Suicide is currently the 10th leading cause of death in the United States and a growing public health problem.1 Despite committed efforts to address this problem, suicide completion rates continue to be alarmingly high among certain at-risk groups. Veterans represent a particularly vulnerable population, carrying a suicide risk 41–61% higher than the general population.2 In 2014, an average of 20 Veterans died by suicide every day.3 Concerningly, it is estimated that for each fatality, approximately 11 nonfatal attempts have occurred,1 indicating a tremendous need for effective intervention, specifically among Veterans. This need has not gone unnoticed within the U.S. Department of Veterans Affairs (VA), with suicide prevention being the agency's highest clinical priority.4
In 2017, the VA introduced the Getting to Zero initiative, which highlighted how suicide prevention would henceforth be viewed as an urgent concern across VA settings.4 Although most suicides occur outside of hospitals, many still happen in general medical settings.5 Suicide is consistently one of the most common sentinel events reported in U.S. hospitals.6,7 Key elements of care provision in a healthcare facility relevant to suicide prevention include tasks such as risk screening and assessment, treatment, discharge, and follow-up care.8 Ultimately, reducing the risk of suicide in medical settings requires collaborative and systematic efforts within the broader healthcare system. Unfortunately, a paucity of research exists considering medical inpatient suicide within the VA.
Process mapping (PM) is the graphic display of steps, events, and operations that constitute a process. Process mapping is a commonly used tool to improve quality in any operation or business with high complexity and high risk,9 potentially positioning it as an appropriate tool for improving processes relevant to suicide risk reduction. Because suicide risk frequently presents across healthcare system settings, collaboration across different medical departments, such as the emergency department, a medical, or surgical unit, and mental health (MH) are often required. In addition, suicide prevention efforts can take place across different hospital systems if a suicidal patient needs transfer to another organization, further complicating an already complex process.
Although PM can be narrowly identified as a visual diagram, the definition of PM can be expanded to encompass the holistic process of networking together the diverse settings and caregivers who touch the patient to identify a comprehensive process of care.10 In addition, PM can increase process literacy within a system by increasing the knowledge of what actually occurs within a given process, considering the many viewpoints that touch the process.11 This ability positions PM as an effective tool for assessing process-related trends across multiple settings within a large healthcare system, such as the VA. However, multisite analysis of PM to aid quality improvement (QI) is not widely documented, with only one prior instance being known in the literature,12 to identify best practices. Thus, although PM could theoretically be used to consider multisite processes across multiple sites of care, currently there is a dearth of knowledge exhibiting its utility.
The purpose of this QI initiative was to complete, through the utilization of PM, a baseline assessment of the current practices for suicide prevention within medical inpatient units across eight VA medical centers throughout the nation, as part of the VAQS program. As one component of a national training program in QI, the authors and their colleagues aimed to examine the utility of multisite PM and engaged in a consensus building process with the hopes of acquiring knowledge to inform future organizational changes within the VA.
Eight VA medical centers located in Center A, Center B, Center C, Center D, Center E, Center F, Center G, and Center H served as independent study sites. Sites were chosen based on their participation in the VAQS Program, a 2-year intensive interprofessional fellowship program for post-residency physicians and postdoctoral nurses, pharmacists, and psychologists. Established in the late 1990s, the VAQS program, an Advanced Fellowship program sponsored by the VA Office of Academic Affiliations, seeks to train interprofessional leaders in healthcare improvement.13,14 The VAQS Coordinating Center develops and delivers a weekly, national curriculum to the sites as well as hosts a face-to-face summer conference, called Summer Institute. The VAQS Summer Institute conference seeks to provide foundational training in quality and safety but also targets collaborations between local hospitals (e.g., VAQS fellows and faculty) and regional and national VA initiatives. Fellows lead and participate in QI projects at their respective sites.
Participants and Procedure
As part of the VAQS curriculum and in preparation for Summer Institute, site-based interprofessional teams of incoming VAQS fellows, including physicians, nurses, pharmacists, and psychologists, collectively engaged in a QI initiative are outlined in Figure 1. As part of the VAQS orientation, incoming VAQS fellows underwent intensive training regarding the fundamentals of QI within healthcare settings, including PM, data analytics, and evaluation tools to prepare fellows, in part, to competently complete this baseline assessment. This initiative focused on delineating the process for suicide prevention within medical inpatient units at each VAQS site. Fellows identified key stakeholders and frontline workers related to their site-specific suicide prevention efforts. Although selection of interviewees was determined by each site individually, considerable overlap among participants across sites presented, as anticipated, due to the shared project objective. Principal individuals interviewed included Suicide Prevention Program Coordinators, MH Nurse Managers, MH and Psychiatric Medicine Chiefs, MH Directors, and/or Emergency Room Directors. In addition, nursing staff in MH, emergency medicine, and medical surgical were interviewed to better understand the processes involved in suicide prevention from the perspective of frontline workers.
