VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities
Published: 2004-12-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: This report on the Department of Veterans Affairs Patient Safety Program  examines the Program’s status, the creation and implementation of a  culture that supports close call and adverse event reporting, and practices  that medical facility leaders have used to promote patient safety. In our  study, we used ethnography, a social science method that includes  qualitative and quantitative techniques developed within cultural  anthropology for studying communities and organizations in natural  settings.
We include recommendations aimed at strengthening the Patient Safety  Program by helping to build a more supportive culture and foster patient  safety.
We are sending copies of the report to appropriate congressional  committees and others who are interested. We will also make copies  available on request. If you have any questions about the report, please  call me at (202) 512-2700.
At the end of the 20th century, a report that the Institute of Medicine  issued estimated that up to 98,000 persons died each year from accidents  in U.S. hospitals. Before the institute published this figure, the Department  of Veterans Affairs (VA) had launched a Patient Safety Program that  included teams investigating the root cause of medical close calls and  adverse events and confidential staff reporting systems. The Program’s  ultimate goal is to create a culture in which VA can discover and correct  unsafe systems and processes before they harm patients. “VA could also better ensure success if it prepared a detailed implementation plan that  identifies how and when VA’s various patient safety Programs will be implemented, how  they are aligned to support improved patient safety, and what contribution each Program  can be expected to make toward the goal of improved patient safety.”
One of the most challenging aspects of VA’s Patient Safety Program is  creating an atmosphere in which employees are willing to reveal system  problems and find system solutions to them. Traditionally, hospital  employees have been held responsible for adverse patient outcomes,  whether they stemmed from employees’ mistakes or the health care  system. For example, a nurse might be blamed for administering the  wrong medicine, even when the system was at fault, as when two  medicines with similar names—one deadly, the other not—were stored on  the same shelf in similar bottles.
The poster and story in figure 1 show how complicated a day in the life of  a healthcare provider can be. In this instance, a VA nurse recognized a  potentially dangerous flaw in the system that could have caused  unintentional harm to patients. In June 2002, she reported the close call,  because she saw that the environment she worked in encouraged  reporting, and she was then rewarded with a gift certificate.
High-risk industries such as nuclear power and aerospace have found that  reliable safety organizations discover and correct system flaws. In  effective safety cultures, frontline workers trust one another and report  close calls and adverse events without fear of blame. Healthcare, which  traditionally employs a culture of blame, must place a premium on  learning from staff reporting of adverse events and close calls. Experts in  patient safety acknowledge that emphasis on culture is important in  preventing medical adverse events and close calls and promoting patient  safety.
To describe the culture in VA’s medical facilities and to search for a  deeper understanding of patient safety from the viewpoint of VA staff, we  proposed to answer the following questions in the context of four VA  medical facilities:  1.  What is the status of the Program’s implementation at four medical  facilities?  2.  To what extent do the four sites we studied have a culture that  supports the Program? What cultural changes can be stimulated?  3.  What practices in the four facilities promoted patient safety?
subsections: section_title: Scope and Methodology
paragraphs: To meet our study’s challenges, we used several methods from  ethnography, and in certain cases we blended them with survey methods  to provide in-depth knowledge of organizational culture from the  perspective of VA’s frontline staff—its physicians, nurses, and others  directly responsible for patient care. We intend this study to complement  our earlier reports on organizational culture and changing organizations.  We chose ethnography because several of its techniques and perspectives  helped us study aspects of patient safety that would otherwise have  remained overlooked or would not have been observed, such as informal  mores, and to assist GAO in the development of new evaluation methods.  These aspects were ethnography’s research traditions of (1)  conversational interviews, enabling interviewers to explore a participant’s  own view of and associations with an issue of interest, (2) the researchers’  observations of real processes to further understand the meaning behind  patient safety from the natural environment of staff, and (3) systems  thinking.
Our study measures, at the facility level, the extent of familiarity with,  participation in, and cultural support for the Program, and it complements  a cultural survey VA conducted in 2000. VA expects to resurvey staff in the  near future, using its past survey data as a baseline. VA’s original,  nonrandom survey contained questions regarding shame and staff  willingness to report adverse events when the safety of patients was at  hazard during their care. The VA survey did not establish staff familiarity  with key concepts of the Program, participation in VA safety activities, or  the facilities’ levels of cultural support for the Program.
subsections: section_title: Conversational Survey Interviews
paragraphs: We recognized that a tradition of fear of being blamed for adverse events  and close calls might make staff reluctant to talk about their experience of  potential harm to patients. Besides breaking through an emotional barrier,  we wanted to understand the private views of staff on what facilitates  patient safety. To achieve the informal, open, and honest discussions we  needed, we conducted private, nonthreatening, conversational interviews  with randomly selected clinicians and other staff in a judgmental sample.  At each site, we chose one random and one judgmental (nonrandom)  sample of staff to interview in a conversational manner, using similar  semistructured questionnaires (see app. III).
For the first sample, we interviewed a random selection of 10 physicians  and 10 nurses at each of the four facilities. While this provided us with a  representative sample of clinicians (physicians and nurses) from each  facility, the sample size was too small to provide a statistical basis  for generalizing our survey results to an entire facility. To give us a better  understanding of the culture and context of patient safety beyond the  clinicians involved in direct patient care at each facility, we also  interviewed more than a hundred other staff in the four study sites,  including medical facility leaders, Patient Safety Managers, and hospital  employees from all levels—maintenance workers, security officers,  nursing assistants, technicians, and service chiefs. (Appendix I contains  more technical detail about our analysis.)
