OIG conducted a healthcare inspection of the Veterans Crisis Line (VCL).
OIG determined that VCL staff did not respond adequately to a veteran’s urgent needs. OIG found deficiencies in the VCL’s processes for managing incoming telephone calls and in governance and oversight of VCL operations. OIG found substantial disagreement about key decisions in operations of the VCL between the VHA Suicide Prevention Office and VHA Member Services. OIG found that VHA contracting staff and leaders lacked an understanding of the backup center contract terms and did not verify quality control aspects of contractor performance, resulting in deficient oversight.Read the full report