Fellows conducted semistructured interviews focused on three questions: (1) What is the process for identification of patients at risk of suicide while admitted to the hospital and outside an MH unit? (2) If a patient is identified as being at risk, what is the process for admitting a patient to an MH unit? and (3) If it is not feasible or a patient is not medically fit to be admitted to an MH unit, what is the process for ensuring patient safety while remaining on the current unit/outside the MH unit? On completion of interviews, incoming fellows developed process maps to illustrate the spectrum and sequence of activities involved in suicide prevention within medical inpatient units. The intention was to capture this process as completely as possible, with the mapping beginning when the Veteran was admitted to the hospital, excluding MH units, and complete when the Veteran was discharged or admitted to an MH unit if necessary. This project was approved as QI by our institutional review board.
Incoming fellows from each VAQS site presented their findings at the 2017 Summer Institute, to an audience that comprised incoming and returning fellows, VAQS faculty and senior scholars, and QI leaders within the VA system. These site-specific presentations allowed for detailed exhibition of each process map and consideration of pertinent findings. At the conclusion of the site-specific presentations, process-related findings were compared across sites and clustered into common themes. These findings were reviewed in an iterative process until consensus was reached across the sites.
This collaborative PM strategy, as part of an early experiential learning opportunity within a healthcare improvement training program, allowed for interprofessional multisite consensus building and resulted in both the identification of general processes and broad themes related to suicide prevention within VA medical inpatient settings, as depicted in Figure 2, and the advancement of knowledge regarding the functionality of multisite PM within large health systems.
Several important themes emerged from the PM activity that can inform best practice and serve as a focus for improvement efforts in VA sites nationwide. Encouragingly, two key strengths were recognized across sites. First, it was generally found that suicide prevention efforts have experienced progressive improvement. This was attributed to increased commitment to new employee training along with enhanced monitoring efforts. Second, an increase in easily accessible supportive resources available to patients identified as at risk was noted. These included the presence of trained clinicians who provided on-site consultation and evaluation, enhanced connection to VA suicide prevention specialists, and extensive adoption of safety planning. In addition to these strengths, opportunities for improvement were revealed (Table 1 for a summary).
First, a need for improved detection and awareness was identified. Five of eight sites highlighted suicide screening–related barriers. For example, screening questions were often embedded in intake forms whose completion could be delayed for hours. Furthermore, awareness of suicide screening protocols was constrained by the varying and fragmented suicide prevention knowledge of the staff. Second, refinement and standardization of responses once a patient is identified as at risk was identified as an area requiring improvements. Due to a patient's medical acuity or MH bed availability, patients may not be transferred to an MH unit or may wait for a prolonged period, respectively. However, no standardized environmental safety protocols were available for this setting (e.g., removing trash can bags or sharp containers). In addition, MH evaluations were not always possible on weekends, potentially delaying possible transfer of at-risk patients to an MH unit and prolonging stays in suboptimal physical spaces. Finally, the provision of patient-centered care was identified as a domain needing enhancement. Current risk-prevention processes fail to adequately elicit the perspective of the patient or family members. There was also no standardized process to educate and communicate treatment options that could facilitate shared decision making. Finally, care coordination demonstrated by communication with the at-risk patient's primary care or MH provider was largely absent.
Functionality of Multisite Process Mapping
Sharing between multiple sites and professions enabled a system-level, mutual understanding, or process literacy, of procedures currently being used in relation to a specific goal, in this case suicide prevention within medical inpatient settings. Furthermore, it allowed for enhanced understanding of the range of approaches being used to accomplish these procedures, their distinct utility, and recommendations for improvement. This was viewed as particularly useful as suicide prevention is one of VA's top priorities; however, prevention efforts were found to vary greatly between sites and no established structure is currently in place to share, or compare, varying methods.
Moreover, applying this strategy created an opportunity to more comprehensively examine health system efforts nationwide without being constrained by the demands or limitations of a single hospital or professional perspective. Specifically, it was discovered that while suicide prevention is the primary clinical priority, many sites do not target their efforts to medical inpatient settings. In addition, because it allowed for a detailed examination of the array of activities implemented to support suicide prevention, this collaborative strategy also improved capabilities to broadly examine this issue in relation to other VA high-priority areas such as access, timeliness, and patient-centered care. Finally, because the interviewers and consensus building contributors comprised individuals from diverse professions, with differing levels of familiarity and expertise on this matter, this activity improved knowledge and familiarity of this topic among participants.
