S02 ATTACHMENT D.29 - SOP 116A-04_SUICIDE_POSTVENTION.pdf

Standard Operating Procedure for Suicide Postvention

SOP 116A-04

Veterans Health Care System of the Ozarks (VHSO) Fayetteville, AR 72703

Signatory Authority:

Deputy Associate Chief of Staff, Mental Health

Responsible Owner:

Suicide Prevention Team

Service Line(s):

Mental Health

Effective Date:

January 13, 2023

Recertification Date:

January 13, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on postvention action steps that occur following a Veteran or employee death by suicide. Note that this SOP is intended to guide and facilitate an inclusive suicide postvention process. Given that no SOP can exhaustively cover all details surrounding all deaths by suicide, it will be necessary to actively include collaborative consultation across key stakeholders (e.g., suicide prevention coordinators, suicide postvention team members, executive leadership, supervisors, employees, police, chaplains) while following SOP recommended action steps.

b. There is no governing document.

2. PROCEDURES

a. Notification of a Suicide.

(1) Any staff member first receiving information of a Veteran or employee suicide, will report all information to their supervisor and/or the Suicide Prevention Team (SPT) and complete a Suicide Behavior and Overdose Report according to staff specific guidance.

(2) The Suicide Prevention Coordinator (SPC) will take necessary steps to officially confirm the cause of death if suicide is suspected. The SPC may contact the county coroner to verify the cause and manner of death, date/time and location of death.

(3) The SPC will inform site leadership and contact the Associate Chief of Mental Health (ACOS-MH) and/or the Deputy Associate Chief of Staff for Mental Health (DACOS-MH) to determine need/responsible person for Issue Brief completion if an Issue Brief is indicated. The SPC will assist with notification of an Issue Brief as determined by ACOS-MH or DACOS-MH.

January 13, 2023 SOP 116A-04

(4) The SPC will inform the Administrator on Duty (AOD) of the death of the Veteran.

The SPC will also alert the Vet Center of the death.

(5) The Suicide Postvention Team, in conjunction with supervisory staff of those on the Suicide Postvention Team, will be notified so that time can be allotted for necessary postvention activities.

(6) The SPC will work with the Suicide Postvention Team to identify all employees that may have been impacted by the death.

(7) The Suicide Postvention Team will contact supervisory staff of those employees affected and will develop a plan for notification to the affected employee(s).

(8) In the case of a death not related to suicide that has been impactful to staff, supervisor or staff member will notify the Postvention Team, as appropriate, for activation of Postvention outreach and supportive services.

b. Mobilize Suicide Postvention Team

(1) The Suicide Postvention Team will determine which team members will be assigned and will brief team members about the death and assignments.

(2) The Suicide Postvention Team confirms the list of all affected employees and begins the action steps outlined in this SOP.

(3) The Suicide Postvention Team Member contacts the clinician(s)/Treatment Team (and if appropriate, any supervisors) as soon as possible after notification of the death, to offer initial psychoeducation, support and resources.

c. Initial Outreach to Treatment Team Members

(1) A Postvention Team member will make an outreach attempt by the treatment team member(s) by phone, Microsoft Teams, and/or email within a timely manner following notification of the suicide. They will provide psychoeducation about losing a patient to suicide, including the personal and professional impacts of suicide loss.

(2) A Postvention Team member will offer services through Suicide Risk Management Consultation Program as a resource for free, confidential 1:1 support following a suicide loss. The Postvention Team will offer any related literature or resources to include but not limited to:

(a) Uniting for Suicide Postvention - MIRECC / CoE (va.gov)

(b) Psycharmor- Postvention

(c) After a suicide: A postvention prevention primer for providers | Suicide Prevention Resource Center (sprc.org) https://www.mirecc.va.gov/visn19/consult/index.asp https://www.mirecc.va.gov/visn19/consult/index.asp https://www.mirecc.va.gov/visn19/postvention/ https://psycharmor.org/suicide-prevention-intervention-postvention/ https://www.sprc.org/resources-programs/after-suicide-postvention-prevention-primer-providers https://www.sprc.org/resources-programs/after-suicide-postvention-prevention-primer-providers

(3) A Postvention Team member will offer 1:1 and/or group postvention support to allow for short-term individual processing in addition to team/group processing by Postvention Team.

(4) A Postvention Team member will ensure all affected staff have site specific Employee Assistance Program (EAP) information and assist with access as needed.

d. Initial Outreach to Family Members

(1) The Suicide Prevention Coordinator will make an outreach attempt by phone to call the deceased Veterans family within a timely manner following notification of the suicide. This call is to express sympathy for their loss and offer support. The SPC will also inquire if there are other survivors affected by the loss whom they would like the team to extend support. Permission is also asked at this time to follow up in other methods to include:

(a) Sending a sympathy letter

(b) Follow up phone call(s)

(c) Referral to Chaplain Services

(d) Offering community resources or making referrals to appropriate postvention services such as:

1. Community support groups

2. American Foundation for Suicide Prevention (AFSP) Survivor Outreach Program

3. TAPS- Tragedy Assistance Program For Survivors (TAPS) Is Here For You!

4. Bereavement and grief for military families and communities | SAMHSA

5. Community_Resources_USPV.pdf (va.gov)

(2) If postvention services are accepted by the family for future follow up, a call will be made by the SPC at the specified time frame agreed upon. Outreach attempts should be at regular intervals (e.g., 3,6,9,12 months following the loss) and/or during anniversaries, holidays and/or other events that might be challenging. Follow-up is strongly recommended at 6-months and 1-year, although this can occur more frequently as noted above.

