[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
AN ASSESSMENT OF ONGOING CONCERNS AT THE VETERANS CRISIS LINE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, APRIL 4, 2017
__________
Serial No. 115-9
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Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
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C O N T E N T S
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Tuesday, April 4, 2017
Page
An Assessment of Ongoing Concerns at the Veterans Crisis Line.... 1
OPENING STATEMENTS
Honorable David P. Roe, Chairman................................. 1
Honorable Timothy J. Walz, Ranking Member........................ 3
WITNESSES
Honorable Michael J. Missal, Inspector General, Office of the
Inspector General, U.S. Department of Veterans Affairs......... 5
Prepared Statement........................................... 40
Kayda Keleher, Legislative Associate, National Legislative
Service, Veterans of Foreign Wars of the United States......... 6
Prepared Statement........................................... 48
Melissa Bryant, Director of Intergovernmental Affairs, Iraq and
Afghanistan Veterans of America................................ 8
Prepared Statement........................................... 50
Steve Young, Deputy Under Secretary for Operations and
Management, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 10
Prepared Statement........................................... 53
Accompanied by:
Matthew Eitutis, Acting Executive Director, Office of Member
Services, Veterans Health Administration, U.S. Department
of Veterans Affairs
STATEMENTS FOR THE RECORD
The Government Acountability Office (GAO)........................ 55
AN ASSESSMENT OF ONGOING CONCERNS AT THE VETERANS CRISIS LINE
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Tuesday, April 4, 2017
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 10:02 a.m., in
Room 334, Cannon House Office Building, Hon. David P. Roe
[Chairman of the Committee] presiding.
Present: Representatives Roe, Bilirakis, Coffman, Wenstrup,
Radewagen, Bost, Poliquin, Higgins, Bergman, Gonzalez-Colon,
Walz, Takano, Brownley, Kuster, O'Rourke, Rice, Correa, Sablan,
Esty, and Peters.
Also present: Representative Young.
OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN
The Chairman. Good morning. The Committee will come to
order. Before we begin today, I would like to ask unanimous
consent for our colleague Representative David Young from Iowa
to sit on the dais and participate in today's hearing. Without
objection, so ordered. Welcome, David.
With that procedural note out of the way, welcome and thank
you all for joining us this morning. We are here today to
discuss a topic that is a top priority for me, for this
Committee, for the Secretary and his staff, and for the entire
military and veteran community: the prevention of suicide among
those who have served this country.
Sadly suicide is an epidemic affecting not just
servicemembers and veterans, but our Nation as a whole.
However, in the last year the Department of Veterans Affairs
released the most comprehensive analysis of veteran suicide
data to date and found that the risk of suicide was 21 percent
higher for veterans than it was for non-veterans. Probably the
most important mission for us in this room is to ensure that
the VA meets the needs of veterans actively contemplating
taking their own life.
The Veterans Crisis Line, VA's 24/7 suicide prevention and
crisis intervention hotline for veterans, servicemembers, and
their loved ones, is a critical tool for the accomplishment of
that mission. The Veterans Crisis Line is meant to be VA's
first line of defense for those in the midst of life's worst
moments. We cannot quantify the number of lives that have been
saved since the VCL was introduced a decade ago. But we know
that more than 2.6 million calls have been answered and
emergency responders have been dispatched to those in need
almost 70,000 times.
The demand for Veterans Crisis Line services, which now
include a call option, an online chat option, and a texting
message option, are growing. However, over the last year the
Veterans Crisis Line has been the subject of three major
investigations by the VA Inspector General and the Government
Accountability Office that have also found serious management
or organizational and quantitative deficiencies in virtually
every facet of the VCL's operation.
In February of 2016 the IG found that some calls placed to
the Veterans Crisis Line were sent to voice mail and that the
Veterans Crisis Line staff failed to promptly monitor the
quality of the services provided and in some cases did not
receive proper orientation or ongoing training.
Four months later in June of 2016, GAO found that the VCL
failed to meet its call wait time goal and neglected to monitor
the quality of the text message service. Five months later in
November 2016 Congress passed Congressman Young's legislation,
the No Veterans Crisis Line Call Should Go Unanswered Act in
recognition of the findings made by the IG and GAO and the need
for the Veterans Crisis Line to institute a robust quality
management plan. Yet just last month the IG published another
report which found that the Veterans Crisis Line had failed to
adequately respond to a veteran caller with urgent needs; that
the VA had instituted a VCL governance structure riddled with
deficiencies and that failed to include clinical perspectives
and input; and that the VCL was not appropriately training and
overseeing certain staff.
Perhaps most troubling, the IG also found that VA had
failed to implement a single action to address the
recommendations made in the IG's initial report even though VA
had agreed with all of the recommendations and committed to
implementing corrective actions no later than September.
I understand that the recommendations that GAO made and the
report last summer are still open. Given that, I question
whether VA has yet to fully comply with the requirements of the
No Veterans Crisis Line Should Go Unanswered Act either. That
is not to say that VA has not taken significant steps in the
last year to address the VCL's shortcomings. Last year the
Veterans Crisis Line has been realigned to the Office of Member
Services. The number of calls that are routed to backup call
centers has been drastically decreased and VA has stood up an
additional VCL call center in Atlanta, Georgia. I believe those
are positive developments and I hope to visit the VCL in person
in the coming months to see for myself.
However, there is very clearly a need for more to be done
and soon so that we can be assured that every veteran or family
member who contacts the Veterans Crisis Line gets the urgent
help he or she needs every single time without fail or delay.
As a physician I am particularly upset that the clinical input
is not being appropriately incorporated into operations and
management of the Veterans Crisis Line. A crisis line by its
very definition is not like any other call line. For an entity
like VCL every missed opportunity can result in a tragic loss
of life. According to VA's own data, 20 veterans a day die by
suicide. Those stakes, the 20 lives per day, are simply too
high for the Veterans Crisis Line not to perform at the highest
level.
VA is fortunate to have an abundance of mental health and
suicide prevention experts working here in D.C. and across the
country and their knowledge and expertise should be
incorporated into the Veterans Crisis Line processes and
procedures at every level. I look forward to hearing this
morning about how VA is going to make sure that that happens
and when all the recommendations for improvement that the IG
and GAO have made over the last year are going to be fully
implemented.
I also look forward to hearing any and every suggestion our
witnesses or my fellow Committee Members might have, what more
we can do to improve not only the Veterans Crisis Line but also
VA's other mental health and suicide prevention programs as
well. Our mission will not be over until a single servicemember
or veteran ever feels helpless or hopeless enough to consider
suicide.
I appreciate our witnesses for being here to discuss this
important topic with us this morning. And with that I will
yield now to my Ranking Member Walz for any opening statements
that he might have.
OPENING STATEMENT OF TIMOTHY J. WALZ, RANKING MEMBER
Mr. Walz. Well thank you, Chairman Roe. And thank you for
holding this. I would like to note that this week we will have
the extension of the Choice Act, the sunset provision and some
of the changes that need to be done in that. I want to thank
the Chairman for tackling a challenging subject and doing it in
a manner that not only is going to get it to the floor, you are
going to get it to the floor in a suspension vote and I assume
we are going to get a unanimous vote. That speaks volumes to
your leadership and I am grateful for that.
I would like to take just a minute on, I think it is
sometimes important and we forget this, the history of how the
Crisis Line came about. At this time I would like to thank Mr.
Young from Iowa because this Crisis Line runs deep through the
heart of Iowa in its genesis.
Back in 2007 my then colleague Representative Leonard
Boswell, himself a Vietnam War helicopter pilot, brought the
story of one of his constituents forward, a young man from
Iowa, Joshua Omvig, who served his country honorably, came home
for Thanksgiving, and took his life in his parents' basement on
the evening of Thanksgiving because of PTSD. I think it is
important for all of us sitting on this panel to recognize
suicide and suicide prevention is not something new. Leonard
was able to bring that to the floor, pass it, and sign it into
law, which one of the provisions was the creation of the Crisis
Line, one of the first acts and one of the first bills I had
the privilege of working on in 2007. So it is not surprising
that there is a deep sense of ownership and a desire to make
this work. I think this Committee with an understanding that
continuing to provide oversight, continuing to provide
improvements and enhancements, is critical. For many of us once
you get on this Committee you start to see many of these
things.
There is much in place but I think our frustration lies
with implementation. That is where I encourage all of us to
stay actively engaged. I worry that sometimes we pass a piece
of legislation and we watch the signing ceremony and we send
that out the door to go on. If there is any lesson I have
learned here is do not send it out the door without being on
top of it. Do not continue to come back.
So Chairman, I too share you concerns over the IG report on
the Crisis Line. You said it exactly right. This is a zero sum
proposition. I know we are going to hear statistics that we
improved from 31 percent dropped calls to less than one
percent. We need to look into those numbers. But again, this is
the one area where we are shooting for perfection. This is
beyond Six Sigma. This is every single one of those calls is
life and death. Every single one of those interventions is life
and death. If it is viewed anything short of that, we are
certainly failing.
So I want to hear exactly what we are going to do. How we
are going to figure that part out. I still believe this was one
of our greatest assets. The numbers seem to support that. I do
want to be very clear about this, that I am absolutely certain
that the VA Crisis Line and those professionals and picked up
and answered the phone have saved lives. It has happened. We
know it has happened. That does not change the fact, though,
that in the progress there are issues.
The IG's finding includes issues like this: lack of
training for quality assurance supervisors, lack of clear
procedures and policies, insufficient data collection and
analysis, failure to oversee contractors with backup call
centers, and lack of leadership and governance. These are
reoccurring issues we see time and time again at the VA and
they are one of the areas and the main concern that the GAO
puts the VA on the high risk list. These have not been
addressed. The folks sitting out here, and I want to be clear,
another failing in my opinion, and we need to expand our
definition of accountability, the director of this critical
service to our veterans, the director position, was left open
for ten months. So we can talk all we want about the folks down
the line answering the phone. But once again, no leadership, no
director, no HR function, no training, no accountability, no
following the GAO.
So this accountability piece that people are rightfully on
extends to a much broader area. So you know the statistics. The
Chairman said it. I am very interested. I, again, I applaud,
Chairman Roe has a way of asking the right questions. In my
opinion that is what leadership is all about. What is the fix?
How is it going to be done? What are the suggestions? Because
what I certainly do not want to hear is someone using semantics
to tell me, well, they were actually placed in a queue, not
placed on hold. If you are in a crisis life and death
situation, you do not give a damn if it is on hold, in a queue,
voice mail, somewhere else. You need a trained professional to
pick up the phone as quickly as possible and direct you to the
services to save your life.
So I look forward to the testimony from folks. I appreciate
you all being here. Again, I would ask my colleagues up here,
our colleague from Iowa started this in 2007. We have got
another colleague from Iowa that worked to enhance upon it. For
all of us, it is our responsibility to fix this. I yield back.
The Chairman. Thank the gentleman for yielding. Joining us
on our first and only panel this morning is the Honorable
Michael J. Missal, VA Inspector General; Kayda Keleher, the
Legislative Associate for the National Legislation Service for
the Veterans of Foreign Wars of the United States; Melissa
Bryant, the Director of Political and Intergovernmental Affairs
for Iraq and Afghanistan Veterans of America; and Steve Young,
VA's Deputy Under Secretary for Operations and Management, who
is accompanied by Matt Eitutis--did I get that right, Matt? I
am amazed I got that right. The Acting Executive Director of
the Office of Member Services. Thank you all for being here
this morning. And Mr. Missal, we now recognize you for five
minutes.
STATEMENT OF MICHAEL J. MISSAL
Mr. Missal. Thank you, Chairman Roe, Ranking Member Walz,
and Members of the Committee. Thank you for the opportunity to
discuss the OIG's recent work on the operations of the Veterans
Crisis Line.
The tragedy of veteran suicide is one of VA's most critical
issues. The rate of suicide among veterans is significantly
higher than the rate of suicide among U.S. civilian adults.
VA's most recent estimate calculates that 20 veterans commit
suicide a day. Of these veterans approximately 14 have not been
seen by VA. The VCL is essential to reduce veteran suicide for
those who call in crisis.
In our February 2016 VCL report we identified several
problems with the VCL, including crisis calls going to voice
mail, a lack of a published VHA directive to guide
organizational structure, quality assurance gaps, and contract
problems. Our February 2016 report resulted in seven
recommendations and VHA concurred with the findings and
recommendations. VHA provided an action plan and timeframe to
implement those recommendations by September 30, 2016. However,
as of today all seven of those recommendations remain open.
In June 2016 we received an allegation related to the
experience of a veteran with the VCL and its backup call
centers. As a result of the complaint and in light of the open
recommendations from our February 2016 report, we expanded our
scope to conduct an in depth inspection of the VCL. We also
received in August 2016 a request from the Office of Special
Counsel to investigate allegations regarding training and
oversight deficiencies with social service assistants who
assist call responders. Our March 2017 VCL report made the
following findings.
We substantiated that VCL staff did not respond adequately
to a veteran's urgent needs during multiple calls to the VCL
and its backup call centers. We also identified deficiencies in
the internal review of the matter by the VCL staff. In the
interests of privacy, information specific to this veteran is
not included in our report. However relevant information has
been provided in detail to VHA.
With respect to the governance structure, operations, and
quality assurance functions, we identified a number of
deficiencies. Among other findings, we reported that there was
a lack of effective utilization of clinical decision-makers at
the highest level of VCL governance; a lack of permanent
leadership during much of the last few years; a failure to
collect the appropriate clinical data necessary to assess
performance; deficient oversight of the backup centers; lack of
background and training and quality management principles; and
the limited experience of supervisors in the new Atlanta call
center.
With respect to the allegations referred by the Office of
Special Counsel, we found that the VCL lacked the process for
monitoring the quality of performance by social service
assistants and deficiencies in SSA training.
All 23 recommendations from our 2016 and 2017 VCL reports
remain open today. They fall into the categories of governance,
operations, and quality assurance. Governance recommendations
include the establishment of a VCL directive that guides
structure, roles, and responsibilities; appropriate
collaboration between clinical and administrative leadership;
and lines of authority that delineate that clinical policy
decisions be made by clinical leadership.
Operations recommendations include information technology
infrastructure improvements, a better tracking of updated
policies and procedures and related staff training, and that
contractors be held to the same standards as the VCL.
Quality assurance recommendations include QA leadership be
fully trained in QA principles; negative clinical outcomes
evaluated in order to improve; quality data be used to enhance
performance; call recordings be used for quality assurance; and
that the performance for the Canandaigua and Atlanta call
centers be analyzed separately.
We recognize the difficulties and challenges in operating a
crisis hot line. Our 2016 and 2017 reports identified various
challenges facing the VCL and their mission to provide suicide
prevention and crisis intervention services to veterans,
servicemembers, and their family members. Until VHA implements
fully the open 23 recommendations from our two reports, they
will continue to have challenges meeting VCL's critically
important mission.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions that you or other Members of the
Committee may have.
[The prepared statement of Michael J. Missal appears in the
Appendix]
The Chairman. Thank you very much. Ms. Keleher, you are
recognized for five minutes.
STATEMENT OF KAYDA KELEHER
Ms. Keleher. Chairman Roe, Ranking Member Walz, and Members
of the Committee, on behalf of the men and women of the VFW and
our Auxiliary, I would like to thank you for the opportunity to
present our views on the Veterans Crisis Line before the
Committee.
In 2007, Department of Veterans Affairs Health
Administration, VHA, established a suicide hotline which became
what we know today as the Veterans Crisis Line, or VCL. Since
then, the responders at VCL have answered more than 2.8 million
phone calls, over 62,000 text messages, and have initiated
emergency dispatch services more than 72,000 times. While these
numbers are impressive, the VFW believes more must be done to
improve the VCL.
Since the GAO report released in May 2016, VA has worked to
improve the VCL in many ways. These efforts have been
successful in bringing the number of calls sent to backup
centers drastically down. In fact, during the first week of
November 2016, the VCL had over 3,000 rollover calls. Now over
the first week of March, VCL only had 28 rollover calls. Yet
without being able to promise every veteran it is practical for
the two current VCL centers to answer every call, it is
imperative that VCL continues contracting SAMHSA approved
backup call centers.
Even with the impressive drop in rollback phone calls, the
VFW worries about quality of crisis intervention provided while
VA currently focuses on quantity of calls answered. While
precise numbers of non-veterans and veterans not in mental
health crisis who dial into VCL are unknown, it is publicly
recognized call lines are sometimes clogged up by them. Last
year it was publicized that four callers called the VCL to
harass responders thousands of times. Estimates said those four
people made up more than four percent of incoming VCL calls.
Even in light of the most recent VA OIG report, veterans have
self-proclaimed that they call VCL for non-crisis issues, such
as to complain about a doctor or try to schedule an appointment
because it is the only VA number that they can find.
For this reason, the VFW believes expanding VA's Office of
Patient Advocacy would greatly benefit VCL. By improving and
expanding patient advocacy offices throughout VA, employees of
these offices would have better visibility and means to assist
non-crisis patients. If veterans become more aware of the
patient advocate mission and capabilities, non-crisis callers
to VCL would decrease. The VFW urges this Committee to conduct
extensive oversight of the VA patient advocate program to
ensure veterans are able to have their non-emergency concerns
answered and addressed without having to call into the VCL.
Employees of VCL undergo extensive training before being
able to answer crisis calls and it takes an additional minimum
of six months before responders are able to answer, chat, and
text conversations. While this training is thorough, it was not
until late December that VCL had the capability to record their
calls. Staff at VHA and VCL currently monitor some calls for
quality assurance, but a better constant process must be
implemented. This would ensure these recordings are being used
to improve the training and capabilities of VCL responders. It
would also assist with ending allegations of responders not
understanding or following protocol and knowing their
resources.
There is zero doubt clinical oversight is a necessity for
VCL. Clinical decisions must be made by clinicians, not
operations and administrative staff. Leadership running VCL
must also have clinical background. This would ensure veterans
calling VCL receive the best clinical judgment and assistance.
Clear guidelines must be established for VCL so non-clinicians
are not forcing a clinically based crisis line to operate as a
business. VHA must also establish clinical and operational
policies specific to VCL. This would allow for easier protocol
standards to be understood and met on a constant basis, while
establishing guidance and regulations to be followed by
employees without clinicians stepping on the toes of operations
or operations stepping on the toes of the clinicians. This can
be done with better collaboration between VCL, VHA member
services, and the Office of Suicide Prevention. If the goal of
VCL is to intervene for veterans in need of immediate
assistance while they are in a mental health crisis, the VCL
should be working with the subject matter experts in suicide
prevention and outreach for VA.
The VCL clinical advisory board must also be more involved.
Currently the board only meets once a month for a one-hour
phone conference meeting. This group was intended to assist VHA
member services and collective expertise of clinicians to
improve the veteran experience, efficiencies of employees, and
increased access to VCL. The board's charter was later changed
by member services leadership and the VFW thinks it is clear
that a one-hour phone call every month is not enough.
Mr. Chairman, this concludes my testimony. I am happy to
answer any questions you or other Members of the Committee may
have.
[The prepared statement of Kayda Keleher appears in the
Appendix]
The Chairman. Thank you very much. Ms. Bryant, you are now
recognized for five minutes.
STATEMENT OF MELISSA BRYANT
Ms. Bryant. Chairman Roe, Ranking Member Walz, Members of
the Committee, on behalf of Iraq and Afghanistan Veterans of
America and our more than 425,000 members, thank you for your
time two weeks ago as IAVA introduced She Who Borne the Battle
Campaign. We look forward to working with you and your staff to
fully recognize and improve services for women veterans.
We also thank you for the opportunity to share our
assessment of ongoing concerns with the Veterans Crisis Line
today. Mental health and suicide prevention remains one of the
top concerns of our members, where 75 percent of respondents to
our recent survey still believe troops and veterans are not
getting the care they need for mental health injuries.
I am here today not only as IAVA's Director of
Intergovernmental Affairs but also as a former Army captain and
a combat veteran of the Iraq War. I was a military intelligence
officer, a leader of men and women in combat, and I bore
witness to the trauma and anguish several of my friends and
soldiers endured when dealing with suicide. While I am
eternally grateful that my soldiers received mental health
interventions, I mourn the loss of my sisters and brothers in
law who lost their battle and died by suicide. I am giving
voice to all of us who served and the invisible wounds of war
as I speak today.
In 2007 IAVA fought for and celebrated the passage of the
Joshua Omvig Suicide Prevention Act, which among other things
requires the establishment of the VCL. IAVA signed an agreement
with the VCL in 2012 and continues to partner with them today
to ensure our vets are aware of the critical services the VCL
offers as well as to provide crisis support to clients who are
seeking help from IAVA's rapid response referral program, or
RRRP. To date our RRRP veteran transition managers have
referred nearly 200 clients to the VCL. These clients share
both positive and negative stories of their experiences with
the VCL. IAVA wants to get to a place where all feedback we
receive about the VCL is positive.
The VA has publicly addressed VCL's inability to handle
call volume and its reliance upon a backup call center to field
these calls. But they have not addressed the additional
findings of the IG report that point to larger, more systemic
issues: the VAL.'s governance structure, operations, and
quality assurance protocols.
IAVA strongly urges the VA to reconsider its management
structure at the Veterans Crisis Line. There must be a dual
leadership structure in which an operations lead can oversee
the functional aspects of the call line while a clinical lead
oversees the clinical aspects. These roles must be
complimentary and cooperative to ensure the success and safety
of both clients of the VAL. and the responders who are
answering their calls.
Finally the Office of Suicide Prevention must be heavily
engaged with the operations, quality assessment, and oversight
of the VAL. IAVA implores the VA to also consider whether the
level of clinical support provided to each call responder is
appropriate, how the VAL. is addressing self-care among
responders, and what mechanisms are in place to prevent staff
burnout and experienced responders from moving on. Compassion
fatigue is real. Moreover, applying a sterilized quality
assurance protocol that could easily be templated for
determining a customer service rating for your home cable
installer is woefully insufficient for our veterans.
We would expect that the Veterans Crisis Line would fall
under the purview of two laws championed by IAVA. The Clay Hunt
SAV Act, which requires the annual evaluation of VA's mental
health and suicide prevention program, and the Female Veterans
Suicide Prevention Act, which goes a step further to require
analysis of these programs by gender. Our She Who Borne the
Battle Campaign is anchored in the fact that women veterans are
the fastest growing population yet often go unrecognized. We do
not know how many women veterans use the VAL., nor how
effective the VAL. is in providing support for women, or even
if they are welcomed by a responder that is answering their
call. As part of our She Who Borne the Battle Campaign we
recognize that the motto of the VA functions as a symbolic
barrier perceived by many women veterans like myself,
emblematic of our lack of parity and care compared to our male
counterparts. Perhaps this culture is trickling down to the
VAL. A holistic program evaluation including gender specific
data should be conducted to know for certain.
We point to IAVA's RRRP program as a model for mental
health case management. This high tech, high touch program has
served over 7,800 clients to date, 20 percent of them women,
connecting them with quality resources and benefits, many of
whom may not have been eligible for VA care due to other than
honorable discharge status. We put a strong emphasis on client
follow up and customer satisfaction at RRRP. Programs like RRRP
complement the VAL. and are valuable partners by supporting
veterans and their families who are not in immediate crisis but
are at risk if these types of services are not provided. Often
veterans have seen bad news stories about the VA or have had a
bad experience and they come to us instead. We are often one of
the best on ramps for veterans into VA support.