Reporting adverse events and close calls is a highly sensitive subject and  can successfully be explored with qualitative methods that allow  respondents to talk privately and freely. When staff did not recognize a key  element of the Program, our interviewers explained it to them. (We were  not giving the respondents a test they could fail.) Selecting clinicians  randomly at each of four facilities, and asking some close-ended questions  such as those expecting “yes” or “no” answers, allowed us to analyze and  present some issues as standard survey data. This combined survey and  ethnographic approach afforded us most of the advantages of standard  surveys while establishing an environment in which the respondents could  talk, and did talk, at length about the cultural context of patient safety in  their own facilities.
Clinicians responded to a standard set of questions, many open ended,  such as, To what extent do you perceive there to be trust or distrust within  your unit or team? Among the advantages these questions had were that  they allowed the clinicians to discuss issues spontaneously and they  allowed us to discover what facilitates trust from their point of view. Thus,  if clinicians thought leadership was important, we had an opportunity to  see this from their viewpoint rather than starting from the premise that  leadership would be important to them.
An important part of our approach was content analysis, which we used to  analyze answers to both the standard and open-ended questions. Content  analysis summarizes qualitative information by categorizing it and then  systematically sorting and comparing the categories in order to develop  themes and summarize them. We determined, by intercoder reliability  tests, that our content analysis results were trustworthy across different  raters. (See app. I.)
section_title: Observation
paragraphs: We added another ethnographic technique in order to more completely  understand the culture within each facility. Since responses to surveys are  sometimes difficult to understand out of context, our in-depth  ethnographic observations of the patient care process gave us a more  complete picture of how the elements of the Patient Safety Program  interacted. They also gave us a better understanding of VA’s medical  facility systems. We observed staff in their daily work activities at each  medical facility, which helped us understand patient safety in context. For  example, we attended staff meetings where the Program was discussed  and we attended RCA meetings, and we followed a nurse on her rounds.  We took detailed field notes from our observations, and we analyzed and  summarized our notes.
We reviewed files to examine data on adverse events, close calls, and RCA  reports. We read files from administrative boards, reward programs, and  patient safety committee minutes. And we interviewed high-level VA  officials.
section_title: Systems Thinking
paragraphs: Finally, our ethnographic research approach was systemic. This was to  help us appreciate interactions between the elements of the Program and  the facilities’ existing culture. Ethnography has traditionally been used to  provide rich, holistic accounts of the way of life of a people or a  community; in recent decades, it has also been used successfully to study  groups in modern societies. A systems approach casts a wide net over the  subject. In this case, we chose to study the Patient Safety Program in  relation to other aspects of culture in VA’s medical facilities that might  affect its adoption, such as the extent to which staff have mutual trust.
We also developed a model, or flow chart, to guide our study of the  Program and the culture of the facilities. The model, in figure 2, helped us  conceptualize the important safety activities within the Program and  analyze and present our results. We looked not only at the Program’s key  elements, in the darkly shaded boxes in figure 2, but also at what  surrounds them—the context of the medical facilities’ culture—and  whether the culture supports the adoption of the Program. Our model  illustrates that our primary focus was measuring clinicians’ supportive  culture for reporting close calls and adverse events and their familiarity  with and participation in reporting programs and RCAs. The model also  depicts the interaction between clinicians’ receiving feedback and being  rewarded and their desire to continue reporting close calls and adverse  events. It also allows us to describe how clinicians’ reporting close calls  and adverse events, and the subsequent investigation of the root causes of  them, developed into system changes that in turn resulted in patients being  safer.
We conducted the study at three medical facilities that VA had  recommended as being well managed. We selected a fourth facility for  geographic balance. Thus, the four facilities were in different regions of  the country. Using rapid assessment techniques, we conducted fieldwork  for approximately a week at each of two facilities, for 3 weeks at a third,  and for 25 days at the fourth. We did our work from November 2002 to  August 2004 in accordance with generally accepted government auditing  standards.
section_title: Background
subsections: section_title: The Patient Safety Goal
paragraphs: “to make health care safe we need to redesign our systems to make error difficult to  commit and create a culture in which the existence of risk is acknowledged and injury  prevention is recognized as everyone’s responsibility. A new understanding of  accountability that moves beyond blaming individuals when they make mistakes must be  established if progress is to be made.”
This vision of making patients safe through “redesign . . . to make errors  difficult to commit” led to VA’s National Center for Patient Safety (NCPS),  established to improve patient safety throughout the largest health care  system in the United States. To transform the existing culture of patient  care in VA’s medical facilities, VA’s leaders aimed to persuade clinicians  and other staff in health care settings to adopt a new practice of reporting,  free of fear and with mutual trust, identifying vulnerabilities, and taking  necessary actions to mitigate risks.
The Under Secretary had recognized risk to patients during care and that a  focus on VA’s existing culture could improve patient safety. Related  research shows that if complex decision making organizations are to  change, they must modify their organizational culture. Traditionally,  clinicians involved in an adverse event could be blamed or sued, but the  roots of unintentional errors are now understood as originating often in  the institutions and structures of medicine rather than in clinicians’  incompetence or negligence.
Several contextual factors influence how the Patient Safety Program is  experienced at the medical facilities we visited and show the increasingly  complex world of patient care. Our study’s limitations meant that we could  not study these factors, but health care facilities in general, as well as VA’s,  are experiencing difficulty in hiring and retaining nurses, as well as  potential staffing shortages. Patients admitted to VA medical facilities have  more multiple medical problems that require more extensive care than in  the past. VA’s eligibility reform allowed veterans without service- connected conditions to seek VA services, leading to a 70 percent increase  in the number of enrolled veterans between 1999 and 2002.
section_title: The Patient Safety Process
paragraphs: VA has provided funding of $37.4 million to NCPS for its Patient Safety  Program operations and related grants and contracts for fiscal years   1999–2004. In fiscal year 1999, NCPS defined three major initiatives: (1) a  more focused system for mandatory close call and adverse event  reporting, including a renewed focus on close calls; (2) reviews of close  calls and adverse events, including RCAs, using interdisciplinary teams at  each facility to discover system flaws and recommends redesign to  prevent harm to patients; and (3) staff feedback on system changes and  communication about improvements to patient safety.
section_title: Close Call and Adverse event Reporting
paragraphs: Starting with the NCPS program in 1999, reporting of close calls increased  dramatically as their value for patient safety improvement was widely  disseminated and increasingly recognized by VA personnel. A close call is  an event or situation that could have resulted in harm to a patient but did  not, either by chance or by timely intervention. VA encourages reporting  close calls and adverse events, since redesigning system flaws depends on  staff revealing them. VA’s Patient Safety Managers told us that only  adverse events and not close calls were traditionally required to be  reported to supervisors and then up the chain of command.
