Veterans Crisis Line: Additional Testing, Monitoring, and Information Needed to Ensure Better Quality Service
Highlights
What GAO Found
GAO found that the Department of Veterans Affairs (VA) did not meet its call response time goals for the Veterans Crisis Line (VCL), although extended call wait times were not common. VA's goal is to answer 90 percent of VCL calls at the VCL primary center within 30 seconds. Currently, calls not answered within 30 seconds route to VCL backup call centers; however, for 5 months of fiscal year 2015, calls were routed to VCL backup call centers after 60 seconds. VA officials told GAO that VA data show about 65 to 75 percent of VCL calls were answered at the VCL primary center in fiscal year 2015 within either 30 or 60 seconds. GAO's covert testing in July and August 2015 confirms VA's data. Specifically, 119 covert test calls show that an estimated 73 percent of calls made during this period were answered within 30 seconds. GAO also estimates that 99 percent of all VCL calls during this period were answered within 120 seconds. GAO also covertly tested the VCL's text messaging services and found that 4 of 14 GAO test text messages did not receive responses. VA officials said they do not monitor or test the timeliness and performance of the VCL text message system and instead rely solely on the VCL's text messaging provider for these functions. VA officials told GAO that the provider had not reported any issues with the system, but the provider told GAO that routine testing of the VCL system is not conducted. Without routinely testing its text messaging system or ensuring that its provider does so, VA cannot identify limitations to this service.
While VA has taken a number of steps to improve its monitoring of the VCL primary center operations, VA has not developed measurable targets and time frames for its key performance indicators, such as the program's percentage of abandoned calls. VA established a permanent VCL call center evaluation team and created a mechanism for tracking complaints about the performance of the VCL primary center from VCL callers or external parties. However, GAO found that VA has not specified quantifiable or otherwise measurable targets and has not included dates for when it would expect the VCL to complete actions covered by each key performance indicator. This is inconsistent with guidance provided by the Office of Management and Budget. As a result, VA cannot ensure that the VCL is providing consistent, high-quality services to callers and cannot effectively track and publicly report progress or results.
VA established an interagency agreement with its service partner, the Department of Health and Human Services' (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA), to manage the shared operations of the VCL and the National Suicide Prevention Lifeline (Lifeline), which include a single national toll-free number used by both. Despite these efforts to coordinate, VA and SAMHSA do not collect information needed to assess how often and why callers intending to reach the VCL do not follow voice prompts and instead reach Lifeline local crisis centers. VA officials told GAO that the type of information that would be needed to do so is not collected because VA has focused on addressing the concerns of those callers who did reach the VCL. In addition, SAMHSA officials said that they do not require Lifeline local crisis centers to collect this type of information, noting that it would be possible to collect it. As a result, VA and SAMHSA do not know the extent to which this occurs and cannot determine the underlying causes that may need to be addressed.
Why GAO Did This Study
VA established the VCL in July 2007 to provide support to veterans in emotional crisis. Between fiscal years 2008, its first full year of operation, and 2015, the number of calls received by the VCL increased almost 700 percent, exceeding VA's expectations. As VA began to address increasing numbers of requests for assistance, reports of dissatisfaction with VCL's service periodically appeared in the media.
GAO was asked to review VA's administration of the VCL. This report, among other issues, examines (1) the extent to which VA meets response-time goals for VCL calls and text messages, (2) how VA monitors VCL primary center call center operations, and (3) how VA works with VCL service partners to help ensure veterans receive high-quality service. GAO visited the VCL's primary center and two backup call centers; tested VCL response time through a generalizable sample of covert telephone calls and a nongeneralizable sample of text messages in July and August 2015; reviewed internal reports and policies and plans; and interviewed VA and SAMHSA officials.
Recommendations
GAO recommends that VA regularly test VCL's text messaging system and document targets and time frames for key performance indicators. GAO also recommends that VA and SAMHSA collect information on how often and why callers reach Lifeline when intending to reach the VCL, review this information, and, if necessary, develop plans to address the causes. VA and HHS concurred with GAO's recommendations and described planned actions to address them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | To improve the timeliness and quality of VCL responses to veterans and others, the Secretary of Veterans Affairs should direct the Under Secretary for Health to regularly test the VCL's text messaging system to identify issues and correct them promptly. |
We tested the Veterans Crisis Line's (VCL) text messaging system and did not receive responses to 4 of 14 test text messages. The Department of Veterans Affairs (VA) did not regularly test its text messaging system and acknowledged that proactively identifying and correcting errors with this system would provide greater assurance that veterans in crisis are able to reach trained VCL responders in a timely fashion. We recommended that VA regularly test the VCL's text messaging system to identify issues and correct them promptly. In July 2016, VA developed and implemented procedures to regularly test the VCL's text messaging system, as well as its telephone and online chat systems. 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 more timely manner.
