Patient Safety in the VA

1. Patient Safety in the VA William B Weeks, MD, MBA National Center for Patient Safety

2. Familiar model Structure Process Outcomes

3. Structure

4. History • Veterans’ benefits system traced to 1636 • Pilgrims of Plymouth at war with Pequot Indians • Continental Congress of 1776 provided pensions to encourage enlistments and discourage desertions • 1866 Congress authorized National Asylum for Disabled Volunteer Soldiers • 1930 Veterans administration established • 1989 Department of Veterans Affairs established • 3rd largest Cabinet • VBA/NCA/VHA

5. Veterans Health Administration • Annual discretionary funding by congress • $33.4 billion • $30 billion for health care services • 5.2 million patients receiving care each year • Poor, old, male • Lower HRQOL scores than age gender matched population

6. Transformation in 1995 • Problems with press, politicians, and patients • Perceived low quality and efficiency • Inpatient focus Transformed to • Outpatient focus • Improved quality and efficiency • High satisfaction

7. Patient Safety Program Structure • National Center for Patient Safety • Established in 1998 • Administration • Responsible for policy development, oversite • Operations • Patient safety managers (160 facilities) • Patient safety officers (21 regions) • Investigation • 4 Patient Safety Centers of Inquiry

8. Process

9. 1. Identification and mitigation of system vulnerabilities • Identification of actual and potential adverse events • Evaluation of severity and frequency • (Aggregate) root cause analysis • Healthcare Failure Mode Effects Analysis • Implementation of corrective actions • Sharing of results

10. Computerized entry

11. Reporting

13. 2. Use of incentives • Performance measures • Widely seen as the key to VA transformation • Safety focus, using results of RCAs • Appropriate use and timeliness of preoperative antibiotics • Timeliness of radiology reporting

14. 3. Support • Program managers who provide guidance and networking • Training, calls, email, alerts, newsletter, web • Toolkits • Falls prevention • Cognitive aids • Patient Safety Improvement Projects • Medical Team Training • Barcode Administration

15. 4. Technology • Bar Code Medication Administration • Computerized Medical Record • Computerized Order Entry • Critical value alerts • Lab, path, card, and radiology reports Not without their own issues and challenges

16. 5. Cooperation with other agencies • JCAHO • Cooperative development of patient safety goals • Pilot and experience in VA can modify • Bagian on review board • AHRQ • Patient safety improvement corps • Modification of training provided to VA PSMs, PSOs • DOD • Joint efforts • Breakthrough series • Sessions

17. Outcomes

18. Current • Internal • Facility participation • Reporting quality • Performance measures • External • JCAHO • NCQA Process measures

19. Future • Focus on patient outcomes • Some challenges…. • Veterans use multiple systems of care • AHRQ indicators may need modification for VA • Potential opportunities to identify vulnerable subpopulations • Non-Medicare enrolled elderly • Patients with psychiatric disorders

20. Thanks