Review of Emergency Dispatch and Facility Transport Processes at the Veterans Health Administration’s Veterans Crisis Line

The VA Office of Inspector General (OIG) initiated a healthcare inspection on June 23, 2025, to evaluate allegations that the Veterans Crisis Line’s (VCL) emergency dispatch and facility transport processes were inefficient and could negatively affect timeliness and quality of care. The review also examined concerns about VCL leaders’ communication and collaboration with staff and staffing methodology.

The OIG substantiated that VCL’s process for distributing emergency dispatch service and facility transport plan requests was inefficient as it did not maximize social service assistant (SSA) staff resources and could potentially affect the quality or timeliness of care received by customers. At the time of the inspection, requests were routed to an SSA team rather than to all available SSAs, resulting in uneven workload distribution. SSA leaders had identified the inefficiencies and initiated a modernization effort in April 2024 to consolidate SSAs into one team. In January 2026, the integration took effect, enabling equitable workload distribution. Although substantiated, the OIG considers this issue resolved.

The OIG substantiated that VCL and SSA leaders did not communicate or collaborate effectively with SSA supervisors and staff by not responding to staff questions about workflow processes that could impact customers, acknowledging suggestions, or engaging staff in improvements directly related to their work. The OIG found an overall sense of disempowerment among SSA supervisors and staff, undermining the tenets of a high reliability organization.

The OIG identified an opportunity to enhance VCL’s methodology for determining SSA staffing levels. VCL leaders determined SSA staffing levels on a fixed ratio of crisis responders to SSAs rather than SSA workload data.

The OIG made two recommendations to the VCL Executive Director related to evaluating and establishing mechanisms for ongoing, bidirectional communication between leaders and frontline staff and utilizing SSA-specific workload data to inform staffing decisions.