Specifically, 
mental health clinical pharmacists acted outside of their scope of 
practice in changing diagnoses and providing psychotherapy. The 
collaborations were insufficient to meet the requirements of mental 
health clinical pharmacists' scope of practice. Their independent 
decisionmaking without sufficient psychiatrist collaboration or 
supervision may have contributed to deficient mental health care. The 
OIG also identified similar deficiencies by a mental health clinical 
pharmacist in the care of another patient that died by suicide 13 
months before the first patient's death. The OIG made recommendations 
related to prescribing practices, including the use of collaborative 
agreements, the assignment of prescribers for patients with complex 
mental health needs, and strengthening mental health clinical 
pharmacists' supervision processes. Based on a review of VA's 
corrective actions, the OIG has closed all report recommendations.
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    \11\ Review of Two Mental Health Patients Who Died by Suicide, 
William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, 
August 1, 2018.

Review of Mental Health Clinical Pharmacists in Veterans Health 
---------------------------------------------------------------------------
Administration Facilities

    The seriousness of the risks identified in the prior report led the 
OIG to initiate a broader review of clinical pharmacists' practice in 
mental health outpatient care settings. The OIG assessed VHA 
facilities' use of clinical pharmacists who work under a scope of 
practice in a mental health outpatient care setting.\12\
---------------------------------------------------------------------------
    \12\ Review of Mental Health Clinical Pharmacists in Veterans 
Health Administration Facilities, June 27, 2019.
---------------------------------------------------------------------------
    Clinical pharmacists have advanced specialized education and 
training that allows them to provide comprehensive medication 
management that includes resolving patient medication nonadherence and 
assisting patients in achieving medication-related therapeutic goals. 
Clinical pharmacists are not licensed independent practitioners and 
therefore must collaborate with licensed independent practitioners who 
have prescriptive authority, as outlined in a collaborative practice 
agreement. Each clinical pharmacist requests the types of services he 
or she will provide, which are reviewed and recommended by the relevant 
facility's service chiefs and executive committee of the medical staff, 
and then approved by the medical facility director.
    The role of clinical pharmacists with a scope of practice in the 
mental health specialty practice area has been a focus of expansion for 
VHA in recent years. As VHA expands and increases its use of mental 
health clinical pharmacists, it is imperative that there are 
collaborating agreements in place and that scopes of practice clearly 
delineate duties and are standardized to maximize patient safety.
    The OIG's review found that mental health clinical pharmacists' 
independence levels were not clearly identified by staff or facilities' 
bylaws. Guidance provided conflicting instructions regarding the 
requirements for collaborating agreements and lacked provisions for 
oversight by a specific physician. Facilities' scopes of practice were 
inconsistent in describing delegated duties that were specific to 
mental health. VHA policy also was insufficient to ensure the chief of 
mental health conducts reviews and endorses mental health clinical 
pharmacists' scopes of practice. Referral processes were not clear or 
standardized regarding how diagnoses were conveyed to mental health 
clinical pharmacists or whether involvement of a licensed independent 
practitioner with prescriptive authority was considered to determine 
appropriateness for patients' referrals. VHA policy does not require a 
defined process to consider a patient's clinical complexity. Policies 
lacked guidance on instructing mental health clinical pharmacists on 
when or how to refer patients to a higher level of care. The OIG made 
nine recommendations to the VHA Under Secretary for Health related to 
autonomy, collaborating agreements, working with licensed independent 
practitioners with prescribing authority, scopes of practice, and 
referrals. Recommendations are to be completed no later than May 2020, 
according to VHA action plans. OIG staff will monitor VA's progress 
until all proposed actions are complete.

Coordination of Care with Non-Mental Health Providers

    Patients' mental health care must be managed together with any 
other medical conditions. Patients with complex medical histories 
require coordination between mental health and non-mental health care 
providers. Failures in communication may result in harm resulting from 
medication side effects or interactions or worsening of the underlying 
medical conditions. The following OIG reports found issues with the 
coordination of care between mental health and non-mental health care 
providers.

The January 2020 Report Deficiencies in Care Coordination and Facility 
Response to Another Patient Suicide in Minneapolis

    In January 2020, the OIG released a healthcare inspection report 
assessing care coordination for a patient who died by suicide while 
admitted to an inpatient medicine unit at the facility.\13\ The patient 
was assessed as at a heightened but not imminent risk for suicide. 
Facility emergency department staff failed to report the patient's 
suicidal ideation to the facility's suicide prevention coordinator. Two 
consulting staff members and an inpatient registered nurse completed 
required suicide prevention training but failed to involve clinicians 
when the patient verbalized suicidal thoughts and warning signs. Two of 
the three staff documented the patient's suicidal thoughts and warning 
signs in consult results notes, but the OIG did not find documentation 
that the inpatient medicine resident reviewed or acted on the consult 
results. The OIG made recommendations to the facility's director 
related to improving emergency department staff's notification to the 
suicide prevention coordinator when a patient presents with suicidal 
ideation. The recommendations also called on the facility director to 
ensure that inpatient consult results are acted upon by the responsible 
care provider or appropriate designee. All recommendations are to be 
completed no later than July 2020, according to VHA action plans. OIG 
staff will monitor VA's progress until the proposed actions are 
complete.
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    \13\ Deficiencies in Care Coordination and Facility Response to a 
Patient Suicide at the Minneapolis VA Health Care System, Minnesota, 
January 7, 2020.

Alleged Deficiencies in Oncology Psychosocial Distress Screening and 
Root Cause Analysis Processes at a Facility in Veterans Integrated 
---------------------------------------------------------------------------
Service Network 15

    In a December 2019 healthcare inspection report, OIG staff examined 
a Veterans Integrated Service Network (VISN) 15 medical facility in 
response to concerns identified in a June 2019 OIG healthcare 
inspection.\14\ In part, this inspection 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. The OIG team found that 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 greater opportunity for suicide prevention 
interventions before the patient left the clinic. The OIG recommended 
that the facility director conduct an evaluation of radiation oncology 
clinic mental health consultation and treatment program needs and 
adjust mental health provider coverage as warranted. The VHA action 
plan projected completion date is May 2020. OIG staff will monitor VA's 
progress until the proposed actions are complete.
---------------------------------------------------------------------------
    \14\ Alleged Deficiencies in Oncology Psychosocial Distress 
Screening and Root Cause Analysis Processes at a facility in Veterans 
Integrated Service Network 15, December 11, 2019; Delay in Diagnosis 
and Subsequent Suicide at a Veterans Integrated Service Network 15 
Medical Facility, June 26, 2019.

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Coordination of Care During the Discharge Process

    When patients transition between providers--whether this is due to 
changes in levels of care (inpatient to outpatient) or to changes in 
treatment settings (patient is moving or a provider leaving)--ethical 
care demands a transfer of information about the patient (or 
``handoff'') between providers to facilitate continuity of medical and 
mental health care. Failure to provide such a handoff may lead to 
patient harm related to interruptions in treatment. It may also result 
in inappropriate repetition of previously completed testing or 
inappropriate medication because of the gaps in transferred information 
about previous intolerance or medication interactions. The following 
reports involve issues with coordination in the discharge process.