Under the Program, staff also have optional routes for reporting—through  Patient Safety Managers or a confidential system outside their facilities.  Staff can now report close calls and adverse events directly to the  facilities’ Patient Safety Managers. They, in turn, evaluate the reports,  based on criteria for deciding which adverse events or close calls should  be investigated further. NCPS also has a confidential reporting option— the Patient Safety Reporting System (PSRS)—through a contract with the  National Aeronautics and Space Administration (NASA). NASA has   27 years of experience with a similar program, the Federal Aviation  Administration’s Aviation Safety Reporting System. Under the contract  with VA, NASA removes all identifying information and sends selected  items of special interest to the NCPS.  NASA also publishes a newsletter  based on reports that have had their identifying information removed.
section_title: Root Cause Analysis Teams
paragraphs: Working on interdisciplinary teams of usually five to seven participants,  staff focus on either one or a group of similar close calls or adverse events  to investigate their causes. Then they search for system flaws and redesign  patient care so that mistakes are harder to make. Under the Program,  NCPS envisioned that these teams would be a key step to improving  patient safety through system change and one of its primary mechanisms  of introducing clinicians to the Program. In 1999, NCPS began RCA  implementation. In this on-the-job training, Patient Safety Managers guide  local interdisciplinary teams in studying reports of close calls or adverse  events to identify and redesign system weaknesses that threaten patients’  safety. Teams are allowed 45 days to learn as much as possible from a  close call or adverse event or a group of similar close calls or adverse  events such as falls, missing persons, medication errors, and suicides  called aggregated reviews. Within the given time period, teams are to  develop action plans for system improvement. Personal experience on  interdisciplinary RCA teams investigating close calls and adverse events at  their home facilities is the clinicians’ key training experience. VA expected  that the RCA experience would persuade staff that VA was changing its  culture by encouraging a different approach to reporting.
section_title: Feedback Mechanisms
paragraphs: Staff need to receive proof that the Program is working by receiving timely  feedback on their reporting. A feedback loop fosters and perpetuates close  call and adverse event reporting. Without it, staff may feel the effort is  not worth their time. NCPS built in feedback loops at several levels of the  system. For example, individuals who report a close call or adverse event  are supposed to get feedback from the RCA team on actions  recommended as a result of their reports. Also, NCPS issues an online  bimonthly newsletter that reports safety changes.
In chapter 2, we measure clinicians' familiarity and participation in the  Program at the four facilities we visited. Chapter 3 is an examination of  whether the culture at the four facilities supports the Patient Safety  Program and chapter 4 provides examples of management practices that  promote patient safety. We asked VA to comment on our report; VA’s  comments are in appendix IV. Our response to their comments is in the  conclusions located in chapter 5. VA also provided some additional  comments to emphasize that it believes that it has taken steps to address  the issue of mutual trust.  VA describes those steps in the report on   page 67.
In general, we found progress in clinicians’ understanding and  participation in the Patient Safety Program. Three facilities had medium or  higher familiarity with and participation in the Program’s core elements,  and one had lower. At that facility, the staff were not following VA’s policy  of reporting close calls and were not being educated in the benefits of  doing so. Examining the data across our total random sample, we found  that some clinicians were familiar with several core concepts of the  Program and were unfamiliar with others—a picture NCPS officials said  did not surprise them.
About three-quarters of clinicians were familiar with the concept of RCAs  (newly introduced in 2000) and the concept of the close call. About half  the clinicians recognized the new confidential reporting process—another  equally important program. One-third had participated in an RCA or knew  someone who had. NCPS staff told us that participation in RCAs is crucial  to culture change at VA, and clinicians who were on RCA teams indicated  that they experienced the beginning of a culture shift. Of the staff who  had participated in RCAs, many indicated that it was a positive learning  experience, but facilities varied in ensuring clinicians’ broad participation.
section_title: Facilities Shared Safety Hazards but Not Program Familiarity and Participation
paragraphs: VA has made progress in familiarizing and involving clinicians with the  Program’s key concepts. But while the facilities we studied shared basic  safety problems, three had made more progress than the fourth. First, all  four experienced similar hazards to patient safety. Second, we report  clinicians’ familiarity with and participation in the Program in two ways— grouped first by facility and then across the four sites.
subsections: section_title: Facilities’ Share Common Safety Reporting Pattern
paragraphs: The four facilities shared an overall pattern in the types of adverse events  they reported, reflecting their common safety challenge. To establish the  Program’s context, we asked at the four facilities to review documents  related to close calls and adverse events reported over a one-month period  (June 2002). All the facilities reported falls for this period, while two  facilities or more recorded patients’ violence toward staff, patients’  suicides and suicide attempts, missing patients, and medication errors (see  fig. 3). Although our data reflect a limited time period, the highly  overlapping types of reporting at the facilities parallel those found in the  wider VA patient care system, as documented in an earlier review by the  VA Medical Inspector.
