Follow-Up Review of the Veterans Crisis Line, Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas

Report Information

Issue Date
Report Number
18-03390-178
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess sustained performance of actions taken to close previous OIG recommendations at the Veterans Crisis Line (VCL) located in Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas. VCL is a crisis hotline providing services to veterans, service members, and their families members. VCL plays a significant role in VHA’s suicide prevention efforts. OIG staff evaluated areas of concern identified in two previous OIG VCL reports, published in 2016 and 2017, related to governance structure and oversight, operations, and quality management. The OIG found that VCL sustained actions related to previous recommendations. Clinical oversight of VCL was improved as a result of VCL’s realignment under the Office of Mental Health and Suicide Prevention. VCL hired a permanent director and operated under a directive that formalized operations guidance. VCL sustained improved operations processes, reduced rollover calls to the backup center, decreased the number of backup centers, and improved backup center oversight. VCL increased staffing at its Atlanta location and ensured that new responders participated in standardized training. VCL sustained actions to address previous concerns related to quality management leadership training, policies, and processes. Quality management reports showed improvements in oversight, tracking and trending of VCL quality indicators by site, and analysis of adverse outcomes. Responder silent monitoring was implemented at all sites. Plans were in place to expand the roles of social service assistants. During the current review, OIG staff found that VCL needed to analyze and address issues affecting rescue efforts, in which emergency services are dispatched to the location of a person determined to be in imminent danger. The OIG made one new recommendation related to improving location determination of veteran callers who need rescue.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Crisis Line director ensures analysis of rescue efforts ending because the caller’s location cannot be found, identifies and analyzes metrics that may have contributed to the inability to locate these rescues, and takes remedial action.