Government and Regulations

VA Pledges to Strengthen Veterans Crisis Line Operations in New York

Inspection prompted by reports of Veterans Crisis Line calls in Canandaigua, New York, going unanswered or directly to voicemail and improperly trained responders.


The VA Office of Inspector General (OIG) released a report of its investigation of quality assurance concerns regarding the Veterans Crisis Line (VCL) in Canandaigua, New York. The investigation began in 2014. Allegations of calls going unanswered or answered by voicemail and improperly trained responders sparked the investigation.

“It is important for veterans and our key stakeholders to know that VA undertook actions to strengthen Veterans Crisis Line operations long before publication of the inspector general report,” Deputy Secretary Sloan Gibson responded in a blog post. Gibson insisted that the VA will “continue that work until the Veterans Crisis Line is the world-class crisis response center veterans deserve.”

The OIG report stated that it “substantiated allegations that some calls routed to backup crisis centers were answered by voicemail, and callers did not always receive immediate assistance from VCL and/or backup center staff.” The investigation also found that the VCL management team did not provide adequate orientation and ongoing training for social service assistants.

Upon the investigation’s completion in fiscal year 2015, the OIG made 7 recommendations to improve the quality of the VCL service for veterans and their families. The executive director of the Office of Mental Health Operations (OMHO) concurred with all 7 and implemented steps to ensure compliance.

For example, OMHO and VCL staff now must submit daily, weekly, and monthly reports that track system issues—including response hold times. The VCL also hired 68 additional crisis line responders, and VCL policy now states that backup centers cannot place callers on hold. Routing “rollover” calls also ensures that no caller waits longer than 2 minutes.

The VCL service has seen its usage grow by 467,000 annual calls from 2008 to 2015. Spurred by this increase in call volume, the VCL also made technology investments last year that upgraded its phone systems and allows for a higher volume of calls.

A New Employee Orientation program, updated employee handbook, and a formal quality assurance program combine to ensure that all VCL employees receive proper training. A VCL Talent Management System also will track and record all employees’ performance data for frequent analysis.

All 7 recommendations are scheduled to be fulfilled by September 30, 2016.

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