section_title: Facilities’ Differences in Participation and Familiarity with the Program
paragraphs: Staff at one facility had less familiarity with and participation in the  Program than staff at the three others (see fig. 4). In the interviews with  the random sample, we found Facility D had lower familiarity with the  Program’s concepts than the other facilities and lower participation in  RCAs; this pattern was buttressed by additional interviews at Facility D.  For example, the quality manager who supervised Patient Safety Managers  at that facility did not realize that close call reporting was mandated, and  the education officer who trained staff in patient safety told us that staff  were generally not acquainted with the concept of reporting close calls.  Because knowing that an initiative exists is often the first step to  participation, the lower familiarity with the Program at Facility D in the  fifth year of implementation was a likely impediment to the adoption of  the Program there.
section_title: Differences in Facilities’ Adhering to Close Call Reporting Policy
paragraphs: The four medical facilities we studied also varied in their adherence to  close call reporting policies under the Program. We found three out of four  facilities followed the policy of reporting close calls. One facility, in  particular, showed a marked increase in the number of close calls in a  short period of time; close call reports were rare in the 6 months before  but numbered 240 in the 6 months after its leaders told staff patient safety  was an organizational priority and introduced a simple reward system for  close call reporting. However, one facility we visited was not reporting  close calls in the Program’s fifth year.
section_title: Familiarity with and Participation in the Program across Four Facilities
paragraphs: We looked at interview responses with randomly selected clinicians across  all four facilities. We found that three-quarters of the clinicians knew the  meaning of close call—that is, when a potential incident is discovered  before any harm has come to a patient—but only half were aware of the  option of reporting close calls and adverse events confidentially. (See  table 1.) Close calls are presumed to occur more often than adverse  events, and reporting them in addition to adverse events is central to the  Program’s goal of discovering and correcting system flaws. Staff who do  not recognize the close call concept cannot bring to light system flaws that  could harm patients. Further, because changing from traditional blaming  behavior to reporting without fear can take time, staff familiarity with the  confidential reporting option is important. However, only half the  clinicians surveyed at the four facilities knew that they could report  adverse events or close calls confidentially under the NASA reporting  contract.
section_title: Culture Shift through Root Cause Analysis
paragraphs: Clinicians who had participated in interdisciplinary RCA teams found that  their participation enabled them to understand the benefits of using a  systems approach rather than blaming individuals for unintentional  adverse events and close calls. To understand the RCA process from close  call reporting to RCA team analysis, we provide an example from  fieldwork that shows how two misidentifications in a surgery ward led to a  reexamination of the preoperative process in an RCA. (See “Developing  Patient Safety from Examining Close Calls and an RCA.”)
While examining how many RCAs were conducted from 2000 to 2003 at  the four facilities, we found that the most active facility we studied had  performed twice as many RCAs as the least active. The RCAs have the  potential to promote a cultural shift from blaming staff for unintentional  close calls and adverse events to a rational search for the root causes, but  clinicians at the four facilities had inconsistent opportunities to participate  in the Program.
section_title: Illustrating the Steps from Close Calls to RCAs
paragraphs: “Developing Patient Safety from Examining Close Calls and an RCA”  illustrates an RCA team’s initial steps by following a series of events  involving two close calls of mistaken identity in surgery at one facility.
Developing Patient Safety from Examining Close Calls and an  RCA  The Patient Safety Manager had an unusual visit from the Chief Surgeon.  He had come to report two recent instances of patients being mistakenly  scheduled for surgery. The identity mix-ups had been discovered before  the patients were harmed—a situation the surgeon recognized as fitting  the Program’s mandate to report close calls in order to identify hazards in  the system. After each close call, he had filled out a form and made a  report to NCPS, which had called him back within 24 hours to ask for  more information and to offer some reengineering suggestions.
At the next weekly surgery preoperation meeting, the Chief Surgeon and  his staff discussed their schedule and details of coming surgeries, using a  matrix timetable projected for all to see. Then he discussed the two close  calls. In both cases, the correct patient had come to the surgery  preparation room, but the staff had been expecting someone else. In one  case, the scheduling staff had confused two similar names. In the other  case, the scheduling staff had, as usual, used the last four digits of the  Social Security number to help identify the patient but had had two  patients with the same last four digits. In the meeting’s discussion, the  staff tried to understand how such mistakes could happen.
The Patient Safety Manager convened an expedited RCA team of three  other VA staff to get at the root cause of such identification problems.  She opened the meeting by saying, “If we don’t learn from this [close  call], we’re all fools.” She announced that the RCA would be limited to  two or three meetings rather than several weeks. After introductions, the  staff members explained their role in scheduling and what happened in  such cases. As they spoke, the staff tried to outline the scheduling  process: what forms were completed, whether they were electronic or  paper, how they moved from person to person, and who touched the  forms.
Several problems emerged. (1) Some VA patients might not always know  their identity or surgical site because of illness or senility or both. Also,  patients with multiple problems cannot always relay them to staff,  because they may focus on one problem while the appointment  scheduled is for another problem. (2) Two key VA staff may be absent at  the same time and a substitute may make the error. (3) In one case, two  patients’ names differed only by m and n. (4) A scheduler noted that  scheduling is filled with interruptions and opportunities for confusion.  For example, it is not uncommon that scheduled patients have  overlapping numerals for the last four digits of their Social Security  numbers.
The RCA team’s next meeting was scheduled. In future meetings, the  RCA team would consider various ways of preventing or minimizing  similar events.
section_title: Clinicians’ Belief in RCAs as a Positive Learning Experience
paragraphs: Staff who had participated in RCAs told us that their experience was a  valuable and convincing introduction to the Patient Safety Program. In lieu  of giving clinicians formal training in the central concepts of the Program,  NCPS expected to change the culture of patient care one clinician at a  time by their individual experience in RCAs. NCPS intended that  experience on multidisciplinary RCA teams investigating the underlying  causes of reported close calls and adverse events at their home facilities  would be clinicians’ key educational experience and that it would  persuade them that VA was taking a different approach to reporting. All  facilities are expected to perform RCAs, in which local interdisciplinary  teams study reports of close calls and adverse events in order to identify  and redesign systems that threaten patients’ safety.