Although this interprofessional multisite approach to PM was found to be an effective method for identifying necessary improvements related to suicide prevention processes within medical inpatient units, further action is needed to translate these findings into clinical implementation. In addition, because this was a multisite endeavor and interviews were semistructured, findings may represent varying levels of detail. However, this PM exercise was a baseline assessment of the first step in identifying barriers, developing solutions, and facilitating the conversation for informed policy changes.
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. This QI-focused baseline assessment used multisite PM as part of a training program to examine the VA's premier clinical priority—suicide prevention, resulting in two central findings. First, multisite PM served to improve communication between stakeholders and supported consensus building among diverse professions. Second, broad strengths and weaknesses in care quality were identified, allowing for improvement opportunities to be recognized.
Suicide prevention–related themes emerging from this project identified improvements in direct treatment services and availability of supportive resources as well as the need to establish adequate methods to detect and track the presence of risk, implement standardized response protocols, and deliver patient-centered care. Although opportunities for improvement exist, this does not serve as an indicator of inferior prevention efforts or overall care quality within the VA. On the contrary, VA suicide prevention efforts have witnessed sustained support and expansion over the past decade and VA MH services demonstrate superior outcomes relative to private care.15,16 Encouragingly, many of the processes uncovered align with the suicide prevention practices supported by the Joint Commission, including using population screening, prompt responses, and informed treatment planning.8 However, findings from this project support previous research noting that care quality varies across VA locations,15 illustrating a need for greater standardization of care.
Because suicides in medical settings have unique characteristics and require distinct assessment,17 introducing screening procedures targeted for this setting will allow for improved detection. Although ideal screening questions for this setting have not been widely agreed upon, a recent finding highlights medical inpatients' preference for direct assessment (e.g., asking specifically about suicidality).18 This direct approach has also shown superiority when considering treatment strategies across medical settings, leading to improved outcomes both immediately and long term.19 However, more research is needed to fully understand the potential benefits and risks associated with population screening within a medical inpatient setting. In addition, because information related to suicide within medical inpatient settings is currently scarce, simplifying the process to obtain these data will enhance the current state of knowledge and ability to track outcomes, allowing for an increasingly tailored response.5 Furthermore, establishing a uniform protocol for patients screened positive for suicide risk in medical inpatient settings will not only aid training and improve the preparedness of clinicians tasked with responding to the presence of risk but will also promote consistency in care provisions.20
Creating safe physical spaces for patients deemed at risk, possibly by using the MH Environment of Care Checklist or a similar tool,21 is critically needed within this setting. Although the medical inpatient environment may pose specific challenges, feasible mitigation strategies have been identified.5 When coupled with these strategies and current findings, further PM could serve as a mechanism to implement more efficient and reliable processes using evidence-based practices (EBPs) to aid suicide prevention efforts. While implementation and maintenance of new EBPs can be difficult to achieve,22 deliberately accounting for organizational and professional demands can serve to promote adoption,23 emphasizing the value of using an interprofessional multisite approach as applied in the current initiative.
Moreover, because Veterans have demonstrated particular apprehension to disclose suicidal ideation,24 strategies to detect and prevent suicide must identify the Veteran as a partner in treatment and incorporate their perspective in risk-prevention processes. Not only does this align with VA goals,25 it improves care engagement and health outcomes.26 Finally, clinical communication with Veterans after discharge must be prioritized because these interactions have been shown to aid care coordination during a time when individuals may be particularly vulnerable to suicidality.27 Ultimately, a streamlined process from the presentation of suicidal risk through to discharge is needed to adequately address risk and reduce lives lost during a time when individuals are facing acute and extremely challenging stressors.
Using interprofessional multisite PM to evaluate the current processes heightened awareness and spurred discussion related to the state of suicide prevention in medical inpatient units, both within and across sites. Because the VA proactively attempts to identify and provide effective care for Veterans, processes of care used throughout the health system need to be considered to inform policy reform and facilitate optimal patient outcomes. The PM method was a successful approach to building consensus toward improving processes in relation to the VA's highest clinical priority, suicide prevention,1 and could likely be beneficially applied to additional VA priorities as well as used within other large multisite healthcare systems.
Using a multisite approach as part of a training program in healthcare quality fostered a shared, and improved, understanding of the many current procedures used to address this complex issue within the VA. Providing a venue to collectively examine the utility and failings of these strategies increases the likelihood that solutions identified will be viewed as acceptable, and subsequently implemented28—this is particularly important in large and diverse health systems such as the VA. Furthermore, the interprofessional method used allowed for the representation of distinct clinical perspectives on this complex task. This outcome was regarded as a significant benefit as suicide prevention is “everyone's business” in the VA4 and thus should encourage diversity in contributions to enhance care quality29 and further adoption of prevention-related interventions.28 Ultimately, these findings are uniquely positioned to inform policy development as they are more capable of recognizing the needs of the VA system as a whole rather than being constrained to viewpoints associated with a single health profession, clinical site, or health system. Moreover, other large healthcare systems could use a similar PM approach to address a complex, multisite problem.