Deficiencies in Discharge Planning for a Mental Health Inpatient Who 
Transitioned to the Judicial System from a Veterans Integrated Service 
Network 4 Medical Facility

    An OIG team responded to allegations related to the discharge of a 
patient from an inpatient mental health unit at a VISN 4 medical 
facility, and subsequent transfer to a Federal detention center where 
the patient died shortly after discharge and while incarcerated.\15\ 
The OIG team determined that VA facility inpatient mental health staff 
failed to engage in proper discharge planning and proper treatment 
planning processes. The VA facility staff did not contact the receiving 
care providers at the detention center to provide any clinical 
information on a patient with serious chronic mental illness and severe 
medical comorbidities. Specifically, the OIG team determined that 
inpatient mental health staff neglected to provide clinical hand-off 
information to the patient's receiving mental health providers, and to 
assign a mental health treatment coordinator responsible for overall 
care and discharge planning coordination. The OIG made a recommendation 
to ensure the provision of a complete medical and psychiatric 
diagnostic summary to receiving providers. That recommendation remains 
open and the OIG will continue to follow up with the facility until it 
is fully implemented.
---------------------------------------------------------------------------
    \15\ Deficiencies in Discharge Planning for a Mental Health 
Inpatient Who Transitioned to the Judicial System from a Veterans 
Integrated Service Network 4 Medical Facility, July 2, 2019.

The September 2018 Review of Mental Health Care Provided Prior to a 
---------------------------------------------------------------------------
Veteran's Death by Suicide in Minneapolis

    In addition to the deficiencies in coordination of care with 
consultants and other non-mental health care providers previously 
mentioned, the September 2018 report also found issues related to 
discharge planning. The OIG team determined that VA's inpatient mental 
health staff failed to include the patient's outpatient treatment team 
in discharge planning, did not identify an outpatient prescriber, and 
neglected to schedule an outpatient medication management follow-up 
appointment. The OIG team noted that the system's suicide prevention 
coordinator did not collaborate with the patient's interdisciplinary 
treatment team during admission or participate in discharge planning. 
The OIG made a recommendation to the facility director to strengthen 
processes that will help ensure mental health interdisciplinary 
collaboration across levels of care in treatment planning, provision of 
clinical services, and discharge planning that includes medication 
management, as required by VHA. Based on a review of VA's corrective 
actions, the OIG has closed the recommendation.

Coordination of Care With the Patient or With the Patient's Family/
Surrogate

    Patient-centered care requires that providers involve the patient 
or a patient's family (or decisionmaking surrogate) in all treatment 
determinations. VA requires informed consent for all treatment options 
across all disciplines. Failure to coordinate treatment decisionmaking 
with patients or family represents a failure of ethical care. The 
following reports involving deficiencies in coordinating care with the 
patient or the patient's family or surrogate.

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

    An OIG healthcare inspection reviewed allegations of deficiencies 
in quality of care and administrative processes that contributed to two 
patients' deaths by suicide and one patient's self-harm at the 
facility's Social and Behavioral Health Services.\16\ Patient 1, who 
was assigned a High Risk for Suicide PRF, visited the same-day access 
clinic and noted on the triage form experiencing high anxiety, 
depression, and hopelessness, but denied suicidal thoughts or plans. 
The patient left the clinic without being seen by a mental health care 
provider. The OIG team substantiated that same-day access clinic staff 
failed to adhere to VHA and facility missing patient policies after 
this at-risk patient left without being seen. However, the OIG team was 
unable to determine that facility staff's lack of timely search and 
outreach to the patient directly contributed to the patient's death by 
suicide approximately 1 week later. Other potential contributing 
factors were unknown.
---------------------------------------------------------------------------
    \16\ Two Patient Suicides, a Patient Self-Harm Event, and Mental 
Health Services Administrative Deficiencies at the Alaska VA Healthcare 
System, Anchorage, Alaska, November 19, 2019.
---------------------------------------------------------------------------
    The OIG team substantiated that Patients 2 and 3 did not have 
appointments scheduled after visiting the same-day access clinic, as 
evidenced in the lack of providers' clinically indicated date, and 
return to clinic orders, respectively. Failure to schedule a follow-up 
appointment with a patient having active psychiatric symptoms can place 
a patient at risk for adverse outcomes. The OIG team, however, was 
unable to determine that the unscheduled appointments contributed 
directly to Patient 2's self-harm and Patient 3's death by suicide.
    The OIG made recommendations related to the Behavioral Health 
Service's policies and procedures, same-day access clinic coverage, and 
scheduling processes. All 11 recommendations are currently open and OIG 
staff will monitor VA's progress until the proposed actions are 
complete.

Deficiencies in Discharge Planning for a Mental Health Inpatient Who 
Transitioned to the Judicial System from a Veterans Integrated Service 
Network 4 Medical Facility

    This previously discussed report also had findings related to 
inadequate coordination of care during discharge planning. The OIG team 
found that the VISN 4 facility staff did not obtain consent for 
voluntary admission from the patient's surrogate as required for 
patients who lack decisionmaking capacity or are subject to the State 
law involuntary commitment options. Additionally, facility staff did 
not discuss or consider issues such as guardianship, competency, 
surrogacy, or alternative placements for the patient who may have 
lacked decisionmaking ability. The family was not allowed to 
participate in treatment team meetings and was not informed about 
discussions that took place during these meetings despite numerous 
attempts to obtain information regarding the patient's treatment and 
discharge plan. Finally, although facility staff knew of the patient's 
pending arrest 1 day prior to the discharge, staff did not inform the 
patient, nor contact the patient's family member until after the 
patient had been removed from the facility and transported to the 
prison. The OIG made a recommendation to the facility director to 
strengthen inpatient mental health unit processes to include the 
patient, family members, or surrogate in treatment and discharge 
planning decisions. That recommendation remains open and the OIG will 
continue to follow up with the facility until it is fully implemented.

DEFICIENCIES IN VHA'S MENTAL HEALTH ENVIRONMENT OF CARE

    While most suicides occur in the community, some do occur in the 
hospital, most commonly by hanging. In 2017, The Joint Commission noted 
that approximately 425 suicides within healthcare settings (not just VA 
facilities) had been reported over the previous 5 years.\17\ For 2012 
through 2017, VHA's National Center for Patient Safety told OIG staff 
there were 37 inpatient suicides at VA facilities, including two in 
locked mental health units. A patient suicide in a healthcare facility 
is a ``never event,'' a largely preventable tragic event of deep 
concern to both the public and healthcare providers.
---------------------------------------------------------------------------
    \17\ The Joint Commission, ``Special Report: Suicide Prevention in 
Health Care Settings,'' Joint Commission Perspectives, November 2017, 
37(11):1 and 3-7.

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OIG Hotline Reviews Related to Mental Health Environment of Care

    OIG's hotline reviews are inspections of VA facilities to review 
specific allegations or concerns that have been submitted to the OIG, 
or that are discovered during the course of other OIG oversight 
projects.\18\ Many hotline reviews focus on vulnerabilities in the 
healthcare environment and are meant to identify and report on ways 
that VHA can reduce and control environmental hazards that can help 
prevent accidents, injuries, and suicide for patients, staff, and 
visitors. The most recent OIG report (2019) related to the environment 
of care examined a patient suicide at the West Palm Beach VA Medical 
Center. It highlights the facility's failure to maintain a safe 
environment for patients with mental illnesses and to take adequate 
steps to mitigate physical risks.\19\
---------------------------------------------------------------------------
    \18\ The OIG operates a hotline that accepts any complaints, 
concerns, or allegations related to VA. The hotline website can be 
accessed at https://www.va.gov/oig/hotline/.
    \19\  Prior OIG reports demonstrate that concerns with a safe 
environment for mental health patients are not new. For example, in 
2013, the OIG substantiated allegations that the leadership at the 
Atlanta VA Health Care System in Decatur, Georgia, did not have 
effective polices and did not properly monitor inpatients at that 
mental health unit. Mismanagement of Inpatient Mental Health Care, 
Atlanta VA Medical Center, Georgia, April 17, 2013.

