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Q & A: Veteran suicide hotline now answers 9 of 10 calls in 8 seconds

Meaghan McDermott | USA Today

ROCHESTER, N.Y. — A 10-year-old suicide hotline designed to assist veterans at their deepest moments of despair has taken heavy criticism recently following a trio of highly critical government reports that questioned answer times, staff preparedness and quality assurance.

Earlier this week Acting Director Susan Strickland, acting director of the Veterans Crisis Line, and Julianne Mullane, assistant deputy director of team operations for the Canandaigua, N.Y., veterans hotline, sat down to discuss the government reports and their agency's efforts to improve operations

• Mostly complete. Although an Office of the Inspector General report in March said numerous recommendations made the year prior about improvements to the Veterans Crisis Line had not been completed, six of the seven recommendations already were put in place by the time the report came out.

• Additional improvements. Sixteen more recommendations made this year will be in place by Dec. 31.

• New automation. Upgraded phone systems now automatically record all calls, as well as log phone numbers of callers — a practice that had previously been done by hand.

• Temporary problems. Opening a new call center in Atlanta this past fall had was temporarily detrimental to service at the Canandaigua site, about 30 miles southeast of Rochester, as staffers there were redeployed to train new employees in Georgia. Since training has settled down, the crisis line now is answering more than 90% of calls within 8 seconds, and only about 1% of calls are being rerouted to a backup call center.

• Quality control. Now silent monitors listen to random calls in real time and review the counselors' advice for quality assurance.

• High demand. In some ways, the center has been a victim of its own success. Started 10 years ago with a skeletal staff and a prevailing attitude that veterans wouldn't call for help, the Veterans Crisis Line has been scrambling to keep up with unanticipated demand ever since. Just since May, calls for service have increased from 2,000 a week to more than 2,250.

A year ago, the Veterans Health Administration Office of Inspector General reported that more than a third of calls to the Veterans Crisis Line, then located only at the Canandaigua Veterans Affairs Medical Center in upstate New York, were being shunted to backup call centers, some calls were taking more than a half hour to be answered and other callers were being given only an option to leave messages on voicemail.

In March, another inspector general's report said not only had recommendations from its previous report not yet been carried out but also that hotline staff had a host of continuing deficiencies in the way they handled incoming phone calls, staff training records and other oversight.

In June, a Government Accountability Office report said nearly 1 in 4 text messages to the center were met with no response.

On Thursday, Secretary David Shulkin of the Department of Veterans Affairs told the Senate Veterans Affairs Committee the operation had made great strides following the March report, including reducing the rate of calls being shifted to backup centers to about 1%. The center handles in excess of 500,000 calls per year, and has initiated nearly 75,000 emergency service responses since its inception in 2007.

In October, an additional call center went online in Atlanta. The new center more than doubles the number of staffers handling calls: 297 in Canandaigua and 281 in Atlanta. Officials expect the sites to have a total of more than 800 workers by the end of the federal fiscal year Sept. 30.

Portions of the discussion with Strickland and Mullane follow, edited for length and clarity:

Question: In March, the inspector general said the Veterans Crisis Line hadn't finished putting in place its recommendations for improvement from the prior year and it issued 16 more recommendations. What have been the holdups and how far along is that process?

Susan Strickland: Let me clarify that.

Six of the first seven recommendations are closed at this time. The one remaining pertains to the backup call center contract and that will be closed by June 30, which is our contract deadline date.

We are negotiating that contract now. We will have it all signed and sealed and ready on June 30. That will close out the first seven.

Then, the inspector general came back last fall and re-looked at things and opened 16 more recommendations. Of those 16, we have recommended two closed already and requested two more to be closed.

So that's a total of four, and we have a timeline and frame to get them all closed by Dec. 31 of this year. We are actively engaged in meeting those requirements every day.

Julianne Mullane: The thing with a lot of those requirements is that they're asking us to provide data that we've implemented them for several months in a row.

So, it's not that we're not doing anything; it's that we have to implement and then show that we've implemented the recommendations over time. So it takes a little while.

Q. Can you speak to the nature of the recommendations? 

Strickland: One is training, and we just went over the training curriculum, written a training curriculum, and implemented and have been using it since last September.

So all of our legacy employees are older employees are now being put through that training. 

(She also said the new curriculum was used to train all the new Atlanta employees, and testing Atlanta's new equipment and systems in Atlanta complicated initial service at both sites.)

Mullane: We have had that training (in New York) since January of last year, but some of the issues were around the tracking of who had completed the training, who had not and the dates.

(Training includes at least three weeks of classroom work, followed by two to three additional weeks of hands-on work before an employee can be cleared to take calls alone.)

We have always had training, and the OIG recommendation focused more on the packaging of it, doing post-tests, formalizing it and making it much easier to report on. Our staff are very well trained in crisis intervention and risk assessment, but they haven’t all been through that more formalized, tested training.

