Patient Safety in the VAPatient Safety in the VA

William B Weeks, MD, MBAWilliam B Weeks, MD, MBA

National Center for Patient National Center for Patient SafetySafety

Familiar Familiar modelmodel

Structure Outcomes

Process

StructureStructure

HistoryHistory

• Veterans’ benefits system traced to 1636Veterans’ benefits system traced to 1636– Pilgrims of Plymouth at war with Pequot IndiansPilgrims of Plymouth at war with Pequot Indians

• Continental Congress of 1776 provided pensions Continental Congress of 1776 provided pensions to encourage enlistments and discourage to encourage enlistments and discourage desertionsdesertions

• 1866 Congress authorized National Asylum for 1866 Congress authorized National Asylum for Disabled Volunteer SoldiersDisabled Volunteer Soldiers

• 1930 Veterans administration established1930 Veterans administration established• 1989 Department of Veterans Affairs established1989 Department of Veterans Affairs established

– 33rdrd largest Cabinet largest Cabinet– VBA/NCA/VHAVBA/NCA/VHA

Veterans Health Veterans Health AdministrationAdministration

• Annual discretionary funding by Annual discretionary funding by congresscongress

• $33.4 billion$33.4 billion– $30 billion for health care services$30 billion for health care services

• 5.2 million patients receiving care 5.2 million patients receiving care each yeareach year– Poor, old, malePoor, old, male– Lower HRQOL scores than age gender Lower HRQOL scores than age gender

matched populationmatched population

Transformation in 1995Transformation in 1995

• Problems with press, politicians, and Problems with press, politicians, and patientspatients

• Perceived low quality and efficiencyPerceived low quality and efficiency

• Inpatient focusInpatient focus

Transformed to Transformed to

• Outpatient focusOutpatient focus

• Improved quality and efficiencyImproved quality and efficiency

• High satisfactionHigh satisfaction

Patient Safety Program Patient Safety Program StructureStructure

• National Center for Patient SafetyNational Center for Patient Safety– Established in 1998Established in 1998

• AdministrationAdministration– Responsible for policy development, oversiteResponsible for policy development, oversite

• OperationsOperations– Patient safety managers (160 facilities)Patient safety managers (160 facilities)– Patient safety officers (21 regions)Patient safety officers (21 regions)

• InvestigationInvestigation– 4 Patient Safety Centers of Inquiry4 Patient Safety Centers of Inquiry

ProcessProcess

1. Identification and mitigation 1. Identification and mitigation of system vulnerabilitiesof system vulnerabilities

– Identification of actual and potential Identification of actual and potential adverse eventsadverse events

– Evaluation of severity and frequencyEvaluation of severity and frequency– (Aggregate) root cause analysis(Aggregate) root cause analysis– Healthcare Failure Mode Effects AnalysisHealthcare Failure Mode Effects Analysis– Implementation of corrective actionsImplementation of corrective actions– Sharing of resultsSharing of results

Computerized entryComputerized entry

ReportingReporting

Before

Local

National

Regional

IncidentReport

Local

National

Regional

After

RegionalReview if

Requested

PossibleRegional

Action

PossibleNationalAction

NationalReview

RegionalReview

PossibleLocal Action

LocalReview

IncidentReport

Analysis andCorrective

Action

LocalReview

DocumentedEffectiveness

of Action

NationalDatabase

2. Use of incentives2. Use of incentives

• Performance measuresPerformance measures– Widely seen as the key to VA Widely seen as the key to VA

transformationtransformation

• Safety focus, using results of RCAsSafety focus, using results of RCAs– Appropriate use and timeliness of Appropriate use and timeliness of

preoperative antibioticspreoperative antibiotics– Timeliness of radiology reportingTimeliness of radiology reporting

3. Support3. Support

• Program managers who provide guidance Program managers who provide guidance and networkingand networking

• Training, calls, email, alerts, newsletter, Training, calls, email, alerts, newsletter, webweb

• ToolkitsToolkits– Falls preventionFalls prevention– Cognitive aidsCognitive aids

• Patient Safety Improvement ProjectsPatient Safety Improvement Projects– Medical Team TrainingMedical Team Training– Barcode AdministrationBarcode Administration

4. Technology4. Technology

• Bar Code Medication AdministrationBar Code Medication Administration

• Computerized Medical RecordComputerized Medical Record

• Computerized Order EntryComputerized Order Entry

• Critical value alertsCritical value alerts

• Lab, path, card, and radiology Lab, path, card, and radiology reportsreports

Not without their own issues and challenges

5. Cooperation with other 5. Cooperation with other agenciesagencies

• JCAHOJCAHO– Cooperative development of patient safety goalsCooperative development of patient safety goals– Pilot and experience in VA can modifyPilot and experience in VA can modify– Bagian on review boardBagian on review board

• AHRQAHRQ– Patient safety improvement corpsPatient safety improvement corps

• Modification of training provided to VA PSMs, PSOsModification of training provided to VA PSMs, PSOs

• DODDOD– Joint effortsJoint efforts

• Breakthrough seriesBreakthrough series• SessionsSessions

OutcomesOutcomes

CurrentCurrent

• InternalInternal– Facility participationFacility participation– Reporting qualityReporting quality– Performance Performance

measuresmeasures

• ExternalExternal– JCAHOJCAHO– NCQANCQA

Process measures

FutureFuture

• Focus on patient outcomesFocus on patient outcomes• Some challenges….Some challenges….

– Veterans use multiple systems of careVeterans use multiple systems of care– AHRQ indicators may need modification AHRQ indicators may need modification

for VAfor VA

• Potential opportunities to identify Potential opportunities to identify vulnerable subpopulationsvulnerable subpopulations– Non-Medicare enrolled elderlyNon-Medicare enrolled elderly– Patients with psychiatric disordersPatients with psychiatric disorders

ThanksThanks