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach 
---------------------------------------------------------------------------
VA Medical Center in Florida

    In August 2019, the OIG reported on its review of the care provided 
to a patient who died by suicide while in the locked mental health unit 
at the West Palm Beach VA Medical Center.\20\ The inspection examined 
whether there were deficient conditions, and if so, their effect. The 
patient (who previously received VA outpatient treatment) was placed on 
``close'' observation status after being involuntarily admitted to the 
medical center's inpatient unit, requiring observation every 15 
minutes. Over the stay of several days, the patient was cooperative and 
engaged in activities. By day four, the patient was planned to be 
discharged to visit a family member, after first returning home, and 
was updated as ``low risk'' of suicide. That afternoon, the 
psychiatrist told the patient that because staff had been unable to 
contact the spouse, the patient's discharge would be delayed. The 
patient became significantly agitated. An hour later, after declining 
medication to decrease agitation, the patient was in the day room using 
the telephone, denied having suicidal ideations, and hopeful of 
discharge the next day. The patient was noted as being in their room 
for the rest of the afternoon.
---------------------------------------------------------------------------
    \20\ Patient Suicide on a Locked Mental Health Unit at the West 
Palm Beach VA Medical Center, Florida, August 22, 2019.
---------------------------------------------------------------------------
    At 5:45 p.m., a nursing assistant documented seeing the patient, 
who refused dinner due to lack of appetite. The staff reportedly did 
not enter the room. At approximately 6 p.m., a fellow inpatient went to 
the patient's room, found the door closed, and encountered resistance 
when trying to open it. A nursing assistant was called and found the 
patient unresponsive with a garment tied around the neck--the other end 
of which was wedged over the top of the door. After lifesaving efforts, 
the patient was declared dead at 6:37 p.m. Inpatient mental health unit 
staff care for some of the most high-risk patients with serious mental 
illnesses, which requires special safety measures to prevent harm. 
Given the need for those measures, the Mental Health Environment of 
Care Checklist (MHEOCC) was designed to help VHA facilities identify 
and address environmental risks for suicide and suicide attempts for 
patients in acute inpatient mental health units. It consists of 
criteria applicable to all rooms on the unit, as well as specific 
criteria for areas such as bedrooms, bathrooms, seclusion rooms, and 
staff work stations. The checklist was implemented in 2007 and research 
has associated it with a substantial decrease in the rate of inpatient 
suicides.\21\ The OIG team found that while the medical center did 
conduct risk assessment rounds of the unit every 6 months, per VHA 
policy, the medical center was not handling other responsibilities:
---------------------------------------------------------------------------
    \21\ Bradley Watts et al., ``Sustained Effectiveness of the Mental 
Health Environment of Care Checklist to Decrease Inpatient Suicide,'' 
Psychiatric Services 2017, 68:4, 405-407.

      The facility did not meet VHA expectations by designating 
an Interdisciplinary Safety Inspection Team to identify environmental 
---------------------------------------------------------------------------
hazards and develop abatement plans.

      Facility leaders failed to ensure that Mental Health 
Environment of Care team members and other responsible staff received 
the relevant checklist training. Staff members who are permanently 
assigned to or have responsibilities on the mental health unit must be 
trained, including housekeepers, chaplains, outpatient providers, and 
police officers.

      Facility staff did not consistently identify noncompliant 
or unsafe environmental conditions. Staff did not identify that 
corridor doors were a risk, claiming that prior oversight inspections 
did not cite the doors. While true, that does not eliminate a need for 
critical thought and risk mitigation. A proper inspection team is 
expected to consider hazards beyond the checklist.

      The facility did not complete the waiver process for 
issues such as lack of seclusion room flooring cushions and cameras to 
mitigate seclusion room blind spots. The OIG found no waiver requests 
from the facility on these issues.

      Oversight and follow-up did not consistently occur at the 
facility, VISN, and VHA central office levels.

    The report also presented findings and related recommendations in 
four other areas regarding clinical care, risk mitigation, unit 
staffing, and leadership responsiveness.\22\ Of particular concern, the 
medical center's Police Chief, Associate Director, Associate Director 
for Patient Care Services, and Assistant Director told OIG staff that 
they were unaware of the facility's requirement for cameras. Leaders 
did not understand the risks associated with the unit's corridor doors. 
One leader told OIG that the facility was going ``above and beyond'' to 
prevent further incidents by counting eating utensils, which, in fact, 
is a long-standing, basic safety requirement.
---------------------------------------------------------------------------
    \22\ Additionally, the OIG found (1) the patient received 
reasonable screening, clinical care, and level of observation given the 
circumstances, although the patient's record did lack a unifying 
treatment plan with measurable goals as required; (2) risk mitigation 
findings included that no documentation was found in the unit's 
rounding sheets that identified the corridor doors as a risk, patient 
observation rounds were not conducted and documented in a manner that 
could reasonably assure patient safety, and cameras, while installed, 
were nonfunctional for years; (3) unit staffing was sufficient on the 
day of the suicide, but one of the nursing assistants assigned to 
conduct 15-minute safety rounds also performed other duties during that 
time, contrary to protocol described by the unit nurse manager; and (4) 
OIG staff found that facility leaders and managers knew, or should have 
known, about lapses in the unit's physical environment, staff training, 
and the MHEOCC inspections. Further, there was no indication they took 
steps to educate themselves on these issues or solve them, and leaders 
and staff accepted noncompliance and unsafe conditions. While the OIG 
team determined that the facility responded promptly after the 
patient's suicide, the actions only occurred after this ``never 
event.''
---------------------------------------------------------------------------
    The current Patient Safety Manager reported to facility leaders in 
a group forum that some of the unit's physical environment conditions 
represented an ``immediate threat to life.'' The Associate Director 
reportedly cautioned the Patient Safety Manager that using the term 
``immediate threat to life'' was ``strong'' and to ``be careful what 
you say.''
    The OIG made 11 recommendations. One recommendation was to the 
Under Secretary for Health to ensure that the MHEOCC work group reviews 
and ranks hazards in mental health units and monitors abatement plans 
or waiver requests. Another recommendation focused on ensuring VISN-
appropriate staff comply with semiannual report reviews and follow up 
on abatement of issues identified in the checklist assessment. The 
other nine recommendations were directed to the facility to improve 
compliance with VHA's guidelines for inspections, operations, safety, 
and training.
    The Under Secretary for Health, the VISN director, and the medical 
center director concurred with the recommendations and provided 
acceptable action plans for implementation. All recommendations were to 
be completed no later than September 2019, according to the action 
plans. The OIG will follow up and review implementation actions to 
determine if the recommendations can be closed in accordance with OIG 
policy.

Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA 
Health Care System

    The OIG conducted a healthcare inspection in response to 
allegations received in 2016 and 2017 related to the clinical 
operations of the inpatient mental health unit regarding patients 
admitted with a diagnosis of dementia.\23\ Among other concerns, the 
OIG substantiated that inpatient mental health unit staff did not 
consistently follow the facility's patient safety observer policy that 
outlined one-to-one care. The OIG reviewed patients requiring one-to-
one care during January 2017 and found patient safety observer--to-
patient ratios were not one-to-one, patient safety observers did not 
maintain constant visual observation of patients, and documentation was 
inconsistent. Additionally, due to the facility's incomplete 
documentation, the OIG was unable to determine whether nurse staffing 
was adequate to meet patient care needs.
---------------------------------------------------------------------------
    \23\ Inpatient Mental Health Clinical Operations Concerns at the 
Phoenix VA Health Care System, Arizona, May 7, 2019.
---------------------------------------------------------------------------
    In 2017, the OIG team substantiated that the inpatient mental 
health unit was not a therapeutic environment due to the absence of 
cleanliness and interior updates, patients not wearing personal 
clothes, and a noncompliant patient advocacy program. In 2018, the OIG 
team noted a satisfactory improvement in the cleanliness after the 
facility contracted with an external company that provided cleaning 
services.
    The OIG made seven recommendations to the facility. The OIG has 
closed the recommendations related to patient safety observer policy 
compliance, inpatient mental health unit nurse staffing methodology, 
the cleanliness of the inpatient mental health unit, and use of the 
Patient Advocate Tracking System. While six of the seven 
recommendations are closed, the OIG continues to monitor compliance 
with training and improvements to the therapeutic environment of the 
unit.

Inpatient Security, Safety, and Patient Care Concerns at the 
Chillicothe VA Medical Center in Ohio

    The OIG reviewed the care of a patient who fell to his death from a 
window at the Chillicothe VA Medical Center in 2017.\24\ The OIG 
determined that there were not adequate security and safety measures in 
place, and these deficiencies contributed to the patient's death. The 
OIG also found that the facility's attempts to provide an institutional 
disclosure to the family were inadequate. Although the patient was not 
cared for in an inpatient mental health unit because of other medical 
conditions, generally the patient received appropriate care.
---------------------------------------------------------------------------
    \24\ Inpatient Security, Safety, and Patient Care Concerns at the 
Chillicothe VA Medical Center, Ohio, September 12, 2018.
---------------------------------------------------------------------------
    The OIG found, however, that the inpatient unit's external windows 
were not secured shut or limited in their opening width, in violation 
of VHA policy. Each VHA facility is required to conduct an Annual 
Workplace Evaluation with occupational safety and health staff 
examining safety and industrial hygiene issues. VHA experts had 
previously sent out guidance on installing brackets to limit opening 
width, and the facility took no action to resolve this issue despite a 
previous attempt by a patient to jump out of a window that opened 
fully. In this case, the patient had been placed on special 
observation, where the observer must remain within arm's length of the 
patient at all times. The observer lost sight of the patient and, in a 
few moments, the patient climbed out of the bathroom window after 
entering the bathroom and closing and locking the bathroom door. The 
observer attempted to grab and rescue the patient, but the patient's 
fall resulted in death. The OIG determined that staff did not adhere to 
the facility's observer policy related to the content, frequency, and 
hand-off documentation requirements. Moreover, facility leaders failed 
to monitor staff compliance with the special observer documentation 
requirements. The OIG also reviewed training records and found unit 
staff did not complete the Prevention and Management of Disruptive 
Behavior training, the special observer competencies, and other 
required trainings. The OIG found that facility leaders' failure to 
ensure that staff were trained in key competencies likely contributed 
to staff being unaware of the guidelines and duties.
    The OIG made four recommendations to the facility director 
regarding exterior windows being made compliant with VHA's guidelines, 
compliance with observation policies and training competencies, and 
reviewing the discussion of the institutional disclosure that took 
place with the next of kin. All recommendations have been closed.

The OIG's Comprehensive Healthcare Inspection Program Focus on 
Inpatient Mental Health Units' Environment of Care

    The OIG uses its Comprehensive Healthcare Inspection Program (CHIP) 
to provide cyclical, focused evaluations of the quality of care 
delivered in the inpatient and outpatient settings of VA facilities. 
OIG CHIP teams evaluate areas of clinical and administrative operations 
that reflect quality patient care, with focused review areas changing 
every fiscal year.\25\ These inspections are one element of the overall 
efforts of the OIG to ensure that the Nation's veterans receive high-
quality and timely VA healthcare services.
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    \25\ The nine areas for Fiscal Year 2018 were leadership and 
organizational risks; quality, safety, and value; credentialing and 
privileging; environment of care; medication management; mental health; 
long-term care; women's health; and high-risk processes. For Fiscal 
Year 2019, medical staff privileging was substituted for credentialing 
and privileging. Fiscal Year 2020 is the same as Fiscal Year 2019 
except care coordination was substituted for long-term care.
---------------------------------------------------------------------------
    OIG staff determine whether facilities maintain a clean and safe 
healing, recovery-oriented environment, particularly in selected areas 
often associated with higher risks of harm to patients, such as in 
locked mental health units.

Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018

    In Fiscal Year (FY) 2018, OIG staff completed 51 CHIP inspections, 
with the results summarized in a report that, among other topics, 
highlighted inpatient mental health units' environment of care 
deficiencies at those facilities inspected from April to September 
2018.\26\ Generally, VA facilities met requirements associated with 
infection prevention, general safety, privacy, and availability of 
supplies. Construction and Nutrition and Food Services areas, locked 
mental health units, and emergency management programs met many of 
their respective requirements. However, the OIG identified concerns 
with environmental cleanliness, installation and testing of panic 
alarms in high-risk areas, seclusion rooms in locked mental health 
units, and emergency management processes.
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    \26\ Comprehensive Healthcare Inspection Summary Report Fiscal Year 
2018, October 10, 2019.
---------------------------------------------------------------------------
    In Fiscal Year 2018, VA inspected 27 mental health units that 
yielded the following findings:

      Twenty-three had evidence of monthly alarm system 
testing, but only 17 of those 23 documented evidence of VA police 
response times.

      Four had dirty ventilations grills and/or floors.

      Five of 19 applicable locked mental health units with 
seclusion rooms lacked flooring made of a material that provides 
cushioning.

    In Fiscal Year 2019, during continued physical inspections of 27 
additional VA inpatient mental health units' environment of care, OIG 
staff found these deficiencies:

      Four of the 27 units did not document evidence of panic 
alarm testing. Of the 23 units that had evidence of panic alarm 
testing, three did not include VA police response times.

      Five units had cleanliness issues.

      Four of 22 applicable units' seclusion rooms did not have 
flooring made of a material that provides cushioning. Facility managers 
reported a lack of awareness of these requirements and admitted to 
their lack of oversight in ensuring a safe environment of care.

    The Fiscal Year 2018 Summary Report made four recommendations to 
the Under Secretary for Health to improve the environment of care 
nationally, based upon aggregate data collected during the related CHIP 
site visits. VHA, VISN, and facility leaders concurred with OIG 
recommended improvements and set their completion timeframes to 
accomplish and monitor compliance with the following:

      Ensure that facility managers maintain a clean and safe 
environment (June 2020 projected completion date).

