IFHC

VA's Patient Safety Program: Ten Years of Growth

Michael Kussman, MD
Under Secretary for
Health Department of Veterans Affairs

The Veterans Health Administration (VHA)’s National Center for Patient Safety has come a long way since it was founded ten years ago. The Center has led the implementation of an inclusive patient safety training program for VA employees nationwide. They have trained representatives of more than 279 federal, state, private sector health care systems; 12 foreign countries; and more than 2,000 VA employees on a wide range of patient safety topics.

The internal, confidential, non-punitive reporting system the Center developed now includes more than 14,750 root cause analysis reports and 427,900 safety reports. The Center’s systems approach to problem solving requires a willingness on the part of VA employees to report problems or potential problems so that solutions can be developed and implemented. As the old saying goes, “you can’t fix what you don’t know about.” The database is a great asset that is mined daily for solutions to specific patient safety issues.

VHA’s recent initiatives include:

Establishing an Office of Quality and Safety to integrate VHA’s quality and safety efforts; identify opportunities for improvement and best practices in these areas; and better integrate the Department’s multiple sources of data about health care and safety to improve the care we provide.
The establishment of one-year fellowships in patient safety, offered jointly by the Center and VHA’s Office of Academic Affiliations. Eleven fellows began the program in July 2007 and are now involved in a wide range of projects – from designing a cognitive aid to improving chronic back pain rehabilitation outcomes to developing a patient safety curriculum for physicians’ assistants.
A Patient Safety Initiative, introduced in 2006 to stimulate creative approaches to complex patient safety issues. Forty-four projects have been funded in the first two years of the program, including a program at the Augusta, Georgia, VA Medical Center which has reduced falls by 25 percent, and another at VA’s Tomah, Wisconsin, hospital which increased flu vaccination rates from 51 to 67 percent of the facilities patients.
A Medical Team Training program, developed because so many safety issues in health care are related to miscommunication. The program works to improve communications among health care professionals working in critical care areas, such as the operating room and the intensive care unit. This long-term effort is to be conducted at all VA Medical Centers. To date, 91 learning sessions at 71 facilities have targeted more than 6,550 caregivers.

VHA is aggressively pursuing innovative quality and safety efforts on numerous fronts. It’s a vital part of our commitment to ensure veterans receive the best health care anywhere.