Findings from an internal investigation into the Department of Veterans Affairs crisis services revealed significant gaps in quality assurance, lack of a proper structure to collect, analyze and back up data, as well as pervasive waste and inefficiency plaguing one of the agency's centers in upstate New York.
The findings released in a document in mid-February were compiled by the VA s compliance and regulatory arm in response to caller complaints about the quality of Veterans Crisis Line, or VCL, services.
A key accusation centered on some calls to the suicide hotline going unanswered, before being redirected to backup centers and then to voicemail. Making matters worse, staffers report being unaware of the existence of a voice mail system.
Other findings focused on staffers answering calls who were not properly trained in how to respond, and an instance in which an ambulance, called to assist a veteran, took nearly three hours to arrive on scene.
The VA Office of Inspector General corroborated the first two out of the three findings, citing as the culprit the absence of a handbook to provide staffers guidance on VCL quality assurance and general procedures.
Wait ¦ what? No handbook?
A look online shows that the VCL bills itself as a compassionate and reliable resource for veterans during their darkest hours. According to its website, VCL has answered over two million calls since its launch in 2007. And as part of its expansion efforts to accommodate the growing number of veterans requiring emergency care the crisis hotline received more than 450,000 calls in 2014, a 40 percent increase over the previous year VCL added text-messaging services, which allowed an estimated 48,000 individuals access to the immediate care that they claim to provide.
But according to the report, about one in every six calls made to the center either go unanswered or are redirected to voicemail. What's more, employees weren't even aware that these systemic issues missed calls, prolonged wait times and straight to voicemails were happening.
Republican Senator John McCain of Arizona told CBS news that he was deeply saddened and disappointed by what was uncovered in the investigation.
"The VA's failure to help our most vulnerable veterans is not only unacceptable, but it is shameful," said the former war veteran. "The VA's inability to run a call center and deal with increasing demand has put our nation's veterans at greater risk."
The VA insists that the organization is making every effort to follow the recommendations outlined in the report. Recommendations include, but are not limited to, increasing the number of staff members during peak calling hours, providing additional sensitivity training for employees and establishing a formal quality assurance process.
The recommendations also propose that the VCL "consider" developing a VCL directive handbook.
Visit the Department of Veterans Affairs Mental Health page addressing Suicide Prevention and the first words that appear are in bold type: "One small act can make a difference." But it's clear, based on this bureaucratic blunder, that the VCL is failing to act effectively and is therefore not living up to the very standards the VA has set for itself.