I cannot stress enough the gratitude IAVA has for those who
staff the VAL. call lines and are there to support the hundreds
of thousands of calls received per year. In our latest survey
20 percent of respondents had reached out to the VAL. on their
own behalf or on behalf of a loved one. This is a critical,
often live saving resource for our community. Sixty-five
percent of our latest survey personally know a post 9/11
veteran who has attempted suicide while 58 percent know a
veteran who died by suicide. As one of those respondents who
personally knows veterans who have either attempted or died by
suicide, this issue is deeply personal to me and one we must
resolve swiftly.
Thank you again for the opportunity to share IAVA's
assessment of the VAL. We look forward to working with you and
the VA in the months ahead to improve this essential resource.
Thank you for your time. I look forward to any questions you
may have.
[The prepared statement of Melissa Bryant appears in the
Appendix]
The Chairman. Thank you. Mr. Young, you are recognized for
five minutes.
STATEMENT OF STEVE YOUNG
Mr. Young. Good morning, Chairman Roe, Ranking Member Walz,
Members of the Committee, Congressman Young, my hometown
congressman, thank you for the opportunity to discuss the
Department of Veterans Affairs Office of the Inspector
General's report on the Veterans Crisis Line. I am accompanied
today by Matthew Eitutis, Acting VHA Member Services Executive
Director.
The primary mission of the VAL. is to provide 24/7 world
class suicide prevention and crisis intervention services to
veterans, servicemembers, and their families. Any person
concerned for a veteran's or military servicemember's safety or
crisis status should call the VAL. by dialing the National
Suicide Prevention Hotline 1-800-273-8255, press one to reach a
VAL. responder. You can also reach the VAL. by texting 838255
and a VAL. responder will text you back. We also offer online
chat at veteranscrisisline.net, and vets.gov.
Since 2007 VAL. has answered nearly 2.6 million calls and
dispatched emergency services to calls in crisis over 67,000
times. In 2009 Veterans Chat launched, providing an online, one
to one chat service for veterans who prefer reaching out for
assistance using the internet. Since its inception we have
answered nearly 314,000 requests for chat. We added text
services in November 2011, resulting in nearly 62,000 requests
for text services received to date. On average, over 99 percent
of calls on a daily basis are answered by the Canandaigua, New
York and Atlanta, Georgia call centers. Less than one percent
roll over to backup centers.
When a veteran calls VCL, we have two objectives. The first
to answer the call and effectively assess the risk of the
caller. As I have detailed in my written testimony, since early
January we have answered over 99 percent of our calls without
rollover. Our second objective is to provide sound crisis
intervention services to our veterans.
A quality management system has been implemented to monitor
the effectiveness of the services provided by VCL. and identify
opportunities for continued improvement. As required by law, VA
will submit a report containing this document outlining the
quality management plan to the House and Senate Committees by
May 27th.
We appreciate OIG's review and take their recommendations
seriously. We are pleased to say we are strengthening our
structure so the Veterans Crisis Line, the Office of Suicide
Prevention, and the Office of Mental Health Operations are
fully integrated to ensure clinical services are optimized.
Care is seamless from the time the veteran reaches out to the
VCL and arrangements are made to ensure the veteran is safe and
timely care and assistance is provided.
We submitted a recommendation that OIG close six of the
seven recommendations from the report published in February
2016 and action plans have been developed to address all of the
recommendations for the March 2017 report, with the expectation
that they will all be implemented by December 2017. During the
time period of the second IG investigation, VCL. was in the
process of transitioning leadership from one organizational
element to another and concurrently standing up the Atlanta
call center. New responders were hired and trained over the
course of three months, averaging 40 new responders being
deployed every two weeks. The standard training cycle includes
three weeks of classroom instruction and three weeks of
preceptorship prior to being released to independent work. This
training took other VCL responders away from their regular
duties. All this while performing some of the most profound and
important work imaginable, addressing the needs on average of
over 2,000 veterans a day and dispatching immediate assistance
to 60 veterans a day who are in crisis.
The OIG investigation concluded shortly prior to the
tipping point of VCL. consistently answering 99 percent of
calls. Since this tipping point we have had 43 days with no
calls rolling over. Furthermore in the past six months VCL has
more than doubled the capacity to ensure appropriate access to
veterans. Today the combined facilities employ 661
professionals and VA is hiring more to handle the growing
volume of calls. VCL is the strongest it has been since its
inception in 2007. VCL has forwarded over 416,000 referrals to
local suicide prevention coordinators on behalf of veterans to
ensure continuity of care with their local VA providers.
Despite all this, there is still more that we can do. We
appreciate OIG's review of VCL. We are committed to
strengthening our governance structure so VCL, Office of Mental
Health Operations, and the Office of Suicide Prevention are
fully integrated to ensure optimal clinical services. We are
committed to seamless care from the time the veteran reaches
out to VCL, arrangements are made to ensure that the veteran is
safe, and we ensure that the veteran receives timely care and
assistance. We are also grateful that Congress provides the
resources necessary to give veterans in crisis access to these
necessary services.
Thank you and Mr. Eitutis and I look forward to your
questions.
[The prepared statement of Steve Young appears in the
Appendix]
The Chairman. Thank you, Mr. Young. And I will now yield
myself five minutes. And I am going to go to another hearing, a
mark-up in another Committee, for just a minute. So I am going
to ahead.
First of all, I think you, the Veterans Crisis Line does
some of the most important work that is done in the VA. I think
when a warrior gets home, or even does not leave home, and
contemplates suicide--I was thinking about this when you all
were giving your testimony about the number of patients I have
seen over the years in my practice that I tried to diagnose a
breast cancer, or a ovarian cancer, or a uterine cancer, and
all that I went through to save their lives and then they went
through to save their lives. And that is what you do. I think
the thing that worried me the most in practice, the objective
things I could see I could go after the treat. The subjective
about how I am going to behave is very, very difficult. And
that is why, as Mr. Walz said, we have to get this as right as
we can. Because you really will never quantify how many people
that never did something, but you may have stepped in at
exactly the right time.
So I am going to just ask a couple, three questions, and
then let a discussion go forward. A question I think I first
have, at the end of your testimony is why were not all these
things that the IG and GAO did a year ago, I hear exactly the
same thing, Mr. Young, that was said a year ago that never
happened. Why is that going to happen now?
Mr. Young. We have submitted plans to the IG. However they
requested additional demonstration that we have sustained the
improvements that we put in place. We have submitted now 386
documents just recently, just in the last few weeks, to
demonstrate that compliance with their recommendations.
The Chairman. Okay. Well I think things are getting better.
The second thing I want to know, this is a constant turmoil in
medical practice, is the, Mr. Missal mentioned this, this
debate over what the clinicians want to do and what the people
who run it want to do. I think that is a huge deal. Because
those decisions ought to be made, many of those decisions I
think should be made by medical professionals. I may be biased,
but when you have the bureaucrats in there telling you what to
do, when a clinician knows this is the most effective way to
provide this care for people, I would like a discussion from
anyone who would like to jump in on that. Because I think that
is a critical, and maybe Ms. Bryant, if you want to start with
that?
Ms. Bryant. Yes, Chairman. As I stated in both my oral and
written testimony, IAVA feels very strongly that a clinician
needs to be in position of leadership in managing the Veterans
Crisis Line. Even within our own RRRP team we recognize that
the clinical decisions are often very highly tailored,
individualized for that specific case, for that veteran who is
in crisis. And you cannot simply, I understand the call volume
is a challenge. And I understand that, you know, it is hard to
template an SOP in which you can at least evaluate the
responders' response or handling of a call, but you have to at
least try to individualize that as best as possible and you
have to do that with a clinician not just in the loop but is
there with equal decision-making authority as the operations
lead.
The Chairman. And why would you not, back to Mr. Young, why
would you not want to have that?
Mr. Young. The Veterans Crisis Line does have a Ph.D.
trained social worker that is the clinical lead of the Veterans
Crisis Line. It is organizationally aligned right now under
Member Services but the Crisis Line itself is a led by a Ph.D.
trained social worker. And in fact the entire leadership team
has 140 years collectively of mental health experience that
lead the Veterans Crisis Line itself.
The Chairman. Well in your testimony you said that the VAL.
is the strongest it has been since its inception, and do you
have any metrics that you have measured to prove that?
Mr. Young. I think that first of all the volume, and I know
that is not the end all be all, that is only one piece of it,
is the volume of calls that are being answered today, the
timeliness of the calls being answered on average within eight
seconds, the calls being answered by VA trained staff
themselves, not rolling over to backup call centers, 99.8
percent being answered by VA trained staff. Since our tipping
point on Friday the 13th of January was when we first hit zero
rollovers. But in addition to that we have processes in place
to evaluate the quality of the calls. We have established
silent monitoring. Since the IG's recommendations, we have put
in place call recording, so we can go back and review the calls
with the responders, ensure that they have established rapport
or established, properly assessed the risk, followed procedures
for linking people in to referrals if needed. And if that, if
there are shortcomings, to be able to pull them off and retrain
and reeducate around the proper procedures.
The Chairman. Okay. My time is expired. Mr. Walz, you are
recognized.
Mr. Walz. Thank you, Mr. Chairman. Captain Bryant, and I
know you do not maybe have the data in front of you, what are
the major negatives that you hear from people who have used
this? What are their concerns with it?
Ms. Bryant. Yes, Congressman. So I do actually have a few
from our rapid response program, comments on the quality of
feedback from the VAL. So on negative experiences, number one
we had one of our case managers visit the VAL. within their
floor. And it was worth noting that they were unable to provide
referrals outside of the VA. So that seemed to be a challenge,
especially when you are looking at total case management for a
client who calls in. We understand that the VAL. will then make
appointments within the VA and they could even track those
appointments through their database. However, what if there are
services that are required that go outside the scope of what
the VA can provide? So that was one major drawback that we saw.
Beyond that, negative experience included a representative
saying, we will not do that, and then they let the caller hang
up. It is important to note that the way our partnership works
with the VAL. is that if a veteran in crisis calls our RRRP
team, we give a warm handoff to the VAL. We stay on the line.
We have an entire SOP that we follow where we ensure that they
are put in contact with the VAL. before we hang up. And then we
do follow up with that client to ensure that they have gone to
their appointments or they have done whatever regimen was
recommended by the VAL. So a lot of what we are hearing on the
negative side speaks to the length of the time to answer the
phones. At one point there was a call that took 16.5 minutes
for the veteran transition manager to get in touch with the
VAL. responder. Clearly these stats are not satisfactory.
Mr. Walz. Okay. No, thank you. Mr. Young, I am going to,
again I want to keep this in perspective. This is about a
decade long. Now we are at the point where we are recording
calls, we are starting to do that. Is that frustration
apparent? I mean, do you understand where we would come from?
Are there best practices that were there? Or is there no
civilian comparison to show how we could do this best? Why it
took ten years to start addressing the recent IG report?
Mr. Young. That frustration is apparent, Congressman,
absolutely. We want to, this is an evolutionary process. And I
think we have made remarkable progress from 2007 to today. But
there is so much more to be done. And fulfilling the OIG's
recommendations are a key step in raising the bar and making
the Veterans Crisis Line even better than it is today.
In direct answer to your question about are there standards
out there, there are accrediting entities around crisis
intervention centers. The American Association of Suicidology
is who our crisis line is accredited by. In the same way we
ensure that those that we work with that do provide the rare
instances of backup, that they also are accredited by those
accrediting bodies. We will be going through a reaccreditation
process later this year with the American Association of
Suicidology to ensure that we are meeting their standards for
what a crisis line should be.
Mr. Walz. Mr. Young, in your opinion, would it lead to a
lack of service? Why did we not have a director? I am at the
point now where my major number one crisis in the VA is the
ability to fill leadership positions over critical agencies. Is
that a problem? Did anybody say, dang, we need a director in
this situation?
Mr. Young. Yes, Congressman. Filling key leadership
positions has been a challenge over time. Broadly speaking,
when we speak of medical center director positions in
particular, you know, we have had a significant number of
vacancies across the country in this positions. And today I
believe we have only 16 of those positions open and we are, you
know, rapidly working toward getting them filled.
In the case of the Veterans Crisis Line, we advertised for
that position. We had three candidates, none of whom were what
we wanted in terms of the caliber to lead it. Fortunately we
had a highly talented individual who was not interested in the
job long term that was willing to step in and help us build
this program as we were building it up. He has since moved on.
He, you know, intended all along to just be there a short time.
And now, again, we have an acting director for the Veterans
Crisis Line, a Ph.D. trained social worker, and we are actively
recruiting right now to fill that job again.
Mr. Walz. We need to help you with that. I will close on
this. This is just, this is not to you. This is to the folks
listening right now. The press release that came out after the
IG report said you had fixed the problems. I would be very
careful saying you fixed the problems with the VAL., just a
suggestion. I yield back.
The Chairman. Thank you, Mr. Walz. Mr. Bilirakis, you are
recognized for five minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it so
much. Mr. Young, among the list of actions VA is taking in
response to the most recent IG report is, and I quote, ensuring
all staff are educated on policies to include roles and
responsibilities. My goodness, I would think so. I mean, it
concerns me that an employee working for a program as critical
as this one in some instances did not know what his or her role
was. Was it evident that all staff was thoroughly educated on
relevant policies? Again, I just, I am astounded by this. Why
would that be the case? And how do you plan on ensuring a
complete understanding of program and agency policies moving
forward? Again, I mean, is this widespread? I would like to ask
the rest of the panel as well. But if you could respond, Mr.
Young? And will you have similar assurance for backup call
center staff as well?
Mr. Young. Congressman, yes. It is an expectation,
absolutely, that employees understand their roles and
responsibilities. I think I will defer to Mr. Eitutis to go
ahead and give us some details on that.
Mr. Eitutis. Sure. The goal of the Veterans Crisis Line
renovation is to do exactly what the OIG recommended. And so we
took the original recommendations from OIG in February of 2016
very seriously and immediately started working on canonizing
processes. The timing of the second OIG investigation was
within a handful of months of the ending of the first and the
publishing of the first OIG recommendation. Taking an
organization where there are few to no SOPs, any standard
operating procedures, no formal curriculum for responder
training, no formal curriculum for SSA training to make sure
that our SSA staff that coordinate emergency dispatches and
attempts, there was very little to nothing in regards to
documentation. That takes time to do that. And the beginning of
another investigation on the heels of beginning to address
those things that need to be place, while it is important to
document those, we feel very confident at this point where we
have documented the procedures and canonized the processes for
the responders that are taking these tough calls, 2,000 a day,
and making sure that our SSAs are full trained. We have
certified that training. We have canonized the processes for
both of those critical functions inside the VCL.
Mr. Bilirakis. Ms. Bryant, what do you think about that?
Ms. Bryant. IAVA wants to see the VAL. brought to a level
to where, as I stated during my testimony, that all feedback is
positive. We think that it is encouraging to hear that the VAL.
has taken steps in recent months to address some of the issues.
But we still believe it does not go far enough. We still
believe that a stronger clinical program is needed. We are
hearing steps in the right direction, but we want to see more.
We really want to see more in the training. We really want to
see more in taking care of the responders who are receiving
these calls. We really want to see more in seeing that clinical
lead being the, really setting the standards for how these
responders not only receive calls but then also receive care
themselves. Again, I go back to what I said during my
testimony. Compassion fatigue is real. We understand that a
strong clinical program requires a one to ten ratio of
responders to clients. We want to see these types of standards
applied as the VAL. goes forward with its reorganization.
Mr. Bilirakis. Thank you. Mr. Young, in the IG report it
was noted that when calls were placed in a queue at a backup
call center, the line was not answered until a representative
was available. There was no process to route the call from one
backup center to another. Is there a process now in place?
Mr. Young. We currently are answering 99.84 percent of the
calls ourselves. So it is the rare instance of a call that is
going to a backup call center. Yesterday we answered 2,406
calls and seven went to a backup call center. So it is the rare
circumstance now where we are even using the backup call
center.
Mr. Bilirakis. But is there a process in place now?
Mr. Young. I will defer to Matt on that.
Mr. Eitutis. There is a process. And historically what the
VCL has done, they are a part of the National Suicide
Prevention Lifeline Network, which consists of 160 other call
centers across the country. So NSPL is managed by a contractor,
the Mental Health Associates of New York City. We are in
current negotiations to redefine what that backup looks like
now that we have actually created near 100 percent success for
VA VCL. to be able to handle that volume. Historically what has
happened prior to where we are today with the access that we
have inside VCL, we had four of those 160 centers in the
National Suicide Prevention Lifeline as part of our contract
where they would take our calls. Unfortunately the volume that
we were rolling over, when you roll over 3,000 to 4,000 phone
calls per week, that is problematic to other call centers that
have their own core mission of providing services for their
communities and for their states. And so we believe that the
right thing to do was to be able to actually demonstrate to
NSPL and SAMHSA and MHANYC that we are going to take care of
our own and make sure that we enter into a new generation in
regards to rollovers and what that means in regards to
catastrophic support.
Mr. Bilirakis. Well thank you. Mr. Chairman, I yield back.
I have some questions but I will submit them for the record. I
yield back.
The Chairman. I thank the gentleman for yielding. Mr.
Takano, you are recognized for five minutes.
Mr. Takano. Thank you, Mr. Chairman. Mr. Missal, your
report highlights several concerns with VAL. governance. In
your opinion, should the VAL. remain under Member Services? Or
should it be transferred back under the VHA Clinical
Administrative and Suicide Prevention Office?
Mr. Missal. I do not know if there is necessarily a right
answer as to what the structure should be. We do feel very
strongly that both Member Services and the clinical staff have
important things to contribute to the VCL. What we identified
was that the clinical staff felt marginalized and that they
were not contributing their fair share or what they wanted to
do to make this as effective a crisis hotline as possible. So
it has got to be a better balance of contributions from the
clinical side with respect to Member Services.
Mr. Takano. You know, I am troubled by knowing about the
chronology of the leadership of the VAL. Am I correct that we
really have not filled that position for the seven years it has
been in existence? Go ahead.
Mr. Missal. It was filled before. It was open for a
significant amount of time in the last couple of years. It was
filled for a short time in 2016. The director left and I do not
believe they had a permanent leader in place, at least since
our review ended in December 2016.
Mr. Takano. Well can Mr. Young or anyone give me an idea of
just the chronology? Since we just, one of the things I am very
troubled by with the VA is a lack of continuity of leadership
at the very top, but this is not the very top. This is kind of
a, you know, a program within the VA. Can you give me an idea
of just the chronology of the leadership?
Mr. Young. That was actually before my time and before I
had an awareness of it. But I will defer to Matt to see if he
can give us a little bit more insight.
Mr. Eitutis. Sure. There has always been a clinician in
charge of the Veterans Crisis Line despite the fact that the
Veterans Crisis Line was realigned to Member Services last
year. The Veterans Crisis Line has always been led by a
director. Our current acting director has got 30 years of
emergent psychiatric experience and is an expert in crisis
management. And with 140 years collectively throughout our
entire leadership team of mental health care experience.
Mr. Takano. Yeah, but I want to get some idea of just to
put a director in place, I mean to have them there for one or
two years, it just does not seem to me enough time to establish
a good program and a good vision.
Mr. Young. So Congressman, I am sorry. I do not know that
history. So I will have to take that for the record and bring
that back to you.
Mr. Takano. If you would, thank you. I appreciate that.
Back to the Inspector General, is VA on track to address the 23
open recommendations in your estimation?
Mr. Missal. We have been working with them with respect to
the 2016 recommendations. Mr. Young pointed out they have
provided us recently with a lot of documentation that we are
reviewing. We would like nothing better than to close out the
open recommendations as quickly as possible. I think there is
sometimes a misunderstanding of exactly what our
recommendations require and we spend time talking to them to
make sure they understand. And let me give you an example which
I think relates to some of the discussion on governance issues
and the fact that we identified that there was not a clear
understanding of the roles and responsibilities in our 2016
report. And here we said they need a VCL handbook. What we got
in return was an employee handbook. And we said an employee
handbook can provide guidance on handling personnel matter such
as the tardiness of employees, or dress, etcetera. It does not
ensure people at the VCL understand their responsibilities. And
that is what we are going to need to close out that
recommendation. We certainly communicated that on more than one
occasion.
Mr. Takano. Does the hiring freeze affect any ability here
to get the VAL. really on track?
Mr. Young. The VCL positions are exempted from the freeze.
Mr. Takano. They are exempted? Okay. Thank you for letting
me know. You know, I would appreciate for the record later any
additional processes the VA, such as the one you mentioned,
should put in place to oversee the backup call center
contracts. We do not have the time but if we can get that later
for my office, I would appreciate it. Thanks.
Mr. Young. Sure.
The Chairman. I thank the gentleman for yielding. I now
yield to Mrs. Radewagen for five minutes.
Mrs. Radewagen. I want to thank the Chairman and Ranking
Member for holding this hearing today. Thank you, Mr. Chairman.
And I want to thank the panel for coming here to share their
testimony.
I also want to say hello to you, Ms. Bryant. Her colleagues
with the IAVA have been to my office several times now and have
helped provide my staff with information on a variety of
veterans' issues and legislation. I am glad you could be here
to share the IAVA's perspective on today's hearing.
Ms. Bryant, based on your testimony, IAVA's Rapid Response
Referral Program does try to address these aspects of caring
for female veterans. Would you please share with us more about
the RRRP and how VA might be able to replicate aspects of the
program to improve the VAL.?
Ms. Bryant. Yes, Congresswoman. First I would like to point
out the director of our RRRP program behind me, Vadim, who is
sitting directly behind. One of the things that we speak about
of RRRP, we specialize again in high tech, high touch. Which
means not only is there the warm handoff to VAL. when there is
a veteran actively in crisis, actively suicidal, but then we
follow up. And that is really the model we would like to see
the VAL. replicate, is the follow up care, to ensure that,
okay, you have made an appointment for a veteran in crisis, but
did they go? Was that effective? We continue to follow up, not
once, but a few times. It just depends on, again, individual
case by case basis. And that is the strength of the RRRP
program, is that it allows for the individualized case
management, depending on what the needs of that veteran are.
And it is not limited in scope to what the VA can provide. It
also is for any other program that is available to veterans
where RRRP can be an advocate for that veteran and allow for
everything ranging from whether it is legal services, to mental
health care, etcetera.
Vis a vis our women veterans, as we know intrinsically as
women veterans, that we do not always receive a welcoming
greeting when we go to the VA and by and large when we call the
VAL. Unfortunately I do not have the data on that so I cannot
speak definitely to that aspect, but I can speak as a woman
veteran of the experience sometimes being cold or dismissive
when women are in crisis. And that is the difference between
what the RRRP program does versus what we are hearing in
negative feedback for the VAL.
I do want to also caveat there is positive feedback. And we
again do not want to see the VAL. fail. We cannot continue to
have the statistic of 20 veterans a day committing suicide.
Thank you.
Mrs. Radewagen. Mr. Young, Ms. Bryant's testimony notes
that we do not know how many women veterans use VAL., nor how
effective VAL. is at providing support for women. Do you have
gender specific caller and outcome data that you can share with
us today? Does VAL. track the gender of all callers? To what
extent are VAL. staff trained to take into account a caller's
gender? And does VAL. have a specific protocol for female
callers? If so, please describe it.
Mr. Young. Thank you, Congresswoman. The first thing I
would like to just add on to the comments that Ms. Bryant just
made and to share that for every intervention that occurs,
every time that we dispatch somebody to intervene in a crisis
situation and deliver them to care, we follow up and ensure
that they did indeed get to a medical center and receive the
care that they were dispatched to do.
As it relates to women veterans and the Veterans Crisis
Line, we do honor any requests from a caller, a woman veteran,
to speak to a woman responder. If we receive such a request, we
will honor it. Similarly, any conversation that go into sexual
trauma, we will ask the caller if they would like to speak to a
person of a specific gender and we will honor that whenever
that occurs.