The authors thank Bilal Ahmad, Muralidharan Chllama, Justin Delwo, Christine Davey Horvat, Lauren Hunt, Jennifer Lewis, Connie Lin, Jea Young Min, Harry Porterfield, Juan Duero Posado, Jennifer Robles, Lucy Spalluto, Erica Stovsky, Susan Swanson, Melissa Swee, Spencer Trooboff, Javier Valle, and Kaitlin Willham.
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Lori Holleran, PhD, MPH, is currently a VA Quality Scholars Fellow at the San Francisco VA Medical Center where she serves clinically as a psychology fellow within primary care. Her research is focused on advancing injury prevention efforts, specifically the assessment of risk of suicide. She received her PhD in Clinical Psychology from Palo Alto University and her MPH in Health Policy from Harvard T.H. Chan School of Public Health.
Samantha Baker, MD, is a third year general surgery resident at the University of Alabama at Birmingham (UAB) who is completing a research fellowship through the Veteran Affairs Quality Scholars Research Fellowship. She is involved in Health Service Outcomes Research through the VA and UAB and Surgical Education Research. She is concurrently obtaining a Masters in Science in Health Professions Education through Massachusetts General Hospital Institute for Health Professions.
Caleb Cheng, MD, is a board-certified pathologist and transfusion medicine subspecialist who is currently a VA Quality Scholar at the VA Greater Los Angeles Healthcare System. While he continues to practice pathology, most of his time is spent improving the quality of care across the healthcare system. Before this position, he was a Transfusion Medicine & Blood Bank Fellow at Yale-New Haven Health and a Pathology Resident at Cedars-Sinai Medical Center. He received his medical education at Sydney Kimmel Medical College.
Jaime Wilson, DNP, RN, PCCN, is a VA Quality Scholars Fellow at the VA Medical Center in Iowa City, IA. She majored in nursing at the University of Iowa, earned a Doctor of Nursing Practice in Health Systems Administration from the University of Iowa, and has several years of experience as a nurse in critical care and nursing education. Jaime's recent projects have focused on improving the early identification and management of sepsis in veteran care via TeleICU collaboration.
Robin Mickelson, PhD, RN, applies human factors and cognitive systems engineering methods and theories in the home health setting to improve the performance and safety of patient health–related activities. Robin received her PhD from Vanderbilt University School of Nursing in 2017 and holds an MS degree in Nursing Informatics from the University of Maryland, Baltimore. Robin is currently a VA Quality Scholar fellow in Nashville, TN, working on research to improve medication reconciliation patient tools and ICU diary optimization.
Izabela Kazana, DNP, APN, PCNP-BC, CCRN, is a doctorally prepared adult-gerontology nurse practitioner. Currently, she is a postdoctoral VA Quality Scholars Fellow at the Louis Stokes VA Medical Center in Cleveland, OH. During the fellowship, she is learning and practicing the skills essential for leading quality and safety improvement in healthcare.
Barbara Messinger-Rapport, MD, PhD, FACP, CMD, HMDC, is an associate professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine. She is currently a VA Quality Scholar at the Northeast Ohio VA Healthcare System in Cleveland, OH.
Jacquelene Shahin, MA, is a research coordinator II with Baylor College of Medicine's Department of Medicine and Section of Health Services Research in Houston, TX. She is also project staff at the Houston Coordinating Center for the Veteran's Affairs Quality Scholars fellowship training program.
Jeffrey Cully, PhD, is a clinical psychologist and professor of Psychiatry in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. He is also the clinical director of the Advanced Fellowship Program for the VA Office of Academic Affiliations.
Aanand D. Naik, MD, is a geriatrician and associate professor of medicine in Health Services Research, the vice chair of QI and Innovation for the BCM Department of Medicine, and chief of Implementation Science and Innovation Core at Center for Innovations in Quality, Effectiveness and Safety (IQuESt) at the Michael E. DeBakey VA Medical Center. He also directs the Coordinating Center for the national VA Quality Scholars Program.
Kyler M. Godwin, PhD, MPH, is an assistant professor of medicine in the Section of Health Services Research at Baylor College of Medicine, and an investigator at the Center for Innovations in Quality Effectiveness and Safety (IQuESt) at Michael E. DeBakey VA Medical Center. She also codirects the Coordinating Center for the national VA Quality Scholars program.