Staff also reported that RCA investigations created a learning environment  and were an excellent way to introduce staff to redesign systems to  prevent harm to patients. Two doctors at one facility, for example, told us  that the RCAs they participated in were a genuine “no blame learning  experience” that they felt good about or found valuable. Two nurses at  another facility reported being amazed at the change from a blaming  culture to an inquiring culture as they experienced the RCA process.  However, staff also told us that the RCA process took too much time or  took time away from patient care. At another facility, where trust was low  and only 5 of 20 clinicians had a positive view of reporting, each of those   5 clinicians had a positive experience with RCAs under the new Program.  “How Participating in RCAs Affects Clinicians’ Work” presents some  clinicians’ own stories of their participation in RCAs.
How Participating in RCAs Affects Clinicians’ Work  Physician 1: I participated in an RCA through my work in the blood  bank. It taught me to look at errors systematically and not rush to blame  individuals. But if an employee were eventually found responsible, then  the Lab would hold that person accountable. [This example reflects the  decision leaders must make between personal accountability and  systemic change.]  Physician 2: RCAs are a good thing. It’s fixing a potential disaster before  it can coalesce and become a disaster.
Nurse 1: I think RCAs are a good thing, because usually the problems are  system problems. I think if you fix the system, you fix the problem. It  seems to be that way in surgery. You try and concentrate on the things  you can fix.
Nurse 2: They used to have a process in psychiatry called “post mortem.”  That process often led to the conclusion that a suicide could not have  been prevented. By contrast, in the new RCA process, we look at how  the RCA can promote system changes.
Nurse 3: RCA does a good job of identifying not only the actual adverse  event but also the contributing factors. This is very helpful because it  allows us to better understand what to do about an adverse event.
Nurse 4: RCA is a good system. It’s a good way to share information and  avoid recurring error.
Nurse 5: My general impression is that RCAs are great. They’re especially  important when teams look for results and action items.
section_title: Variation in Facilities’ RCA Activity
paragraphs: Over the 4 years of the RCA implementation, the most active facility we  studied (Facility A) had performed twice as many RCAs as the least active  facility (Facility D). (See table 2.) The number of RCAs, similar to the  number of close calls and adverse events, does not reflect the actual  numbers of adverse events or close calls that occurred or how safe the  facility is; rather, it reflects whether organizational learning is taking place,  through increasing participation in a core Program activity. Similarly,  NCPS staff recently reported to a facility leaders’ training session that  networks of their facilities varied fourfold in fiscal year 2002 with respect  to number of RCAs conducted. Facility D’s director told us that NCPS had  recently identified his facility as having too few RCA reviews.
section_title: Inconsistent Opportunities to Participate in RCAs
paragraphs: One facility was more successful than the three others at providing busy  physicians with the opportunity to participate in RCA teams by adopting a  mandatory rotation system.
RCAs have been required under the Program since 2000. About three- fourths of the respondents were familiar with the RCA concept. Seventy- five percent staff familiarity represents substantial learning, given when  the concept was introduced. However, only about a third had participated  in an RCA or knew someone who had. At one facility, we found broad  participation by physicians because management required it. NCPS  envisions RCA experience as central to changing to a culture of safety, but  many VA clinicians (approximately 65 percent) at the facilities we studied  had yet to participate in the nonblaming process that NCPS’s director told  us he viewed as the most effective experience for culture change: “We  don’t want professional root cause analysis people doing this stuff. Then  you don’t change the culture.”
We found a wide spectrum of methods being used to recruit physicians  into RCA teams. One facility had broad physician participation in RCAs as  its policy, and at another facility one unit had a rotational plan that  encouraged its own clinicians to participate, in contrast to the whole  facility. Administrators at three of the four had no policy across the facility  to ensure physician participation on the teams. At two facilities, Patient  Safety Managers told us it was difficult to get physicians to participate  because of their busy schedules. Understandably, most of the clinicians we  surveyed had not served on RCA teams.
section_title: Varying Cultural Support
paragraphs: Clinicians at three of the four facilities had medium or higher cultural  support for the Program. One facility had lower support, and many  clinicians indicated that they would not report adverse events because  they feared punishment. This suggests that the Program will not succeed  unless cultural support is bolstered. We explored the cultural support from  these four groups in two ways: (1) by graphically comparing the groups’  levels of mutual trust and comfort in reporting close call and adverse  events with their levels of familiarity with the Program and (2) by  graphically demonstrating the barriers clinicians see as blocking their  close call and adverse event reporting, in conjunction with some elements  of basic familiarity with and cultural support for the Program.
subsections: section_title: Clinicians’ Trust and Comfort in Reporting Varies by Facility
paragraphs: In figure 5, we compare our findings on clinicians’ mutual trust and their  comfort in reporting close calls and adverse events at the four facilities.  The levels of these components of a supportive culture appeared to vary  among the clinician groups. For example, staff at Facility A had medium  familiarity with the Program but had the lowest levels of comfort in  reporting adverse events and close calls and mutual trust among the four  facilities. Knowledge from specific safety training or RCA participation  was not sufficient for them to readily change to safety practices under the  Program if levels of comfort in reporting and mutual trust were not high  enough. Figure 5 contrasts information on the supportive culture (mutual  trust and comfort in reporting) with a measure of staff familiarity with the  Program from figure 4.