Mrs. Radewagen. Thank you. Mr. Chairman, I yield back.
The Chairman. I thank the gentle lady for yielding. Ms.
Brownley, you are recognized for five minutes.
Ms. Brownley. Thank you, Mr. Chairman. I thank you and the
Ranking Member for holding this hearing. I think there are
probably a lot over very important Committee hearings that are
going on today. But I think this hearing today is by far and
away the most important that we can have here on Capitol Hill.
And it just, it still affects all of us, I think, very, very
much that indeed I think we are losing more life when our men
and women soldiers return home than their experience on the
battlefield. And we know we train our men and women very well
and prepare them for the battlefield to avoid loss of life. And
we have got to do equally the same in terms of preparing the
men and women in these call centers to address this high level
of suicide. And Captain Bryant, I want to thank you for
bringing up the issues around women and women suicide. And we
know that women, veteran women are six times more likely to
commit suicide than women in, regular women living in our
communities. And so, Mr. Young, I, we passed a bill to say we
need to look at data vis a vis our women veterans and to
bifurcate that data so that we understand what best practices
are in terms of treating our women in relationship to suicide.
Can you share with us where we are with that and how we are
doing?
Mr. Young. Thank you, Congresswoman. The first thing that I
would say, just to go back to the last answer that I gave, is
that we do know that the percentage of callers to the Veterans
Crisis Line that are women is 13 percent of our callers. The
specific question that you are asking, I am going to have to
take that for the record and bring that back to you.
Ms. Brownley. Thank you. I just believe that that is a
problem in and of itself, when you express data that only 13
percent of the women are using the call center. Because I feel
intuitively that there is a reason for that. There are more
that need it but do not. And I think that is, we have got to
really drill down to understand that. And you know, which kind
of makes me want to ask, you know, what are we doing just in
general outreach to veterans early on when they leave service
that they know this service is available to them? And what are
we doing on a sort of an ongoing basis so that we, that men and
women know that this service is available to them? What are we
doing?
Mr. Young. VA has had a pretty aggressive effort at
advertising the suicide prevention hotline, 1-800-273-TALK,
press one, to utilize the National Suicide Prevention Hotline
as a pathway into the Veterans Crisis Line, as well as our
texting, as well as the online chats. And putting the online
chat available right on the Vets.gov page so that it is
available for veterans. We also have research that occurs and
we have a mental health focused research center in the Rocky
Mountains that is focused specifically on suicide. We have a
center of excellence based in New York that looks specifically
at the ideas of how do we convey the availability of these
services. How effective are these communications that we put
out about the availability of suicide prevention services and
the utilization of those services? So there are efforts
underway.
Ms. Brownley. So if a veteran goes to see a doctor for
primary care, does a provider continue to provide that
information to veterans?
Mr. Young. Thank you, Congresswoman, for that reminder.
Because we do have suicide screens, depression screens that are
a routine part of every primary care visit to try to identify
veterans that may be at risk for suicide.
Ms. Brownley. Thank you. And to the IG, if I may, just
very, very briefly because my time is about to run out. But it
seems to me that we need to have better information. It seems
as though we get sort of an annual follow up to how things are
going as opposed to sort of interim reports. Because I think
that we need to be really vigilant about making sure that we
are adhering. I get frustrated because I hear a report from you
and then I hear on the VA's side and they do not seem to add up
all the time. And I certainly would like to know more
information as we move forward about how we are doing on this.
So by the time we end 2017 we know that everything has been
adhered to and instituted. So my time has run out. But if you
could follow up with me on that, I would appreciate it. I yield
back.
Mr. Missal. Sure.
The Chairman. I thank the gentle lady for yielding. General
Bergman, you are recognized for five minutes.
Mr. Bergman. Thank you, Mr. Chairman. Folks, having been
fortunate enough to wear the cloth of our Nation for 40 years,
I am honored to be among you today. And we know that all of us
have had experiences where those we served with chose different
means to end their lives. There is no way to even measure what
an impact that has on the families and on the unit members that
served with these folks. Because you are always wondering,
could you have done something different? Could we have had one
more conversation?
I heard Captain Bryant say, I believe, or someone said
about the goal was all feedback being positive. I would suggest
to you all feedback needs to be relative. Because the one thing
that is common in all these situations is they are all
different. And we hear more than we, when we are not talking.
So anyway, Mr. Missal, your report mentioned that the VAL.
managers were unaware of the performance standards in the
contract. If they were unaware of the standards, how were they
monitoring the contractors' performance?
Mr. Missal. Our report identified that they were not
adequately monitoring the contractors' performance, and we made
a recommendation relative to this finding.
Mr. Bergman. So they were aware but just monitoring of the
standards?
Mr. Missal. They were not totally aware of all the
responsibilities under the contract.
Mr. Bergman. Okay. Mr. Young, I understand that the VA is
working on a new contract to support the VAL. which will
include the OIG's recommendations, correct?
Mr. Young. That is correct, sir.
Mr. Bergman. Okay. How will this contract be different?
Mr. Young. I will go ahead and defer to Matt, who is the
person on the ground working that.
Mr. Eitutis. That is a good question, Congressman. So what
we are working on, we are in current contract negotiations to
make sure that the veteran experience, whether it takes place
in the VCL or one of the backup contract call centers, is a
symmetrical veteran experience. That includes some very core
competencies that we believe that the backup contract call
center should demonstrate proficiency on.
One is the service level and we are asking them to abide by
the same service level that we have implemented inside the
Veterans Crisis Line. There is no standard in regards to the
percentage of calls answered within so many seconds. We have
adopted the National Emergency Number Association's service
level. That is 95 percent of your calls being answered in 20
seconds or better. We are right there, we are just shy of 94
percent. We are expecting our backup contract center to be able
to perform at the same rate.We are also expecting them to adopt
our training that we have for our responders as well as our
SSAs that coordinate our dispatches.
In addition to that, we are asking them to adopt very
similar key performance indicators and quality measures. We
measure 21 different measures on our quality performance
program. We have done over 4,000 of them since VCL came into
Member Services. They include eight very critical elements that
assess suicidal ideation, third party outreach, as well as
assessing past suicide and current issues with the veteran. And
those items are going to be included in the current contract
and we are under negotiations right now.
We are also establishing some separate positions inside my
compliance department to make sure that they are reviewing
routinely the performance of the backup contract call centers
to ensure that the veteran experience is as symmetrical as we
can possibly make it between the backup contract call centers
inside NSPL versus VCL.
Mr. Bergman. Okay. Thank you. I think I heard Mr. Young,
someone mentioned about a call roll rate of one percent?
Mr. Young. Less than one.
Mr. Bergman. Less than one percent. Okay. With a call roll
rate of less than one percent, is there sufficient volume to
warrant this contract?
Mr. Young. We think that it is important that we still have
a means to support us if we should have failures. As an
example, this morning in Canandaigua, New York we had some
problems with the phone lines. Now we were able to roll things
over, able to handle it all within our existing staff. But if
that had been a larger problem, we need the mechanism to be
able to have that backup. So we are working with, as we are
developing the contract our intention is to roll over actually
a few more than we are rolling over right now because we need
them to be able to maintain critical mass to maintain their
competency working with veterans' crisis issues. So right now
we are at 99.84 percent. But we are going to deliberately roll
over a few more than that so that they can maintain that
competency level.
Mr. Bergman. Okay. Thank you. I yield back.
The Chairman. I thank the gentleman for yielding. Ms. Esty,
you are recognized for five minutes.
Ms. Esty. Thank you, Chairman Roe and Ranking Member Walz
for today's incredibly important hearing. And when Secretary
Shulkin was with us a couple of weeks ago he flagged that as
with us this is his highest priority. It is a tragedy for the
country when we lose a man or a women in uniform on the
battlefield. It is a stain on our society when we lose them
when we come home. And I know we are all committed in our
effort to reduce those numbers and do everything we can, and I
want to applaud all of your efforts. But I think we can agree
not good enough. And we need to do better. So I want to thank
you for your efforts in this but recognize we have, we need to
maintain a sense of urgency about doing better for each and
every one, every one of those calls that does not get answered
in time. And my office has had those calls directly to our
office, and then have had to deal with staffers afterwards to
try to deal with talking people back down.
So I wanted to talk a little bit, Mr. Young, that Captain
Bryant talked about and flagged the importance of supporting
the responders. So I want to know what are we doing to better
support those answering these calls, both in terms of their
training, respite? What are we looking to, for example, for
best practices? Are we looking at the national centers? Or how
are we figuring out the right way to support the people on the
front lines taking those calls every day?
Mr. Young. Sure. Thank you. No, you are absolutely right.
This is the most profound and important work imaginable. And
many years ago I was a suicide intervention counselor at a
crisis line. I know on a personal level the impact that it has
working with somebody who may be horribly depressed, actively
suicidal. It takes a toll on the human beings that are doing
this work.
One of the very first things that has been so important for
us to do is to get staffed up so that we have the ability to be
able to pull people off the phone so they can decompress for a
while. We have wellness programs in place at both centers to be
able to support our employees. I would like to defer to Matt to
give a little bit more detail on some of those very specific
things that we are doing to support the employees.
Mr. Eitutis. Thank you. I believe that the photo of one of
our responders in New York, Robert Griffo, who was photographed
in regards to the recipient of the Oscar for the work done at
the Veterans Crisis Line. Robert's dedication is significant.
But what you see in that photograph is the grief and the burden
associated with doing this work. And the first thing that we
owed our Veterans Crisis Line responders that are now up to 523
responders, was in the 200 range a year ago, the first thing
that we owe Robert and his peers, as well as the SSAs, was to
decompress the work load for them. Rolling over 3,000 phone
calls meant that every single time there was a responder
available a call was going to them. And so we owed them making
sure that we could internally take care of all of that volume,
and making sure that we had enough space between calls to allow
some room between calls to allow these responders and SSA to be
able to disenroll from the actual telephone system and walk
away and get the help that they need, or to take some time to
be able to reconstitute in between these phone calls. And so
creating near 100 percent success was the first thing.
The second thing we have done is establish a wellness
coordinator at each campus, both in Atlanta, Georgia and
Canandaigua, New York. The third thing that we are doing is we
are developing a program called Employee Readiness and
Resiliency. Because we believe that an employee when they come
to work, they should have time to be able to get ready to do
this type of work. It should not be to just walk in, sit down,
and start dealing with some of the toughest work that you can
possibly find to do. And so we are implementing that program.
We are also hiring clinicians that will be a part of a
process that will be available internal to our employees at any
given time, 24 hours a day, at both campuses that will support
those employees. But make no mistake whatsoever, these
employees know that when they have a tough call and when they
need a minute to reconstitute or when they need to be debriefed
in regards to some of these tough calls, that is their call.
And they know they have the opportunity to make that decision.
Ms. Esty. Well, thank you. Because I think that is
tremendously important. I will follow up because I see my time
is out. But on the warm handoff, that is what I am hearing a
lot, and that follow up. We want to make sure clinicians are
actually looped back in. So I want to follow up in writing.
Thank you very much for the work you do.
The Chairman. I thank the gentle lady for yielding. Mr.
Poliquin, you are recognized for five minutes.
Mr. Poliquin. Thank you, Mr. Chairman, very much. Thank
you, Mr. Ranking Member. I appreciate all the witnesses for
being here today. This is incredibly important to everybody I
know in this country.
The wonderful thing about these hearings, Mr. Chairman, is
that we are all on the same page. We have folks here who have
fought for our country and given us our liberties, and now they
are at very high risk, a lot of them. And when you see 20
veterans who commit suicide every day, that should be a real
wake up call for us. I do not know what the number is in the
rest of our country among our fellow Americans, but I am sure
it is not as high here.
So my question goes to you, Mr. Missal. Am I pronouncing
your name correct, sir?
Mr. Missal. No, it is actually Missal.
Mr. Poliquin. Missal. Mr. Missal, okay. When, I am reading
your reports here, and when was the first time that you folks
at the--let me back up a little bit. You are the IG at the VA?
Mr. Missal. Yes.
Mr. Poliquin. And you are appointed by the President of the
United States?
Mr. Missal. Correct.
Mr. Poliquin. And you have complete independence at the VA?
Mr. Missal. I am sorry?
Mr. Poliquin. You have complete independence at the VA?
Mr. Missal. We do, yes.
Mr. Poliquin. Right? So you have unfettered access to all
this data, and what have you. Do you have subpoena power?
Mr. Missal. We do have subpoena power for documents.
Mr. Poliquin. Got it. Okay. When is the first time that you
folks found that there were problems with the crisis hotline
over at the VA, roughly?
Mr. Missal. We issued a report in February of 2016 which
identified a number of problems. I started in--
Mr. Poliquin. Okay, and how long did that--
Mr. Missal [continued]. I am sorry?
Mr. Poliquin [continued]. How long had that report gone on?
It was February 2016, but how far back did you--
Mr. Missal. We looked back to 2014 for that.
Mr. Poliquin. Okay. Okay. So roughly you know there have
been problems there for a couple of years, roughly?
Mr. Missal. Correct.
Mr. Poliquin. Okay. And you have 23 recommendations that
were supposed to be fixed last September that have not been
fixed, correct?
Mr. Missal. Seven of the recommendations should have been
fixed, or rather VA said they could fix by September 2016. The
other 16 recommendations are from our report that was just
issued in March--
Mr. Poliquin. In March of this year? Okay. Got it. So my
question to you, Mr. Missal, is that do you think it is
reasonable with 20 veterans per day committing suicide that the
VA has not fixed what they were supposed to fix six months ago?
Mr. Missal. This is why we consider this such an important
program.
Mr. Poliquin. Okay.
Mr. Missal. Why we give it such great attention.
Mr. Poliquin. Okay. Good. It is not money, right? Because
the budget we have talked about here, Mr. Chairman, has gone up
I think threefold in the last ten years, or something to that
effect. Okay. So it is not money. It is something at the VA.
Who is responsible? Who is the head banana there that is
responsible for fixing these problems? Who is that person?
Mr. Missal. I think it ultimately goes up to the Secretary.
Mr. Poliquin. Okay. Okay. And who reporting to the
Secretary is responsible for this problem? This set of
problems?
Mr. Missal. There are a number of people within the VCL,
from the VCL Director all the way to the Secretary.
Mr. Poliquin. Okay. So we can, I have a terrific staff
member in the back room, Dennis Cakert, he can find out through
the Web site or what have you who is specifically responsible
so we can get on the phone with that person, find a way to do
that. I think I have that authority to do that as a Member of
Congress, correct?
Mr. Missal. Sure.
Mr. Poliquin. Okay. Neither of those individuals is here
today, is that correct?
Mr. Missal. I am sorry?
Mr. Poliquin. Are any of those individuals in that line of,
that chain of command here today? In this room?
Mr. Missal. Mr. Eitutis is in that line.
Mr. Poliquin. Great. Why have these problems not been
fixed?
Mr. Eitutis. Sir, we took the original recommendations from
OIG very seriously. When--
Mr. Poliquin. Yeah, I am sure you did. But why have they
not been fixed?
Mr. Eitutis. Well we have been working on them since we
received the first OIG report last winter.
Mr. Poliquin. Mm-hmm.
Mr. Eitutis. And we had submitted, actually of the original
seven recommendations we submitted recommended closures for
those seven recommendations on ten different occasions. In
June, October, and then most recently in March. And so we do
take it seriously. Again--
Mr. Poliquin. Let me, I am reclaiming my time, please, make
sure I understand this. Seven of the 23 were supposed to be
fixed by September. Is that correct, Mr. Missal?
Mr. Missal. That is what they originally said, yes.
Mr. Poliquin. And that is what you said, correct?
Mr. Eitutis. The response from VA was originally that we
would have those closed by September--
Mr. Poliquin. Okay, were you involved in that response?
Mr. Eitutis. No, I was not.
Mr. Poliquin. Okay. But someone above your chain of command
was?
Mr. Eitutis. Somebody different, yes.
Mr. Poliquin. Who was that?
Mr. Eitutis. Dr. David Carroll.
Mr. Poliquin. Okay. How do you spell his last name?
Mr. Eitutis. C-a-r-r-o-l-l.
Mr. Poliquin. Okay. That will be easy to find his number to
give him a call. Do you know why those seven problems have not
been fixed yet?
Mr. Eitutis. Yes, I do. And so for context associated with
what I had mentioned earlier, I believe that the lack of
documentation, the lack of formalized and canonized processes
surrounding responder work, SSA dispatches, and referrals, much
of that was not in documentation. There was not much that was
in documentation.
Mr. Poliquin. Okay, why did you tell us it was going to be
fixed in September?
Mr. Eitutis. Well that is a very good question. And so
taking an organization from having very little being actually
documented and not having canonized curriculum--
Mr. Poliquin. Yet you have 360,000 employees at the VA. How
can you not have documentation?
Mr. Eitutis. Well again, we take this seriously and--
Mr. Poliquin. It does not sound like you take it seriously
enough in my opinion. You know, we are on the same page. We
want to help you--
The Chairman. The gentleman's time has expired.
Mr. Poliquin [continued]. --20 of them are dying per day.
So we want to help you do that. But I am not quite sure I am
very satisfied with these answers, Mr. Chairman.
The Chairman. I thank the gentleman for yielding. Ms. Rice,
you are recognized.
Miss Rice. Thank you, Mr. Chairman. Mr. Young, you had
mentioned before, one of the frustrations I feel, and I am not
speaking for anyone else on the Committee, is that there are
parts of the VA that work really, really well around the
country and could be qualified as best practices. And yet the
VA is not very good at identifying those programs that work and
then implementing them elsewhere. So when you talked about the
center of excellence in New York, can you just expound a little
bit? Can you explain what that is and why you pointed to them
as something that was effective?
Mr. Young. Sure. Thank you, congresswoman. The center of
excellence works around the issue of suicide and they focus on
doing epidemiological studies around suicide. They focus on the
communication and how we are conveying the availability of
suicide prevention services and how effective that
communication is working in relation to getting veterans linked
in to the care that they are needing.
Miss Rice. So they do that analysis based on the program as
it exists now? Or is it just general information about suicide
in general? Are you talking about specifically within the VA?
Mr. Young. Specifically in VA, and specifically with the
Veterans Crisis Line.
Miss Rice. Okay, specifically with that. Were they asked to
do that or did they take that upon themselves, the center?
Mr. Young. You know, that actually predates my coming onto
the scene in this position. So I do not know its history in
terms of how it was established, when it was established. I
just simply know what they are doing now.
Miss Rice. And what they are doing you think is good. And
how does that get exported to other, to the VCLs?
Mr. Young. Well the center of excellence works in
partnership with the Veterans Crisis Line in evaluating the
work that they do and--
Miss Rice. But how are their recommendations implemented?
And are they? I mean, you have an IG who has done a report that
says these 23 things should be done and the VA has not gotten
around to most of them. So when you say the center of
excellence is going a really great job, how is that measurable?
Mr. Young. I think that some of the things that we can turn
to talk about the effectiveness of the Veterans Crisis Line, we
talk about, A, the number of calls that we are receiving, you
know, over 2,000 a day, 189 texts, 79 chats. But more
importantly 371 times, just yesterday, 371 times yesterday,
that the Veterans Crisis Line referred veterans to suicide
prevention coordinators. We have over 400 suicide prevent
coordinators spread throughout the Nation and 371 times
yesterday we referred veterans to them for care and then those
suicide prevention coordinators link up with the veterans and
ensure that they are getting in and receiving the care that
they need.
Miss Rice. So is that the kind of follow up that Ms. Bryant
mentioned about within the, is there that kind of follow up?
Mr. Young. It is part of the follow up that Ms. Bryant
referenced. But in addition to what Ms. Bryant referenced,
whenever we dispatch anybody out to do a rescue, if you will,
yesterday we had 63 times that we dispatched people to rescue
or to intervene in a veteran that was either suicidal or
actively in a state of crisis, where they were needing care. We
follow up on every single one of those and make certain that
they have gotten in and gotten the care that they need.
Miss Rice. When you talked before about having three
resumes of people for the position to head up the VAL., is that
right?
Mr. Young. Say again, please?
Miss Rice. The resumes that you were talking about that you
found to be insufficient for the position of running the VAL.,
right?
Mr. Young. Correct.
Miss Rice. What, I mean, so it is not a, it is not as if
you are not getting resumes. What qualities are you looking for
in hiring this person? And is there anything that we can do,
clearly it is not a money issue, I do not think. It is not an
applicant issue. You are getting applicants. What are you
looking for?
Mr. Young. We had, when we stood up the Atlanta call
center, had over 1,000 applicants of those responder positions.
Among our responders, we have 99 that have bachelor's degrees,
377 with master's degrees, and 14 with Ph.Ds. These are really
highly qualified individuals. Our current leadership, the
acting leadership in the Veterans Crisis Line, has a Ph.D. We
have 140 years collectively of mental health experience among
the leadership in the Veterans Crisis Line. So I am hopeful
that this next round, as we are advertising and looking for a
new leader for the Veterans Crisis Line, that we are going to
have success in getting a highly qualified individual to come
in and be able to lead those already very well qualified and
high level responders.
Miss Rice. It seems to me that that should just be priority
number one.
Mr. Young. Absolutely.
Miss Rice. Given the need for it. Thank you. I yield back.
The Chairman. I thank the gentle lady for yielding back.
Let us see, next is Miss Gonzalez, you are recognized for five
minutes.
Miss Gonzalez-Colon. Thank you, Mr. Chairman. And I want to
thank you, you and the Ranking Member, for having this
Committee hearing. And I think this is very important. And I
just have a task force with veterans organizations in San Juan
last Sunday. And this was one of the main issues they were
asking for. So most of the questions have been answered, so I
do not want to be repetitive. But I want to say that Chairman
Roe has emphasized the need to provide the best health care
services to the heroes of our Nation. In San Juan we have got
over 93,000 veterans that do not receive the same benefits as
those that live in the mainland. So my question would be, one,
if we got enough data to identify the sex, the state,
territory, or statistics about age or one of the mechanisms to
those people who call to the Veterans Line, Mr. Young?
Mr. Young. Thank you, Congresswoman. I do not have that
information here with me today. I can take that for the record
and bring it back to you.
Miss Gonzalez-Colon. But it is available?
Mr. Young. We certainly have information available on the
phone numbers that the phone calls come from.
Miss Gonzalez-Colon. Area code, yes.
Mr. Young. Although with cell phones today, who knows. My
cell phone is Tampa, Florida, you know, but that is not where I
live. So it is not always an absolute where the person is
calling from.
Miss Gonzalez-Colon. Besides the area code, do we have what
sex they are or age of those callers?
Mr. Eitutis. Yes. We use a customer relationship management
software that is currently being replaced with an even more
advanced version of CRM and that is going to allow us to be
able to build a number of different areas and sub-areas for us
to be able to collect a lot of data that we can then reflect
on, do the analysis, and make some additional programmatic
changes based on the epidemiology associated with the analysis
and partnering with the centers of excellence that Mr. Young
referred to as well as with the Office of Suicide Prevention's
expert, as well as Office of Mental Health Operations.
Miss Gonzalez-Colon. Can you provide the Committee or at
least this Congresswoman the data regarding those calls from
the last report?
Mr. Eitutis. Yes, we will take that.
Miss Gonzalez-Colon. Thank you. I do not know if you are
aware that a group of 86 congressmen and congresswomen just
sent a letter to the Secretary. I am included in those Members.
We are very upset and aware of the situation. Do you already
correct or establish text monitoring to the system of text
calls?