(3) Postvention efforts will be documented in the VHSO Suicide Prevention Share Point Spreadsheet and documented in Computerized Patient Record System (CPRS).

3. ASSIGNMENT OF RESPONSIBILITIES

a. Suicide Prevention Team. The Suicide Prevention Team is responsible for:

https://www.taps.org/ https://www.samhsa.gov/resource/dbhis/bereavement-grief-military-families-communities https://www.mirecc.va.gov/visn19/postvention/docs/Community_Resources_USPV.pdf

(1) Taking necessary steps to inform MH leadership and begin Issue Brief process at direction of MH leadership.

(2) Notifying Suicide Postvention Team and working together to identify all employees who may be impacted by the death.

(3) Working with the Suicide Postvention Team and clinicians/treatment team to develop a plan for family outreach and ensure clarification of roles.

(4) Completion of documentation for the Behavioral Health Autopsy Program (BHAP) and Family Interview Tool - Contact (FIT-C) within required timeframes.

b. Supervisors of Staff Impacted by Suicide Loss, when notified of a death by suicide that impacts a direct report, are responsible for:

(1) Providing support and a reminder of resources available (e.g., EAP, encouragement to attend postvention group supports offered), ensuring staff have protected time to engage in these supports if staff are interested, and consider any time-off needs that staff may request in order to grieve and process the loss. Sick leave, annual leave, or leave without pay may be considered for personal bereavement.

(2) Supervisors may approve Authorized Absence for employee attendance at the funeral, burial service, or vigil for the deceased client if the employee’s attendance is within his/her job duties or at the benefit of the organization and welcomed by the family.

c. All Staff. All staff are encouraged to communicate with their supervisor any leave requests that may be needed for grieving and self-care. All staff are responsible for:

(1) Notifying their supervisor and/or Suicide Prevention Coordinator as soon as possible when they are the first to learn of a Veteran death by suicide (or suspected death by suicide).

(2) Completion of Suicide Behavior and Overdose Report according to staff specific guidance VHA Office of Mental Health & Suicide Prevention - Suicide Behavior and Overdose Reporting - All Documents (sharepoint.com).

d. Clinicians/Treatment Team

(1) Work with Suicide Prevention and Postvention Teams on plan for family outreach as well as support to other Veterans impacted by the death, if indicated. If outreach is to be completed by Suicide Postvention Team, clinician will help inform the Postvention Team member of any relevant Veteran and family information.

e. Suicide Postvention Team. Suicide Postvention Team members should remain independent from any Root Cause Analysis (RCA) or Peer Review process. The Suicide Postvention Team is responsible for:

https://dvagov.sharepoint.com/sites/VACOMentalHealth/Safety%20Planning%20%20SBR/Forms/AllItems.aspx?cid=4fd1427a%2D4e23%2D4edf%2D9deb%2Ddd978cdb1044&RootFolder=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting&FolderCTID=0x012000DE91F7B35CBFA54990ED960043820E7F https://dvagov.sharepoint.com/sites/VACOMentalHealth/Safety%20Planning%20%20SBR/Forms/AllItems.aspx?cid=4fd1427a%2D4e23%2D4edf%2D9deb%2Ddd978cdb1044&RootFolder=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting&FolderCTID=0x012000DE91F7B35CBFA54990ED960043820E7F

(1) Suicide Postvention Team leads will identify team members to be assigned and brief them about the death and notify supervisors of assigned team members so that time can be allotted.

(2) Working with the Suicide Prevention Team to identify all employees who may be impacted by the death and make a plan that ensures staff notification.

(3) If possible, contacting supervisors of employees identified as having been impacted by the death and educating supervisors about suicide postvention best practices.

(4) Scheduling and facilitating group postvention support opportunity to be made available to all impacted staff.

(5) Coordinate with Suicide Prevention Team and Clinical/Treatment Team to ensure plan for outreach and support for family members. If plan is made for clinician to provide outreach, Suicide Postvention Team will offer coaching to help the Clinician prepare for this outreach.

(6) Completion of training on providing postvention processing, for example VA 131002802: Recommendations for Postvention Processing Sessions.

(7) Limiting access to the Electronic Health Record to purposes consistent with their role and responsibilities as a member of the Suicide Postvention Team. Access is intended to be limited based on suicide postvention needs. Chart review is not intended to review notes on care provided, documentation, assessment, etc. The following parameters outline the limited access for supportive-based purposes:

(a) Determine providers/treatment teams involved in the Veteran’s care (current and past). This information facilitates provider/treatment team notification of the death and assists with potential clinical concerns that may involve the care of other Veterans (e.g., provider/treatment team should be notified if deceased Veteran was involved in group therapy as the provider/treatment team may need to provide suicide postvention support to other Veterans, etc.)

