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Using Multisite Process Mapping to Aid Care Improvement

An Examination of Inpatient Suicide-Screening Procedures

Holleran, Lori; Baker, Samantha; Cheng, Caleb; Wilson, Jaime; Mickelson, Robin; Kazana, Izabela; Messinger-Rapport, Barbara; Shahin, Jacquelene; Cully, Jeffrey; Naik, Aanand D.; Godwin, Kyler M.

The Journal for Healthcare Quality (JHQ): March/April 2019 - Volume 41 - Issue 2 - p 110–117
doi: 10.1097/JHQ.0000000000000182
Original Article

ABSTRACT Although most suicides occur outside of medical settings, a critical and often overlooked subgroup of patients attempt and complete suicide within general medical and inpatient units. The purpose of this quality improvement initiative was to perform a baseline assessment of the current practices for suicide prevention within medical inpatient units across eight Veterans Affairs medical centers throughout the nation, as part of the VA Quality Scholars (VAQS) fellowship training program. In conjunction with the VAQS national curriculum, the authors and their colleagues used multisite process mapping and developed a heuristic process to identify best practices and improvement recommendations with the hopes of advancing knowledge related to a key organizational priority—suicide prevention. Findings demonstrate a multitude of benefits arising from this process, both in relation to system-level policy change as well as site-based clinical care. This interprofessional and multisite approach provided an avenue for process literacy and consensus building, resulting in the identification of strengths including the improvement of prevention efforts and accessibility of supportive resources, the discovery of opportunities for improvement related to risk detection and response and the patient centeredness of current prevention efforts, and the provision of solutions that aim to achieve sustained change across a complex health system.

For more information on this article, contact Kyler M. Godwin at

This work is supported in part by the VA Quality Scholars Program Coordinating Center Grant (VA Office of Academic Affiliations) and the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the U.S. Department of Veterans Affairs or the U.S. government.

The authors declare no conflicts of interest.

© 2019 National Association for Healthcare Quality
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