Mr. Young. Thank you, Congresswoman. Yes, we do accept
texts. As a matter of fact just yesterday 79 texts that we
dealt with yesterday. But since the advent of the texting
option, which was in November of 2011, we have had over 62,000
texts that we have responded to.
Miss Gonzalez-Colon. But do we already correct the issue
regarding who is making the monitoring or the testing of the
timelines of the answering of those texts? Or no?
Mr. Young. I am sorry, can you--
Miss Gonzalez-Colon. Do we already have tests about the
timelines of the answering of those texts? Or no?
Mr. Young [continued]. Yes.
Miss Gonzalez-Colon. Because the last report just said that
14 texts were unanswered by the VA.
Mr. Young. So we have processes in place to respond to, to
all of the phone calls, the texts, the online chats in a timely
manner. I will defer to Matt to talk details on that.
Mr. Eitutis. We do have that data and we test that system
in regards to making sure that texts and chat are properly
working. We do the same thing with option seven that we rolled
out in 2016, where we added the option that has the language on
every single major medical center in the country. We added the
language if you are having thoughts of suicide, press seven.
That work comes to us. We even test that as well. And so we
test all of our modalities to make sure that they are up and
running. I would be glad to provide that--
Miss Gonzalez-Colon. Question, do we have just two call
centers? Or do we have more than that?
Mr. Eitutis. We have two main call centers, on in Atlanta,
Georgia and one in Canandaigua. And then our current backup
contract call center with NSPL is out of Portland, Oregon.
Miss Gonzalez-Colon. Okay. Thank you. Thank you, Mr.
Chairman. I yield back.
The Chairman. I thank the gentle lady. Mr. Peters, you are
recognized.
Mr. Peters. Thank you, Mr. Chairman. And thanks to everyone
for being here. And I do want to just echo that we really, we
appreciate your sense of urgency about this. We think this is
of the highest priority and so appreciate your spending some
time with us. And I had some specific questions about the
backup call center contracts because it looked from the GAO and
IG reports that there are some things missing.
I want to call your attention to a program we have in San
Diego. The county government and other entities have been using
211 services. You just dial 211 on your phone and it is a
clearinghouse for benefits, emergency services, social
services. One of the programs coincidentally, it is not a VA
program, it is called Courage to Call, which often receives
calls from veterans or servicemembers in crisis and sometimes
they refer to the VA. Now the county ties its payments directly
to wait times. And I do not know if you have any objective, so
if each call is not picked up by a live person within 30
seconds the payment is diminished automatically. And there is a
referral for each call, a warm hand off we have been talking
about, to another live person at an agency where the
professionals have been vetted for things like customer service
and cultural sensitivity. So Mr. Eitutis--is that?
Mr. Eitutis. Eitutis.
Mr. Peters. Eitutis, backwards. Eitutis. You had talked
about, you had given some pretty encouraging metrics about the
background call centers. But I was not clear about how you
enforce those.
Mr. Eitutis. Well we are developing a table of penalties
right now through our contract negotiations with the contractor
that oversees that National Suicide Prevention Lifeline. And so
the table of penalties that were previously nonexistent in
previous versions of the contract, we are going through that
right now.
Mr. Peters. And I would maybe, do you think something like
a, you know, a failure to answer within a certain time might be
automatically tied to payments as part of the contract?
Mr. Eitutis. Well we believe that they should be able to
establish based on the way that we design the contract, that
they should establish the same service level that we have
implemented inside our organization with a minor exception. And
that is if and when we have a catastrophic situation where we
cannot get to all of our phone calls, if any of them, that
would be a different set of circumstances. However, the actual
experience for the veteran when they contact the backup call
center versus us should be symmetrical.
Mr. Peters. So I would just say, I would suggest to you
then on an quantitative measures, like the amount of time on
the phone waiting, it is great to think about tying that
directly to performance so you do not have to go through the
appeals process and charge them with a penalty. And I just
commend that process to you for the objective side. On the non-
objective side, you know, there are issues about how to measure
the quality of the experience and I think that is more
difficult. But a lot of that has to do with training. And in
the report there is a lot of suggestion that there is a lack of
training for even the VA staff and superiors, supervisors. So
we know the people answering the calls, they have very
stressful jobs. The call center requires particular kinds of
skills. How do you, what do you want to do to ensure a healthy
work environment and retention in order to provide veterans the
best service both inside and then in the contract services as
well?
Mr. Young. Sure. Thank you, Congressman. The first thing
that I would say is that our turnover rate is less than four
percent right now at both of the call centers. It is slightly
less in Atlanta than it is in Canandaigua. But we have got by
way of comparison to the rest of government we have a very
attractive turnover rate right now for employees. I will defer
to Matt on the details for the rest.
Mr. Eitutis. So anytime we have the opportunity to hire a
supervisor or a senior official inside the Veterans Crisis Line
we try to take advantage of the talent that we actually have
and the experience that we have inside the Veterans Crisis
Line. One example of that Julianne Melane, who has been with
the Veterans Crisis Line for years, who is now one of our
senior deputies at the Canandaigua, New York campus who has
taken tens of thousands of these phone calls as a responder.
And so she understands what the process is. She understands
what that veteran experience should consist of in regards to
the 13 non-critical elements in our quality assurance program,
our eight critical elements. And those will be symmetrical in
the contract associated with the veteran experience when it
comes to backup support.
Mr. Peters. Yes, and I just want to, I mean, again. I think
that is terrific. I am sure you have great employees, many of
whom get it. It is just a question when you contract this stuff
out, how do you enforce it? And maybe we could follow up and
hear some more ideas. How you enforce the qualitative aspects
of that is not clear to me.
Mr. Eitutis. Sure. So the other thing we are doing is we
are setting aside several positions inside my internal controls
and compliance department that will do nothing but dedicated
work towards making sure that the backup contract call center
is actually doing what they are supposed to be doing based on
the new contract that is going to be place by the 1st of July.
Mr. Peters. Okay. Well thank you. My time is expired. And
but I do appreciate your attention to that and look forward to
working with you. Thank you, Mr. Chairman. I yield back.
The Chairman. I thank the gentleman for yielding. Mr.
Higgins, you are recognized.
Mr. Higgins. Thank you, Mr. Chairman. I think it should be
noted that prior to 2007 when VAL. was initiated, veterans had
a crisis hotline. It was each other. We called each other. And
it is startling to me that since the government got involved it
seems like the suicide rates have increased.
Mr. Young, who is responsible for hiring at VAL.?
Mr. Young. The individual responsible for hiring at the
VCL. would be Mr. Eitutis as the Director of Member Services,
and then we have an acting Director of the Veterans Crisis Line
itself.
Mr. Higgins. Okay. Are you aware of how many veterans live
in the United States? How many living veterans we have in the
United States of America? It is 22 million.
Mr. Young. I was going to say, I know the number but--
Mr. Higgins. According to the numbers that I am reading, of
594 employees, 23 percent are veterans. So is this Committee to
understand that out of 22 million veterans across the country,
137 are available that have the skills described as to hold a
degree in a field relating to social science with a focus on
social work and mental health counseling? Is this the best that
we can do for our veterans, that out of 22 million from sea to
shining sea, 137 of them are available to answer the phone on a
crisis hotline?
Mr. Eitutis. No, sir. That is not the best we can do. What
I would tell you is that we actually exceed 40 percent of our
staff as being veterans. We hired as many as we possibly could.
We exhausted every veteran certificate that we had in Atlanta,
Georgia when we hired those positions. The other thing I would
tell you is that we are in cooperation with the Office of
Mental Health Operations to establish a next generation of VCL.
in regards to outreach that will include peer support
specialists that would have background and experience with
mental health and substance abuse and those types of issues, as
well as being a veteran. And so we agree with you, Congressman,
that that is something that needs to be part of the portfolio
of the Veterans Crisis Line.
Mr. Higgins. One would hope so. Are the veterans service
organizations counseled regarding hiring? There are many VSOs
across the country that are dedicated veterans themselves that
generally work for free in service of their fellow veterans
across the country, male and female. Does the VAL. hiring
process consult with VSOs in order to seek veterans that carry
the qualifications that can fill these roles?
Mr. Eitutis. That is an area that we can work more closely
with them on.
Mr. Higgins. Ms. Keleher, did I pronounce your name right,
ma'am?
Ms. Keleher. Yes, sir.
Mr. Higgins. Thank you. Ms. Keleher, as a representative of
the VFW, in your opinion, in your humble opinion, ma'am, would
the VAL. be best able to address some of these problems that we
are discussing today by filling the ranks with veterans
themselves whereby when a veteran does call seeking help they
are talking to a fellow veteran?
Ms. Keleher. Sir, in my opinion and the VFW we have always
supported peer to peer support and the expansion of it. VA has
had great successes with it. Veterans who do use VA have
responded with much positive feedback. The VFW has been
advocating for more expansion of that, and increasing the
employees at VAL who are veterans would, in my opinion, be a
great benefit. But at the same time I do not think we can ask
VAL. to strictly hire based off of veteran status. They need to
look at the most qualified candidates and make sure that they
are training the best while expanding peer to peer. Twenty-two
million veterans is a lot and I think in a dream world we would
be able to have that many filling the rolls at VAL. But we
cannot guarantee every veteran in Canandaigua and Atlanta want
that position. So, as long as VAL, is continuing to hire
effectively with a focus on veterans, and VA continues focusing
on peer to peer, other VSOs, and I know VFW, have been
partnering with VA. We have our Mental Wellness Campaign. So we
partnered with VA on suicide prevention and expanding and
making sure that veterans know the signs of distress and then
making sure VA has the resources available to provide to those
veterans.
Mr. Higgins. Thank you for that answer, ma'am. That was a
very thorough response. Mr. Chairman, I yield back.
The Chairman. I thank the gentleman for yielding. Mr.
Sablan, you are recognized for five minutes.
Mr. Sablan. Thank you very much, Mr. Chairman. Welcome,
everyone. I truly apologize for not being here earlier. I have
four things going on at the same time. But one, let me extend
this welcome. But Ms. Keleher, I want to let you know that
members of your organization in the Northern Marianas, I am
from the Northern Marianas. They are some of my people I turn
to on many issues of veterans. They are very helpful and I
appreciate them.
Mr. Young, or Mr. Matthew, I come from a place, sir, where
today we have been a part of the United States since 1978. But
today someone would go to a post office in some rural place and
try to mail something to my island, my district, and they would
be told that it is international. Or there is no post office
there. Or that the U.S. does not, it is not part of the United
States. Sometimes people, telephone companies make mistakes,
and the area code is 670. That happens to be the country code
also for East Timor so they get charged.
So we are far out. And when you talk about territories,
people hear about Puerto Rico and Guam. We tested the hotline.
We have tested the texts. It works. Now let me ask you, if a
veteran would go to that hotline, place a call, how would you
find someone there that would be able to provide immediate
attention to a veteran who may be considering, who may be in a
difficult situation and may be considering harming himself. And
I am talking about three separate islands here now.
Mr. Young. Thank you, Congressman. I think that is one of
our more challenging areas.
Mr. Sablan. Yes, sir.
Mr. Young. We do have suicide prevention coordinators
around America, including a suicide prevention coordinator in
the Pacific Islands Healthcare System, that is able to engage
by phone and to stay in contact with veterans that may be at
risk. The suicide prevention coordinators, especially in areas
like you are describing, and it is elsewhere in America, too.
It is in some of our more rural areas as well. Where they have
a responsibility to know of the resources that are available
locally and be able to refer people appropriately for those
resources. And so that is how we would approach it in that
instance.
Mr. Sablan. So the Crisis Line, if I was placing a call,
the Crisis Line would be able to find someone for me to talk to
if I was in a precarious situation?
Mr. Young. The Crisis Line regularly refers veterans out to
our suicide prevention coordinators around America and so in
this instance they would, if there was an individual that they
felt was at risk in your district, they would refer to the
Pacific Islands suicide prevention coordinator, and then that
person--
Mr. Sablan. Where is that?
Mr. Young. That is in Hawaii. Which obviously is a long
ways away. But it is in the, it is the same circumstance that
we have, as I said, in other parts of the Nation in terms of
being familiar with local resources and being able to connect
those veterans using telehealth technologies and other
mechanisms to stay connected with them. So it is less than
ideal but it is a mechanism--
Mr. Sablan. It is very wanting. It is not, less than ideal
is a perspective. I understand that we are so removed and but I
appreciate what you guys do. I am, hopefully we could work
something together where there is a more personal response. You
know, I mean, if I am thinking of trying to end my life it is a
serious situation. And but thank you very much for what you
guys do. And again, to the Veterans of Foreign Wars, please
know my gratitude for your members. Thank you, Mr. Chairman. I
yield back.
The Chairman. I thank the gentleman for yielding. Dr.
Wenstrup, you are recognized.
Mr. Wenstrup. Thank you, Mr. Chairman. I thank you all for
being here today and addressing this very challenging
situation. And I am going to address this to you, Mr. Young.
You know, I know that to the caller every call is a, situation
is a crisis to them. I am curious if there is tracking of the
numbers of types of calls that you are getting. For example,
non-crisis type calls, whether they are harassment calls, or
true crises. That, like I said, it is probably a crisis to
whoever is calling. But do you categorize them? That is one of
my questions. And I mean, do we define crisis for our veterans?
Do they understand what crisis means? Are we defining it for
them? Because or do we need a helpline, for example? I mean,
our offices are helplines, believe me. We get the harassment
calls. We get people that are in need of help and guidance and
direction. And that may be something that we need to expand on.
Are we triaging the types of calls that we are getting? I guess
my question is are we really achieving the intent of the
hotline vis-a-vis crisis, if you will?
Mr. Young. Thank you, Congressman. I think that the very
fact that we have just since January done 4,600 interventions
where we have dispatched people out to rescue, if you will,
that is probably not the right term, but to intervene in
individuals that are experiencing a crisis to such a degree
that the responder thought it necessary to engage local
responders, local EMS, to reach out to that veteran and bring
them into health care. 4,600 times just since the beginning of
this calendar year. I think that that says something very
serious about the seriousness of the calls that we receive.
In addition to that over 25,000 times since the beginning
of the year we have referred out to suicide prevention
coordinators out across the country. Again, speaking to the
seriousness of the calls that are coming in. Do we get some
calls that are people harassing? Yeah. Do we get some that they
are asking for information? Yeah. But the majority of the calls
are those very serious, profound, important work that happens
every day.
Mr. Wenstrup. So it is not an overwhelming amount of having
to really readdress where they need to be calling?
Mr. Young. I would agree with the VFW's comments earlier,
that we do need to redirect people to our patient advocates and
be able to work with that mechanism that is already in place to
try to reduce those calls that are really unnecessary to go to
a crisis line so that we are able to focus on true crises.
Mr. Wenstrup. Okay. I appreciate that. Thanks for the
feedback and I yield back.
The Chairman. I thank the gentleman for yielding. Mr.
Young, thank you. You have been very patient. You are now
recognized for five minutes.
Mr. Young of Iowa. Thank you, Mr. Chairman and Ranking
Member Walz, and my colleagues, and Members of the panel here
today. Thank you for your commitment to our veterans.
Under Secretary Young, the Veterans Crisis Line Handbook,
what is the status of that?
Mr. Young. If you are referring to the directive on the
Veterans Crisis Line, it is in draft. It is going through
concurrence.
Mr. Young of Iowa. How long has it been being worked on?
Mr. Young. We have, well I have been in the job three
months. It has been in the works since I have been officially
in the job, I know that much.
Mr. Young of Iowa. Are you working with veterans service
organizations on that? I mean, are you opening up that process
and taking input from other, from veterans groups out there
regarding this? And maybe the American Association of
Suicidology, and those kind of folks?
Mr. Young. Well we certainly work with in the Veterans
Crisis Line, which is accredited by the American Association of
Suicidology, and work to be in compliance with their standards.
So our directive absolutely will be in alignment with the
requirements to be accredited by an outside entity.
Mr. Young of Iowa. When were you accredited by the AAS?
Mr. Young. I am going to defer to Matt on that. That was
before my time.
Mr. Eitutis. I believe that was in 2012, was the last date
of our accreditation. It goes for five years. We are in--
Mr. Young of Iowa. It goes for five years. Okay. So you are
up here this year?
Mr. Eitutis [continued]. This--
Mr. Young of Iowa. Okay. So it is not a one-time process.
It is once every five years. Do they accredit the whole
program? Do they go and accredit the call, do they visit the
call centers, backup call centers? How is the accreditation
done?
Mr. Eitutis [continued]. So individual call centers are
accredited. So inside the National Suicide Prevention Lifeline
what I have learned from our partnership with NSPL is that
individual call centers can be accredited I think through seven
different bodies of accreditation. We have chosen to remain
with the American Association of Suicidology.
Mr. Young of Iowa. I want to talk about silent monitoring.
And you are increasing the frequency of that use?
Mr. Eitutis. Well going back a year there was no silent
monitoring, there was no quality assurance program.
Mr. Young of Iowa. What percentage of the calls now do you
think are monitored silently?
Mr. Eitutis. I can get you the percentage on that. But what
I will tell you is in a year we have reviewed 4,178 calls.
Mr. Young of Iowa. What are you doing with the information
and do you find it effective?
Mr. Eitutis. We find it very effective. In fact, there is
not a better way for us to be able to determine the success of
a phone call in regards to establishing both non-critical and
critical elements inside that veteran experience.
Mr. Young of Iowa. Thank you. Ms. Bryant, you have strong
feelings about organizational structure and making sure that
clinicians need to be a stronger role there. How can they work
together? How do you envision that?
Ms. Bryant. Well we envision the clinicians being at the,
first of all, a part of the leadership team and it should be an
operations management and a clinical lead that work in tandem
to establish protocols. And we would love to provide feedback
if asked by the VA in order to demonstrate how we think that
those best practices could be employed.
Mr. Young of Iowa. You said if asked by the VA?
Ms. Bryant. Well--
Mr. Young of Iowa. I hope the VA will ask.
Ms. Bryant [continued]. We do regularly consult with and
they do call us for our best practices.
Mr. Young of Iowa. Good. Good.
Ms. Bryant. And so we are in close conversation with the
VA. We could do more. And so we are happy to offer our services
in doing that and in helping to provide that evaluation. But
again, we strongly believe that there is a robust way in which
you can silently monitor calls, in which you could review
calls, but then also manage the quality management and the
clinical review as a part of that expansion of the current
protocol. It simply just does not go far enough. And so what we
envision is more of that clinical lead and that clinical aspect
that individualized care being established into best practices
that would need to go into that handbook.
Mr. Young of Iowa. You mentioned something in your
testimony that struck me. You mentioned compassion fatigue.
Those, the veterans would call, those on the other line, the
stories they hear. Tell me about compassion fatigue and is it
real? And then how do you deal with that? How would the VA, the
VAL. deal with that?
Mr. Young. I am going to go ahead and defer to Matt for
that.
Mr. Eitutis. Again, that compassion fatigue, one of the
first things we knew we needed to do was to establish the
access. That simply meant hiring more qualified responders and
SSAs. We have got an SSA, which is one of our employees that is
the specialty inside the Veterans Crisis Line that is
responsible for coordinating emergency dispatches for
intervention for those veterans that are at the highest risk of
suicide, to include having a plan and ready to carry that plan
out. And so one of the first things that we knew that we needed
to do was to establish the capacity to be able to defuse the
amount of the workload. And so as I mentioned earlier to the
previous Congressman in that discussion, we addressed that. We
are now at near 100 percent access and establishing that
employee readiness and resilience program is important. Adding
those additional clinicians inside the organization so that we
have those on board 24/7, 365. And again, make no mistake. Any
employee involved in Veterans Crisis Line experiences they have
the option, and they are in charge, of making sure that they
take the time out in addition to the resources that exist
inside VCL. And so they have got the opportunity to do that
anytime they want.
Mr. Young of Iowa. Mr. Chairman, my time is up. But I beg
for maybe another minute or two.
The Chairman. That will be all right.
Mr. Young of Iowa. Thank you. Thank you. Ms. Bryant, you
talked about the importance of data and how can it help
decrease in the end veteran suicides by driving, looking at
that data, then driving it backwards to its impetus?
Ms. Bryant. Right. Well we believe that the Veterans Crisis
Line should fall under the purview of the Clay Hunt SAV Act as
well as the Female Veterans Suicide Prevention Act. We ask for
data reporting mechanisms just for that very reason,
Congressman. To allow for us to utilize that data and figure
out what we call in the Army TTPs, our techniques, tactics, and
procedures, that are our best practices for evaluating calls,
for providing the highest standard of care. But we need the
data to see that.
I mentioned women veterans. I mentioned the fact that while
13 percent of your calls may be from women, that is all we
know. We do not know anything beyond that and we certainly do
not know an evaluation of those women veterans, of their
experience during those calls. We would like to see that data
recorded.
Mr. Young of Iowa. Under Secretary Young, I hope that you
hear her and the others who are calling for some great data
mining on this. Ms. Keleher, how is the VA doing with the VAL.
in your assessment of connecting veterans with these emotional
war wounds, these battle scars, to the local level where they
can get some real help right at home?
Ms. Keleher. VFW believes that overall VAL. has done great
with improving, particularly after the report last year. And
since the launching of the ATLVCL, the Atlanta one. And the
resources, we firmly believe that the majority of responders do
know. But unfortunately if even one does not know the resources
available locally or the proper protocol, just like anything,
it brings the whole thing down. You are only as strong as your
weakest link.
So we do believe that with the monitoring capabilities that
they do have now that that will help, you know, hold those
individuals more accountable as well as show just how many
people are not aware fully of the local resources. But we do
believe that they are overall doing much better and improving.
Mr. Young of Iowa. Just a final question. Ms. Bryant, you
mentioned in your testimony about the invisible wounds of war
and these emotional battle scars. It is one thing when the
military leaves the Department of Defense and leaves their
service, and they are told about their benefits and services
available to them, and presumably the Veterans Crisis Line that
could be available to them. I am wondering if going back even
further than that upon leaving the Department of Defense, is
there any kind of emotional or mental review or debriefing or
checkup that the Department of Defense gives those who are
leaving? And if not, should there be?
Ms. Bryant. Thank you, Congressman, for that question. It
is definitely something that can be improved upon. A lot of the
time when we talk about veterans issues as a whole, we
recognize that things should happen ``left of the bang.''
Things should happen while you are still in uniform,
transitioning from DoD, or under the purview of DoD. And you
have that continuity of care as you move forward to the VA. You
have Military OneSource, you have other mental health services
that are provided while you are still in uniform and that is
usually reported through reporting procedures through your
chain and command and sometimes you do not even have to go
through them to dial Military OneSource. So that would be what
I understand the DoD's answer to giving that veteran care. But
then you also have the transition and you have the evaluation
that you go through at the time when you first separate from
the military.
I can speak to my own experiences when I separated from the
military to where I went through my physical evaluation at the
VA. Yes, there was a screening for mental health but this was
also 2009 when I separated and I will say that it was nowhere
near what is probably provided today and it was probably
insufficient for what I received when I separated from military
service. I would love to see a robust battle handoff from
uniform to when you come home.
Mr. Young of Iowa. Well, thank you for that. And I want to
thank all of you for coming here today and your love and care
for our veterans, and your wanting to make the VAL. strong. And
I want to thank our Chairman and Ranking Member for allowing me
to be here today and your pressing on this issue to make sure
we get it right, all of us.
The Chairman. Thank you. We now know what an Iowa minute
is, don't we?
Mr. Walz. I spent a lifetime in Iowa one day.
Mr. Young of Iowa. Come on back.
