The federal government might lack significant data on veteran suicides for a program specifically designed to mitigate the psychological damage of war, according to a watchdog report released Friday.
The Government Accountability Office said that the Department of Veterans Affairs has not been verifying the accuracy of some of its medical centers’ reporting on the number of veterans who take their own lives.
The investigation, which probed records from five department facilities between fiscal years 2009 and 2013, led the report’s authors to posit that the data misreporting “could be symptomatic nationwide.”
“VA may not be getting the data it needs across the Department to make appropriate resource decisions and develop new policy,” the GAO concluded.
A key deficiency noted by the GAO was the failure of the department to get its satellite facilities to share records collected through a postmortem initiative called the Behavioral Health Autopsy Program (BHAP).
One facility observed had completed 13 BHAP forms without submitting them until prompted by the GAO review. Neither the medical center nor the department’s central bureaucracy were aware these documents had not been passed along.
Amid the inquiry, another facility told the GAO it had only started centrally sharing records of suicides that took place in fiscal year 2014. Contradicting its own October 2012 request for a copy of any report on a suicide within 30 days of its processing, department officials told the GAO that its medical facilities could start submitting the records “at any point.”
Exacerbating the problem, the GAO found, is a lack of clarity on responsibility for fact-checking. Department policy devolves oversight of BHAP data management to VA medical centers and regional nodes called the Veterans Integrated Service Network. The networks and centers observed, however, said they “do not conduct data checks on the information submitted in the BHAP templates.” The oversight organ concluded that the data are not checked for accuracy “at any level,” running afoul of “internal control standards for the federal government.”
“Checking and verifying the data submitted to VA Central Office,” the report stated, “would help ensure that changes made to suicide prevention efforts…are based on actual trends in veteran suicides.”
It recommended that the VA “implement processes to review data on veteran suicides” collected by its medical centers. The department agreed with the GAO findings and prescriptions, and “provided information on its plans for implementing each recommendation, with estimated completion dates in calendar year 2015.”
The BHAP is one of several programs employed by the VA to obtain data on veteran suicides with a view of improving its mental healthcare services. It was launched in December 2012, the GAO explained, “to collect demographic, clinical, and other related information on veteran suicides.”
“VA Central Office officials explained that they transitioned to the BHAP initiative to collect more systematic and comprehensive information about suicides, to incorporate interviews of family members of those who die by suicide, and to collect more contextual information,” the report said.
A department report published in February 2013 found that 22 veterans committed suicide every day in 2010–up from 20 per day in 1999.
In May 2011, a US Court of Appeals for the Ninth Circuit accused the VA of “unchecked incompetence” and ordered it to reform its mental healthcare system.
In November, USA Today reported that 600,000 veterans, or one out of every ten VA patients, must wait a month or more for an appointment at a department facility. The number of veterans waiting for department care for more than four months fell from 120,000 in May to 23,000 in October, the paper said, due mostly to stop-gap service provided by the private sector. Long waiting lists for care forced former VA Secretary Eric Shinseki to retire in late May.
