VA makes improvements in patient safety

A post from Jim Toole that discusses the VA's integrated approach to care delivery.

by Jim Toole, SOA Board Member

JimToole The Veterans Administration (VA) hospital system has made quality and patient safety a priority, and according to a recent study their efforts have paid off. After implementing programs emphasizing team training, preoperative checklists and postoperative briefings, it was recently reported that event rates in VA hospitals have dropped 25 percent from 3.21 per month in 2006 to 2.4 per month in 2009.

The VA is known worldwide as a best in class provider of healthcare services, and patient safety is the primary concern, not an afterthought. The VA has an advantage over for-profit

and not-for-profit hospital chains because of their integrated approach to care delivery. Part of their success is a result of the depth of integration of health IT, but on the other end of the spectrum the VA incorporates some of the most thorough error reporting in the United States. And they do not leave it at that. Each year there is a “root cause analysis” (RCA), a deep dive by team members to fully examine factors contributing to serious errors and near misses.

Every year the RCA is performed in a very intensive and time consuming process. This root cause analysis is mandatory process involving locally developed inter disciplinary teams. They do not just pay lip service to the idea of improving the quality of care; in every VA hospital, individuals representing different aspects of care delivery are “chartered” or selected to play a leading role in the error review teams. The teams carefully review all the steps leading up to each error in an attempt to understand the cause, and work as a team to develop actions plans and follow up steps to address them so they do not happen again. The same process is used to address near misses.

controlcycle_smWhen the fixes are implemented, the outcomes are data driven. The approach is not unlike the actuarial control cycle  where problems are defined, potential solutions are designed, and then the results monitored. The technique of root cause analysis is derived from the military’s after action review. This after action review process is not punitive but an analysis of problems that arose in an operation with an attempt to learn from their mistakes and how they can fix and prevent it in the future. Actuaries are familiar with this through the actuarial control cycle and the ERM process.

  ERM Framework chart

Other systems which can compare to the VA’s results include the well-known names of Geisinger, Kaiser, Mayo and Cleveland Clinics.

What are the defining characteristics you have seen that take a hospital or system from good to great when it comes to patient safety?

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