[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


     AN ASSESSMENT OF ONGOING CONCERNS AT THE VETERANS CRISIS LINE

=======================================================================

                                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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                     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 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

                              ----------                              

                         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

                              ----------                              


                         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.
---------------------------------------------------------------------------
    \8\ Business Dictionary's definition of governance.
    \9\ Our review period was from June through December 2016.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \12\  The Office of Suicide Prevention leads suicide prevention 
efforts for VHA and coordinates and disseminates evidence-based 
findings related to suicide prevention.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \19\ VHA Directive 1028, VHA Enterprise for Framework for Quality, 
Safety, and Value, August 2, 2013.

---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \20\ VHA Directive 1026, VHA Enterprise for Framework for Quality, 
Safety, and Value, August 2, 2013.

---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
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\
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    \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.
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    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.
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    \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 
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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 
---------------------------------------------------------------------------
    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

    For questions about this statement, please contact Seto J. Bagdoyan 
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Public Affairs may be found on the last page of this statement.
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Julie T. Stewart.

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