And that’s what we’re in the process of doing, getting everyone through it, But it’s two weeks long, so if doing 10 responders at a time and we have 200, it takes a little while.

Strickland: The other big piece of the OIG recommendations had to do with quality metrics and quality assurance. So we now have a very robust and strong quality management program.

We have 26 silent monitors all hired now and trained. And they listen to calls 24/7, and the staff does not know they’re going to be listened to.

Then the monitors give feedback to our staff on what they did right, what they did incorrectly, what they could have done better. That feedback is given to staff and to their supervisor.

Q. Other recommendations had to do with your technology infrastructure, like the ability to record calls, to log phone calls automatically. What's been done to address that?

Mullane: We already had a lot of that technology in place but not yet implemented when OIG came.

So since their visit, we are recording calls, and use them to clear people and in our quality management system, We have also upgraded our phone system, and we are still in the process of upgrading our customer relations management system, our database where we record every call.

That is a new system that is just about done, but we have to get all the staff trained on it now.

Q. The reports had questions about quality assurance at the backup centers. How will the hotline handle that going forward?

Strickland: The new contract dictates symmetrical training and quality control.

So the backup center will mirror what VCL does. It's a matter of making tight the contract so we're getting a good service on the back end when calls do roll over.

Q. Congress finalized a sweeping Veterans Affairs accountability bill earlier this week. Would that bill allow the department to operate the Veterans Crisis Line more efficiently or improve service?

Strickland: When a new employee comes on to work for VCL, they are on probation for the very first year of their employment in a new position.

So anyone can be let go during that year of probation. We do have a lot of accountability in that.

Once someone (goes) beyond the year and becomes a permanent employee, then we of course, we track conduct, track performance and utilize performance-improvement plans. And we utilize evaluation and metrics to hold people accountable for their jobs.

Q. The inspector general report said no formal process was in place to debrief an employee in the event of an attempted or completed suicide. Has that issue been addressed?

Strickland: If there is a completed suicide, we do a root-cause analysis where we drill down, listen to the call recording, look at what kind of variables went on that we could change or done something differently about.

Mullane: As soon as we find out about a death where we did have last contact, we take the (employees involved in the case) aside and tell them in private so they can process that.

We don't want them to hear about it in passing or while they're on another call. It's startling, and we need to give people time to process that.

People put their heart and souls into these calls here. They're very mission driven, and they take it hard.

And we are constantly improving our documentation. We had a lot of great practices already in place that are based on the latest evidence-based research, and we're getting better at documenting it.

Q. Is there anything the general public may not know about the inspector general reports?

Strickland: Often the press ends up reporting on things way later than what’s happened.

So those first recommendations were already worked on before they made it out there, and when the OIG released them, they were already closed. There’s a lag time of about a year between when an investigation and recommendations are given, and the agency’s already working on it by the time the report gets published.

Mullane: Also, about the few people that reached a voice mail because the backup center's lines went down: ... We tracked every person. We were able to contact them back.

We tracked them, and they were all doing OK. And we were able to get them connected with their suicide prevention coordinator.

And that was immediate. Within 24 hours after we learned what happened, we had started our outreach to them.

When these types of reports come out and recommendations come, we are open to the recommendations.

We’re going to work hard to implement them. We're going to constantly strive to document better and be able to present our work better.

But in no way does that take away from what our staff do every day, how much they believe in the mission and how much they give to the job.

I’ve never worked with such a mission-driven group of people who are so passionate. Kudos to them who do the hard work every day.

All of the bad press is really not about the work they are doing on the phones, it’s about the infrastructure and how fast we grew and us learning how to be a grown-up call center.

Q. Where do things stand now with calls?

Strickland: We have worked very hard on our answer times. We are now answering 95% of our calls within 8 seconds.

And we have now about 1% of calls on any given day rolling over to a backup center.

That's significant. Six months ago, that wasn't the case.

But since January, between 90% and 95% of all calls are being answered within 8 seconds. We have worked incredibly hard. 

Q. You mentioned "learning to be a grown-up call center." What did you mean by that?

Strickland: We keep increasing in call volume.

Things just exploded over the last year for who knows what reasons — perhaps because the VA has made suicide a priority. And we were not ready for that on the VCL side, to be the first line of defense on that.

But since then, we have built up and met the challenge and are able to meet it at this point and are working hard to be ahead of the demands. ... We are looking ahead to Suicide Prevention Month in September, to the Department of Defense's initiatives for suicide prevention and our own department's initiatives to get us to zero suicides.

We're trying to be proactive in building up capacity rather than reacting to what's happening out there.

Mullane: And we have been reactive since the beginning of the hotline. People didn’t think veterans would call at first.

They said, "Yeah, start this hotline, but we don’t think veterans are going to reach out for help."

And every year our volume increased dramatically. We started with what, 20 people maybe? And four phone lines?

So look how far we’ve come.

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