      Confirm that VA police test panic alarms and document 
response times to alarm testing in locked mental health units and high-
risk outpatient clinic areas (November 2019 projected completion date).

      Make certain that facility managers install floor 
cushioning in locked mental health unit seclusion rooms (June 2020 
projected completion date).

      Verify that facility managers annually review emergency 
operations plans and resource and asset inventories (November 2020 
projected completion date).

    OIG staff will monitor VA's progress.

Other OIG Work Related to VHA Mental Health Care Experience

    The OIG has released reports on other issues that can directly 
affect VHA's ability to provide effective mental health care. The 
following recent reports highlight areas within VHA that require 
attention to help ensure a supportive environment and appropriate 
coordination for effective mental health care.

OIG Determination of VHA's Occupational Staffing Shortages, Fiscal Year 
2019

    Since January 2015, the OIG has reported on VHA clinical staffing 
shortages as required by the Veterans Access, Choice, and 
Accountability Act of 2014 (PL 113-146).\27\ Although the 2018 report 
was the fifth OIG report on staffing shortages within VHA, it was the 
first report that included facility-specific data reported by leaders 
at 140 VA medical centers. Users can examine the particular self-
reported needs of an individual facility as opposed to only national 
data.
---------------------------------------------------------------------------
    \27\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages reports were previously published on 
June 14, 2018; September 27, 2017; September 26, 2016; September 1, 
2015; and January 30, 2015.
---------------------------------------------------------------------------
    It was also the first report to include nonclinical positions, such 
as police and custodial personnel, as required by the VA Choice and 
Quality Employment Act of 2017 (PL 115-46).\28\ These nonclinical 
occupations also can affect the ability of VHA facilities to provide 
quality and timely patient care in a safe and clean environment. The 
results of the review underscore the extent to which mental health care 
and related shortages are a widespread issue across VHA.
---------------------------------------------------------------------------
    \28\ OIG Determination of VHA's Occupational Staffing Shortages, 
Fiscal Year 2019, September 30, 2019.
---------------------------------------------------------------------------
    Medical center directors most commonly cited the need for medical 
officers and nurses, which is consistent with the OIG's five previous 
VHA staffing reports. The data showed that 131 of 140 facilities listed 
the medical officer occupational series (or a related VHA assignment 
code) as experiencing a shortage, with the psychiatry and primary care 
positions being the most frequently reported. Of the 140 facilities, 
102 listed the nurse occupational series (or a related VHA assignment 
code) as experiencing a shortage, with practical nurse and staff nurse 
as the most frequently reported. Within nonclinical occupations, the 
OIG found that police occupations, general engineering, and custodial 
workers were among the most often cited as shortages. Overall, 99 out 
of 140 VHA facility directors reported at least one severe shortage in 
mental health occupations.\29\
---------------------------------------------------------------------------
    \29\ Mental health occupations include Psychiatry; Registered 
Nurses - Inpatient and Outpatient Mental Health; Nurse Practitioner - 
Mental Health/Substance Use Disorder; Clinical Nurse Specialist - 
Mental Health/Substance Use Disorder; Social Science/Licensed 
Professional Mental Health Counselor; Psychology; Psychology Aid and 
Technician.

---------------------------------------------------------------------------
Inadequate Governance of the VA Police Program at Medical Facilities

    The safety of VA personnel, veterans and their families, and 
visitors to VA facilities is not just a responsibility for clinical and 
administrative VHA personnel but also VA's police service. Veterans may 
have interactions with VA police during their care at a VA facility--in 
some cases it may be the first interaction they have upon entering a 
facility. These interactions underscore the importance of an 
appropriately governed, well trained, and adequately staffed VA police 
service, particularly when they interact with veterans experiencing a 
mental health crisis.
    The OIG in this report did not focus on VA police encounters with 
individuals in mental health crisis. It examined the effectiveness of 
the police program governance structure and the challenges in staffing 
and overseeing its police workforce.\30\ Accordingly, there is some 
concern about how overall governance and police staffing might affect a 
broad array of facility duties, including those related to mental 
health concerns.
---------------------------------------------------------------------------
    \30\ Inadequate Governance of the VA Police Program at Medical 
Facilities, December 13, 2018.

---------------------------------------------------------------------------
ONGOING OIG WORK RELATED TO VHA MENTAL HEALTH CARE

    In addition to the recent work highlighted in this statement, the 
OIG has many other ongoing and planned projects related to VHA mental 
health care. The OIG recognizes the tremendous importance of mental 
health care and suicide prevention and is coordinating and focusing 
efforts across the OIG to ensure effective oversight of VHA's efforts. 
For example, the OIG is conducting an audit to determine whether 
suicide prevention coordinators are effectively managing crisis line 
referrals to connect at-risk veterans with needed services. 
Specifically, the audit will assess whether VHA provided oversight and 
established processes for suicide prevention coordinators to ensure 
veterans are reached to assess their needs.
    Additionally, the OIG is in the final stages of developing a 
focused review that will evaluate the quality of care provided at 
Readjustment Counseling Services clinics, also known as Vet Centers. 
The review will cover key clinical and administrative processes at Vet 
Centers that are associated with promoting quality care such as 
effective governance, appropriate environment of care, VHA care 
coordination and collaboration, and suicide prevention. The OIG also 
has ongoing reviews of recent incidents in which there are allegations 
that veterans experiencing a mental health crisis did not receive 
appropriate or adequate care. This includes incidents that have 
occurred at VA medical centers and at the Veterans Crisis Line. The OIG 
hotline continually works with expert staff to triage incoming 
information and remains vigilant to issues that could undermine 
appropriate and timely mental health care, and investigate thoroughly 
allegations of patient harm, suicide, and related concerns at VHA 
facilities.

CONCLUSION

    This Committee and VA have made it a priority to improve the mental 
health care and suicide prevention capabilities of VHA. All OIG staff 
share your sense of urgency in addressing these issues. Recent OIG work 
has detailed the challenges some veterans face accessing and receiving 
high-quality mental health care within VHA. However, we should not lose 
sight of the good work that dedicated mental health care providers and 
other professionals are doing within VA. There are tremendous numbers 
of patients and providers who have had positive experiences that should 
be valued and applauded. The reports highlighted in this statement show 
that there are still considerable challenges however, particularly 
regarding deficiencies in the environment and coordination of mental 
health care that have persisted and led to negative outcomes for 
veterans experiencing mental health crises. The OIG is committed to 
providing recommendations that flow from our oversight work to help VHA 
improve its programs and veterans' experiences. The OIG will continue 
to monitor the many aspects of mental health care and suicide 
prevention provided by VHA to help ensure the improvements sought by 
this Committee and our Nation are realized.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Committee may have.
                                 ______
                                 

