Patient Safety in the VA
William B Weeks, MD, MBA
National Center for Patient Safety
Familiar model
Process
Structure
Outcomes
Structure
History
• Veterans’ benefits system traced to 1636
– Pilgrims of Plymouth at war with Pequot Indians
• Continental Congress of 1776 provided pensions to
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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
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
Transformation in 1995
• Problems with press, politicians, and patients
• Perceived low quality and efficiency
• Inpatient focus
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Transformed to
Outpatient focus
Improved quality and efficiency
High satisfaction
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
Process
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
Computerized entry
Reporting
Before
Local
Incident
Report
Local
Review
Possible
Local Action
Regional
Review if
Requested
Regional
National
After
Local
Incident
Report
Local
Review
Regional
National
National
Database
Analysis and
Corrective
Action
Documented
Effectiveness
of Action
Regional
Review
Possible
Regional
Action
National
Review
Possible
National
Action
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
3. Support
• Program managers who provide guidance and
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networking
Training, calls, email, alerts, newsletter, web
Toolkits
– Falls prevention
– Cognitive aids
• Patient Safety Improvement Projects
– Medical Team Training
– Barcode Administration
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
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
Outcomes
Current
• Internal
– Facility participation
– Reporting quality
– Performance measures
• External
– JCAHO
– NCQA
Process
measures
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
Thanks