Veterans Crisis Line Still in Crisis

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I. just. don’t. understand. Really, I don’t. How can we, the people, pay these Veterans Affairs bureaucrats six-figure salaries for such two-bit performance? Last year, Matt Eitutis, a VA bureaucrat who led the VA’s Health Resource Center to a whopping 26% call abandonment rate (when callers in queue finally hang up when no one takes their calls), was appointed to rescue the Veterans Crisis Line. (See “New VA Hotline Chief Has a History of Dropped Calls from Veterans,” USA Today, 3/4/2016.) About a year after that article, the VA’s Inspector General issued a report dated 3/20/2017 that found some alarming deficiencies, not to mention that Veteran’s Crisis Line management had still not successfully addressed recommendations in a previous February 2016 report issued by the IG. Some of the more disturbing findings of the 2017 IG report appear below. My comments appear in brackets:

  • The Suicide Prevention Office leads suicide prevention efforts for VHA and coordinates and disseminates evidence-based findings related to suicide prevention. The Director of the VHA Suicide Prevention Office stated that the Acting Director of the VCL informed her that she had no authority over the VCL. We found limited communication between the VHA Suicide Prevention Office and VHA Member Services about suicide prevention and the VCL. [So administrative people at Member Services, led by Eitutis, weren’t listening so well to the clinical people, the people who actually know how to save lives.]
  • We were also informed during interviews that Member Services leaders did not heed warnings from VCL clinical staff who predicted obstacles to achieving proposed operational targets in the intended timeline (such as inadequate staffing and training resources). Lack of formal planning and inaccurate forecasting resulted in more than 16,000 hours of Canandaigua FTE (full–time equivalent) employees being temporarily redirected to the Atlanta Call Center for training and operations. This led to an increase in the number of calls that rolled over to backup centers and delays in the development and implementation of VCL processes, policies, and procedures. [No surprise here, given the first bullet in this list.]
  • VCL leaders defined the success of the call center partly in terms of suicide reduction. However, the VCL had no process in place for routinely obtaining or reviewing data on serious outcomes, such as attempted or completed suicides by veterans who made contact with the VCL prior to the event. By not reviewing serious adverse outcomes, VCL QM managers missed opportunities for quality improvement. [They weren’t even bothering to look if they were actually preventing suicides.]
  • We found that VCL leadership had not established expectations or targets for queued call times or thresholds for taking action on queue times. A veteran could be queued for 30 minutes, for example, and that wait time might not be reflected in hold time data; however, the result of the delay is the same, whether the veteran was in a queue or on hold. [They weren’t counting queue times. A bureaucrat will always find a way to look good somehow.]
  • The QM [quality monitoring] 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.
  • We made seven recommendations in a previously published report, Healthcare Inspection–Veterans Crisis Line Caller Response and Quality Assurance Concerns Canandaigua, New York (Report No. 14-03540-123, February 11, 2016). VHA concurred with the recommendations and agreed to a completion deadline of September 30, 2016. We consider all prior recommendations to remain open as of the publication of this report. [This report’s date is 3/20/2017. Here’s one of the findings from that report: “We substantiated the OSC complainant’s allegations that SSAs [Social Service Assistants] 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.”]

Every one of the action items from an IG report in February 2016 was STILL open as of the March 2017 report, over a year later and six months after the initial deadline for taking care of those deficiencies. And we pay these VA big-shots six figures? Go figure!


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