Report Summary

Title: Follow-Up Review of the Veterans Crisis Line, Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas
Report Number: 18-03390-178 Download
Issue Date: 7/31/2019
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

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.