The Chairman. Thank you, Mr. Young. And thank you all of
you all for being here today. I think you can see by the
participation in today's hearing how important it is to this
Committee that this work and work right. I mean, you would not
have seen this kind of questioning and Members who were on a
lot of different Committees taking time to be here. And I guess
the final thing I would like to do is just to yield to Mr. Walz
and see if he has any closing comments.
Mr. Walz. Yeah, just a moment. I would thank the Chairman
on behalf of all of us. Mr. Young, thank you. You are carrying
on a legacy that did begin with Mr. Boswell and I am
appreciative. All of you, thank you. I am incredibly hopeful.
And Mr. Eitutis, your professionalism and passion gives me
great reason to be hopeful. I appreciate that.
I would just close with those two most important groups
that we are talking about here. To any of those veterans in
crisis listening, this Nation loves you. We are here to help.
There is a better day. Make that call. Talk to the family. Do
what needs to be done. Because all of us want to get that
right. To those employees out there picking up the phone, the
same thing. I do not want them to take anything away from this
other than we are eternally grateful for them. We need to give
them the training, the tools, everything necessary, and the
leadership for them to do what they are doing, and that is
saving lives. So thank you for that and I appreciate the time.
I yield back.
The Chairman. I thank the gentleman for yielding. And once
again, the folks out there in the trenches are the ones that
our hats are off to, that are answering the phone right now as
we speak. While we are talking, they actually are intervening
with somebody, who perhaps is saving a life. And I want to
thank them for that. We want to be sure that they have the
resources they need to do their job.
And I guess one of the final things I want to leave on the
table is a year ago, over a year, about a year ago we were told
that VA was going to have all these manuals and have all these
recommendations carried out and nothing happened. And nothing
happened adversely to anybody. So what I would want to see you
do is are we going to have that policy manual by the end of the
year so people will know? That is very important for people to
have that come on the job, to know what are my
responsibilities? What kind of resources do we need for this
job? And I think we need to know that. And if the IG report and
the GAO report and since you agreed to it and do not carry it
out, then something ought to happen to somebody if again
nothing happens.
So I hope by the end of this year we can have a follow up
that says this has been done and somebody has been held
responsible for getting this done. It does sound like things
are improving. But remember, 500,000, all those numbers are
just numbers. It is an individual that really matters. That one
person that picks up the phone call, the phone at 10:00
tonight, desperate. And make sure that we have a human being on
the other end who is empathetic to their problem and can get
their needs met. That is the whole purpose of this meeting.
I ask unanimous consent that all Members be given five
legislative days to revise and extend their remarks. And
without objection, so ordered. This hearing is adjourned.
[Whereupon, at 12:04 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Michael J. Missal
Mr. Chairman, Ranking Member Walz, and Members of the Committee,
thank you for the opportunity to discuss the Office of Inspector
General's (OIG) recent work on the operations of the Department of
Veterans Affairs' (VA) Veterans Crisis Line (VCL). My statement will
discuss two OIG reports, one from March 2017, Healthcare Inspection -
Evaluation of the Veterans Health Administration Veterans Crisis Line,
and one from February 2016, Healthcare Inspection - Veterans Crisis
Line Caller Response and Quality Assurance Concerns, Canandaigua, New
York.
BACKGROUND
The tragedy of veteran suicide is one of the Veterans Health
Administration's (VHA) most significant issues. The rate of suicide
among veterans is significantly higher than the rate of suicide among
U.S. civilian adults. VA's most recent estimate calculates that 20
veterans commit suicide a day. Of those veterans, approximately 14 have
not been seen in VHA.
In 2007, VHA established a telephone suicide crisis hotline located
at the Canandaigua, New York, VA campus. Initially called the National
Veterans Suicide Prevention Hotline, its name changed to the VCL in
2011. \1\ VHA established the VCL through an agreement with the U.S.
Department of Health and Human Services' Substance Abuse and Mental
Health Services Administration (SAMHSA). This agreement provided for
VHA's use of the already existing National Suicide Prevention Line
(NSPL) toll-free number for crisis calls. \2\ The VCL was managed by
the VHA Office of Mental Health Operations at the time of the February
2016 OIG report. Subsequently the VCL was realigned under VHA Member
Services (Member Services), an organization within the Chief Business
Office that runs customer call centers for VHA. \3\
---------------------------------------------------------------------------
\1\ Veterans Crisis Line 1-800-273-8255 Press 1, https://
www.veteranscrisisline.net/About/AboutVeteransCrisisLine.aspx. Accessed
December 4, 2016.
\2\ The toll-free number is (800) 273-8255.
\3\ VHA Member Services Member Services is an operation and support
office within the Chief Business Office and has two main "front-end"
elements of interaction with VA's health care enrollee population,
providing oversight, review, and direct service in the following areas:
Eligibility and Enrollment Determination and Contact Management.
---------------------------------------------------------------------------
The VCL is part of an overall strategy to reach out to veterans in
a time of crisis with the goal of reduction of veteran suicide. \4\ The
VCL's primary mission is ``to provide 24/7, world class, suicide
prevention and crisis intervention services to veterans, service
members, and their family members.'' \5\ Since its launch in 2007, VCL
staff have answered nearly 2.8 million calls and initiated the dispatch
of emergency services to callers in crisis over 74,000 times. \6\
Currently, the VCL responds to over 500,000 calls per year, along with
thousands of electronic chats and text messages. The VCL initiates
rescue processes for callers judged at immediate risk of self-harm. The
number of calls to the VCL has increased markedly since the VCL's first
full year of operation in 2007, with a corresponding increase in VCL
annual funding. The total number of calls answered by the VCL and
backup centers was 9,379 in 2007 and grew to 510,173 in fiscal year
(FY) 2016. In FY 2010, the VCL was funded at $9.4 million, increasing
to $31.1 million in FY 2016.
---------------------------------------------------------------------------
\4\ https://www.va.gov/opa/publications/factsheets/Suicide--
Prevention--FactSheet--New--VA--Stats--070616--1400.pdf
\5\ VCL Mission Statement.
\6\ https://www.veteranscrisisline.net/About/
AboutVeteransCrisisLine.aspx. Accessed on March 27, 2017.
---------------------------------------------------------------------------
A component of the VCL's long-term continuing operations plan was
to expand beyond the Canandaigua Call Center to a second site, to
ensure geographic redundancy and meet increasing VCL demands. The VCL
and VHA Member Services leadership determined that the Canandaigua Call
Center location did not have the necessary space or applicant pool to
allow for the needed future growth. An expansion site was chosen in
Atlanta, Georgia, because Member Services had a preexisting call center
infrastructure at its Atlanta-based Health Eligibility Center (HEC).
\7\ Planning began in July 2016 with a phased rollout of responding to
calls starting in October 2016 and continuing over the next two months.
---------------------------------------------------------------------------
\7\ The HEC provides information and customer service on key
veteran issues such as benefits, eligibility, billing, and pharmacy.
https://www.va.gov/CBO/memberservices.asp. Accessed December 1, 2016.
---------------------------------------------------------------------------
In our February 2016 VCL report, we identified several problems
including crisis calls going to voicemail, a lack of a published VHA
directive to guide organizational structure, quality assurance gaps,
and contract problems. The February 2016 report resulted in seven
recommendations and VHA concurred with the findings and
recommendations. VHA provided an action plan and timeframe to implement
those recommendations by September 30, 2016.
INSPECTION OF VETERANS HEALTH ADMINISTRATION VETERANS CRISIS LINE
In June 2016, we received an allegation related to the experience
of a veteran with the VCL and its backup call centers. As a result of
the complaint, and in light of the open recommendations from the OIG's
February 2016 report, we expanded our scope to conduct an in-depth
inspection of the VCL. During our inspection, in August of 2016, we
received a request from the Office of Special Counsel (OSC) to
investigate allegations regarding training and oversight deficiencies
with staff that assist call responders (Social Service Assistants/
SSAs). This inspection, in addition to our previous inspection, found
organizational deficiencies and foundational problems in the VCL. We
also identified key changes needed by VA in order to achieve VA goals
of service for veterans in crisis.
Our inspection included the following objectives:
To respond to a complaint alleging that the VCL did not
respond adequately to a veteran's urgent needs.
To perform a detailed review of the VCL's governance
structure, operations, and quality assurance functions in order to
assess whether the VCL was effectively serving the needs of veterans.
To evaluate whether VHA completed planned actions in
response to OIG recommendations for the VCL, published on February 11,
2016, in our report titled Healthcare Inspection-Veterans Crisis Line
Caller Response and Quality Assurance Concerns, Canandaigua, New York.
To address complaints received from the OSC alleging
inadequate training of VCL SSAs resulting in deficiencies in
coordinating immediate emergency rescue services needed to prevent
harm.
Veteran's Urgent Needs
Regarding the first objective, we substantiated that VCL staff did
not respond adequately to a veteran's urgent needs during multiple
calls to the VCL and its backup call centers. We also identified
deficiencies in the internal review of the matter by the VCL staff. In
the interest of privacy, information specific to this veteran is not
included in the report. However, relevant information has been provided
in detail to VHA.
Governance, Operations, Quality Assurance Functions
Governance is defined as the establishment of policies, and the
continuous monitoring of their proper implementation, by members of the
governing body of an organization. \8\ During the time of our review,
\9\ the leadership, governance, and committee structure was in an
immature state of development. Examples include a governance structure
without clear policies and unclear mandates to review clinical
performance measures and make improvements. These structural problems
led to operational and quality assurance gaps.
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\8\ Business Dictionary's definition of governance.
\9\ Our review period was from June through December 2016.
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In our February 2016 report, we cited the absence of a VCL
directive as a contributor to some of the quality assurance gaps
identified in the review. VHA concurred with this recommendation and
provided an initial target date for completion of June 1, 2016. As of
the publication of our March 2017 report, this action was not complete.
We found continuing deficiencies in governance and oversight of VCL
operations.
During the August 2016 site visit to Canandaigua, the VCL's acting
director told us that the VCL was using the Baldridge \10\ framework
for governance. For the VCL, the central leadership group in this model
would be the Executive Leadership Council (ELC). \11\ The ELC
integrates the business and clinical aspects of operating the VCL. We
requested all ELC draft policies to ensure that the ELC had a process
for achieving its intended goals. We were informed that no current
policies related to the ELC existed and that creation of such policies
was in progress. The VCL and the services it provides have grown
considerably since 2007, but VCL leadership did not develop a plan
until 2016 that defined the strategic approach for the VCL to provide
consistent, timely, and high quality suicide prevention services. For
its Baldridge framework goals, VCL leadership was unable to provide
policies, dashboards, or quality monitors for this governance
initiative.
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\10\ The Malcolm Baldrige National Quality Award is the highest
level of national recognition for performance excellence that a U.S.
organization can receive. The award focuses on performance in five key
areas: product and process outcomes, customer outcomes, workforce
outcomes, leadership and governance outcomes, financial and market
outcomes. https://www.nist.gov/baldrige/baldrige-award. Accessed
December 23, 2016.
\11\ ELC membership includes VCL Director, Chairperson, VCL Deputy
Director, Business Operations Lead, Veteran Experience Lead, Employee
Experience Lead, Partnerships Lead, Clinical Quality Lead, AFGE
Leadership Member, Union Leadership Member, Clinical Psychologist, and
CAC.
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Shortly after the publication of the 2016 OIG report, the VCL was
realigned under VHA Member Services, although VA leadership stated that
the VCL would remain closely tethered to VHA's clinical operations.
VHA's Office of Suicide Prevention \12\ leads suicide prevention
efforts for VHA and coordinates and disseminates evidence-based
findings related to suicide prevention. However, we found a disconnect
between the VHA Office of Suicide Prevention and Member Services in
communicating about suicide prevention and the VCL. While the
expectation was that Member Services and subject matter experts on
suicide prevention would work closely together, we found substantial
disagreement about key decisions and oversight between the two groups.
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\12\ The Office of Suicide Prevention leads suicide prevention
efforts for VHA and coordinates and disseminates evidence-based
findings related to suicide prevention.
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The lack of effective utilization of clinical decision makers at
the highest level of VCL governance resulted in the failure to include
fully clinical perspectives impacting the operations of the VCL.
Administrative staff made decisions that had clinical implications.
Examples include disagreements about the scope of services associated
with core versus non-core calls \13\ and the selection of training
staff who did not have clinical backgrounds. Clinical leaders stated
concerns about staff morale, decisions impacting VCL capacity of
responders to assist callers in crisis promptly, and effective training
of new responders.
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\13\ Core calls are calls defined as calls resulting in referral
to the Suicide Prevention Coordinator and/or calls requiring the
application of crisis management skills (example: a suicidal caller).
Non-core calls are defined as those that do not require specific crisis
intervention skills (example: a caller inquiring about benefits).
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Another example of deficient governance was a lack of permanent VCL
leadership. During most of 2015, the VCL was without a permanent
director. At the end of 2015, a permanent director was chosen. However,
the new permanent director resigned his position in June 2016. As of
December 2016, the VCL continued to operate without a permanent
director.
Operations
The VCL was undergoing changes throughout our review. For example,
there were three versions of the VCL organizational chart between June
2016 and September 2016. The evolving VCL staffing model was based on a
service level of zero percent rollover, answering all calls within 5
seconds, and forecasting call volume based on historical interval data.
Calls to VCL and Contracted Backup Centers
To reach the VCL (Canandaigua or Atlanta) through its toll-free
number, a caller is instructed to press 1 (for veterans) on the
telephone keypad. If the caller does not press 1, the caller is routed
to a National Suicide Prevention Line center. The caller still speaks
with a responder. However, this route will take the caller to a non-VCL
and non-VA contracted backup call center. If the caller presses 1, as
instructed for veterans, and the call cannot be answered within 30
seconds by the VCL, it rolls over to a VA contracted backup center.
During our review, VHA leadership was in the process of
implementing an automatic transfer function, which directly connected
veterans who call their local VA Medical Centers to the VCL by pressing
7 during the initial automated phone greeting. Member Services
leadership determined that the implementation of various communication
enhancements that increased VCL access, including Press 7, voice
recognition technology, vets.gov, and MyVA311, \14\ created increased
demand for services.
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\14\ VA is introducing 1-844-MyVA311 (1-844-698-2311) as a go-to
source for veterans and their families who do not know what number to
call.
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When a call is answered by VCL staff, a trained crisis responder
answers the call, and after engaging with the caller and building
rapport, the responder asks about suicidal ideation. \15\ Depending
upon the caller's answer, the responder may conduct a more detailed
assessment of lethality, which addresses a range of both suicide risk
factors as well as protective factors. Callers may choose to remain
anonymous and the responder may only be able to identify the caller by
phone number.
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\15\ Suicidal ideation is thinking about, considering, or planning
suicide. Centers for Disease Control and Prevention, http://
www.cdc.gov/violenceprevention/suicide/definitions.html. Accessed
December 2, 2016.
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We identified a deficiency in the VCL's processes for managing
incoming telephone calls. Callers may decide to remain anonymous, but
in every case responders document the incoming telephone number.
However, responders must manually enter the number into the electronic
documentation system, increasing the risk of human error. While
reviewing responders' call documentation, we found that the
documentation was often lacking in sufficient detail to facilitate
retrospective assessment of the interaction between the caller and
responder.
VCL call complaint data included callers' complaints about being on
hold. We found that some contracted backup call centers used a queuing
(waiting) process that callers may perceive as being on hold. During
the queue time, or wait time, the caller waits for a responder to
answer. The caller's only option is to abandon the call (hang up) and
call back, or continue to wait for a responder to pick up. The backup
centers had processes to record wait times and abandonment rates. We
found that VCL leadership had not established expectations or targets
for queued call times, or thresholds for taking action on queue times,
resulting in a systems deficiency for addressing these types of
complaints. At the time of our review, there were four contracted
backup centers. Two of the backup centers queued calls and two did not
queue calls.
VHA contracted with an external vendor \16\ to manage backup center
performance and report back to the VCL, with administrative and
clinical oversight of the contract terms by VCL managers. We found that
the VHA contracting staff and Member Services and VCL leaders
responsible for verifying and enforcing terms of the contract did not
provide the necessary oversight and did not validate that the
contracted vendor provided the required services before authorizing
payment.
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\16\ Link2Health Solutions, Inc.
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Atlanta Call Center
On July 21, 2016, planning for the new Atlanta-based call center
started. By November 21, 2016, Member Services anticipated that
staffing at the Atlanta Call Center would be sufficient to allow for
zero rollover calls to backup call centers. \17\ Member Services
leaders planned to have the Atlanta facility fully staffed and
telephonically operational by December 31, 2016. Text and chat services
would begin in June 2017. \18\
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\17\ Backup centers will be used on a contingent basis.
\18\ Responders are required to have 6 months of VCL telephone
experience, prior to engaging in training for text and chat services.
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Member Services leaders made the decision to roll out the Atlanta
Call Center without first establishing on-site leadership, a critical
piece to ensuring proficient execution of call center function. The
September 2016 VCL organizational chart called for Atlanta to have its
own Deputy Director and Director for Team Operations. However as of
September 20, 2016, even though the leadership positions had not even
been advertised much less filled, the Atlanta office held its inaugural
responder training class with plans to begin operations on October 10,
2016. As of November 8, 2016, this iteration of the organizational
chart had been rescinded. VCL leadership structure reverted to that
outlined in the July 2016 organizational chart, which does not include
either a Deputy Director, a Director of Team Operations for Atlanta, or
other leadership positions specific to the Atlanta Call Center.
Bringing the Atlanta Call Center online in a three-month period
entailed the rapid hiring and training of new staff. The training
content is the same for responders at both the Atlanta and Canandaigua
sites, but with notable differences in trainer-to-learner ratios. For
instance, in order to accommodate the sizable number of trainees, class
sizes were larger at the Atlanta Call Center, ranging from 44 to 62
trainees, versus 20 trainees per class at the Canandaigua Call Center.
Once the responders completed classroom training and passed a
proficiency test, they were assigned to work with a preceptor for one
to three weeks. The preceptor-to-responder ratio at the Canandaigua
Call Center is 1:1. The original plan for the Atlanta Call Center
called for a 1:2 or 1:3 preceptor to responder ratio. However, due to
limited preceptor availability and large class sizes, the ratios were
as high as 1:16.
The supervisors hired to work at the Atlanta Call Center did not
have the same skill set as those at the Canandaigua Call Center.
Canandaigua Call Center supervisors first served in a responder role,
while most Atlanta Call Center supervisors had not. Because of this, we
were told that Atlanta Call Center supervisors would be required to
complete responder training prior to supervisor training. One VCL
supervisor told us that inexperience might detrimentally affect
practice at the Atlanta Call Center because new responders,
particularly linked with new supervisors, may be too quick to call
rescues whereas more experienced responders may be able to de-escalate
the situation. Despite the experiential and training differences
between sites and the potential for variances in practice, with the
exception of silent monitoring, we found no documentation of plans to
compare metrics between sites, including rescue rates.
The rapid establishment of the Atlanta Call Center required that a
substantial number of staff from the Canandaigua Call Center be
detailed to the Atlanta Call Center to train staff as well as assist
with workload. The diversion of Canandaigua Call Center staff to
Atlanta in order to achieve VCL programmatic milestones also
contributed to a delay in the development and implementation of
policies, programs, and procedures for the VCL. Examples of delays
cited by staff include the deferral of annual lethality assessment
training for responders, the delayed rollout of chat and text
monitoring at the Canandaigua Call Center, and delayed implementation
and utilization of wellness programs.
Prior to the end of our review in December 2016, the VCL
implemented audio call recording capability for incoming and outgoing
calls for quality assurance purposes, but had yet to provide
procedures, protocols, or policies that provided guidance for listening
to or using recorded call information. VCL Quality Management (QM)
program leaders could enhance performance improvement evaluations by
using call recording to monitor the quality of interactions between
responders and callers and by collecting and analyzing performance data
from the new Atlanta Call Center separately from the Canandaigua Call
Center. The new call center in Atlanta could have QM concerns that are
no different from its Canandaigua partner, but the ability to recognize
site-specific issues, especially in a new program, is facilitated by
separating quality data elements by site.
Quality Assurance
Systematic collection of relevant and actionable data for analysis
is crucial when making decisions that will prevent problems. To be
effective, VCL's QM data collection and analysis should be accurate and
inform VHA and VCL leadership and staff whether their actions
effectively serve veterans and others who use VCL services. In our
February 2016 report, we recommended that VHA establish a formal
quality assurance process and develop a VHA directive or VHA handbook
for the VCL. We reviewed the VCL QM program structure and processes,
the VCL QM program manual, and the draft VCL directive and identified
systems deficiencies in QM program processes. We further found that
neither the VCL QM program manual nor the draft VCL directive provided
a framework for a QM program structure.
Quality Management Leadership
VHA does have a directive that outlines leadership responsibilities
for program integration and communication, and the designation of
individuals with appropriate background and skills to provide
leadership to promote quality and safety of care. \19\ In order to
implement the foundational principles of QM, leaders within a program
must be able to promote, provide, and recognize QM practices that will
lead to better outcomes. After reviewing the number and types of QM
roles in the VCL, as well as QM staff experience and background, we
determined that the challenges likely stemmed from the QM staff's lack
of training in QM principles. Member Services leadership tasked QM
staff with multiple responsibilities and competing priorities that
included VCL QM program and policy development, data collection and
analysis, data presentation for evaluation and action planning, and
identification of outcomes measures. However, the QM staff had not been
provided with training in the skills needed to provide leadership to
promote quality and safety of care, leading to deficiencies in the QM
program.
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\19\ VHA Directive 1028, VHA Enterprise for Framework for Quality,
Safety, and Value, August 2, 2013.
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Quality Management Data Analysis
We found that while VCL staff collect data on clinical quality
performance measures, the QM program lacked defined processes for
analyzing and presenting data and for developing a committee structure
for reporting the analysis, making recommendations and following up.
Quality Management Committees and Planning
VHA requires a standing committee to review data, information and
risk intelligence, and to ensure that key quality, safety and value
functions are discussed and integrated on a regular basis. This
committee should be comprised of a multidisciplinary group, should meet
quarterly, and should be chaired by the Director. We did not identify a
VCL standing committee that met the intent of VHA requirements outlined
in Directive 1026.
Policies, Procedures, and Handbooks
VHA Directive 6330 (1), Controlled National Policy/Directive
Management System, established policy and responsibilities for
managing, distributing, and communicating VHA directives. VCL policies
have been created in response to external reviews and internal
processes but a controlling directive has not yet been published. A
draft directive was in development, dated April 4, 2016; however, it
lacked defined roles and responsibilities for VCL leaders, such as the
VCL Director. We found that VCL policies, procedures, or handbooks were
not readily accessible for staff reference.
VCL leaders developed a QM Program Manual which was updated in July
2016 (no initial publication date was available). The program manual
did not outline a framework for the QM program that is consistent with
relevant existing VHA directives providing guidance for QM programs.
Outcome Measures for Quality Improvement
We found that while the VCL measured internal performance of its
staff (silent monitors, End of Call Satisfaction question, and
complaints), its QM data analysis did not include measures of clinical
outcomes for callers. During interviews, we inquired about outcome
measures to evaluate the success of a veteran's transition from the VCL
to other dispositions. We identified deficiencies in the VCL QM program
including data analysis and presentation of clinical quality
performance measures, lack of development of a directive consistent
with established VHA guidance, lack of a reporting structure for
regular review of performance measures, and frequent changes in the
organizational structure of the QM program. We found that deficiencies
in the QM program were related to VHA leadership failing to provide a
developmental plan, appointing staff into positions without formal QM
training, and assigning staff multiple competing priorities. \20\
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\20\ VHA Directive 1026, VHA Enterprise for Framework for Quality,
Safety, and Value, August 2, 2013.
