QUERI – Quality Enhancement Research Initiative

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Examining the Effectiveness of an Adaptive Implementation Intervention to Improve Uptake of the VA Suicide Risk Identification Strategy

Denver, CO


Over the past decade, the reduction of Veteran suicide has been one of the Department of Veterans Affairs' (VA) top priorities. Current research suggests that early and accurate detection of suicide risk among all Veterans presenting for VA care is a critical component of reducing Veteran suicide. On October 1, 2018, VA leadership mandated implementation of a national suicide risk identification strategy. The VA Suicide Risk Identification Strategy (VA Risk ID), which consists of three stages (Figure 1) is the largest implementation of population-based suicide risk screening and evaluation in any United States healthcare system to date.

 3 stages of suicide risk identification

To facilitate continuous quality improvement, ongoing evaluation of VA Risk ID and interventions to improve implementation of the three-stage screening and evaluation process are needed. Creating an adaptive implementation strategy that provides different degrees of implementation support in a step-wise fashion is expected to be a practical and efficient way of improving implementation of VA Risk ID. Therefore, this QUERI Partnered Evaluation Initiative aims to develop an adaptive implementation strategy to improve the implementation of VA Risk ID among patients receiving care in ambulatory care settings. Universal screening of this patient population provides an important opportunity to identify Veterans with unrecognized risk that may present to a wide range of healthcare settings, including primary care.

Suicide rates for both Veterans and non-Veteran adults increased between 2005 and 2016. There were more than 6,000 Veteran suicides each year from 2008 to 2016. In 2016, the age-and gender-adjusted rates of suicide were 26.1 per 100,000 for Veterans and 17.4 per 100,000 for non-Veteran adults. (VA National Suicide Data Report, 2005-2016 – updated 2018; Office of Mental Health and Suicide Prevention.)


A sequential multiple assignment randomized trial (SMART) design will be used to evaluate two evidence-based implementation strategies: 1) Audit and Feedback (A/F) and 2) Audit and Feedback plus External Facilitation (A/F+EF). Using a mixed-method framework, investigators will evaluate these strategies across several domains. In addition to focusing on implementation outcomes (i.e., impact of these strategies on the implementation of VA Risk ID and potential barriers to adopting these strategies), they also will examine the impact of VA Risk ID on clinical outcomes.

Up to 141 VA healthcare facilities across the US will be recruited to participate in this project, focusing on Veterans who are eligible for depression and PTSD screening and present to ambulatory care settings. This cohort of patients represents approximately 76% of Veterans receiving VA care (potential reach = ~4 million Veterans). Sites that do not meet the program office’s performance benchmark will be randomized to receive the implementation interventions, beginning with a less intensive intervention (A/F) for 10 months. Sites that still do not meet the performance benchmark after receiving A/F, will be re-randomized at the end of Phase I to continue receiving either A/F or a more intensive intervention consisting of A/F + external facilitation (A/F + EF) for another 10 months.

Potential Impacts:

This project directly addresses VA's highest priority—reducing Veteran suicide. On a systems level, this project is intended to help VA facilities address challenges to implementing VA Risk ID using a sequence of evidence-based implementation strategies. By doing so, it will ensure that more Veterans are screened and evaluated for suicide risk, which is the basis of effective, patient-centered suicide risk management. Moreover, by adapting the implementation intervention “dose” based on facility performance and monitoring implementation over time, this project will allow the program office to focus resources where and when needed the most.

Corresponding PI: Nazanin Bahraini, PhD, Rocky Mountain MIRECC for Veteran Suicide Prevention.

Operations Partners: VA’s Office of Mental Health and Suicide Prevention.