Docstoc

Efforts to Achieve a Culture of Safety in the Veterans Health Administration

Document Sample
Efforts to Achieve a Culture of Safety in the Veterans Health Administration Powered By Docstoc
					 Using survey data to evaluate
progress and consider areas for
    improvement in the VA

      Edward J. Dunn, MD, MPH
     William B. Weeks, MD, MBA
         Scott McKnight, PhD
  VA National Center for Patient Safety
    National Center for Patient Safety
•   Established in 1998
•   Developed models for systems based problem solving in the VHA
     –   RCA
     –   HFMEA
     –   PS Manager in every VA health system
•   Provides educational resources, reporting system for adverse events & close calls,
    programs for improving patient safety in HS
     –   SPOT reporting system – web based by Sept. 2007
     –   Alerts & Advisories
     –   Med Team Training Program
     –   PS Curriculum workshops
     –   Falls Toolkit - prevent harm from falls
     –   PS Assessment Tool – assess PS environment
     –   Directives: ECS; Prevention of Retained FB in Surgery; Airway management in code events;
         Recall of defective med devices; Reducing fire hazards when O2 is present
     –   PS Improvement Corps (partner w/ AHRQ)
     –   Newsletters: TIPS; Briefings & Debriefings; Frontlines
     –   PS Fellowship
•   One goal is to achieve a culture of safety within VA
              Culture of safety
• To assess the culture of safety within VA, NCPS
  has conducted two national surveys
• Survey developed by NCPS – some dimensions
  overlap with ARHQ patient safety culture survey
  – 2000 – distributed through patient safety managers at
    facilities. N=6153
     • 120 items, 9 dimensions (factors)
  – 2005 – distributed through website with email
    reminders. N=42561
     • 77 items, 14 dimensions (factors)
  – Ability to identify job categories of respondents
    (physician, nurse, allied health professional,
    administrator)
Improving perceptions and resources
 5
                                                                                               2000
                                                                                               2005
 4


 3


 2


 1


 0
        All VA




                                        All VA




                                                                        All VA
                  Physicians




                                                  Physicians




                                                                                  Physicians
                               Nurses




                                                               Nurses




                                                                                                Nurses
     Overall perception of patient               Shame                  Education and training
                safety                                                       resources
     Challenges in communication,
    perceived safety, job satisfaction
5
     2000
     2005
4


3


2


1


0
     All VA




                                         All VA




                                                                        All VA
                   Physicians




                                                  Physicians




                                                                                      Physicians
                                Nurses




                                                               Nurses




                                                                                                    Nurses
                                                     (NS)




                                                                                         (NS)
              Communication              Comparisons to others                   Job satisfaction
               Benchmarked
         strengths and weaknesses
100%


80%


60%


40%


20%


 0%
       All VA




                                      All VA




                                                                     All VA




                                                                                                    All VA
                             Nurses




                                                            Nurses




                                                                                           Nurses




                                                                                                                          Nurses
                Physicians




                                               Physicians




                                                                              Physicians




                                                                                                             Physicians
         Organizational               Feedback about                 Teamwork across                Teamwork within
            learning                       error                          units                         units
                    Summary
Strengths
  –   Improvement in perception of patient safety
  –   Improvement in PS education/training resources
  –   Organizational learning/QI
  –   Feedback about adverse events/close calls
Weaknesses
  – Decline in communication (more among nurses)
  – Decline in job satisfaction (especially among nurses)
  – Relative weakness in teamwork, within and across
    units (compared to AHRQ benchmarks)
                               Plan
• Medical team training rollout (2007-2009)
   – Uses crew resource management applied to health care to
     enhance communication
   – Targets surgical services and critical care
   – Early evidence demonstrates improvement in
      •   Communication
      •   Job satisfaction
      •   Nurse participation/empowerment
      •   Teamwork
      •   Surgical performance measures
   – Program Evaluation will measure effect on
      • Risk adjusted surgical outcomes
      • Surgical and critical care performance measures
      • Surgical staff job satisfaction

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:48
posted:4/12/2008
language:English
pages:8