Many staff at Facility A were afraid of being punished, and they mistrusted  management and other work units. One staff member explained why staff  would not report adverse events: “We have a culture of back-stabbing  here. They are always covering themselves.” Many other staff members  echoed this characterization of the atmosphere, linking the lack of cultural  support to their decision not to perform the most basic of the Program’s  activities. Staff at that facility needed a boost in supportive culture to fully  implement the Program. In contrast, Facility D, with the least familiarity  with the Program, had trust and comfort levels almost as high as any of the  others, indicating that if the Program were to be pursued with greater  vigor there, cultural support would not be a barrier to reporting close calls  and adverse events.
section_title: Barriers to Reporting
paragraphs: In interviewing clinicians, we found that barriers remain to reporting  adverse events and close calls. Even for staff familiar with the concepts,  reporting required overcoming numerous remaining obstacles. These staff  indicated that reporting formally would be a time-consuming diversion  from patient care or, worse, “an invitation to a witch hunt.” In figure 6, we  display the cumulative effect of the barriers to reporting close calls that  staff told us about, in conjunction with familiarity with and cultural  support for the Program.
Clinicians told us about barriers to their participation in reporting,  including (1) limited perceived value, (2) not knowing how to report,   (3) not having enough time to report, (4) fearing traditional blame or  punishment, (5) lacking trust that coworkers would not shame them, and  (6) lacking knowledge of the confidential reporting option. Staff at all four  sites reported such barriers in reporting both close calls and adverse  events. We present some of their views in “Clinicians’ Barriers to  Reporting Close Calls and Adverse Events.”
Clinicians’ Barriers to Reporting Close Calls and Adverse Events  Nurse 1: Some clinicians feel comfortable reporting adverse events and  close calls. I agree with the concept. It depends on the person. Some  would feel it would be used against them. I’ve seen nonreporting,  because, before, they got written comments such as “This is not a near  miss.” “This is not a close call.” We get shut down instead of worked  with. [By “shut down,” she meant that management told her it was not a  close call and not to report it.] It happened to me. Management generally  discourages and does not empower staff to feel comfortable reporting  patient safety conditions. Instead, I reported and it was used against me.
Physician 1: I can’t remember if I’ve written a close call. That does not  happen here—only very, very rarely. Maybe I wrote one early on in my  career, but I’m not sure.
Physician 2: I thought I had a close call once and showed it to the chief  of staff and he told me that it was not a close call. I’m unclear what the  definition of a close call is.
Physician 3: I know what a close call is in other settings, but not in the  hospital setting.  They are not  reporting on close calls in this hospital.
Physician 4: Yes, I know what a close call is. I’ve not reported a close  call, but if I were to, I would go to a nurse supervisor and tell her about it  orally and have her report it. I would not use incident reports to report a  close call—only actual events.
Physician 5: I have not reported a close call. I’m removed from the  nursing communications.
Physician 6: I’m unsure if it is safe to report close calls without  punishment.
Nurse 2: If I saw a close call, I would go talk to the nurse who did it.  Writing up a close call on someone would be cruel. I would not write up  a close call or adverse event report on someone else. If something  happened to the patient, I would write it up. Writing up another person  would cause conflict. We need to help each other, and writing each other  up is not considered helpful.
section_title: Additional Steps to Stimulate Culture Change
paragraphs: The themes for work conditions that promote a supportive culture for  patient safety that clinicians articulated most often were (1) leadership,  (2) communication, (3) professional values, and (4) workflow.
section_title: Building a Supportive Culture
paragraphs: A few strong patterns emerged from the clinicians’ responses to our open- ended interview questions about what affects trust and comfort in  reporting close calls and adverse events. First, across the survey, the  clinicians said their leaders’ actions were most likely to increase or  decrease comfort and trust. Attributes of communication were the second  most common aspect of their work that they said influenced their comfort  and trust. Third, and somewhat less commonly, clinicians thought that the  values and norms that they had developed in their professional training  and that had been reinforced on the job influenced their culture, but they  also thought that workflow could support or undercut trust generally. In  their view, trust literally could be made or broken, depending on whether  tasks shared between individuals or between units went smoothly and  cooperation was maintained. Table 3 shows the results of our content  analysis, listing the clinicians’ four top themes—leadership,  communication, professional values, and workflow—and how many times  we found these themes in our analysis.
When we asked clinicians what affected a culture that supported comfort  in reporting and trust among the different professions, departments,  teams, and shifts they worked with, their most frequent answers were  effective leadership and good two-way communication. Moreover, the  clinicians told us that an unsupportive culture lacks these characteristics.  Clinicians gave us these same answers, whether we asked about comfort  in reporting or mutual trust. Further, we found that the culture of blame  and punishment traditionally learned in medical training hampers close  calls and adverse event reporting but that mutual trust is developed more  by workplace conditions.
subsections: section_title: Effective Leadership
paragraphs: Leadership’s role is important in fostering a supportive cultural  environment for the Program. Clinicians reported examples of leaders  facilitating comfort in reporting and mutual trust that enabled them to  participate in the Program. But at several facilities we also heard about  distrust of the Program that resulted from leaders’ action or lack of action.
Clinicians told us that some VA leaders had not focused sufficiently on  building the supportive culture that the Program requires. Staff reported  that in order to trust, they needed information and needed to take part in  decisions about their workplace and policies that affect their work. For  example, clinicians told us that they wanted to be part of management’s  decisions or, at the very least, to be informed about management’s  decisions when a number of changes were being introduced, such as when  medical supplies and software were purchased, clinicians were assigned  temporary rotations, and performance measures were implemented. Their  observations are in line with other studies that show that leaders’ making  decisions without consulting frontline workers can cause serious  problems of trust.
In “Clinicians’ Perspectives on Leaders’ Supporting Trust,” we illustrate  staff’s positive attitudes toward patient safety and how leadership is  instrumental in developing mutual trust and comfort.
