Patient Safety in the VA

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Patient Safety in the VA

• William B Weeks, MD, MBA
• National Center for Patient Safety

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Familiar model
Structure
Process
Outcomes
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Structure
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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

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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

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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

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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

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Process
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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

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Computerized entry
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Reporting
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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

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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

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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
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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

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Outcomes
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Current

• Internal
• Facility participation
• Reporting quality
• Performance measures
• External
• JCAHO
• NCQA

Process measures
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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

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Thanks