                 Prepared Statement of C. Edward Coffey

    Good morning, Chairman Takano, Ranking Member Roe, and Members of 
the Committee. Thank you for inviting me to participate in this very 
important hearing on suicide prevention for America's veterans. I am 
Dr. Ed Coffey, a neurologist and psychiatrist, and Affiliate Professor 
of Psychiatry and Behavioral Sciences at the Medical University of 
South Carolina, in Charleston, SC.
    You requested that I share insights about the efforts of non-VA 
health care systems to establish comprehensive suicide prevention 
approaches. I am happy to do so. While as a physician I have always 
viewed suicide prevention as a key priority for my patients, my 
involvement in suicide prevention at a healthcare systems level began 
over 20 years ago, when I served as Vice President for Behavioral 
Health Services at the Henry Ford Health System in Detroit, MI (1996-
2014). In that capacity I had the great pleasure to lead a team of 
incredible individuals who set out to radically transform a large 
mental health care delivery system by participating in the Robert Wood 
Johnson Foundation's ``Pursuing Perfection National Collaborative.'' We 
chose to focus our initiative on ``perfecting'' the care of persons 
with depression, and by leveraging the power of an audacious goal - the 
elimination of suicide - we achieved dramatic and sustained reductions 
in patient suicide, as well as improved performance of our entire 
delivery system. Our approach to achieve these results has since been 
endorsed by numerous organizations - including The Joint Commission and 
the U.S. Surgeon General's 2012 National Strategy for Suicide 
Prevention - and recently SAMHSA has funded the implementation of the 
Zero Suicide model by numerous states, tribes, and health care systems 
across the US. In addition, the vision of ``Zero Suicide'' has inspired 
an international movement, and I am pleased to be supporting such 
implementation which is underway in Canada, Australia, New Zealand, the 
Netherlands, and the United Kingdom.
    In my remarks today, I will briefly review the origin of our Zero 
Suicide model and discuss its key components. But first, by way of 
background I want to review some statistics that highlight the growing 
suicide crisis in our country.

The Suicide Crisis in America

    This Committee is well aware of the growing tragedy of suicide in 
America.

      While deaths from cancer and heart disease have declined 
in the US, the rate of death by suicide has increased 33 percent in the 
past 16 years (1999 - 2017) (Figure 1). That rate is actually 
accelerating more recently, and it is disproportionately higher in 
women and in people living in rural areas.

      The statistics are worse for veterans, where the 
incidence of suicide is 50 percent higher than the general adult 
population, and 80 percent higher in female veterans.

      Suicide is the 10th leading cause of death in the US, and 
the second leading cause of death between ages 10 - 34. In 2017, we 
lost 850,000 Americans to suicide, 86100 of whom were veterans.

      Many more Americans - 81.4 million - report having 
attempted suicide each year, and over 10 million report seriously 
considering suicide.

    In light of these grim statistics, a new approach to suicide 
prevention is clearly needed.

[GRAPHIC] [TIFF OMITTED] T8957.061


The Origin of the Zero Suicide Model


    In 2001, the Institute of Medicine's Crossing the Quality Chasm 
report called for sweeping reform of the American health care system, 
and the Robert Wood Johnson Foundation together with the Institute for 
Healthcare Improvement responded with a $26 million national 
demonstration project - known as the ``Pursuing Perfection National 
Collaborative'' - that challenged health care systems to dramatically 
improve patient outcomes by redesigning all major care processes in 
order to deliver ideal care. At Henry Ford Health System, our 
participation in the first phase of Pursuing Perfection (we were not 
ultimately awarded an implementation grant) challenged us to create a 
workplace culture in which the performance goal was perfection, not 
just incremental improvement.
    We selected for transformation the care of persons with depression, 
but we struggled initially to articulate what a vision of ``perfect 
depression care'' would look like. Finally, one of our staff suggested 
that if depression care was truly perfect, no patient would die from 
suicide. That stunning idea set in motion a debate that continues even 
today. Some have argued that a goal of no suicide is not realistic or 
achievable (e.g., How can we stop it if someone really wants to do 
it?), that it is overly simplistic, and that it could provoke distress 
among patients, family members, and health care providers that would 
only make matters worse. Our team challenged these assumptions and 
asked, If zero is not the right goal for suicide occurrence, what 
number possibly could be? Very quickly we came to realize that because 
of its radicalism, the goal of Zero Suicide provided the requisite 
galvanizing force essential to drive the hard work of transformation.
    It should be noted that the concept of ``zero defects'' has been 
around since at least 1966, spreading to industries throughout the 
world, and recently, innovating to zero was called 1 of 10 megatrends 
for innovation. High-reliability organizations aggressively pursue 
perfection, an approach that has driven commercial aviation to achieve 
remarkable levels of safety. Why shouldn't this same approach be 
applied to health care?

The Zero Suicide Model

    In our view, the Zero Suicide Model is an approach to system 
transformation that consists of three essential components (Figure 2):
[GRAPHIC] [TIFF OMITTED] T8957.062


      A radical conviction that ideal (perfect) health care is 
attainable.

        Such a conviction is fundamental to the model, as it provides 
        the driving force essential for the hard work of relentless 
        transformation. Absent such a radical conviction, implementing 
        multimodal suicide prevention strategies is less likely to be 
        effective and sustainable.

      A roadmap to achieve that vision.

        Performance is about ``pursuing perfection,'' not simply 
        incremental improvement. Such performance is made possible by a 
        ``just culture.'' A ``just culture'' is one that embraces the 
        radical goal of perfect care, and that makes the pursuit of 
        that care possible by viewing errors or near misses as system 
        failures from which to learn and rapidly improve. In response 
        to errors, a just culture asks ``What happened and how?'', not 
        ``Who did it?'' A just culture seeks recovery, restoration, and 
        improvement, not blame, punishment, or retribution.

      A requisite expertise in systems engineering.

        Teammates must be expert in promoting and implementing 
        systematic evidence-based approaches. In our Perfect Depression 
        Care Initiative, we focused on three key strategies: safety 
        planning (particularly safe gun ownership), rapid access to 
        definitive care, and managing the transitions of care. 
        Teammates must also be quick learners when mistakes happen, so 
        that they can rapidly correct system defects and continually 
        improve to achieve zero defects.

    With this model we were able to reduce the rate of suicide among 
our patients by 75 percent, even while over that same 10-year period 
the rate of suicide actually increased in the general population of the 
State of Michigan. As noted earlier, others are now adopting iterations 
of the Zero Suicide model and are describing similar positive results. 
Additionally, research (funded by NIH and SAMHSA) is underway to 
formally study the effectiveness of the Zero Suicide model.

Conclusion

    As noted by the Institute of Medicine in its report Crossing the 
Quality Chasm, ``In its current forms, habits, and environment, 
American health care is incapable of providing the public with the 
quality health care it expects and deserves. ...The current care 
systems cannot do the job. Trying harder will not work. Changing 
systems of care will.''
    Zero Suicide is an example of how we might change our systems of 
care, and it provides a potential model for achieving dramatically 
improved performance, including the audacious goal of eliminating 
suicide. To be sure, suicide prevention is a very complex issue that 
involves clinical and socio-cultural-political components. Still, the 
Department of Veterans Affairs is in a position to address such 
complexity, and there is no reason why it couldn't become the world 
leader in dramatically improving systems issues such as health 
engagement, healthcare access, and the social determinants of health, 
among others. In addition, because veterans and service members are 
venerated in our society and widely acknowledged as expert in injury 
prevention, they have the opportunity to serve as the model for safe 
gun ownership in our broader society, and in so doing, catalyze a 
movement that would save thousands of lives.
    Thank you again for the opportunity to participate in this hearing 
today, and to represent my many colleagues around the globe who have 
courageously embraced a vision of ideal care and Zero Suicide. I am 
happy to respond to any questions you may have.

