Report Summary

Title: Healthcare Inspection - Evaluation of the Veterans Health Administration Veterans Crisis Line
Report Number: 16-03985-181 Download
Issue Date: 3/20/2017
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

OIG conducted a healthcare inspection of the Veterans Crisis Line (VCL) with four primary objectives:

To evaluate an allegation that VCL staff did not respond adequately to a veteran’s urgent needs;

To perform a detailed review of VCL’s governance structure, operations, and quality assurance functions;

To evaluate whether VHA completed planned actions in response to VA OIG recommendations from a previously published OIG report; and

To address complaints received from the U.S. Office of Special Counsel (OSC).

We determined that VCL staff did not respond adequately to a veteran’s urgent needs. We found deficiencies in the VCL’s processes for managing incoming telephone calls and in governance and oversight of VCL operations. We found substantial disagreement about key decisions in operations of the VCL between the VHA Suicide Prevention Office and VHA Member Services. We found that VHA contracting staff and leaders lacked an understanding of the backup center contract terms and did not verify quality control aspects of contractor performance, resulting in deficient oversight. We found some backup call centers used a queuing process that may lead callers to perceive they were on hold, and that VCL leadership had not established expectations or targets for queued call times, or thresholds for taking action on queue times. We discovered deficiencies in the VCL Quality Management program. We found several challenges in VCL QM staff’s ability to collect, analyze, and effectively review relevant QM data. VCL policies were not consistent with existing VHA policies for veteran safety or risk management and did not incorporate techniques for evaluating available data to improve quality, safety, or value for veterans. We found that the VCL had not completed actions to fully implement the seven recommendations from our prior report. We substantiated the OSC complainant’s allegations that SSAs were allowed to coordinate emergency rescue responses independently after the end of a 2-week training period, without supervision and regardless of performance or final evaluation; that a newly trained SSA contacted a caller in crisis by telephone to solicit the veteran's location; and an SSA did not document when closing out a veteran’s case. We made 16 recommendations.