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The Common Wealth Fund: Creating a Culture of Safety in the U.S. Department of Veterans Affairs Health Care SystemBy: Brandon D. Morrow

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History/IntroductionAs the United States entered World War I, Congress established a new system of veterans benefits, including programs for disability compensation, insurance for service personnel and veterans, and vocational rehabilitation for the disabled. In 1945, General Omar Bradley took the reins at Veterans Affairs and steered its transformation into a modern organization (U.S. Department of Veterans Affairs. n.d.).

Healthcare for Veterans within the United States had it's humble beginning with the Continental Congress establishing pensions for wounded disabled veterans eventually evolving into our modern day systemknown asthe Department of Veterans Affairs.2

OverviewTo make health care safe, we need to redesign our systems to make errors difficult to commit and create a culture in which the existence of risk is acknowledged and injury prevention is recognized as everyones responsibility-VA Undersecretary for Health, Kenneth Kizer, M.D. (Weeks et al. 2000)

The Dept. of Veterans Affairs is the nations largest integrated health care system with over 5.1 million veterans and 7.6 million enrollees. The VA issued sweeping changes beginning in the 1990s to reallocate resources, have accountability for quality and value, and develop an information infrastructure to support the needs of patients, clinicians, and administrators. This was known as the Patient Safety Program (McCarthy and Blumenthal. 2006).3

StrengthsThe VA drew upon experience and lessons from industries such as aviation and nuclear power to form The National Safety Program.The National Center for Healthcare Services maintains a database of root causes and investigates issues pertaining to patient care. Reporting of incidents increased thirty-fold after a promise of confidential and non-punitive reporting.Nearly all root cause analyses have resulted in recommendations leading to improved patient safety (McCarthy and Blumenthal. 2006).

The National Center for Healthcare Services maintains a database of root causes and investigates issues, topics include, patient falls, medication errors, missing patients, and suicidal behavior.After 10 months of implementing the National Safety Program, the VA had a 30x increase in reporting of incidents after a promise of confidential, non-punitive reporting. This helped create data to identify all major root causes and recommended action. Medication administration errors decreased using a bar coding medication system and staffing personnel began to lead the way by exceeding instead of simply meeting JCAHO standards.

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WeaknessesA culture of identifying and then blaming an individual was not effective in promoting quality patient care. Poorly designed processes led to delays in critical decision making.Poor communication between disciplines involved in care was rampant.A lack of established procedures led to frequent failure to communicate when additional aid was required.Failure to recognize and respond to fetal distress and initiate timely cesarean delivery increased risk for both infants and mothers. (McCarthy and Blumenthal. 2006).

A culture of identifying and then blaming an individual was not working. Employees should report all adverse events and close calls to centrally locate reports. This provides a safety valve for those not comfortable reporting to the internal VA patient safety reporting system. Examples of root causes include, delays in critical decision making, poor communication between disciplines involved in care, failure to escalate communication to obtain help, failure to recognize and respond to fetal distress and initiate timely cesarean delivery, and inconsistent mobilization for emergency interventions (Nunes et al. 2004).5

OpportunitiesA culture of safety emphasizes system learning.Research determined which actions were blameworthy, assuring confidentiality, and non-punitive responses to reporting.The National Safety Program created tools to better understand errors and prevention.Understanding the obstacles to patient safety, led to improved processes. (McCarthy and Blumenthal. 2006).

With the majority of the root cause analysis completed the VA can begin to expand the Patient Safety program and emphasize a culture of safety based on learning, determine which actions are blameworthy while assuring confidentiality and non-punitive actions. They can create tools, charts and graphs to better understand and prevent errors and attempt to identify future obstacles that may impede patient safety.

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ThreatsInadequate teamwork and suboptimal communication among health care professionals are major causes of preventable adverse events and other undesirable outcomes, such as delays in surgery (Risser et al. 1999).Delays and failure in reporting of errors can lead to inaccurate data and a lack of accountability.

Communication is the key to understanding and preventing the majority of safety incidents that occur within the health care system. The VA must work tirelessly in order to reduce delays in reporting, failure in reporting errors and remain accountable when accidents occur.

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Conclusion/ImplicationsCreating a culture of safety is the only way to create a sustainable organizational focus on patient safety.-Dr. James Bagian, M.D. director of the VAs National Center for Patient Safety (McCarthy and Blumenthal. 2006).

The Patient Safety Program must remain focused on outcomes, not just reducing errors. The VA system should attempt to prevent errors and decrease likelihood of harm to the patient when they occur. Voluntary external safety reporting by employees will complement internal reports, which in turn, provide insights into broad system vulnerabilities. The volume of external reports can help gauge how well internal reports are working. With feedback taken from front line staff we can assess how programs are viewed and work toward improvement (McCarthy and Blumenthal. 2006).8

ReferencesMcCarthy, D., & Blumenthal, D. (2006). Creating a culture of safety in the U.S. Department of Veterans Affairs Health Care System. Committed to Safety: Ten Case Studies on Reducing Harm to Patients, 2:22-30. Nunes J. et al. (2004). Perinatal Patient Safety Project. Oakland, Calif.: Kaiser Permanente.Risser D.T. et al. (1999). The potential for improved teamwork to reduce medical errors in the emergency department. Annals of Emergency Medicine 34:373-83.U.S. Department of Veterans Affairs. (n.d.) History - Department of Veterans Affairs. Retrieved from http://www.va.gov/about_va/vahistory.asp Weeks W.B., & Bagian J.P. (2000). Developing a culture of safety in the Veterans Health Administration. Effective Clinical Practice 6:270-6.

Thank you for reviewing the Department of Veterans Affairs Patient Safety Program. Please see below for additional information.

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