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Measurement of Program Success with Adverse Outcomes Reviews
We found that the VCL had no process in place for routinely
obtaining or reviewing data on serious adverse outcomes, such as
attempted or completed suicides by veterans who made contact with the
VCL prior to the event. We learned that adverse outcomes were not
aggregated for review by VCL leadership in order to measure performance
improvement for achieving more successful outcomes. The Acting Director
and Acting Quality Assurance Clinical Officer confirmed that
debriefings or other reviews were not conducted after known suicide
attempts or completions. By not reviewing serious adverse outcomes, VCL
QM managers missed opportunities for quality improvement.
We reported systems deficiencies in the VCL Quality Management
program in our 2016 and 2017 reports. VHA provides a framework for QM
program structure and leadership to ensure delivery of safe and
effective care; however, we found multiple program deficiencies
remained during our second review.
Status of Recommendations from OIG's February 2016 Report
In our report from February 2016, we made seven recommendations. VA
concurred with the recommendations and at the time provided action
plans and a time frame for implementation of all recommendations by
September 2016. We reviewed VHA documents submitted as evidence to
support the completion of the planned actions. However, VHA has not
completed the planned actions and we consider those recommendations as
open. We would note that VHA established the time frame for
implementation and not the OIG.
Inadequate Training Allegations Received from OSC
We found that VCL managers developed a process for monitoring the
quality of crisis intervention services provided by responders;
however, VCL lacked a process for monitoring the quality of performance
by SSAs. We identified deficiencies in SSA training and substantiated
complaints referred to us by the OSC in regard to SSA training and
performance. Specifically, we substantiated 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 in mid-2016, a newly trained SSA
contacted a caller in crisis by telephone to solicit the veteran's
location, although we found that no harm resulted from the interaction;
and we substantiated a lack of documentation by an SSA when closing out
a veteran's case in mid-2016. We could not substantiate an allegation
that documentation by an SSA resulted in conflicting information about
a veteran being contacted within 24 hours. The complainant (who
remained anonymous) was not interviewed by us, and we did not have
identifiers for the veteran caller.
Report Recommendations
The OIG recommendations from 2016 and 2017 fall into the categories
of governance/leadership, operations, and quality assurance. It is
noteworthy that many of these recommendations cut across all three
categories.
Governance - Governance recommendations include the
establishment of a VCL directive that guides structure, roles, and
responsibilities. Additional recommendations include that the
governance structure ensures cooperation between clinical and
administrative leadership. We also recommended that lines of authority
delineate that clinical leadership make clinical policy decisions.
Operations - Operations recommendations include that SSAs
are certified by supervisors before engaging in independent assistance
with rescues. Other recommendations involve information technology
infrastructure including an automated process for transcription of
telephone numbers, and audio call recording with related policies and
procedures. We recommended improved control of policy and document
management so that updated policies and procedures and related staff
training can be tracked. We issued recommendations related to backup
center and contractor performance, including an enforceable quality
assurance surveillance plan for contracted backup centers, and
establishing targets for rollovers and call queuing. We recommended
that contractors are held to the same standards as the VCL, and
contract performance is monitored to assure that the terms of the
contract are met. We also recommended that contractor performance is
verified prior to payment.
Quality Assurance - Quality assurance recommendations
include establishing a formal quality assurance process that
incorporates policies and procedures consistent with the VHA framework.
Other recommendations include QA leadership being fully trained in QA
principles, evaluating negative clinical outcomes in order to improve,
and ensuring that VCL silent monitoring frequency meets established VCL
standards. We also recommended that VCL develop structured oversight
processes for tracking and trending of clinical quality performance
measures. We recommended that quality data be used to enhance
performance, that call recording be used for quality assurance, and
that Canandaigua and Atlanta are analyzed separately with performance
measures. We recommended consistent quality assurance and monitoring
policies are established for responder staff and SSAs.
A complete listing of the individual recommendations from both
reports is attached in Appendix A and Appendix B.
CONCLUSION
Our 2016 and 2017 VCL inspections identified various challenges
facing the VCL in their mission to provide ``suicide prevention and
crisis intervention services to veterans, service members, and their
family members.'' We found numerous deficiencies and made seven
recommendations in the 2016 inspection and sixteen additional
recommendations in the 2017 inspection. All recommendations remain open
today. Until VHA implements fully these recommendations, they will
continue to have challenges meeting the VCL's critically important
mission.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or members of the Committee may have.
Recommendations from Healthcare Inspection - Veterans Crisis Line
Caller Response and Quality Assurance Concerns Canandaigua, New York
(February 11, 2016)
Recommendation 1. We recommended that the OMHO (now VHA Member
Services) \21\ Executive Director ensure that issues regarding response
hold times when callers are routed to backup crisis centers are
addressed and that data is collected, analyzed, tracked, and trended on
an ongoing basis to identify system issues.
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\21\ The VCL was realigned under VHA Member Services in the spring
of 2016. At the time the February 2016 OIG report regarding the VCL was
published, the Office of Mental Health Operations was responsible for
the VCL.
Recommendation 2. We recommended that the Member Services Executive
Director ensure that orientation and ongoing training for all VCL staff
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is completed and documented.
Recommendation 3. We recommended that the Member Services Executive
Director ensure that silent monitoring frequency meets the VCL and
American Association of Suicidology requirements and that compliance is
monitored.
Recommendation 4. We recommended that the Member Services Executive
Director establish a formal quality assurance process, as required by
VHA, to identify system issues by collecting, analyzing, tracking, and
trending data from the VCL routing system and backup centers, and that
subsequent actions are implemented and tracked to resolution.
Recommendation 5. We recommended that the Member Services Executive
Director consider the development of a VHA directive or handbook for
the VCL.
Recommendation 6. We recommended that the Member Services Executive
Director ensure that contractual arrangements concerning the VCL
include specific language regarding training compliance, supervision,
comprehensiveness of information provided in contact and disposition
emails, and quality assurance tasks.
Recommendation 7. We recommended that the Member Services Executive
Director consider the development of algorithms or progressive
situation-specific stepwise processes to provide guidance in the rescue
process. \22\
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\22\ VCL staff consider rescues, welfare checks, and dispatch of
emergency services to be equivalent terms.
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Recommendations from Healthcare Inspection - Evaluation of the Veterans
Health Administration Veterans Crisis Line (March 20, 2017)
Recommendation 1. We recommended that the Under Secretary for
Health implement an automated transcription function for callers' phone
numbers in the Veterans Crisis Line call documentation recording
system.
Recommendation 2. We recommended that the Under Secretary for
Health ensure that Veterans Crisis Line policies and procedures, staff
education, Information Technology support, and monitoring are in place
for audio call recording.
Recommendation 3. We recommended that the Under Secretary for
Health implement a Veterans Crisis Line governance structure that
ensures cooperation and collaboration between VHA Member Services and
the Office of Suicide Prevention.
Recommendation 4. We recommended that the Under Secretary for
Health develop clear guidelines that delineate clinical and
administrative decision-making, assuring that clinical staff make
decisions directly affecting clinical care of veterans in accordance
with sound clinical practice.
Recommendation 5. We recommended that the Under Secretary for
Health ensure processes are in place for routine reviewing of backup
call center data, establish wait-time targets for call queuing and
rollover, and ensure plans are in place for corrective action when
wait-time targets are exceeded.
Recommendation 6. We recommended that the Under Secretary for
Health ensure processes are in place to require contracted backup
centers to have the same standards as the Veterans Crisis Line related
to call queuing and wait-time targets.
Recommendation 7. We recommended that the Under Secretary for
Health ensure that VHA Member Services leadership, Veterans Crisis Line
leadership, VHA Contracting Officers, and Contracting Officer
Representatives implement the quality control plan and conduct ongoing
oversight to ensure contractor accountability in accordance with their
roles as specified in the contract with backup call centers.
Recommendation 8. We recommended that the Under Secretary for
Health ensure that training is provided to Veterans Crisis Line quality
management staff in the skills needed to provide leadership to promote
quality and safety of care.
Recommendation 9. We recommended that the Under Secretary for
Health ensure the development of structured oversight processes for
tracking, trending, and reporting of clinical quality performance
measures.
Recommendation 10. We recommended that the Under Secretary for
Health ensure processes for Veterans Crisis Line quality management
staff to collect and review adverse outcomes so that established
cohorts of severe adverse outcomes are analyzed.
Recommendation 11. We recommended that the Under Secretary for
Health direct the Veterans Health Administration Assistant Deputy Under
Secretary for Health for Quality, Safety, and Value to review existing
Veterans Crisis Line policies and determine whether the policies
incorporate the appropriate Veterans Health Administration policies for
veteran safety and risk management, and if not, establish appropriate
action plans.
Recommendation 12. We recommended that the Under Secretary for
Health ensure that Veterans Crisis Line quality management staff
incorporate call audio recording into quality management data analysis.
Recommendation 13. We recommended that the Under Secretary for
Health ensure that processes are in place to analyze performance and
quality data from the Atlanta Call Center separately from the
Canandaigua Call Center data.
Recommendation 14. We recommended that the Under Secretary for
Health ensure that quality assurance monitoring policies and procedures
are in place and consistent for both Social Service Assistants and
responders.
Recommendation 15. We recommended that the Under Secretary for
Health ensure that supervisors certify Social Service Assistant
training prior to engaging in independent assistance with rescues.
Recommendation 16. We recommended that the Under Secretary for
Health ensure a process is in place to establish, maintain, distribute,
and educate staff on all Veterans Crisis Line policies and directives
that includes verifying the use of current versions when policies and
directives are modified.
Prepared Statement of Kayda Keleher
Chairman Roe, Ranking Member Walz and members of the Committee, on
behalf of the men and women of the Veterans of Foreign Wars of the
United States (VFW) and its Auxiliary, I want to thank you for the
opportunity to present the VFW's views on the Department of Veterans
Affairs (VA) Office of the Inspector General's (OIG) report on the
Veterans Crisis Line (VCL).
In 2007, Department of Veterans Affairs Health Administration (VHA)
established a suicide hotline. The hotline, which later became known as
the VCL, was established to provide 24/7, suicide prevention and crisis
intervention to veterans, service members and their families. This was
necessary as a means of constant availability to individuals in need of
crisis intervention. The VCL provides crisis intervention services to
veterans in urgent need, and helps them begin their path toward
improving their mental wellness. The VCL plays a critical role in VA's
initiative of suicide prevention, and ongoing efforts to decrease the
estimated 20 veterans who die by suicide each day. The VCL answers more
than 2.5 million calls, responds to more than 62,000 text messages and
initiates the dispatch of emergency services more than 66,000 times
each year. Yet, there is still more work that must be done to improve
the VCL.
The VA OIG released a report March 20, 2017. This report came after
the United States Government Accountability Office (GAO) release of
another VCL report in May 2016. Of the four objectives highlighted by
VA OIG, there are 16 recommendations. The VFW applauds the VCL for the
progress it has made since the reports were released. To continue
improvements the VCL must improve quality control, implement clinical
oversight and increase collaboration.
Quality Control
From January 1 - March 11, 2017 the VCL received a total of 133,694
calls between their two locations in Canandaigua, N.Y., and Atlanta,
Ga. Of those calls, 552 were rolled over to a backup call center. It is
also worth noting VA does not have the capability of monitoring any
calls which are sent to their Substance Abuse and Mental Health
Services approved backup call centers. While 552 unanswered VCL phone
calls may seem high, the VFW believes rollover calls cannot be
completely eradicated. We believe the goal of VCL responders should be
quality of crisis intervention, not quantity of calls answered. Though
it should still be a priority for responders to answer as many calls as
possible, the number one goal must be successful crisis intervention.
Yet, without being able to promise every veteran it is completely
practical for the employees in New York and Georgia to always have
somebody available to answer the call, it is imperative VCL continue
contracting backup call centers with oversight and monitoring of the
quality of those calls. Since the mark of the New Year, VCL roll overs
have decreased from 1.99 percent of calls to anywhere from .02 to .47
percent of calls. This is a huge improvement since November 2016, when
31.34 percent of calls were being sent to backup centers and throughout
much of the time VA OIG was doing its investigation. The consistent and
dramatic decreases in amount of calls being sent to backup centers can
be directly correlated with the second VCL location opening in Atlanta,
Ga., on Oct. 1. Each individual employee at the VCL is answering an
average of nine calls per day, and those calls are being answered
quicker than 911 and the National Emergency Number Association
standards. While these improvements compared to the past are
commendable, the VCL must focus on quality of crisis intervention
provided- not strictly on quantity of calls answered. The VFW believes
with the right adjustments, VCL staff can maintain this quantity of
service while also improving the quality.
Precise numbers of non-veterans and veterans not in a mental health
crisis calling VCL are unknown. Last year it was publicized that four
callers were calling and harassing VCL employees thousands of times,
estimates of four percent of incoming calls were to harass VCL
responders. Other veterans admit to calling VCL when not in mental
health crisis because it is the first phone number they see publicly
available. They have called in hopes of being able to schedule
appointments or to complain about unsatisfactory care they received.
Completely screening these calls and assuring only individuals in
crisis are calling the VCL is not practical, and most callers are in
need of some level of intervention. Crisis is defined individually, and
everyone in crisis deserves support. Yet the VFW is concerned some of
the calls not being answered by VCL responders may be due to non-crisis
callers clogging the system.
The VFW believes expanding VA's Office of Patient Advocacy would
greatly benefit the VCL. By improving and expanding the patient
advocacy offices throughout VA, employees of these offices would have
better visibility and means to assist non-crisis patients. If veterans
become more aware of the patient advocate mission and capabilities,
non-crisis callers to the VCL would decrease. The VFW has been working
to expand and improve patient advocacy within VA and we will continue
to monitor progress. The VFW urges this Committee to conduct extensive
oversight of the VA Patient Advocate Program to ensure veterans are
able to have their non-emergent concerns addressed without having to
call the VCL.
Employees at VCL undergo extensive training before being allowed to
answer calls, and it takes at least six months before they may begin
training to also answer chat and text conversations with veterans in
crisis. Yet it was not until late December 2016 that the VCL had the
capability to record and monitor their calls. Without this crucial
technological capability, there was no way for calls to be truly
monitored for quality control. Now that this capability is available
the technology must be properly utilized. Staff at VHA and the VCL
monitor some ongoing calls for quality assurance, but a better,
constant, process must be implemented to ensure these recordings are
being used to improve the training and capabilities of VCL responders.
This would not only improve crisis intervention, but would assist with
ending allegations of responders not understanding or following
protocol, instructions and resources.
Over the last six months, turnover rate for employees at both VCL
locations have been far below the national average. Canandaigua
currently has 361 employees, they have lost 15 employees since October
2016, with a turnover rate of 4.1 percent. In Atlanta, there are
currently 275 employees. The Atlanta call center has lost 10 employees
since October 2016, with a turnover rate of 3.6 percent. According to a
2015 study published by Nursing Solutions, Inc., the average turnover
rate for health care employers was 19.2 percent. This may in part be
due to increased morale thanks to the VCL employee wellness program.
Leadership at VCL took notice in the past to low morale amongst
employees, which is completely reasonable given the nature of
responders' jobs. The employee wellness program provides responders at
VCL 15 minutes to prepare themselves mentally before and after their
shifts. This allows them time to enter the mindset necessary for their
emotionally demanding job, as well as time to decompress and adjust
their mindset or talk amongst others before leaving their workplace.
The employee wellness program also improved the supervisor to responder
ratio. Prior to the program, there were 20 employees for every
supervisor. The ratio was decreased to ensure the needs of employees
are not overseen so that now there are 11 employees to every one
supervisor.
Clinical Oversight
There is no doubt clinical oversight at VCL is a necessity.
Clinical decision making must be made by clinicians and not by
operations and administrative staff. Leadership running the VCL must
also have clinical background. This would ensure veterans in crisis who
call the VCL receive the best clinical judgement and assistance
possible. Clear guidelines must be established for the VCL so non-
clinicians are not forcing a clinically based crisis line to operate as
a business. This has a clear link to quality control as well. The VFW
believes that while the number of calls going to backup centers
decreasing at such a rapid rate is a positive, it is not a sign of the
quality of work being provided. Veterans, service members and their
families deserve the best clinical care available, and VA is known for
outperforming the private sector in many areas of health care. In fact,
of the estimated 20 veterans who commit suicide every day, only six of
them are enrolled in VHA. This shows that clinicians within VA know
what they are doing, and they do it well.
The VFW believes VHA must establish both clinical and operational
policies specific to the VCL. This would allow for easier protocol
standards to be understood and met on a regular basis, while
establishing guidance and regulations to continue being followed by
employees without clinicians stepping on the toes of operations, or
operations stepping on the toes of clinicians.
In March 2016, VCL established a Clinical Advisory Board at the
request of VHA Member Services. This board was intended to assist and
work with VHA Member Services, to assure no clinical necessities were
being dismissed after VCL operations were moved to the non-clinical
office within VHA. This group was intended to assist VHA Member
Services in collective expertise of clinicians to improve the veteran
experience, efficiencies of employees and increase access to the VCL.
The charter for the advisory board was later changed by different
leadership within VHA Member Services. The board now has one meeting
per month where they call in for one hour. Call data is presented to
the board members, but a monthly hour long meeting does not provide
them with the means to effectively obtain clinical input for policy
decisions to improve the VCL.
Collaboration
The VFW firmly believes VCL has improved and will continue to
improve. Though that improvement will continue to be slow, frustrating
and life-endangering if VCL does not begin collaborating with others.
Aside from working with patient advocacy offices to cut down on non-
crisis calls and VHA Member Services to re-adjust the advisory board
and increase clinicians- VCL must also work more closely with the
Office of Suicide Prevention (OSP).Member Services has undoubtingly
assisted VCL in quantity control, but OSP can also assist VCL in
quality control. If the goal of the VCL is to intervene on veterans in
need of immediate assistance while they are in the middle of a mental
health crisis - the VCL should be working with the subject matter
experts and leaders in suicide prevention and outreach for VA. If all
three offices could collaborate together, with better guidelines,
Member Services must be able to continue improving VCL call center
expertise and business, while OSP can make sure the VCL is up-to-date
with the most current clinical expertise on suicide prevention and
outreach.
Prepared Statement of Melissa Bryant
Chairman Roe, Ranking Member Walz, and Distinguished Members of the
Committee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
our more than 425,000 members, thank you for your time last week as
IAVA introduced our She Who Borne the Battle Campaign. We look forward
to working with you and your staff to fully recognize and improve
services for women veterans. We also thank you for the opportunity to
share our assessment of ongoing concerns with the Veterans Crisis Line
(VCL) today. Mental health and suicide prevention remains one of the
top concerns of our members, where an overwhelming 75% of respondents
to our latest survey (to be published later this spring) still believe
troops and veterans are not getting the care they need for mental
health injuries.
I am here today not only as IAVA's Director of Intergovernmental
Affairs, but also as a former Army Captain and a combat veteran of
Operation Iraqi Freedom. I was a military intelligence officer, a
leader of men and women in combat, and I bore witness to the trauma and
anguish several of my soldiers and friends endured when dealing with
suicidal ideations or attempts. I bore the battle with these brave men
and women, with two soldiers in particular--one male and one female--
who were under my direct charge and I felt a special duty to protect
and care for. And while I am eternally grateful these two soldiers were
saved by mental health interventions, I mourn the loss of my sisters
and brothers in arms who lost their battle and died by suicide. I am
giving voice to all of us who served and the invisible wounds of war as
I speak today.
In 2007, IAVA fought for and celebrated the passage of the Joshua
Omvig Suicide Prevention Act, which among other things required the
establishment of a hotline to provide information on and referrals to
mental health services. This established the VCL. IAVA signed an
Memorandum of Agreement with the VCL in 2012, and continues to partner
with them today to both ensure our members are aware of the critical
services the Crisis Line offers, as well as to provide crisis support
to clients who are seeking support from IAVA's Rapid Response Referral
Program (RRRP). To date, our RRRP Veteran Transition Managers (VTMs)
have referred nearly 200 clients to the VCL. These clients share both
positive and negative stories of their experiences with the VCL. IAVA
wants to get to a place where all of the feedback we get about the VCL
is positive.
The Veterans Crisis Line provides a critical service to veterans
and their loved ones. Since its inception, the crisis line has provided
around the clock support to 2.8 million calls, engaged in 332,000 chats
and answered 67,000 texts. IAVA recognizes the life-saving services the
VCL offers every day. It is a vital resource for our community, and we
are committed to ensuring that it continues to fulfill its mission to
provide 24/7, world class suicide prevention and crisis intervention
services to veterans, service members, and their family members.
Media reports covering the recent Department of Veterans Affairs
Office of the Inspector General Report, Evaluation of the Veterans
Health Administration Veterans Crisis Line focused on the finding that
the Veterans Crisis Line could not handle call volume and had to rely
on a back-up call center to field these calls. The VA has addressed
this specific piece in their press release and data that they've shared
with the community. But they haven't addressed the additional findings
of the IG report that point to larger, more systemic issues. These
findings point to institutional challenges with the VCL: its governance
structure, operations, and quality assurance protocols. These are the
deficiencies that still need to be addressed.
IAVA strongly urges the VA to reconsider its management structure
of the Veterans Crisis Line. There must be a dual leadership structure
in which an operations lead can oversee the functional aspects of the
call line while a clinical lead oversees the clinical aspects. These
roles must be complementary and cooperative to ensure the success and
safety of the those both clients of the VCL and the responders who are
answering their calls. Finally, the Office of Suicide Prevention must
be heavily engaged with the operations, quality assessment, and
oversight of the VCL.
IAVA already brought some of these concerns before the committee
last year, particularly regarding the governance structure and quality
control measures. In 2016, the VA moved the VCL from the directorship
of the VA Suicide Prevention Office to VA Member Services. While VA
Member Services oversees all of the call lines at VA, what makes the
VCL different is it inherently requires a strong clinical component. We
worried that the restructuring was discounting the clinical piece that
is so critical to the success of the Crisis Line. Specifically, we
raised the following questions:
Understanding that there are existing quality standards
in place at VCL, are these standards being enforced?
Are they being met?
Do these standards apply to contracted call centers, as
well?
Are the existing standards strict enough to ensure no
call goes unanswered?
We recommended in 2016 the VA consider shifting management back to
the Suicide Prevention Office, with consultation on operations from
Member Services of another appropriate entity, to ensure appropriate
operational management of the call line.
The IG report confirmed our concern that not enough is being done
to manage quality across the VCL calls or more broadly, define through
data how the VCL accomplishes its mission. Some of our questions were
answered in conversations with the VA. The VA shared with IAVA a
quality management matrix that is being used to assess call quality. We
feel this matrix does a decent job of setting baseline standards for
each phone call, but does not go far enough to assess broader program
effectiveness or implement a higher standard of clinical care for
callers. The delay in implementing this in Atlanta is a real issue, but
the VA assures us that delay has been remedied. We encourage the VA to
share those data with the veteran community and Congress on a regular
basis, as we all have skin in the game when it comes to ensuring the
VCL is running efficiently and effectively. The IG report also
highlights concern that the Atlanta call center was opened too quickly
and the staff were ill prepared to handle the case load placed on them.
IAVA agrees and hopes the VA will be transparent in sharing solutions
to address these challenges. Finally, we understand that the VA
continues to work to define expectation for the contracted call centers
to ensure no call goes unanswered and to refine expectations for these
centers, an absolutely critical aspect of this conversation.
IAVA implores the VA to also consider whether the level of clinical
support provided to each call responder is appropriate, how the VCL is
addressing self-care among responders, and what mechanisms are in place
to prevent staff burnout and experienced responders from moving on.
