January 29, 2020

Chairman Takano: “We cannot tolerate any number of veteran suicides.”

 

WASHINGTON, D.C. – Today, House Committee on Veterans’ Affairs Chairman Mark Takano (CA-41) delivered opening remarks before the full committee oversight hearing entitled “Caring for Veterans in Crisis: Ensuring a Comprehensive Health System Approach.” Today’s hearing examined Veterans Health Administration (VHA) policies in light of the Committee’s comprehensive 7 pillar strategy to address veteran suicide. A link to the video Chairman Takano’s opening statement and remarks as prepared can be found below.

 

Full video of the Chairman’s remarks

 

Chairman Takano’s remarks as prepared:

 

This Committee’s top priority is addressing the public health crisis of veteran suicide. This is why the first full committee hearing of 2020 will explore 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 people died by suicide in 2017 in the United States. Of these, 6,139 were veterans of the U.S. Armed Forces.

 

As Ranking Member Roe astutely noted in a recent interview, almost as many veterans die 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. That is simply not acceptable. VA data indicates that of these 20 veterans and servicemembers, 6 had received care in the past two years from a VA health care provider.

 

Our focus is not only on the 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 VHA work hard every day to provide high-quality, life-saving mental health care to veterans and 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 lack of care coordination at VA facilities.

 

According to today’s testimony, “The OIG found inadequate coordination of care to be an underlying theme in every one of its recently conducted reviews.” 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 at 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 same facility, the OIG determined that VA’s inpatient treatment team failed to coordinate with the patient’s outpatient 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 has 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 each 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. 

 

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 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 resources for Suicide Prevention Coordinators at VA hospitals and clinics to coordinate care for veterans in crisis.

 

And 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 OIG noted at the West Palm Beach VA, the Patient Safety Manager did the right thing and reported concerns to leadership about hazards in the inpatient mental health unit that represented an “immediate threat to life.” But the employee’s concerns were dismissed, and eventually a veteran died.

 

No VA 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 an 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’s observer policy, and facility leadership failed to monitor staff compliance. The right policy was in place, but it 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 isn’t 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 must be.

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