VA Patient Safety Program:

A Cultural Perspective at Four Medical Facilities

GAO-05-83: Published: Dec 15, 2004. Publicly Released: Dec 15, 2004.

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The Department of Veterans Affairs (VA) introduced its Patient Safety Program in 1999 in order to discover and fix system flaws that could harm patients. The Program process relies on staff reports of close calls and adverse events. GAO found that achieving success requires a cultural shift from fear of punishment for reporting close calls and adverse events to mutual trust and comfort in reporting them. GAO used ethnographic techniques to study the Patient Safety Program from the perspective of direct care clinicians at four VA medical facilities. This approach recognizes that what people say, do, and believe reflects a shared culture. The focus included (1) the status of VA's efforts to implement the Program, (2) the extent to which a culture exists that supports the Program, and (3) practices that promote patient safety. GAO combined more traditional survey methods with those from ethnography, including in-depth interviews and observation.

GAO found progress in staff familiarity with and participation in the VA Patient Safety Program's key initiatives, but these achievements varied substantially in the four facilities we visited. In our study conducted from November 2002 through August 2004, three-fourths of the clinicians across the facilities were familiar with the concepts of teams investigating root causes of unintentional adverse events and close calls. One-third of the staff had participated in such teams, and most who participated in these teams found it a positive learning experience. The cultural support clinicians expressed for the Program also differed. At three of four facilities, GAO found a supportive culture, but at one facility the culture blocked participation for many clinicians. Clinicians articulated two themes that could stimulate culture change: leadership actions and open communication. For example, nurses need the confidence to disagree with physicians when they find an unsafe situation. Although VA has conducted a cultural survey, it has not set goals or explicitly measured, for example, staff familiarity and mutual trust. Clinicians reported management practices at one facility that had helped them adopt the Program, including (1) story-telling techniques such as leaders telling about a case in which reporting an adverse event resulted in system change, (2) management efforts to coach staff, and (3) reward systems. The Patient Safety Program Process shows how ideally (1) clinicians have cultural support for reporting adverse events and close calls, (2) teams investigate root causes, (3) systems are changed, (4) feedback and reward systems encourage reporting, and (5) patients are safer.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To better assess the adequacy of clinicians' familiarity with, participation in, and cultural support for the Program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to set goals for increasing staff (1) familiarity with the Program's major concepts (close call reporting, confidential reporting program with NASA, root cause analysis), (2) participation in root cause analysis teams, and (3) cultural support for the Program by measuring the extent to which each facility has mutual trust and comfort in reporting close calls and adverse events.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: The Secretary of the VA concurred and promised an action plan to implement GAO's recommendations in the 12/03/2004 agency review of draft. In a 2007 Congressional Submission, VA reports steps toward program assessment, but not the goal-setting forth program constructs (familiarity, mutual trust, participation) GAO recommended. A large 2005 survey of VHA staff added elements from the GAO review, including familiarity with and participation in the safety program concepts. Measuring mutual trust and comfort in reporting close calls was attempted by their survey. Reports to regions and facilities included results for unit and national averages. An official of the Patient Safety Office ( 09/28/07) stated that while they expect to see participation and understanding increase for these program "constructs", they ask VA staff to do many things (wash hands, mark body parts)therefore, they "hesitate to set numeric goals [for program constructs] when the evidence base is not there". However,he said, by displaying annual statistics ( number of Root Cause Analyses, actions opened and closed) by facility on the internet for all to see, they have removed "plausible deniability" for facility and regional directors.

    Recommendation: To better assess the adequacy of clinicians' familiarity with, participation in, and cultural support for the Program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop tools for measuring goals by facility.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: The program official offered examples of goals explicitly defined, redefined and when measured at the facility level showed sustained improvement year after year. According to the program official (09/21/07)and the 2007 Congressional Submission, they have developed measurement tools and set numeric goals for several objective measures linked strongly to patient welfare such as timely reading of diagnostic images (90% in 48 hours), administration of pre-op antibiotics and specific short-term goals for installation of software patches. Measures defined, measured and reported by facility for all to see on the intranet( but currently without numeric goals) are number of RCA's/year, number of safety reports (of close calls) and tracking of action plan results of the RCAs. The program official wrote:I think making this data available to managers at the network and VAMC level is responsive to the recommendation to develop tools to allow performance to be measured.

    Recommendation: To better assess the adequacy of clinicians' familiarity with, participation in, and cultural support for the Program, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop interventions when goals have not been met.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Not Implemented

    Comments: VA reports to congress (2007 Submission) that data on "achieving goals" impacts the network director's assessment, retention and pay and that 2005 survey results were reported to them in the last year. However specific interventions "primarily take place at the...local level" while some may involve direction from VHA central offices.

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