Appropriate and continued training is critical to ensure call quality,
but training cannot be replaced with experience, and the VA must ensure
that it has protocols in place to support its staff. Compassion fatigue
is real. The employees answering the calls of veterans, service
members, and families are dedicated and tireless advocates. We, and the
VA, owe it to them to ensure they are being cared for and supported
both emotionally and professionally. We strongly believe there is a
robust way to silently monitor and review calls, both for quality
management and clinical review, which would require an expansion of the
current quality assurance protocol. Given the challenges the IG report
highlights with training, particularly at the opening of the Atlanta
call center, IAVA believes this is critical for both continued staff
training and staff support.
We also believe that a strong clinical program will allow a ratio
of one clinician to ten responders and will encourage weekly reviews of
calls with rigorous review and critique of call responses. The current
emphasis on business process and optimized workflow over
individualized, clinical service to a veteran in crisis places already
vulnerable veterans in peril. And applying a sterilized quality
assurance protocol that could also be templated for determining a
customer service rating for your home cable installer is woefully
insufficient for our veterans.
While quality control is an important aspect of assessing the VCL,
again, application of a larger program evaluation is critical. We would
expect that the Veterans Crisis Line would fall under the purview of
two bills championed by IAVA: the Clay Hunt SAV Act, which requires
annual evaluation of VA's mental health and suicide prevention program;
and the Female Veterans Suicide Prevention Act, which goes a step
further to require analysis of these programs by gender. IAVA's She Who
Borne the Battle Campaign is anchored in the fact that women veterans
are the fastest growing veteran population, yet often go unrecognized.
We do not know how many women veterans use VCL, nor how effective VCL
is at providing support for women, or even how they are welcomed by a
responder that is answering their call. As part of our She Who Borne
the Battle Campaign, we recognize that the motto of the VA functions as
a symbolic barrier perceived by many women veterans like myself,
emblematic of our lack of parity in care compared to our male
counterparts; perhaps this culture is trickling down to the VCL, but a
holistic program evaluation including gender-specific data should be
conducted to know for certain.
We point to IAVA's own best-in-class case management and referral
program, the Rapid Response Referral Program, as a model. This high-
tech, high-touch program provides one-on-one support, connecting
veterans, service members and their families to a highly skilled and
trained Veteran Transition Manager with a Masters in Social Work. It is
supported without government funding by generous foundations like the
Wonderful Foundation, The Annenberg Foundation, The Goldhirsh
Foundation, the New York State Health Foundation, the Robin Hood
Foundation, the May and Stanley Smith Charitable Trust, and the Schultz
Family Foundation, among others. Since its inception in 2012, we have
served over 7,800 clients, 20% of them women, connecting them quality
resources and benefits. We have put a strong emphasis on client follow-
up and customer satisfaction at RRRP. Programs like RRRP can help
complement the VCL and be valuable partners by supporting veterans and
their families who are not in immediate crisis, but are at risk if
these types of services are not provided; support for these programs is
critical.
RRRP's VTMs engage in rigorous follow-up with clients prior to
closing their case to ensure their needs have been met and referrals
made are providing quality level of services and support. They also
regularly follow-up with referral partners to ensure that they are
connecting with RRRP clients and continuing to provide the standard of
service that our program advertises. We believe the VCL could benefit
from our model. To truly understand the impact of the VCL, the metrics
must go beyond the number of calls or the number of emergency services
dispatched. The VCL must conduct routine follow-up calls with clients
and referral partners and regularly review VA data sources to ensure
service delivery and better quantify the impact of the VCL.
In closing, I cannot emphasize enough on behalf of IAVA the
gratitude that we have for those who staff the VCL call lines and are
there to support the tens of thousands of calls received each year. In
our 7th Annual Member Survey, nearly 20% of respondents had reached out
to the VCL on their own behalf or on behalf of someone they loved. It
continues to be a resource well known and highly recommended by IAVA
members for mental health support. This is a critical, often life-
saving resource for our community. 65% of respondents to our latest
survey personally know a post-9/11 veteran who attempted suicide, while
58% of respondents to our survey personally know a veteran who died by
suicide. And as one of those respondents to our survey who personally
knows veterans who have either attempted or died by suicide, this issue
is deeply personal to me, and one we must resolve swiftly.
It's important to emphasize that these reports and conversations
should not deter our community from reaching out, but rather
reinvigorate Congress, the VA and the VSO community to work together to
continue improving this critical program. I think this is best captured
by a statement made by the VA OIG report in its opening pages, which
highlights the inherent challenges facing the VCL and other programs
like it, but also the critical benefit:
The VCL faces two major challenges. First is to meet the
operational and business demands of responding to over 500,000 calls
per year, along with thousands of electronic chats and text messages,
and initiating rescue processes when indicated. Second is to train
staff to respond to veterans and their family members in individual
encounters. These complex and difficult challenges are not unique to
the VCL as we observed other crisis hotlines that face similar issues.
Although we made findings and recommendations concerning the VCL, we
note an unwavering and impressive commitment by VCL staff who
compassionately assist veterans in crisis.
Members of the Committee, thank you again for the opportunity to
share IAVA's assessment of the Veterans Crisis Line with you here
today. We look forward to working with each of you and the VA in the
months to continue to improve this essential resource. I look forward
to answering any questions you may have.
Prepared Statement of Steve Young
Good morning Chairman Roe, Ranking Member Walz, and Members of the
Committee. Thank you for the opportunity to discuss the Department of
Veterans Affairs (VA) Office of the Inspector General's (OIG) report on
the Veterans Crisis Line (VCL). I am accompanied today by Matthew
Eitutis, Acting Veterans Health Administration (VHA) Member Services
Executive Director.
Introduction
VA recognizes the importance of VCL as a life-saving resource for
our Nation's Veterans who find themselves at risk of suicide. Of all
the Veterans we serve, we most want those in crisis to know that
dedicated, expert VA staff, many of whom are Veterans themselves, will
be there when they are needed. The primary mission of VCL is to provide
24/7, world class, suicide prevention and crisis intervention services
to Veterans, Servicemembers, and their family members. However, any
person concerned for a Veteran's or Servicemember's safety or crisis
status may call VCL.
Positive Actions Taken to Date
Since 2007, VCL has answered nearly 2.6 million calls and
dispatched emergency services to callers in crisis over 67,000 times.
Consistent with our mission, we have implemented a series of
initiatives to provide the best customer service for every caller,
making notable advances to improve access and the quality of crisis
care available to our Veterans, such as:
Launching ``Veterans Chat'' in 2009, an online, one-to-
one chat service for Veterans who prefer reaching out for assistance
using the Internet. Since its inception, we have answered nearly
314,000 requests for chat.
Expanding modalities to our Veteran population by adding
text services in November 2011, resulting in nearly 62,000 requests for
text services.
Opening a second VCL site in Atlanta in October 2016,
with over 200 crisis responders and support staff.
Implementing a comprehensive workforce management system
and optimizing staffing patterns to provide callers with immediate
service and achieve zero percent routine rollover to contracted back-up
centers.
VCL is the strongest it has been since its inception in 2007. VCL
staff has forwarded over 416,000 referrals to local Suicide Prevention
Coordinators on behalf of Veterans to ensure continuity of care with
their local VA providers. Initially housed in 2007 at the Canandaigua
VA Medical Center in New York, it began with 14 responders and two
health care technicians answering four phone lines. In the past 6
months, VCL has nearly doubled the capacity to ensure appropriate
access to Veterans. Today, the combined facilities employ more than 500
professionals, and VA is hiring more to handle the growing volume of
calls. Atlanta offers 200 call responders and 25 social service
assistants and support staff, while Canandaigua houses 310 and 43,
respectively. Despite all this, there still is more that we can do.
VA Office of Inspector General (OIG) Report
VA OIG published a report on February 11, 2016, Healthcare
Inspection-Veterans Crisis Line Caller Response and Quality Assurance
Concerns Canandaigua, New York (Report No. 14-03540-123) and a follow-
up on March 20, 2017, Healthcare Inspection-Evaluation of the Veterans
Health Administration Veterans Crisis Line (Report No. 116-03985-181).
These reports detailed issues and subsequent recommendations for VCL.
The March 2017 report made 16 recommendations associated with the
review that occurred June 2016 through December 2016. We take these
reports very seriously. VHA concurred with all of the new
recommendations and developed action plans. In fact, we were addressing
many of the recommendations even before receiving the recent OIG
report.
Response
Action plans have been developed to address all of the
recommendations for the March 2017 Report. We expect to begin
implementation in May, and to be completed by December 2017. These
actions include:
Incorporating a new Customer Relationship Management
(CRM) system so caller information is automatically populated with the
phone number of the caller.
Evaluating policies and procedures related to VCL call
recordings, and ensuring all staff are educated on policies, to include
roles and responsibilities.
Developing and implementing a training plan for educating
staff on the use of call recordings and how to walk a caller through
any concerns regarding the recording of calls.
Establishing a governance structure to ensure cooperation
and collaboration between program offices and appropriate
responsibility for clinical and administrative functions.
Developing clear guidelines for clinical and
administrative decision-making. These guidelines will focus on ensuring
Veterans who call receive high-quality care based on clinical judgement
and operations are managed with sound business practices.
Collaborating with other VA program offices to provide
training to VCL management staff in core competencies of safe and high
quality leadership.
Adding to VCL Executive Leadership Council's (ELC)
responsibilities. VCL ELC is the governance structure responsible for
documenting, tracking, and directing action on clinical quality
performance measures.
Implementing root cause analysis and corrective action
plans to ensure opportunities for improvement are appropriately
implemented.
Progress
Prior to opening the Atlanta VCL call center in October 2016, VCL
saw in excess of 3,000 calls per week roll over to back-up call
centers. From January 8-14, 2017, we maintained rolled over only 58
phone calls. Since then, we continue to keep rollover calls well below
one percent. This means that on average, we answer over 99 percent of
calls received on a daily basis by the Canandaigua, New York, and
Atlanta, Georgia, call centers.
VCL implemented a comprehensive workforce management system and
optimized staffing patterns to provide callers with immediate service
and to achieve zero percent routine rollover to contracted back-up
centers.
During the time period of the second OIG investigation, VCL
actively staffed the Atlanta call center. New responders were hired and
trained over the course of three months, averaging 40 new responders
being deployed per pay period. The standard training cycle includes
three weeks of classroom instruction and two weeks of preceptorship
prior to being released to independent work.
The chart below indicates VCL's progress over the course of the
last several months in offering superior access for Veterans during
their time of need. It is worth noting, the rollover rate has dropped
even while the number of calls has increased.
Weekly VCL Access Table
----------------------------------------------------------------------------------------------------------------
Week for 2016-2017 Total Number of Calls Total Rollovers Rollover %
----------------------------------------------------------------------------------------------------------------
10/30 - 11/5........... 10558 3309 31.34%
11/6 - 11/12........... 10485 2274 21.69%
11/13 - 11/19.......... 11344 2484 21.90%
11/20 - 11/26.......... 9508 1363 14.34%
11/27 - 12/3........... 12477 2097 16.81%
12/4 - 12/10........... 12,380 1,488 12.02%
12/11-12/17............ 12,613 1,396 11.07%
12/18 - 12/24.......... 12,257 640 5.22%
12/25 -12/31........... 12,852 507 3.94%
1/1 - 1/7.............. 14,768 294 1.99%
1/8 - 1/14............. 12,233 58 0.47%
1/15 - 1/21............ 14,117 58 0.41%
1/22 - 1/28............ 12,768 16 0.13%
1/29 - 2/4............. 13,309 11 0.08%
2/5 - 2/11............. 13,925 3 0.02%
2/12 - 2/18............ 12,690 10 0.08%
2/19 - 2/25............ 12,956 12 0.09%
2/26 - 3/4............. 13,193 28 0.21%
3/5 - 3/11............. 13,735 62 0.45%
3/12 - 3/18............ 13,711 16 0.12%
3/19 - 3/25............ 13,966 16 0.11%
----------------------------------------------------------------------------------------------------------------
The No Veterans Crisis Line Call Should Go Unanswered Act (Public
Law 114-247) directed VA to develop a quality assurance document to use
in carrying out VCL. It also required VA to develop a plan to ensure
that each telephone call, text message, and other communication to VCL,
including at a backup call center, is answered in a timely manner by a
person. This is consistent with the guidance established by the
American Association of Suicidology. In addition to adhering to the
requirements of the law, VCL has enhanced the workforce with qualified
responders to eliminate routine rollover of calls to the contracted
backup center. We also implemented a quality management system, to
monitor the effectiveness of the services provided by VCL. This also
will enable us to identify opportunities for continued improvement. As
required by law, VA will submit a report containing this document and
the required plan to the House and Senate Veterans Affairs Committees
by May 27, 2017.
Conclusion
We appreciate OIG's review of VCL. We are committed to
strengthening our governance structure so that VCL, Office of Mental
Health Operation, and Office of Suicide Prevention are fully
integrated, in order to ensure optimal clinical services. We are
committed to seamless care from the time the Veteran reaches out to
VCL, arrangements are made to ensure that the Veteran is safe, and we
ensure that the Veteran receives timely care and assistance.
We also are grateful that Congress provides the resources necessary
to give Veterans in crisis access to these necessary services. Thank
you and we look forward to your questions.
Statements For The Record
The Government Accountability Office (GAO)
Chairman Roe, Ranking Member Walz, and Members of the Committee:
We are pleased to submit this statement on our May 2016 report
regarding the Department of Veterans Affairs' (VA) Veterans Crisis Line
(VCL). \1\ Upon returning home from deployments in Afghanistan, Iraq,
Vietnam, and other locations, many servicemembers struggle with mental
health issues, including post-traumatic stress disorder, depression,
and substance abuse. Several of these mental health issues have been
identified as risk factors for suicide among veterans. As part of the
continuum of mental health services it provides, VA established the VCL
in July 2007. \2\
---------------------------------------------------------------------------
\1\ GAO, Veterans Crisis Line: Additional Testing, Monitoring, and
Information Needed to Ensure Better Quality Service, GAO-16-373
(Washington, D.C.: May 26, 2016).
\2\ VA established its crisis line at the VA medical center located
in Canandaigua, New York. The original name of VA's crisis line was the
National Veterans Suicide Prevention Hotline until it was rebranded as
the VCL in 2011.
---------------------------------------------------------------------------
The VCL supports veterans in emotional crisis and helps implement
VA's goal of improving mental health outcomes for servicemembers,
veterans, and their families through a number of actions-including
reducing barriers to seeking mental health treatment and expanding
access to VA services. During the time of our review for the May 2016
report, the VCL operated through a VA-operated primary center staffed
with VA-employed responders and five backup call centers that provided
additional responders and other services through a backup call coverage
contract. \3\ Veterans can access the VCL by calling a national toll-
free number-1-800-273-TALK (8255). The VCL and the National Suicide
Prevention Lifeline (Lifeline) share this national number through an
interagency agreement between the VA and the Substance Abuse and Mental
Health Services Administration (SAMHSA). \4\ In addition to responding
to calls, the VCL can also be accessed via online chat and text
message.
---------------------------------------------------------------------------
\3\ For the purposes of this statement, the term "VCL service
partners" includes the Substance Abuse and Mental Health Services
Administration (SAMHSA), the VCL backup call coverage contractor, and
the backup call centers that this contractor used to provide coverage
to the VCL at the time of our 2016 review. VA has since opened an
additional call center in Atlanta.
\4\ The VCL is distinct from Lifeline, which operates through a
network of private, nonprofit providers working independently of one
another while maintaining agreed-upon clinical standards. SAMHSA is an
agency within the U.S. Department of Health and Human Services that
leads public health efforts to advance the behavioral health of the
nation. SAMHSA funds a cooperative agreement grant to administer
Lifeline with the same entity that VA contracts with to provide VCL
backup call coverage. Through this interagency agreement, VA and SAMHSA
set out to establish a seamless crisis management system through a
collaborative and cooperative relationship between the agencies that
provides consistent suicide prevention techniques to callers
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Since it was established, demand for the VCL's services has
exceeded VA's expectations. The VCL received about 534,000 calls in
fiscal year 2015, an almost 700 percent increase from the about 67,000
calls it received in fiscal year 2008, its first full year of
operation. In response, VA steadily increased the VCL's spending from
about $3 million to $30 million from fiscal year 2008 through fiscal
year 2015, devoting additional staff and resources to the VCL over
time. As VA endeavored to address increasing numbers of requests for
assistance, reports of dissatisfaction with VCL service periodically
appeared in the media, and the VA Office of Inspector General was asked
to investigate complaints about the VCL's lack of timely response to
callers. \5\ The Inspector General identified gaps in the VCL quality-
assurance process, including challenges associated with supervisory
review, tracking of issues, and collection and analysis of data from
VCL backup call centers. In addition, the Inspector General found that
in some cases callers did not receive immediate assistance from
responders.
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\5\ Department of Veterans Affairs, Office of Inspector General,
Veterans Crisis Line Caller Response and Quality Assurance Concerns
(Washington, D.C.: 2016).
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Our statement discusses (1) the extent to which VA met response-
time goals for calls, online chats, and text messages received through
the VCL; (2) how VA monitored the performance of the VCL primary center
responders and call center operations; and (3) how VA worked with VCL
service partners-backup call centers and SAMHSA-to help ensure veterans
receive high-quality service from responders. This statement is based
on our May 2016 report on VA's oversight of the VCL as well as updates
from VA and SAMHSA about efforts to address the report's
recommendations.
For the May 2016 report, we made covert test telephone calls, text
messages, and online chats to assess the extent to which VA met its
response-time goals through the VCL. The test calls included a
generalizable sample of 119 calls that could be used to describe all
callers' wait times when calling the VCL during July and August of
2015. We also sent a nongeneralizable sample of 15 test online chats to
the VCL and 14 test text messages during the same time period. In
addition, we examined telephone call, online chat, and text message
data and summary reports from January 2013 through December 2015 that
VA maintained related to the timeliness of the VCL's operations. \6\
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\6\ We reviewed telephone call data to determine how many calls
were answered at the VCL primary center; we reviewed online chat data
to determine how many online chat requests received by the VCL received
a response within 1 minute; and we reviewed text message data to
determine how many text messages sent to the VCL received a response
within 2 minutes.
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We reviewed VCL policies, procedures, and monitoring data and
interviewed VA officials. We also compared VA's use of key performance
indicators to the Office of Management and Budget's guidance on
performance goals, which are consistent with the Government Performance
and Results Modernization Act of 2010. \7\ We observed call centers'
operations and interviewed officials and representatives of the VCL
primary center and two of the five VCL backup call centers to examine
the extent to which VA coordinates with the VCL's service partners in
ensuring that veterans receive high-quality service from responders.
Further, we reviewed VA's contract that provides backup call coverage
and VA's interagency agreement with SAMHSA. We also made 34 covert
calls in which we mimicked the experience of veterans who did not
follow the instructions of a voice prompt to press "1" to reach the
VCL. Finally, to examine the extent to which VA had plans to improve
VCL operations, we reviewed VA's improvement plans and interviewed VA
officials responsible for planning and implementing those improvements.
More detailed information on our objectives, scope, and methodology for
this work can be found in our 2016 report.
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\7\ See Office of Management and Budget, Preparation, Submission,
and Execution of the Budget-Strategic Plans, Annual Performance Plans,
Performance Reviews, and Annual Program Performance Reports, Circular
No. A-11, pt. 6 (Washington, D.C.: June 2015).
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We conducted the work on which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. In addition, the related
investigative work was performed in accordance with the standards
prescribed by the Council of the Inspectors General on Integrity and
Efficiency.
Background
In 2007, VA established the VCL, a 24-hour crisis line staffed by
responders trained to assist veterans in emotional crisis. Through an
interagency agreement, VA collaborated with SAMHSA to use a single,
national toll-free number for crisis calls that serves both Lifeline
and the VCL. \8\ Through this interagency agreement, VA and SAMHSA set
up a cooperative relationship between the agencies that would provide
consistent suicide-prevention techniques to callers.
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\8\ SAMHSA and the Mental Health Association of New York City
launched Lifeline on January 1, 2005. Lifeline provides free and
confidential emotional support to people in suicidal crisis or
emotional distress, 24 hours a day, 7 days a week.
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The national toll-free number presents callers with choices.
Callers are greeted by a recorded message that explains the function of
the crisis line and prompts individuals to press "1" to reach the VCL.
Callers who do not press "1" by the end of the message are routed to
one of Lifeline's 164 local crisis centers. \9\ All callers who press
"1" are routed first to the VCL primary center. Calls that are not
answered at the VCL primary center within 30 seconds of the time that
the caller presses "1" during the Lifeline greeting are automatically
routed to one of five VCL backup call centers. If a call is not
answered by the VCL backup call center that initially receives it, the
call may be sent to another VCL backup call center. \10\ VA entered
into a contract with a firm to oversee the operations of the VCL backup
call centers.
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\9\ The automated greeting also prompts Spanish speakers to press
"2" for assistance in Spanish.
\10\ Some VCL backup call centers do not allow calls to be rerouted
to another VCL backup call center and instead hold the call in a queue
awaiting response by that backup call center's responders.
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At the time of our 2016 report, there were a total of 164 Lifeline
local crisis centers, 5 of which also serve the VCL. \11\
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\11\ VA does not directly contract with any of the VCL backup call
centers.
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VA added online chat and text message capabilities to the VCL in
fiscal years 2009 and 2012, respectively. The number of online chats
and text messages handled by the VCL generally increased every year,
though the number of online chats decreased in fiscal year 2015.
Extended Call Wait Times Were Uncommon in July and August 2015, but VA
Did Not Meet Its Call Response Time Goals and Some Text Messages
Did Not Receive Responses
VA Responded to Most Calls within 30 Seconds in July and August 2015,
but Did Not Meet Its Goal to Answer 90 Percent of Calls within 30
Seconds at the VCL Primary Center
In our covert testing of the VCL's call response time in July and
August 2015, we found that it was uncommon for VCL callers to wait an
extended period before reaching a responder since all of our calls that
reached the VCL were answered in less than 4 minutes. However, we also
found VA did not meet its goal of answering 90 percent of calls to the
VCL within 30 seconds for test calls that we made. Our test calls
included a generalizable sample of 119 test calls that could be used to
describe all callers' wait times when calling the VCL during this
period. \12\ On the basis of our test calls, we estimated that during
July and August 2015 about 73 percent of all VCL calls were answered at
the VCL primary center within 30 seconds. \13\ VA officials told us
that, during fiscal year 2015, about 65 to 75 percent of VCL calls were
answered at the VCL primary center and about 25 to 35 percent of VCL
calls were answered at the backup call centers. These VA-reported
results indicate that about 65 to 75 percent of VCL calls were answered
within either 30 or 60 seconds. \14\ These results are consistent with
our test results for July and August 2015.
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\12\ For these test calls, callers' wait times refer to the length
of time that elapses between when callers press "1" and when responders
at either the VCL primary center or backup call centers answer the
calls.
\13\ In addition, we estimated that during July and August of 2015,
99 percent of all VCL calls were answered within 120 seconds and the
median call response time was 17 seconds. These percentage estimates
have a margin of error of within plus or minus 9 percentage points, and
the median response times estimates have a relative margin of error
that is less than 9 percent at the 95 percent confidence level.
\14\ For approximately 5 months of fiscal year 2015, VA allowed
calls to ring at the VCL primary center for 60 seconds before routing
the calls to VCL backup call centers. VA then returned to the standard
that calls not answered at the VCL primary center within 30 seconds are
then routed to VCL backup call centers.
