Supporting the VA’s High Reliability Organization Journey Through Suicide Prevention

By Kassi L. Goodman, Ed.S.

Leading health information technology solutions providers DSS, Inc. and Iconic Data Inc. have deep experience in supporting the U.S. Department of Veterans Affairs’ mission of care to Veterans. Throughout the years, they have been helping the VA in evaluating and evolving its operations to maintain high standards in patient care.

A powerful example of this is how the DSS Iconic Data Patient Case Manager High Reliability Organization (PCM HRO) solution has helped the VA strengthen its suicide prevention efforts. PCM HRO helps VA medical centers continuously monitor performance and achieve excellence on key VA performance and outcomes measures.

This kind of improved performance is critical for the VA’s journey towards becoming a High Reliability Organization, or HRO. Aviation and nuclear power are examples of industries that have applied HRO principles to achieve minimal errors, despite highly hazardous and unpredictable conditions.

There are five main attributes of HROs:

•  Sensitivity to operations (heightened awareness of the state of relevant systems and processes); 

• Reluctance to simplify (the acceptance that work is complex, with the potential to fail in new and unexpected ways); 

• Preoccupation with failure (viewing near misses as opportunities to improve, rather than proof of success); 

• Deference to expertise (valuing insights from staff with the most pertinent safety knowledge over those with greater seniority); 

• Practicing resilience (prioritizing emergency training for many unlikely, but possible, system failures). 

HRO and Suicide Prevention

Preventing Veteran suicide is the VA’s top priority. As such, the Department is intensely focused on developing and implementing efforts and approaches to identify and support at-risk Veterans. One example of such an effort is the critical work of the Veterans Crisis Line, a 24/7 hotline for confidential crisis support for Veterans and their loved ones. In addition, each VA medical center has a Suicide Prevention Coordinator whose job is to ensure that at-risk Veterans receive timely and effective care when and how they need it.

And while suicide is a complex human phenomenon with no single cause or risk factor, it is preventable. In 2020, there were 6,146 Veteran suicide deaths - 343 fewer than in 2019. Because VA recognizes both the complexity of the challenge as well as the potential to save more Veterans, it continues to make great strides in improving the quality of Veteran health and mental health care by embracing the HRO principles.

To become an HRO, the VA continues to empower their employees with advanced tools that provide the right data at the right time. To be quickly recognizable, data and analytics need to be presented via data visualization tools that permit important trends in operating statistics and the status of patient care to be easily monitored and tracked. 

To accomplish this, the VA continues to equip its staff with more advanced and effective tools. VA employees can’t be aware of every factor affecting every Veteran in their care, even the most heroic and dedicated staff members can miss potentially important information. But with PCM HRO, they can access the right data in real-time so that they are able to perform their duties more efficiently and effectively, improving the reliability of the care provided.

Source: Iconic Data Inc.

Real-time Situational Awareness for Better Care

To deliver proper care, employees need real-time situational awareness – information that is accurate right now – not data that is 24 or 48 hours old. This is the kind of up-to-date information needed to accomplish sensitivity to operations, one of the key HRO principles. This is the kind of real-time, workflow technology that members of Congress have recommended to support VA suicide prevention teams. And this is a hallmark of all DSS, Inc. and Iconic Data Inc. effective solutions – developed to integrate with the unique workflows of health care, not conflict with them.

PCM HRO is bringing this kind of situational awareness for suicide prevention to all facilities in VA Veterans Integrated Service Network (VISN) 21, along with other locations within VISNs 6, 9 and 10. Below is a comparison of what the PCM HRO real-time platform can provide in those facilities, compared to the prior system present in facilities that have yet to deploy PCM HRO.

Proven Success Metrics

When a Veteran is found to have elevated suicide risk in a VA emergency department (ED) environment, VA staff are required to complete a safety plan for that Veteran prior to the Veteran’s departure from the ED should they be discharged home. The effectiveness of this process is tracked by the VA’s Safety Planning in the Emergency Department (SPED) metric.

Facilities implementing PCM HRO have seen significant improvement in their SPED performance, underscored by documented achievement of sustained periods of 100% compliance. This improvement results in better care for our Veterans. Critical improvements like these are possible because of the improved situational awareness facilities attained via the real-time clinical care intelligence provided by PCM HRO. 

PCM HRO also saves VA suicide prevention teams significant time by driving efficiencies in key daily workflows. PCM HRO’s functionality and features streamline a myriad number of critical and required prevention and care monitoring activities, easing the burden on VA staff and allowing more time for direct patient care.  An analysis of time saved by VA suicide prevention teams using PCM HRO found an average 80% decrease in time required for several data retrieval, care coordination and care pathway compliance monitoring activities.

These are critical minutes saved that translate directly into care for Veterans.

These are the efficiencies gained by advanced software tailored to the workflow processes of the VA. These tools are powering the VA’s journey towards becoming an HRO, supporting and enabling the development of a culture that embodies all the attributes of that designation. And in the process, saving lives by supporting the heroic work of VA suicide prevention teams.

To learn more about the PCM HRO solution, click here.