Selected Supporting Documents

    Coffey CE. Building a system of perfect depression care in 
behavioral health. Jt Comm J Qual Patient Saf, 33:193-199, 2007.
    Coffey CE, Coffey MJ, Ahmedani BK. An update on Perfect Depression 
Care. Psychiatric Services, 64:396, 2013.
    Coffey MJ, Coffey CE, Ahmedani BK. Suicide in a health maintenance 
organization population. JAMA Psychiatry, 72:294-296, 2015.
    Coffey MJ, Coffey CE. How we dramatically reduced suicide. Case 
Study. NEJM Catalyst. (Posted April 20, 2016 at http://
catalyst.nejm.org/dramatically reduced-suicide/).
    Coffey CE. Perfect depression care and the origin of Zero Suicides. 
National Academies of Science, Engineering, and Medicine Workshop on 
Improving Care to Prevent Suicide Among People with Serious Mental 
Illness, Washington, DC, September 11, 2018. Proceedings published in: 
National Academies of Sciences, Engineering, and Medicine. 2019. 
Improving Care to Prevent Suicide Among People with Serious Mental 
Illness: Proceedings of a Workshop. Washington, DC: The National 
Academies Press. doi: https://doi.org/10.17226/
    Coffey CE, Ahmedani BK, Coffey MJ. Challenges in suicide prevention 
research (letter). JAMA, 321 (11):1105, 2019.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                       Statements for the Record

                              ----------                              


                 Prepared Statement of American Legion

    Chairman Takano, Ranking Member Roe, and distinguished members of 
the Committee, on behalf of National Commander James Oxford and the 
nearly two million members of The American Legion, we thank you for the 
opportunity to address the important issue of caring for veterans in 
crisis. As the largest veterans service organization in the United 
States, we stand ready to assist this committee and the Department of 
Veterans Affairs to ensure that America's veterans are provided with 
the highest level of support and healthcare.

                       The Comprehensive Approach

    Veteran suicide is a national issue and far exceeds the ability of 
any one organization to handle alone. The American Legion stands behind 
the Department of Veterans Affairs (VA) in its efforts to collaborate 
with partners and communities nationwide to assist veterans in crisis. 
The public health approach looks beyond the individual to involve 
peers, family members, and the community in preventing suicide. 
Preventing veteran suicide is a top priority for VA, but they need help 
from dedicated partners to reach veterans who are in crisis.
    On April 24, 2019, National Commander Brett Reistad teamed up with 
Dr. Keita Franklin, VA's previous Executive Director of Suicide 
Prevention, and penned a letter emailed to nearly 850,000 American 
Legion members, family, and friends, to let them know that we are 
working together to adopt a public health approach to suicide 
prevention.\1\ It is imperative that the entire extended veteran 
network is involved in assisting veterans in crisis. Equally as 
essential is the need to centrally coordinate all efforts to ensure 
valuable resources are not squandered in duplicative efforts, as well 
meaning as they may be.
---------------------------------------------------------------------------
    \1\ https://www.legion.org/commander/245458/legion-va-team-
approach-suicide-prevention
---------------------------------------------------------------------------
    In an effort to increase collaboration with partners and 
communities nationwide, The American Legion's TBI/PTSD Committee 
developed a Mental Health Survey. The target audience was veterans and 
caregivers, of which 13,648 responded. The data collected indicated 
82.47 percent of survey participants never received any form of suicide 
prevention training, and 67.39 percent of survey participants were 
somewhat likely, likely, or very likely to take suicide prevention 
training if offered. Survey participants identified training as a 
critical area and are ready to participate if the opportunity is made 
available.

                          VHA Staffing Issues

    The American Legion remains deeply concerned by the trend of 
suicides reported at VA facilities. One contributing factor to the 
increase in suicide on VA campuses may be traced to staffing shortages 
experienced by VA hospitals and clinics. Data released in September 30, 
2019, as mandated by the VA Choice and Quality Employment Act of 2017, 
reported 2,500 occupational staffing shortages across the VHA system. 
Of note, 60 percent of the facilities noted severe occupational 
shortages for Psychiatry, making it the most cited clinical 
occupational shortage.\2\ The high rate of employee turnover, 
insufficient recruitment, non-competitive salary, geographical 
recruitment challenges, private sector competition, and drawn-out 
hiring processes attribute to shortages in VA personnel. These factors 
inherently lend themselves to overworked staff, poor patient 
experiences, and lower quality of care.
---------------------------------------------------------------------------
    \2\ OIG report 19-00346-241
---------------------------------------------------------------------------
    In keeping with The American Legion Resolution No. 115, Department 
of Veterans Affairs Recruitment and Retention, we urge Congress to pass 
legislation to improve VA's tedious hiring process and increase VA's 
recruitment, retention and relocation budget.\3\ It will allow VA to 
retain quality mental health providers, incentivize exemplary 
performance, and increase employee morale. Improvements in these areas 
will lead to increased customer satisfaction and overall quality of 
care for veterans.
---------------------------------------------------------------------------
    \3\ https://archive.legion.org/bitstream/handle/20.500.12203/5772/
2016N115.pdf
---------------------------------------------------------------------------

                   Access to Care for Rural Veterans

    Connecting those who served to the medical resources they deserve 
is a top priority for The American Legion.\4\ Many veterans live in 
remote areas and are unable to access care in a timely manner which can 
create major issues in a time of crisis. The VA has taken action to 
address this issue by expanding its Telehealth capabilities, and has 
teamed up with The American Legion and Philips to bring VA healthcare 
to veterans in a familiar setting - their local posts. Through Project 
ATLAS (Accessing Telehealth through Local Area Stations), Philips will 
install video communication technologies and medical devices in 
selected American Legion and VFW posts to enable remote examinations 
through a secure, high-speed internet line. Veterans will be examined 
and advised in real time through face-to-face video sessions with VA 
medical professionals, who may be located hundreds or thousands of 
miles away. Project ATLAS aims to increase the convenience and 
accessibility of care which will prove to be essential to veterans in 
crisis.
---------------------------------------------------------------------------
    \4\ https://archive.legion.org/bitstream/handle/20.500.12203/6926/
2017N075.pdf
---------------------------------------------------------------------------

                               Conclusion

    Chairman Takano, Ranking Member Roe, and distinguished members of 
this committee, The American Legion thanks you for holding this 
important hearing and for the opportunity to explain the views of the 
nearly 2 million members of this organization. The American Legion is 
committed to working with the Department of Veterans Affairs and this 
committee to ensure that America's veterans are provided with the 
highest level of support. For additional information regarding this 
testimony, please contact Mr. Jeffrey Steele, Senior Legislative 
Associate of The American Legion's Legislative Division at (202) 263-
2993 or [email protected]
                                 ______
                                 

 Prepared Statement of American Federation of Goverment Employees, AFL-
                                  CIO

    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
The American Federation of Government Employees, AFL-CIO and its 
National Veterans Affairs Council (AFGE) appreciate the opportunity to 
submit a statement for the record on caring for veterans in crisis, and 
the essential role that Department of Veterans Affairs (VA) police play 
in deescalating crises and ensuring that every veteran receives timely, 
comprehensive care. AFGE represents more than 700,000 Federal and 
District of Columbia government employees, 260,000 of who are proud VA 
employees. The workforce we represent includes police officers working 
at the vast majority of VA medical facilities across the Nation, and 
many of these officers are veterans themselves.
    Short staffing of police officers and clinical staff, reduced 
emergency and urgent care services within the VA, and lack of permanent 
medical center leadership all threaten the ability of VA police 
officers to adequately respond to veterans in crisis. These are all 
symptoms of a health care system under great strain from the ever-
increasing privatization of veterans' health care.