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During our 2016 review, VA officials told us that VA attempts to
maximize the percentage of calls answered at the VCL primary center
because these responders have additional resources-including access to
veterans' VA electronic medical records-that are unavailable to VCL
backup call center responders. All responders-whether at primary or
backup centers-receive specialized training to assist callers in
crisis. \15\
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\15\ All VCL primary and backup call center responders are required
to complete Applied Suicide Intervention Skills Training in which they
learn to use a suicide intervention model to identify persons with
thoughts of suicide, seek a shared understanding of reasons for dying
and living, develop a safe plan based on a review of risk, be prepared
to do follow-up, and become involved in suicide-safer community
networks.
To Help Achieve Response-Time Goals, VA Implemented Changes at the VCL
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Primary Center
To improve its performance toward meeting the goal of answering 90
percent of calls at the VCL primary center within 30 seconds, VA
implemented two changes in fiscal year 2015-namely, staggered work
shifts for responders and new call-handling procedures.
Staggered work shifts. VA implemented staggered shifts for
responders at the VCL primary center on September 6, 2015. Staggered
shifts are work schedules that allow employees to start and stop their
shifts at different times as a way to ensure better coverage during
peak calling periods. Specifically, it helps schedule more employees to
work when call volume is highest and fewer employees to work when call
volume is lowest. \16\ Additionally, staggered shifts help limit
disruptions in service as responders begin and end their shifts.
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\16\ The International Customer Management Institute includes
staggered shifts as a best practice among call centers.
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By comparing VCL telephone call data from September through
December of 2014 to that of September through December of 2015, we
found that VA's implementation of staggered shifts at the VCL
primarycenter had mixed results. \17\ For example, the average
percentage of calls answered per hour at the VCL primary center from
September through December 2015-after staggered shifts were
implemented-was 75 percent, slightly less than the average of 79
percent answered during the corresponding period in 2014 before
staggered shifts were implemented. However, the VCL received an average
of about 1.3 more calls per hour during this period in 2015 than it
received during the corresponding period in 2014 and, according to VA
officials, the VCL primary center employed fewer responder staff in
2015 than 2014.
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\17\ Our analysis compared VCL call data from September 6, 2015,
through December 31, 2015, to VCL call data from September 1, 2014,
through December 31, 2014. The percentage of calls answered was likely
affected by several factors, such as call volume, staffing levels, and
complexity of calls. Our analysis controlled for day of the week, time
of day, and holidays, but did not control for all factors that may
affect the percentage of calls answered.
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New call-handling procedures. VA implemented new call handling
procedures at the VCL primary center beginning in June 2015 that
provided responders with specific guidance to more efficiently handle
"noncore" callers-those callers who were not seeking crisis assistance
but rather seeking help with other issues, such as help with veterans'
benefits questions. For example, if a caller reached the VCL with a
question about VA disability benefits, the VCL primary center responder
would verify that the caller was not in crisis and transfer the caller
to the Veterans Benefits Administration to address the question.
VCL telephone call data provided by VA suggest that the average
time VCL primary center responders spent handling noncore calls
decreased by approximately 30 percent over a 5-month period after
responder training began on these new call-handling procedures. \18\ We
would expect that as the average time VCL primary center responders
spent handling noncore calls decreased, these responders would have
more time available to answer additional incoming calls.
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\18\ We did not test this aspect of VCL operations with covert test
calls.
In July and August 2015, Most of Our Test Online Chats Were Answered
Within 30 Seconds, but VA Did Not Ensure That Veterans Received
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Responses through Its Text Messaging Service
To determine the timeliness of the VCL's responses to online chats
and text messages, we conducted a covert test in July and August 2015
using nongeneralizable samples of 15 online chats and 14 text messages.
All 15 of our test online chats received responses within 60 seconds,
13 of which were within 30 seconds. This result was consistent with VA
data that indicated VCL responders sent responses to over 99 percent of
online chat requests within 1 minute in fiscal years 2014 and 2015.
During our 2016 review, VA officials told us that all online chats are
expected to be answered immediately. Although this was an expectation,
we found in 2016 that VA did not have formal performance standards for
how quickly responders should answer online chat requests and expected
to develop them before the end of fiscal year 2016.
However, our tests of text messages revealed a potential area of
concern. Four of our 14 test text messages did not receive a response
from the VCL. Of the remaining 10 test text messages, 8 received
responses within 2 minutes, and 2 received responses within 5 minutes.
As we reported in May 2016, VA officials stated that text messages
are expected to be answered immediately, but, as with online chats, VA
had not developed formal performance standards for how quickly
responders should answer text messages. VA data indicated that VCL
responders sent responses to 87 percent of text messages within 2
minutes of initiation of the conversation in both fiscal years 2014 and
2015. During our 2016 review, VA officials said that VA planned to
establish performance standards for answering text messages before the
end of fiscal year 2016. VA officials noted and we observed during a
site visit that some incoming texts were abusive in nature or were not
related to a crisis situation. \19\ According to VA officials, in these
situations, if this is the only text message waiting for a response, a
VCL responder will send a response immediately. However, if other text
messages are awaiting responses, VA will triage these text messages and
reply to those with indications of crisis first. This triage process
may have contributed to the number of our test texts that did not
receive responses within 2 minutes.
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\19\ Our test text messages consisted of a simple greeting, such as
"Hi" or "Hello."
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The VCL's text messaging service provider offered several reasons
for the possible nonresponses that we encountered in our test results.
These included: (1) incompatibilities between some devices used to send
text messages to the VCL and the software VA used to process the
textmessages, (2) occasional software malfunctions that freeze the text
messaging interface at the VCL primary center, (3) inaudible audio
prompts used to alert VCL primary center responders of incoming text
messages, (4) attempts by people with bad intentions to disrupt the
VCL's text messaging service by overloading the system with a large
number of texts, and (5) incompatibilities between the web browsers
used by the VCL primary center and the text messaging software.
At the time of our 2016 review, VA officials told us that they did
not monitor and test the timeliness and performance of the VCL text
messaging system, but rather relied solely on the VCL's text messaging
service provider for such monitoring and testing. They said that the
provider had not reported any issues with this system. According to the
provider, no routine testing of the VCL's text messaging system was
conducted. Standards for internal control in the federal government
state that ongoing monitoring should occur in the course of normal
operations, be performed continually, and be ingrained in the agency's
operations. \20\ We concluded that without routinely testing its text
messaging system, or ensuring that its provider tests the system, VA
cannot ensure that it is identifying limitations with its text
messaging service and resolving them to provide consistent, reliable
service to veterans.
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\20\ See GAO, Standards for Internal Control in the Federal
Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).
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We recommended that VA regularly test the VCL's text messaging
system to identify issues and correct them promptly. In response, VA
developed and implemented procedures to regularly test the VCL's text
messaging system, as well as its telephone and online chat systems. We
believe this change will allow VA to more reliably and quickly identify
and correct errors in the text messaging system and therefore help
veterans reach VCL responders in a timelier manner.
VA Had Taken Steps to Improve Its Monitoring of VCL Primary Center
Performance but Had Not Established Targets and Time Frames for VCL
Key Performance Indicators
VA Established a Call Center Evaluation Team, Implemented Revised
Responder Performance Standards, and Analyzed VCL Caller Complaints
As we reported in May 2016, VA had sought to enhance its
capabilities for overseeing VCL primary center operations through a
number of activities-including establishing a call center evaluation
team, implementing revised performance standards for VCL primary center
responders, implementing silent monitoring of VCL primary center
responders, and analyzing VCL caller complaints. \21\
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\21\ VCL also tracks and analyzes complaints about the services of
VCL backup call centers as a part of this effort.
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Establishment of a call center evaluation team. In October 2013, VA
established a permanent VCL call center evaluation team that is
responsible for monitoring the performance of the VCL primary center.
\22\ As we reported in May 2016, the call center evaluation team
analyzes VCL data, including information on the number of calls
received and the number of calls routed to backup call centers from the
primary center. VA officials told us that they use these data to inform
management decisions about VCL operations.
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\22\ According to VA officials, this team was initially staffed
with VA employees detailed from other areas of the department in
December 2012. Permanent staff for call center evaluation were hired in
October 2013.
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Implementation of revised performance standards for VCL primary
center responders. In October 2015, VA implemented new performance
standards for all VCL primary center responders that will be used to
assess their performance in fiscal year 2016. According to VA
officials,these performance standards include several measures of
responder performance-such as demonstrating crisis-intervention skills,
identifying callers' needs, and addressing those needs in an
appropriate manner using VA approved resources.
Silent monitoring of VCL primary center responders. In February
2016, VA officials reported that they were beginning silent monitoring
of all VCL responders using recently developed standard operating
procedures, standard data collection forms, and standard feedback
protocols.
Analysis of VCL caller complaints. In October 2014, VA created a
mechanism for tracking complaints it receives from VCL callers and
external parties, such as members of Congress and veterans, about the
performance of the VCL primary and backup call centers. According to VA
officials, each complaint is investigated to validate its legitimacy
and determine the cause of any confirmed performance concerns. The
results and disposition of each complaint are documented in VA's
complaint tracking database.
VCL Key Performance Indicators Lacked Measureable Targets and Time
Frames
In 2011, VA established key performance indicators to evaluate VCL
primary center operations; however, in our May 2016 review, we found
these indicators did not have established measureable targets or time
frames for their completion.
VCL key performance indicators lacked measurable targets. We found
that VA's list of VCL key performance indicators did not include
information on the targets the department had established to indicate
their successful achievement. For example, VA included a key
performance indicator for the percentage of calls answered by the VCL
in this list but did not include information on what results would
indicate success for (1) the VCL as a whole, (2) the VCL primary
center, or (3) the VCL backup call centers. As another example, VA had
not established targets for the percentage of calls abandoned by
callers prior to speaking with VCL responders. Measureable targets
should include a clearly stated minimum performance target and a
clearly stated ideal performance target. \23\ These targets should be
quantifiable or otherwise measurable and indicate howwell or at what
level an agency or one of its components aspires to perform. \24\ Such
measurable targets are important for ensuring that the VCL call center
evaluation team can effectively measure VCL performance.
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\23\ See GAO, VA Health Care: Additional Guidance, Training, and
Oversight Needed to Improve Clinical Contract Monitoring, GAO-14-54
(Washington, D.C.: Oct. 2013).
\24\ Consistent with the Government Performance and Results
Modernization Act of 2010, the Office of Management and Budget states
that a performance goal should include a tangible, measurable objective
or a quantifiable standard, value, or rate. See Office of Management
and Budget, Preparation, Submission, and Execution of the Budget-
Strategic Plans, Annual Performance Plans, Performance Reviews, and
Annual Program Performance Reports.
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VCL key performance indicators lack time frames for their
completion. We found that VA's list of VCL key performance indicators
did not include information on when the department expected the VCL to
complete or meet the action covered by each key performance indicator.
For example, for VA's key performance indicator for the percentage of
calls answered by the VCL, the department had not included a date by
which it would expect the VCL to complete this action. As another
example, VA had not established dates by which it would meet targets
yet to be established for the percentage of calls abandoned by callers
prior to speaking with VCL responders. Time frames for action are a
required element of performance indicators and are important to ensure
that agencies can track their progress and prioritize goals. \25\
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\25\ Consistent with the Government Performance and Results
Modernization Act of 2010, the Office of Management and Budget defines
a performance goal as a statement of the level of performance to be
accomplished within a time frame. See Office of Management and Budget,
Preparation, Submission, and Execution of the Budget-Strategic Plans,
Annual Performance Plans, Performance Reviews, and Annual Program
Performance Reports.
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Guidance provided by the Office of Management and Budget states
that performance goals-similar to VA's key performance indicators for
the VCL-should include three elements: (1) a performance indicator,
which is how the agency will track progress; (2) a target; and (3) a
period. \26\ Without establishing targets and time frames for the
successful completion of its key performance indicators for the VCL, we
concluded that VA could not effectively track and publicly report
progress or results for its key performance indicators for
accountability purposes.
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\26\ See Office of Management and Budget, Preparation, Submission,
and Execution of the Budget-Strategic Plans, Annual Performance Plans,
Performance Reviews, and Annual Program Performance Reports.
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We recommended that VA document clearly stated and measurable
targets and time frames for key performance indicators needed to assess
VCL performance. While VA officials have informed us that they have
created scorecards that track information related to calls answered,
staffing, and average handle times, as of March 2017, clearly stated
and measurable targets and time frames have not yet been developed.
VA Was Strengthening Requirements for VCL Backup Call Centers, but VA
and SAMHSA Did Not Collect Information to Assess How Often and Why
Callers Were Not Reaching the VCL
VA Was Enhancing Performance Requirements for Its Backup Call Coverage
Contractor
As we reported in May 2016, VA's backup call coverage contract,
awarded in October 2012 and in place at the time of our review, did not
include detailed performance requirements in several key areas for the
VCL backup call centers. Clear performance requirements for VCL backup
call centers are important for defining VA's expectations of these
service partners. However, VA had taken steps to strengthen the
performance requirements of this contract by modifying it in March 2015
and was beginning the process of replacing it with a new contract.
According to VA officials, the new contract was awarded in April 2016.
October 2012 backup call coverage contract. This contract provided
a network of Lifeline local crisis centers that could serve as VCL
backup call centers managed by a contractor. \27\ This contractor was
responsible for overseeing and coordinating the services of VCL backup
call centers that answer overflow calls from the VCL primary center.
This contract as initially awarded included few details on the
performance requirements for VCL backup call centers. For example, the
contract did not include any information on the percentage of VCL calls
routed to each VCL backup call center that should be answered. Detailed
performance requirements on these key aspects of VCL backup call center
performance are necessary for VA to effectively oversee the performance
of the contractor and the VCL backup call centers. By not specifying
performance requirements for the contractor on these key performance
issues, we believe that VA missed the opportunity to validate
contractor and VCL backup call center performance and mitigate
weaknesses in VCL call response.
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\27\ The backup call coverage contract in place at the time of our
review was awarded in October 2012 with a 1-year base and two 1-year
option periods (for a total of 3 years of coverage) and was set to
expire in September 2015. However, according to VA officials, the
contract was extended through May 2016 while the department was
finalizing a new contract. VA officials reported that the new backup
call coverage contract was awarded in April 2016.
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As we reported in May 2016, VA officials told us about several
concerns with the performance of the backup call centers operating
under the October 2012 contract based on their own observations and
complaints reported to the VCL. These concerns included the
inconsistency and incompleteness of VCL backup call centers' responses
to VCL callers, limited or missing documentation from records of VCL
calls answered by VCL backup call center responders, limited
information provided to VA that could be used to track VCL backup call
center performance, and the use of voice answering systems or extended
queues for VCL callers reaching some VCL backup call centers. For
example, VA officials reported that some veterans did not receive
complete suicide assessments when their calls were answered at VCL
backup call centers. In addition, VA officials noted that they had
observed some VCL backup call centers failing to follow VCL procedures,
such as not calling a veteran who may be in crisis when a third-party
caller requested that the responder contact the veteran. According to
VA officials, these issues led to additional work for the VCL primary
center, including staffing one to two responders per shift to review
the call records submitted to the VCL primary center by backup call
centers and to determine whether these calls required additional
follow-up from the VCL primary center. Theseofficials estimated that 25
to 30 percent of backup call center call records warranted additional
follow-up to the caller from a VCL primary center responder, including
approximately 5 percent of backup call center call records that needed
to be completely reworked by a VCL primary center responder.
March 2015 backup call coverage contract modification. Given these
concerns, in March 2015, VA modified the October 2012 backup call
coverage contract to add more explicit performance requirements for its
backup call coverage contractor, which likely took effect more quickly
than if the department had waited for a new contract to be awarded.
These modified requirements included (1) the establishment of a 24-
hours-a-day, 7-days-a-week contractor-staffed emergency support line
that VCL backup call centers could use to report problems, (2) a
prohibition on VCL backup call centers' use of voice answering systems,
(3) a prohibition on VCL backup call centers placing VCL callers on
hold before a responder conducted a risk assessment, (4) documentation
of each VCL caller's suicide risk assessment results, and (5)
transmission of records for all VCL calls to the VCL primary center
within 30 minutes of the call's conclusion.
Development of new backup call coverage contract. In July 2015, VA
began the process of replacing its backup call coverage contract by
publishing a notice to solicit information from prospective contractors
on their capability to satisfy the draft contract terms for the new
contract; this new backup call coverage contract was awarded in April
2016. \28\ We found that these new proposed contract terms included the
same performance requirement modifications that were made in March
2015, as well as additional performance requirements and better data
reporting from the contractor that could be used to improve VA's
oversight of the VCL backup call centers. Specifically, the proposed
contract terms added performance requirements to address VCL backup
call center performance-including a requirement for 90 percent of VCL
calls received by a VCL backup call center to be answered by a backup
call center responder within 30 seconds and 100 percent to be answered
by a backup call center responder within 2 minutes. In addition, the
proposed contract terms included numerous data reporting requirements
that could allow VA to routinely assess the performance of its VCL
backup call centers and identify patterns of noncompliance with the
contract's performance requirements more efficiently and effectively
than under the prior contract. The proposed terms for the new contract
also state that VA will initially provide and approve all changes to
training documentation and supporting materials provided to VCL backup
call centers in order to promote the contractor's ability to provide
the same level of service that is being provided by the VCL primary
center.
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\28\ This notice-referred to as a sources sought notice-included a
draft performance work statement. In April 2016, VA officials reported
that this contract was awarded to the previous backup call coverage
contractor.
VA and SAMHSA Did Not Collect Information Needed to Assess How Often
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and Why Callers Were Not Reaching the VCL
In May 2016, we found that when callers did not press "1" during
the initial Lifeline greeting, their calls may take longer to answer
than if the caller had pressed "1" and been routed to either the VCL
primary center or a VCL backup call center. \29\ As previously
discussed, VA and SAMHSA collaborated to link the toll-free numbers for
both Lifeline and the VCL through an interagency agreement. The
greeting instructs callers to press "1" to be connected to the VCL; if
callers do not press "1," they will be routed to one of SAMHSA's 164
Lifeline local crisis centers. To mimic the experience of callers who
did not press "1" to reach the VCL when prompted, we made 34 covert
nongeneralizable test calls to the national toll-free number that
connects callers to both Lifeline and the VCL during August 2015 and we
did not press "1" to be directed to the VCL. \30\ For 23 of these 34
calls, our call was answered in 30 seconds or less. For 11 of these
calls, we waited more than 30 seconds for a responder to answer-
including 3 calls with wait times of 8, 9, and 18 minutes.
Additionally, one of our test calls did not go through, and during
another test call we were asked if we were safe and able to hold. \31\
VA's policy prohibits VCL responders from placing callers on hold prior
to completing a suicide assessment; Lifeline has its own policies and
procedures. \32\
---------------------------------------------------------------------------
\29\ At the time of our tests, the initial greeting was about 30
seconds long and prompted the caller to press "1" to be connected to
the VCL at the end of the greeting. If callers did not press"1," the
call was routed to one of SAMHSA's 164 Lifeline local crisis centers
based on the area code of the callers' telephone numbers.
\30\ These 34 calls were a random but nongeneralizable sample.
\31\ When asked if we were safe and could hold, we terminated this
test call.
\32\ We did not review Lifeline's policies and procedures as a part
of our May 2016 report due to our focus on the VCL. We focused our
review of Lifeline on those elements of their operations that
interacted with the VCL or VA, such as the interagency agreement
between VA and SAMHSA that governs the shared use of a single national
toll-free number between the VCL and Lifeline.
---------------------------------------------------------------------------
According to officials and representatives from VA, SAMHSA, and the
VCL backup call centers, as well as our experience making test calls
where we did not press "1," there are several reasons why a veteran may
not press "1" to be routed to the VCL, including
an intentional desire to not connect with VA,
failure to recognize the prompt to press "1" to be
directed to the VCL,
waiting too long to respond to the prompt to press "1" to
be directed to the VCL, or
calling from a rotary telephone that does not allow the
caller to press "1" when prompted.
As we found in May 2016, VA officials had not estimated the extent
to which veterans intending to reach the VCL did not press "1" during
the Lifeline greeting. \33\ These officials explained that their focus
had been on ensuring that veterans who did reach the VCL received
appropriate service from the VCL primary center and backup call
centers. In addition, SAMHSA officials said that they also did not
collect this information. \34\ These officials reported that SAMHSA did
not require the collection of demographic information, including
veteran status, for a local crisis center to participate in the
Lifeline network. However, they noted that SAMHSA could request through
its grantee that administers the Lifeline network that local crisis
centers conduct a one-time collection of information to help determine
how often and why veterans reach Lifeline local crisis centers. SAMHSA
officials explained that they could work with the Lifeline grantee to
explore optimal ways of collecting this information that would be (1)
clinically appropriate, (2) a minimal burden to callers and Lifeline's
local crisis centers, and (3) in compliance with the Office of
Management and Budget's paperwork reduction and information collection
policies. The interagency agreement between VA and SAMHSA assigns
SAMHSA responsibilities for monitoring the use of the national toll-
free number that is used to direct callers to both the VCL and
Lifeline. These responsibilities include monitoring the use of the
line, analyzing trends, and providing recommendations about projected
needs and technical modifications needed to meet these projected needs.
Using the information collected from the Lifeline local crisis centers
on how often and why veterans reach Lifeline, as opposed to the VCL, VA
and SAMHSA officials could then assess whether the extent to which this
occurs merits further review and action.
---------------------------------------------------------------------------
\33\ According to SAMHSA officials, in 2014, about 383,000 callers
abandoned their calls to Lifeline during the initial greeting used to
direct callers to either Lifeline local crisis centers or the VCL. We
did not assess the reasons these calls were abandoned.
\34\ According to SAMHSA officials, the SAMHSA grantee responsible
for administering Lifeline conducted a survey in 2014 that captured
veteran-related data. However, SAMHSA had no involvement with this
survey or the data collection activities of the Lifeline local crisis
centers that provided the information because it was outside the scope
of SAMHSA's grant to the organization. Further, HHS stated that the
SAMHSA grantee did not share the results of the survey with SAMHSA. We
did not evaluate the results of this survey.
---------------------------------------------------------------------------
Although the results of our test were not generalizable,
substantial wait times for a few of our covert calls suggested that
some callers may experience longer wait times to speak with a responder
in the Lifeline network than they would in the VCL's network. We
concluded that without collecting information to examine how often and
why veterans do not press "1" when prompted to reach the VCL, VA and
SAMHSA could not determine the extent veterans reach the Lifeline
network when intending to reach the VCL and may experience longer wait
times as a result. In addition, limitations in information on how often
and why this occurs did not allow VA and SAMHSA to determine whether or
not they should collaborate on plans to address the underlying causes
of veterans not reaching the VCL. Standards for internal control in the
federal government state that information should be communicated both
internally and externally to enable the agency to carry out its
responsibilities. \35\ For external communications, management should
ensure there are adequate means of communicating with, and obtaining
information from, external stakeholders that may have a significant
impact on the agency achieving its goals.
---------------------------------------------------------------------------
\35\ GAO/AIMD-00-21.3.1
---------------------------------------------------------------------------
We recommended VA and SAMHSA collaborate in taking the following
two actions: (1) collect information on how often and why callers
intending to reach the VCL instead reach Lifeline local crisis centers
and (2) review the information collected and, if necessary, develop
plans to address the underlying causes. We understand that VA and
SAMHSA have been coordinating on these issues. However, as of March
2017, both of these recommendations remain open.
Chairman Roe, Ranking Member Walz, and Members of the Committee,
this concludes our statement for the record.
GAO Contact and Staff Acknowledgments
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Cathleen J. Hamann, Marcia A. Mann, Vikki Porter, Lisa Rogers, and
Julie T. Stewart.
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