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Readjustment Counseling Service Vet Center Report

quality reports demonstrated that 197 (97 percent) out of 203 Vet Centers reported having an active crisis plan in place and that all staffs were familiar with the crisis procedures. All the Vet Centers inspected during our site visits had comprehensive crisis intervention plans or guidelines.

Formal Mortality and Morbidity Reviews

VHA policy19 requires that a mortality and morbidity (M&M) review should be completed in cases of homicides and/or suicides by active20 clients and that all cases are to be reported to the Office of the Medical Inspector (OMI).

According to the RCS Chief Officer, Vet Centers followed VHA policy and reported all known suicides to the VHA Patient Safety Office, which would then assign the respective medical centers to do a root cause analysis (RCA).21 The RCS Chief Officer stated that suicides and/or homicides are only reported to the VHA’s OMI upon OMI’s request.

In FY 2008, there were no known or reported homicide cases involving active Vet Center clients. However, Vet Centers reported five known suicide cases including three active clients and two closed cases. Three veterans were of the OEF/OIF era, with one each from the Gulf War and Vietnam eras. All the cases were reviewed either by RCA (three cases), Suicide Committee review, or M&M review (initiated by RCS).

In four of the five suicides, a VAMC was the primary provider with the Vet Center providing auxiliary services to the physician, usually a psychiatrist. VHA performed the analysis of the suicides when they were the primary provider. Vet Center staff were involved in the suicide analyses either through participating as a team member or by providing testimony. The Vet Centers reported that they did not receive the outcomes of these reviews.

RCS conducted the M&M review, even though the suicide occurred 6 months after their last contact with the veteran. The Vet Center’s external clinical consultant, a psychiatrist, headed the board and reviewed the case. The purpose of the M&M review was to determine whether care was appropriate and adequate, whether other steps and interventions might have altered the outcome, and whether the Vet Center practices were adequate.

Regardless of the type of review used to analyze the suicides, we found that most reviews concluded that the collaboration and sharing of patient information between VAMCs and Vet Centers needed strengthening.

19 20 21 VHA Manual, M-12, Part II, Chapter 4, Operational Procedures, April 21, 1992. A veteran is considered inactive if not seen within 90 days of their last visit. RCA is a focused review process for identifying the basic or contributing causal factors that underlie variations in performance associated with Adverse Events or Close Calls.

VA Office of Inspector General


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