Veterans Crisis Line Leadership Failures: A Culture of Turning a Blind Eye

Tragic Incident at Veterans Crisis Line

• 💔 A veteran died by suicide on September 23rd after contacting the Crisis Line via text message.
• ⚠️ The responder missed multiple critical cues indicating the veteran was actively attempting suicide, including losing consciousness.
• 📉 Despite the severity, the responder reported the call ended normally, and the veteran was pronounced dead two minutes later.

Failure to Conduct Root Cause Analysis

• 🔍 A root cause analysis (RCA) is a standard process to identify the underlying reasons for an event, commonly used in business and healthcare.
• 🚫 An RCA was not performed in 2021 when the incident was first reported, described as 'business as usual' due to a lack of concern and absence of a transcript.
• ⏳ The executive director decided against performing an RCA in 2021, but later deemed it appropriate in 2022, suggesting a reactive approach to potential IG findings.

Culture of Permissiveness and Neglect

• 🚩 Senator Moran described a pervasive 'culture of turning a blind eye' and 'covering up deficiencies' at the Veterans Crisis Line (VCL).
• 🎯 This culture is attributed to leadership, starting from the executive director of the suicide prevention program, who has fostered an environment where metrics are prioritized over lives.
• 🗣️ Call center staff are described as 'rock stars,' but the overall management team is criticized for creating a permissive atmosphere.

Deficiencies in VCL Leadership and Management

• 📉 Miss Blaine highlighted a lack of active standard operating procedures, elevation of positions based on 'clicks' rather than experience, and ignorance of union contracts.
• 🧑‍💼 Many management staff hired in 2016 were new to federal employment, lacked experience in managerial principles, and were unaware of union contracts.
• 🚫 Attempts to offer experienced training to management were rejected, indicating a resistance to external expertise and a failure to develop internal capabilities.

Consequences and Atmosphere of Silence

• ❓ Several individuals involved in the described failures are still employed at the VA, with some having left but no clear indication of significant consequences.
• 🤐 An atmosphere of 'be quiet, keep your head down, or face the consequences' discourages employees from speaking out about issues.
• 🎖️ This silence is particularly poignant given that the individuals served the country and had no option of 'keeping their head down' during their service.