Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York

OIG conducted an inspection at the Veterans Crisis Line (VCL), located in Canandaigua, NY, in response to allegations involving unanswered phone calls or calls routed to a voicemail system, lack of immediate assistance to callers, ambulance timeliness, untrained staff, and confusing contact information. We also received complaints from the U.S. Office of Special Counsel that VCL social service assistants were not properly trained, and callers to the VCL were forwarded to volunteer backup call centers that lack appropriately trained staff. We substantiated that some calls routed to backup centers went into a voicemail system and that the VCL and backup center staff did not always offer immediate assistance to callers. We also substantiated that VCL management did not provide social service assistants (who do not answer calls) with adequate orientation and ongoing training. The VCL program does not provide or monitor backup centers’ staff training; therefore, we could not substantiate that backup center staff did not receive adequate training. We did not substantiate the allegations that staff who respond to callers did not receive proper training or that VCL staff were responsible for the 3-hour delay a veteran experienced while waiting for an ambulance. In addition, we did not substantiate that the VCL phone number was difficult to use during a crisis. We identified gaps in the VCL quality assurance process: an insufficient number of required staff supervision reviews, inconsistent tracking and resolution of VCL quality assurance issues, and a lack of collection and analysis of backup center data. We determined that a contributing factor for the lack of organized VCL quality assurance processes was the absence of a Veterans Health Administration directive or handbook to provide guidance for VCL quality assurance and other processes and procedures. We made seven recommendations.