![]() However, most of these efforts have focused on downstream interventions to reduce suicidal behavior among those already identified to be at high risk. In the last decade, the Department of Veterans Affairs (VA) has made significant strides in suicide prevention, particularly for veterans receiving Veterans Health Administration (VHA) care. If this study finds that the proposed stepped implementation strategy is effective at increasing uptake and maintaining performance improvements, this approach may be used as an overarching QI strategy for other national suicide prevention programs. This national QI study will use a SMART design to evaluate whether an adaptive implementation strategy is effective in improving uptake of a mandated VHA-wide suicide risk screening and evaluation initiative. Secondary outcomes include rates of other clinical outcomes (i.e., safety planning) and organizational factors that may impact Risk ID implementation (i.e., leadership climate and leadership support). Implementation outcomes of interest include uptake of secondary suicide risk screening and uptake of comprehensive suicide risk evaluation (stages 2 and 3 of Risk ID). Using a sequential multiple assignment randomized trial (SMART) design, two evidence-based implementation strategies will be evaluated: (1) audit and feedback (A&F) (2) A&F plus external facilitation (A&F + EF). This protocol describes the stepped implementation approach and proposed evaluation plan. In addition, this study will examine specific factors that may impact the uptake of suicide risk screening and evaluation and the adoption of different implementation strategies. Thus, the objective of this study is to examine the effectiveness of an adaptive implementation strategy to improve the uptake of suicide risk screening and evaluation in VHA ambulatory care settings. Moreover, given that facilities will vary with respect to implementation needs and barriers, the dose and type of intervention needed may vary across facilities. In order to ensure continuous quality improvement (QI), ongoing evaluation and targeted interventions to improve implementation of Risk ID are needed. The goal of Risk ID is to improve the detection and management of suicide risk by standardizing suicide risk screening and evaluation enterprise-wide. In 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk ID).
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