(b) Determine next-of-kin. This information is used to facilitate outreach to suicide loss survivors to offer suicide postvention support and resources.

4. DEFINITIONS

a. Suicide: Suicide is a death caused by self-inflicted, injurious behavior with intent to die as a result of the behavior.

b. Postvention. Activities that occur after a death which are designed to support those exposed to and impacted by the death and to ensure that resources and support are provided to VA employees. Postvention efforts occur immediately after a death and are ongoing in nature. The activities and staff of the Postvention Team are kept separate from formal Issue Briefs or RCA processes.

https://va-hcm03.ns2cloud.com/learning/user/common/viewItemDetails.do?componentTypeID=VA&componentID=131002089&revisionDate=1641877200000&catalogCurrencyCode=USD&returnLink=%2Flearning%2Fuser%2Fcatalogsearch%2FcatalogSearchDispatchAction.do%3FsearchType%3DfilteredSearch%26keywords%3D&backto=%2Flearning%2Fuser%2Fcatalogsearch%2FcatalogSearchDispatchAction.do%3FsearchType%3DfilteredSearch%26keywords%3D https://va-hcm03.ns2cloud.com/learning/user/common/viewItemDetails.do?componentTypeID=VA&componentID=131002089&revisionDate=1641877200000&catalogCurrencyCode=USD&returnLink=%2Flearning%2Fuser%2Fcatalogsearch%2FcatalogSearchDispatchAction.do%3FsearchType%3DfilteredSearch%26keywords%3D&backto=%2Flearning%2Fuser%2Fcatalogsearch%2FcatalogSearchDispatchAction.do%3FsearchType%3DfilteredSearch%26keywords%3D

c. Suicide Postvention Team. The Suicide Postvention Team is a group of individuals, made up of trained, clinical staff to provide postvention services to affected staff. Employees who are interested in serving on the postvention team are allowed dedicated time away from their primary roles to provide services to Medical Center employees. The Suicide Postvention Team will consists of Suicide Prevention Coordinator(s), Chaplain(s), Mental Health Provider(s), and/or members of other disciplines as the team deems appropriate.

5. REFERENCES

a. Suicide Risk Management Consultation Program

b. Suicide Postvention Team Pilot Standard Operating Procedure, Version 06.01.20

c. Tragedy Assistance Program For Survivors (TAPS) Is Here For You!

d. Bereavement and grief for military families and communities | SAMHSA

e. Uniting for Suicide Postvention (USPV) Community Resources

f. Suicide Postvention for Clinicians and Survivors - VISN 1 Toolkit

g. VHA Office of Mental Health & Suicide Prevention - SBOR Staff-Specific Guidance.pdf - All Documents (sharepoint.com)

6. RECORDS

All records will be maintained and inventoried in accordance with Medical Center Memorandum (MCM) 04-03 and Records Control Schedule (RCS) 10-1. Records will be inventoried on the Mental Health record file and inventory plan.

7. REVIEW

This SOP must be reviewed, at a minimum, at recertification, when there are changes to any of the governing documents, and any regulatory requirement for more frequent review. VHSO Suicide Prevention Team will submit proposed modifications to this SOP to the VHSO Mental Health Care Line Executive a minimum of 1 month prior to recertification.

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of January 2023. In the event of contradiction with national policy, the national policy supersedes and controls.

https://www.mirecc.va.gov/visn19/consult/index.asp https://www.taps.org/ https://www.samhsa.gov/resource/dbhis/bereavement-grief-military-families-communities https://www.mirecc.va.gov/visn19/postvention/docs/Community_Resources_USPV.pdf https://dvagov.sharepoint.com/sites/VACOMentalHealth/Safety%20Planning%20%20SBR/Forms/AllItems.aspx?cid=4fd1427a%2D4e23%2D4edf%2D9deb%2Ddd978cdb1044&FolderCTID=0x012000DE91F7B35CBFA54990ED960043820E7F&id=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting%2FSBOR%20Staff%2DSpecific%20Guidance%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting https://dvagov.sharepoint.com/sites/VACOMentalHealth/Safety%20Planning%20%20SBR/Forms/AllItems.aspx?cid=4fd1427a%2D4e23%2D4edf%2D9deb%2Ddd978cdb1044&FolderCTID=0x012000DE91F7B35CBFA54990ED960043820E7F&id=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting%2FSBOR%20Staff%2DSpecific%20Guidance%2Epdf&parent=%2Fsites%2FVACOMentalHealth%2FSafety%20Planning%20%20SBR%2FSuicide%20Behavior%20and%20Overdose%20Reporting

9. SIGNATORY AUTHORITY

Brian L. Moore, LCSW Deputy Associate Chief of Staff Mental Health

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

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