Overview

    VA police officers are very often the first point of contact for a 
veteran in crisis at a VA medical center. Their mission is to provide a 
compassionate, safe response that ensures that the veteran is quickly 
connected to the treatment he or she needs. The veteran's mental health 
is the priority of the officers. In many instances, the police officer 
is the one who deals directly with a homicidal or suicidal individual 
who tries to leave the facility and is refusing to be admitted for 
inpatient care. As one officer stated
    These officers are an integral part of both the Behavioral 
Emergency Response Teams (BERT) that handle crisis situations inside 
inpatient and outpatient facilities and the external response teams 
that cover the rest of the campuses. Officers may identify veterans in 
crisis when they seek help at a VA emergency department (ED), VA urgent 
care center or through outreach by VA mental health professionals or 
Crisis Line of call center employees. The officer then attempts to 
engage the veteran, deescalate and connect to clinical care by phone or 
in person. If needed, the VA police officer will reach out to local law 
enforcement to go to the veteran's home and convince him or her to come 
into the VA for treatment. Depending on the State and individual 
facility policy, the officer may also be able to impose a temporary 
detention order on the veteran to secure an initial mental health 
assessment.

Dangers of Short Staffing

    VA officers have reported that their facilities have been at 
minimal staffing levels for years. The Department's outdated staffing 
policy risks the safety of the veteran in crisis, other veterans and 
family members and employees. If one of the officers must leave the ED 
to address an incident elsewhere on the campus, often there is simply 
not enough coverage to properly respond to another emergency involving 
a veteran. The larger the campus, the greater the gap in police 
coverage becomes. As an officer who works at one of the 39 medical 
centers with the greatest complexity (based on patient volume, patient 
risk, teaching and research, specialists and ICUs) reported, even 
though their staffing minimums are usually higher (4 officers per 
facility), they still lack sufficient coverage when they are responding 
to multiple calls or need to leave the campus to have a veteran 
detained.
    The VA Office of Inspector General (OIG)'s June 2018 report found 
that VA police rank seventh highest in the Veterans Health 
Administration (VHA) regarding occupational shortages, with 52 
facilities reporting police shortages, an 18 percent vacancy rate and 
numerous facilities staffed below authorized levels.\1\ Turnover of VA 
police officers is also very high; an officer reported to us that 
nearly a third of the officers at his facility leave every year. 
Reports we received from the field confirm what the OIG found in its 
2018 report--that noncompetitive wages are a top cause of the inability 
to recruit and retain officers at the VA.
---------------------------------------------------------------------------
    \1\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortage Fiscal Year 2018, June 14, 2018.
---------------------------------------------------------------------------
    The OIG also identified a serious structural problem in its June 
14, 2018 report: a lack of standardized police officer staffing models 
that can be utilized by medical facilities to determine the appropriate 
number and composition of officers. The lack of a sound staffing model 
forces facilities to resort to extreme short-term measures such as 
contracting out critical police officer functions to companies without 
specialized experience or training, or ``borrowing'' VA officers from 
other nearby facilities.
    A number of additional factors further strain already short-staffed 
police forces, including large campus sizes, facilities in urban areas 
and high crime areas, high usage levels, large rehabilitation and 
homeless veteran units and EDs at maximum capacity.
    Severe short staffing of clinical staff on emergency response teams 
further endangers veterans in crisis. Officers express frustration over 
the inability to access front line medical staff, especially during 
transitions from the day to evening shifts, before night staff and on 
call staff come on duty.
    Chronic short staffing and high turnover at the leadership level is 
also taking its toll on the VA police force. Officers find it 
increasing difficult to determine where to bring concerns given 
constant changes in leadership at their facilities. In addition, front 
line officers feel that their voices are not welcome. They no longer 
have the ability to express their views through labor-management groups 
that would be convened in the past. In contrast, VHA regularly receives 
input and recommendations from facility level chief of policy 
committees, that often include officers who come from outside the VA 
and lack the critical hands on experience that rank and file officers 
could bring to the table. These committees appear to communicate with 
VA Central Office but not with the rank and file officers at the 
facility.
    Sadly, Secretary Wilkie continues to appear unwilling to fill the 
nearly 50,000 vacancies that the VA is required to report under the VA 
MISSION Act. The VA must be held accountable for this chronic and 
harmful short staffing, which continues to erode VA's capacity every 
year and provide the justification for further dismantling of the VA 
through privatization.

    AFGE urges the Committee to insist on firm deadlines for filling 
the unfilled vacancies in the VHA police force and other VHA positions 
that have been identified by the OIG. We also recommend that the VA's 
current mandate to report vacancies under the VA MISSION ACT be 
expanded to include a breakdown by profession so that veterans and the 
public know which facilities have a shortage of police, clinical staff 
and other positions.

Training

    Officers are generally satisfied with the Standardized Training 
they receive at the VA Law Enforcement Training Center (LETC). However, 
they express interest in receiving more skills training at their 
facilities to ensure that they are fully equipped to serve as the first 
point of contact for veterans with suicidal ideations and engage in 
successful de-escalation. For instance, while everyone gets 
standardized mental health training to assess immediate threats made by 
a veteran, the initial LETC training is only an acceptable baseline and 
VA leadership should consider providing more hands-on training with 
role playing using the Crisis Intervention Team (CIT) model that 
originated in Memphis and has been replicated in facilities across VA. 
AFGE also recommends updating the LETC training to include more 
training models that focus on treatment rather than arrests, consistent 
with VA policy that law enforcement should be the last resort.

The Danger of Closed VA Emergency Departments and Urgent Care Centers

    Improvements in officer training and staffing will be of far less 
value if veterans in crisis do not have a designated place to go for 
help and comprehensive care within the VA. Sadly, that is exactly the 
direction that the VA is heading toward. AFGE has raised concerns with 
Congress for over a decade about the dismantling of VA health care 
through the closing of in-house EDs and urgent care centers. We know 
anecdotally that many VA medical centers across the country have lost 
EDs and urgent care centers over the years but are not aware of any 
comprehensive studies of this trend.
    VA officers have reported that the absence of a designated place in 
medical centers for a veteran to go to when he or she is crying out for 
help greatly impedes their mission to make treatment, rather than 
arrest, the first priority. One officer at a facility that lost its ED 
expressed concern that veterans in his community no longer have an 
appropriate place to go where they can just get ``something off their 
chest.'' As he explained, when a veteran becomes agitated, he now has 
to be sent across town for emergency care and then back again to the VA 
for continued treatment. This breakdown in continuity of care can cause 
a great deal of stress for the veteran. Additionally, the VA officers 
and clinicians risk ending up with less information because the 
emergency care was provided outside of the VA instead of within VA's 
integrated system. Therefore, AFGE urges the Committee to conduct 
oversight into the status of EDs and urgent care centers across VHA 
facilities and how their closures are impacting veterans in need of 
crisis intervention.

    AFGE appreciates the Committee's attention to the important issue 
of caring for veterans in a crisis and the role of the VA police. We 
look forward to working with you to address needed improvements in 
order to provide VA police officers with more tools to assist veterans. 
Thank you.

                                 [all]