Clinicians’ Perspectives on Leaders’ Supporting Trust  Nurse 1: I asked my staff what the role of leaders should be so I could  serve staff better. Many answered, “communication” and “knowing what is  happening at the facility is important.”
Physician 1: Leaders often bring up patient safety. They’re “taking a lead  in making staff aware of patient safety.” At my facility, they hold staff  meetings to review the patient safety goals of the Joint Commission on  Accreditation of Healthcare Organizations (JCAHO). The chief of staff  constantly brings up patient safety in meetings. The administration takes  the lead, not only “talking the talk” but also “walking the talk.”
Nurse 2: Trust is sustained, in part, because of weekly meetings with  management, where they talk about patient safety.
Physician 2: It’s leadership’s responsibility to communicate that staff are  accountable for cooperation and coordination of patient care.
Conversely, respondents said leaders’ actions can diminish clinicians’  comfort and trust, as summarized in “Clinicians’ Perspectives on Leaders’  Undercutting Trust.” Physicians and nurses at different facilities told us  that trust is diminished when staff do not work in stable teams. Some of  the policies that clinicians told us were obstacles to building a stable team  include assigning floating or nonpermanent supervisory personnel,  rotating physicians on and off the ward, and the monthly rotation of  student nurses and doctors.
Clinicians’ Perspectives on Leaders’ Undercutting Trust  Physician 1: For 20 years, there was nothing but “blame and train.” In  the past, an adverse event or close call was associated with a person you  had to blame, and the “fix” was to train them.
Nurse 1: We have a panel of nurse managers who have discouraged  adverse event reports for medication errors. I vow to encourage  reporting errors without blame. We still have a way to go to be honest  about reporting.
Nurse 2: I know of instances when staff reported adverse events, they  were transferred, so that does not make staff comfortable reporting  them. There is no trust of management.
Nurse 3: Decisions that affect our work are made without talking to staff  or understanding our work situation.
Physician 2: If you don’t know what’s going on, you invent it.
Physician 3: The most critical change needed at this facility is in the  area of leadership. Leaders are ineffective because they are not good at  communication. We hear about reasons why we are blamed. This causes  a feeling of distrust.
Physician 4: Leadership has little grasp of patient care and, thus, policy  directives have little impact. If we’re given a policy to spend a maximum  of 20 minutes per patient, including completing records, I do what the  patient needs. Management can just yell at me.
section_title: Communication
paragraphs: Staff indicated that communication in the workplace affects trust and  comfort in reporting. Further, they told us that communication is  challenging, since it involves coordinating tasks with and between leaders  and teams and their empowerment, all of which can be problematic in the  medical setting.
Some VA staff told us that unequal power relationships and hierarchical  decision making are often obstacles to patient safety. They also elaborated  on the kinds of communication that support patient safety, including  empowering staff so that they can be heard. Traditionally, a nurse’s status  is lower than a physician’s in hospitals, and some nurses could find it  difficult to speak up in disagreement with physicians. For patients to be  safe, however, nurses indicated they wanted to be empowered to openly  disagree with physicians and other staff when they found an unsafe  situation. For example, nurses told us that they had to speak up when they  disagreed with the medication or dosage doctors had ordered. They also  said that they had problems when physicians telephoned nurses and gave  directions orally when policy stated that physicians’ orders must be  written.
The clinicians spoke to us about empowerment and their involvement or  lack of involvement in decision making. “Clinicians’ Perspectives on How  Communication Promotes Trust” gives some examples of what they told  us about communication that they believed supports patient safety.
Clinicians’ Perspectives on How Communication Promotes Trust  Nurse 1: We interact with doctors and nurses in clinic. If something  happens, we share with one another about how we might have done it  differently. This goes on daily.
Nurse 2: The director of the medical facility is a good communicator; he  keeps us informed. He maintains a personal newsletter. Our nurse  manager is well rounded and she listens.
Nurse 3: Peers and coworkers communicating with one another  supports patient safety. For instance, sometimes we have patients who  have a history of violence. This information is reflected in the computer  and comes up when they “chart them in,” but sometimes a nurse may still  not know of such a history. Therefore, in the nurses’ reports, the history  of violence and the need for caution is passed on. Extra information  about the patients can also help them deescalate confrontations between  patients.
Physician 1: VA’s Computerized Order Entry system [a computerized  method for ordering medications] promotes patient safety. Before, it was  hard to read the physicians’ handwriting. The Computerized Order Entry  at least eliminated the legibility problem. They do not have  Computerized Order Entry at the university where I also work. VA also  got rid of using Latin abbreviations. Now everything has to be written  out.
Physician 2: Open communication promotes team buy-in and therefore  better customer service. (continued from previous page)
Physician 3: We have a good department because staff can  communicate their complaints.
Nurse 4: We do an RCA on our own close call or adverse event or those  from other sources, and then we present the results to the staff. I  brought a PowerPoint briefing to our staff meeting about another  hospital’s wrong site surgery, so we could know what had happened. If  JCAHO published an adverse event, I put it in our staff notes and have it  discussed at the next staff meeting.
Nurse 5: Management is more involved with the workers. It seems that  they are listening more.
Physician 4: Within the unit, we have good trust. Outside the unit, the  administration has more trust and more communication. We’re in the  loop more. In the clinic, we have good trust in nurse-to-doctor and  doctor-to-doctor relationships and with leadership.
Physician 5: I reported a close call recently and feared blame, but it was  not that way at all. It was a learning experience for all who heard about  it. I think it’s wonderful that VA has created this open atmosphere.  Formerly, you might be a scapegoat, have backlash, and get a poorer  rating. Today, we don’t feel we’re going to be punished.