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| Department of Veterans Affairs | To improve the timeliness and quality of VCL responses to veterans and others, the Secretary of Veterans Affairs should direct the Under Secretary for Health to document clearly stated and measurable targets and time frames for key performance indicators needed to assess VCL performance. |
In July 2017, VA updated its Veterans and Military Crisis Line Quality Assurance Plan, which documents measurable targets and time frames for key performance indicators need to assess VCL performance. Additionally, in March 2017, VCL established an Executive Leadership Council (ELC) which oversees organizational governance and reviews quality data to ensure information and key quality components are discussed. The charter for the ELC states the VCL key performance indicators are central to the mission of the ELC and will be closely monitored. By documenting measurable targets and time frames for performance indicators needed to assess VCL performance and establishing a council to monitor data on the key performance indicators, VA has taken steps toward ensuring that the highest level of service is provided to every veteran seeking support in a crisis situation.
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| Department of Health and Human Services | Under the applicable terms of their interagency agreement, the Secretary of Veterans Affairs and the Secretary of Health and Human Services should direct the Under Secretary for Health and the Administrator of the Substance Abuse and Mental Health Services Administration, respectively, to collaborate and collect information on how often and why callers intending to reach the VCL instead reach Lifeline local crisis centers. |
In April 2017, HHS provided documentation showing that it collaborated with VA to collect information on how often and why a caller might not reach the VCL through a survey of Lifeline-affiliated crisis centers. This survey was completed in November 2016. By collecting this information, HHS and VA will be able more effectively determine the extent to which veterans intending to reach the VCL reach Lifeline instead and whether this merits further review and action.
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| Department of Veterans Affairs | Under the applicable terms of their interagency agreement, the Secretary of Veterans Affairs and the Secretary of Health and Human Services should direct the Under Secretary for Health and the Administrator of the Substance Abuse and Mental Health Services Administration, respectively, to collaborate and collect information on how often and why callers intending to reach the VCL instead reach Lifeline local crisis centers. |
In April 2017, VA provided documentation showing that it collaborated with HHS to collect information on how often and why a caller might not reach the VCL through a survey of Lifeline-affiliated crisis centers. This survey was completed in November 2016. By collecting this information, VA and HHS will be able more effectively determine the extent to which veterans intending to reach the VCL reach Lifeline instead and whether this merits further review and action.
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| Department of Health and Human Services | Under the applicable terms of their interagency agreement, the Secretary of Veterans Affairs and the Secretary of Health and Human Services should direct the Under Secretary for Health and the Administrator of the Substance Abuse and Mental Health Services Administration, respectively, to collaborate review the information collected and, if necessary, develop plans to address the underlying causes. |
In April 2017, HHS provided documentation showing that HHS and VA collaborated to review the results of the November 2016 survey of Lifeline-affiliated crisis centers. HHS and VA officials determined that action was needed to ensure that callers intending to reach the VCL are able to do so. Through April 2017, HHS and VA officials collaborated to develop a warm transfer proposal, which will allow Lifeline centers to quickly transfer veterans to the VCL. By collaboratively reviewing the survey results and developing a proposal allowing Lifeline centers to quickly transfer callers to the VCL, HHS and VA officials have taken steps toward ensuring that every veteran who wants to reach the VCL to receive support in a crisis situation can do so.
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| Department of Veterans Affairs | Under the applicable terms of their interagency agreement, the Secretary of Veterans Affairs and the Secretary of Health and Human Services should direct the Under Secretary for Health and the Administrator of the Substance Abuse and Mental Health Services Administration, respectively, to collaborate review the information collected and, if necessary, develop plans to address the underlying causes. |
In April 2017, VA provided documentation showing that VA and HHS collaborated to review the results of the November 2016 survey of Lifeline-affiliated crisis centers. VA and HHS officials determined that action was needed to ensure that callers intending to reach the VCL are able to do so. Through April 2017, VA and HHS officials collaborated to develop a warm transfer proposal, which will allow Lifeline centers to quickly transfer veterans to the VCL. By collaboratively reviewing the survey results and developing a proposal allowing Lifeline centers to quickly transfer callers to the VCL, VA and HHS officials have taken steps toward ensuring that every veteran who wants to reach the VCL to receive support in a crisis situation can do so.
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