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

2. Familiar model Structure Outcomes Process

3. Structure

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

5. Veterans Health Administration Annual discretionary funding by congress Annual discretionary funding by congress $33.4 billion $33.4 billion –$30 billion for health care services 5.2 million patients receiving care each year 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 Problems with press, politicians, and patients Perceived low quality and efficiency Perceived low quality and efficiency Inpatient focus Inpatient focus Transformed to Outpatient focus Outpatient focus Improved quality and efficiency Improved quality and efficiency High satisfaction High satisfaction

7. Patient Safety Program Structure National Center for Patient Safety National Center for Patient Safety –Established in 1998 Administration Administration –Responsible for policy development, oversite Operations Operations –Patient safety managers (160 facilities) –Patient safety officers (21 regions) Investigation 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 Performance measures –Widely seen as the key to VA transformation Safety focus, using results of RCAs 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 Program managers who provide guidance and networking Training, calls, email, alerts, newsletter, web Training, calls, email, alerts, newsletter, web Toolkits Toolkits –Falls prevention –Cognitive aids Patient Safety Improvement Projects Patient Safety Improvement Projects –Medical Team Training –Barcode Administration

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

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

17. Outcomes

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

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

20. Thanks