'Culture Of Turning A Blind Eye': Jerry Moran Flames Bad Leadership At Veterans Crisis Line

Forbes Breaking News

In a Senate Veterans' Affairs Committee hearing on Wednesday, Sen. Jerry Moran (R-KS) asked former employees of the Veterans Crisis Line about failed leadership.

Transcript

00:00Thank you, Ms. Blaine. Mr. Combs, thank you again for bringing these serious matters to our attention,

00:08for working with me and our team and the Government Accountability Office, and for being here today.

00:15I know your motivation is to help improve the circumstances at the veteran crisis line and

00:21to protect the well-being of those in need of services. Would you describe for me, for the

00:28committee, the interaction between the veteran caller and the responder that led to the September

00:3523 OIG report? Yes, sir. If I could, real quick, I'd like to thank you for listening. It's been really

00:46important that you listen and for John and Emily and your staff for everything they did for these

00:50past couple years. It was really important. Thank you. The interaction that took place, the veteran

00:58was an act of accomplishing a suicide. He contacted the crisis line via text message. The responder

01:08missed multiple cues, multiple cues that the veteran had a butter on his neck, that he was losing

01:15consciousness, that he was actually attempting suicide as he was texting her. She reported

01:25that the call ended normally. Two minutes later, the veteran was dead and, in fact, died in his

01:31garage behind his house, mere feet from his entire family. My understanding, based upon what my staff

01:40tells me, that an interaction like that should trigger a root cause analysis. Tell me what that is and

01:48tell me if one occurred. Yes, sir. A root cause analysis. Why or why not? Yes, sir. Root cause analysis

01:56within the VA, they use it on a clinical basis, but it's a very common thing that, frankly, everyone does

02:03to get down to what was the root cause of the issue that led to the event. She's in business as well.

02:09A root cause analysis in VA's and VCL's terminology is to identify what the actual root cause of the

02:17event was that led to the suicide after VA was last touched, after VA was involved or VCL was involved

02:25or could be involved in a suicide. The root cause analysis was not performed in 2021 when we were

02:33first informed of the veteran because we didn't have a transcript and no one was actually all that

02:37concerned about it. It was kind of business as usual, but when the IG said they were coming in,

02:45we were very concerned about what the IG might identify, so we wanted to dig into what the IG might

02:52find out and try to get ahead of the train. Frankly, they'd be able to put a point on this. The executive

03:01director determined that a root cause analysis would not be performed in 2021 and in 2022 decided that

03:09root cause analysis was appropriate to perform. My takeaway from your testimony, Mr. Combs, and perhaps you too,

03:17Ms. Blaine, is that there's this culture of turning a blind eye, outright covering up of deficiencies,

03:29and what it seems is that it may be really common at the veterans crisis line and none of this makes

03:36sense to me. I don't think I know people who would not take those circumstances seriously, whether you're

03:43the responder, whether you're the person on the line, or whether you're that person's supervisor. I don't

03:49think I understand how anyone could not see the importance and take every step necessary to protect

03:56the life of the caller. What's missing? How does this take place? I wrote down training, attitude,

04:04leadership. I don't know what supervision. What's missing here that would cause somebody to do something

04:11that seems to me to be so inhumane? Sir, it is an attitude or a culture of permissiveness.

04:19It starts from the top. It's the executive director of suicide prevention program that, again,

04:25has been running the program as well as the VCO since 2017, who's created the culture of permissiveness

04:34and his management team outside the call center, because I want to be very clear, call center people are

04:39rock stars. But the management team overall, the cultural permissiveness has led to this environment

04:46where they chase metrics and not lies. And what do they benefit by having better metrics?

04:52Is there an incentive for better metrics? Mr. Chairman, I can't answer that because it's

04:59completely foreign to me from a from a service point of view. All I know is to serve. Senator Blumenthal,

05:06I wish he was here. He and I, on a different committee, the Senate Committee on Commerce,

05:10conducted a long investigation into the sexual abuse of gymnasts in the Olympics. And I remember the

05:19Olympian, at least one of them, saying what stuck with me from the very beginning is, and it was a

05:25series of women who were harmed. And it was, why was there more than one? And it strikes me as something

05:35very similar here about if there's an error, a poor performance, disregard for human life. It happened

05:45once, but then it was taken care of. And so while I would condemn the bad behavior of any employee,

05:54I don't understand how it wouldn't be corrected so that it never happened again.

05:57Ms. Blaine, let me ask you, I also thank you for being here and your courage and explaining and

06:05sharing your experience. Describe the VCL leadership. What's the story there?

06:13Ms. Thank you so much for that question. I have to start with the fact that I have a lot of leadership

06:20experience coming from IRS. So coming into the VCL, notable things such as no active standard operation

06:32procedures were written. There was elevation of positions by clicks, not by experience. There was

06:42an ignorance to what was in the union contract, what was right, what was wrong, what was indifferent.

06:48And I think that because of a lack of leadership skills, trained individuals on running departments

06:56from that manner trickled down to what was happening at the bottom line with the crisis

07:03respondent and all of the teams. When we onboarded in 2016, the management staff were new hires off the

07:13street. They had not been federal employees before. They knew nothing about union contracts. They knew nothing

07:19about managerial principles. In fact, I went to the then director and said, listen, I know I'm not in

07:27management, but I can guarantee you with all the years that I've been training managers at IRS, I can help get

07:32your people on their feet. They said, no, thank you. So at that point, I had to begin looking at how could I be a voice

07:40on behalf of the responders and the employees because I knew that the management staff, their abilities, even in projecting staffing was not

07:52that great because they just didn't have the experience. I need to wrap up my questions quickly for the benefit of my colleagues.

07:58I want to ask two more and then I will move on. Are the people who you are describing here today, are they still employed at the VA?

08:12Has there been any consequences? What's the one or both of you, either of you?

08:18Mr. Chairman, I think Marcia, she's been there. She just left the VCL, so she's probably better situated to answer.

08:26Several of them are still employed. Some have left, but yes, the answer to your question.

08:34And finally, and it kind of fits with what Mr. Combs just said when he deferred to you.

08:40So if you were still an employee at the VA and you were here in front of us,

08:44is that something that you would be honored for or something you'd be punished for?

08:50More than likely punished. There is an atmosphere of be quiet, keep your head down, or face the consequences.

09:02It strikes me so sadly because we're dealing with people who didn't,

09:08people who served our country who had no option of keeping their head down.

09:11Correct.

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