# Presentation: 700150

## VA National Center for Patient Safety and IHS: Background and Potential Collaboration 

**12/12/03**
**Noel Eldridge, MS****	****	****	****Richard Olson, MD, MPH**
**VA National Center for Patient Safety****	****IHS Office of Clinical and **
**(202) 273-8878 ****	****	****	****	****  Preventive Services**
**	****	****	****	****	****(301) 443-4644**
**	****	****	****	****	**

## The Origin of the VA Patient Safety Improvement Program

- VA (VHA) identified patient safety as a high priority issue in 1997 and began a Patient Safety Improvement Initiative.
- This was over 2 years before the IOM report, *To Err is Human*.

**Notes:**
Close calls occur far more frequently than adverse events but identify many of the same vulnerabilities.
Since close calls result in no harm it can be easier to get them reported.

## Improving Patient Safety is a Full-Time Job in VA

**Our National Office in Ann Arbor is staffed.  NCPS FY 03 budget was $4.25M.**
**Patient Safety Managers have been assigned for 163 VA hospitals and 21 networks.  They report to facility management, not NCPS.  (Patient safety improvement is not a new collateral duty for Quality Managers.)**
**Over 200 VHA total FTEEs, about 30 at NCPS.**
**Doing RCAs and other NCPS reviews takes about another 200 FTEEs/year – spread throughout VHA.**

## Current NCPS Initiatives

_**Root Cause Analysis (RCA)**_
**Healthcare Failure Modes and Effects Analysis**
**Performance Measures**
**Demonstrating the Business Case**
**Continue and Develop National Training**

**Develop and Deploy Tools, e.g., Cognitive Aids**
**Develop and Implement Patient Safety Assessment Tool**
**Ensuring Correct Surgery **
**Improving Hand Hygiene Practices**

## Root Cause Analysis in VA

- Root Cause Analysis (RCA): a process for identifying the basic or contributing causal factors that underlie variations in performance associated with Adverse Events _or Close Calls_.
- interdisciplinary in nature with involvement of those knowledgeable about the processes involved in the event
- RCA team is comprised of individuals from the facility where the adverse event occurred
- focuses primarily on improving systems and processes rather than individual performance.
- 	(See Handbook at http://www.patient safety.gov)

## What’s Off-Limits for RCA

**Intentionally Unsafe Acts **
***An “intentionally unsafe act” is defined as “a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse by an impaired provider and/or staff; or events involving alleged or suspected patient abuse of any kind.”***** **

## RCAs: Numbers and Utility

**RCAs provide insights into how and why adverse events occur, but...**
**Implementing the RCA’s Corrective Actions is key to preventing future adverse events.**
**Corrective Actions are developed by RCA teams for local use...**
**Once the RCA is completed and entered into the NCPS database, the information is available for analysis or dissemination throughout VHA. **

## Number of Actions to Eliminate/Control Events 

## Potential VA/IHS Collaboration (1)

**Providing Patient Safety Resources:**
**Root Cause Analysis “Form”**
**Various “Flipbooks” and other educational materials, e.g., Posters, Videos, Code Cart Emergency References, etc. – use as is or adapt by your graphics staff**
**Various policy guidelines for patient safety, e.g., Patient Safety Improvement Handbook, Disclosing Adverse Events, Informed Consent Processes, Ensuring Correct Surgery – already written and ready to be adapted to your use.**
**Position Descriptions for Patient Safety Managers and Officers**
**Any other things that are easily transferable...**** **

## Potential VA/IHS Collaboration (2)

**VA NCPS Training Opportunities**
**Patient Safety 101**
**Patient Safety for Leadership**
**AHRQ/VA Patient Safety Improvement Corps**
**Fellowship at NCPS Ann Arbor Office**
**Discuss these now or later?**

## Training Opportunity Details

## Patient Safety 101

- February 24-26 in Las Vegas.
- This is a comprehensive 3-day session aimed at patient safety managers and others who will be responsible for patient safety programs at hospitals.  In addition to lecture presentations, there are demos, exercises for individuals and small groups, etc. People from all over the world (Japan, Australia, UK, Denmark, et al) have flown in just to come to this over the last few years.

## Patient Safety for Leadership

- February 25-26, 2004   in Las Vegas
- May 18-19, 2004   in Washington D.C.
- June 8-9, 2004   (location TBD)
- This is for personnel such as hospital directors, associate directors, chiefs of staff, nurse managers, etc. Some patient safety managers are also attending to get a refresher with senior colleagues learning for the first time. This 1-day session provides an overview and orientation for people who need to know how the patient safety program is supposed to work but don't actually have to run it themselves.

## AHRQ/VA Patient Safety Improvement Corps

- For state staff (e.g., patient safety officers) and hospital counterparts (selected by state).
- Three one week-long sessions with work in-between and a project.  FY 2004 is first year. Program is planned to run at least 3 years.
- States for FY 2004: Alaska, Connecticut, Maryland, Massachusetts, Minnesota, Missouri, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Virginia, Wisconsin
- Right now it is only open to states so IHS would need to work it out with AHRQ before applying for the next year's session.
- See http://www.patientsafety.gov/psic/

## Fellowship at VA NCPS Ann Arbor

- IHS could send a key member of the staff who will be involved in patient safety to work with us on-site at the NCPS main office in Ann Arbor, Michigan, office.
- The UK’s National Health System did this with one of their staffers for 4 months this year.