In “Clinicians’ Perspectives on How Faulty Communication Diminishes  Trust,” we give clinicians’ examples of management’s undermining patient  safety by deciding policies without consulting them, as when nurses were  not included in decision making. Such policies sometimes proved  dysfunctional or were ignored.
Clinicians’ Perspectives on How Faulty Communication  Diminishes Trust  Nurse 1: I have to double-check changes in supplies in order to  safeguard patients, because Supply often sends ABC instead of XYZ.  Since we’re not included in decisions about product changes, we’re  forced to continually double-check Supply to keep patients safe.
Nurse 2: We have poor communication between other units and the  radiology unit. They send incontinent or violent Isolation   patients without notifying X-ray staff to be wary.
Facility staff also wanted additional and more timely feedback on what  happens to their reports of close calls, adverse events, and the results of  RCAs. Some Patient Safety Managers often felt too busy to provide  feedback to staff because their jobs included a number of activities,  including facilitating RCAs. At one facility, Patient Safety Managers  routinely reported system changes back to staff who made the reports, but  at the other facilities, they did not have a routine way of doing this. Many  staff at the four facilities told us that they did not know the  recommendations of the RCA teams or the results of close call or adverse  event reports.
NCPS agrees that feedback to staff is necessary but inadequate, and it  plans to focus on the need for feedback at facilities in the near future.  NCPS’s Web site publicizes selected results of RCAs and alerts and system  changes that result from reporting. Some of what VA’s leaders and  frontline clinicians told us about the need for more feedback is presented  in “Facility Staff Concerns about Limited Feedback.”
Facility Staff Concerns about Limited Feedback  Nurse Manager: We do a good job of following up on close call or  adverse event reports in my unit, but not as good a job following up on  the recommendations from RCAs. I was able to implement the action  items right away in my unit after I participated in an RCA on patients’  falls, but other nurse managers didn’t hear about the results from the  RCA for 2 or 3 months. The RCA teams develop really good ideas, but we  need follow-through to make sure everyone knows that this is what  we’re going to do to change the system. Delays result from organizational  routing and financial constraints. Even when the recommendation is  signed, sometimes there’s a delay getting the information down to the  nurse managers.
Physician 1: There should be an annual report of actions taken as a  result of reporting adverse events and close calls. For example, if three  units have developed a different way of labeling medication that used to  be labeled alike, then the rest of the staff should know about it. [This was  a reference to medication that looks alike and confuses staff. One  solution is for the pharmacy to buy the two medications from different  manufacturers so that the labels will be different.] It makes people feel  better to know the information they reported helped make things better.  I’d make sure that the information on improved medical care gets  reported back to the staff.
Administrative Official: The distribution of RCAs has been limited to  staff responsible for the action or system change, but in the future the  results will be distributed more broadly.
Physician 2: I haven’t heard any results from the RCAs. A pamphlet on  the results would be a good idea.
section_title: Workflow and Professional Training
paragraphs: In addition, staff spoke to us frequently about workflow issues—how  safely handing off tasks between shifts and teams required trust but could  cause mistrust when the transition was not smooth or efficient. VA  clinicians clarified for us that mutual trust could be either gained or lost  between workers and units, depending on coordination. And they drew  conclusions about the importance of the quality and nature of workflow to  patient safety. Clinicians also elaborated on aspects of the values they  learned in training that did not facilitate a blame-free workplace.
They indicated that shifting patient care between groups was an ongoing  challenge to patient safety. For analysis purposes, we found these issues in  continuity of care to be part of the larger problem of workflow, because  they entailed the coordination of tasks and communication within and  across teams. In the views of the clinicians at the facilities we studied, if  staff, teams, or units begin to feel they cannot adequately communicate  their patients’ needs for care because of workflow problems, then trust  may be lost, in turn diminishing patient safety. At one facility, where trust  and comfort were lower than at the others, clinicians told us that  workflow failures diminished trust and threatened patient safety. In  “Clinicians on Workflow Problems and Patients’ Safety,” some physicians  and nurses talk about these problems and how they tried to find solutions  to promote patients’ safety.
Clinicians on Workflow Problems and Patients’ Safety  Nurse 1: Some units are less particular about paperwork and records  than others, so when we transfer patients, their information is sometimes  incomplete. Patients don’t come back to my unit as quickly from one unit  as from other units, and sometimes their information is not available.
Physician: Personnel tends to lose things, and this makes it hard to  recruit new staff.
Nurse 2: We often have difficulty getting the supplies we need. For  example, it’s especially difficult to obtain blood on the night shift.
Nurse 3: At the change of a shift, I had to discharge one patient and  admit another. Since I couldn’t do both at the same time, I chose to admit  but not to discharge. But my relief nurse expressed unhappiness about  the situation, suggesting that I had left my work for another crew to do. I  spoke with the relief nurse, and the problem of mistrust was resolved  when everyone understood the work context better. When people  communicate across shifts this way, they have a better understanding of  and appreciation for one another.
Nurse 4: I go to the ward before my shift starts to make sure the patients’  wounds have been properly dressed. I take dressings to homebound  patients when they weren’t sent home with them. I cultivate motivated  individuals from the ward staff, letting them see the procedures in the  Dialysis Unit, and give them responsibility for those patients when  they’re back on the ward and reward them. I stock snacks because feeble  elderly patients are sent to Dialysis without breakfast, and then they’re  expected to get to breakfast after their dialysis session and pay for their  own meal. I see this situation as inherently unsafe, so I supply them with  free snacks.
The professional values physicians and nurses learned in their formal  education or on the job can also be an obstacle to the Program, because  these values do not always foster a nonpunitive atmosphere. Some of the  values clinicians have been trained in run counter to the Program’s  expectations for open reporting, as we show in “Clinicians’ Professional  Values and the Patient Safety Program.”
Clinicians’ Professional Values and the Patient Safety Program  Nurse 1: There is much trust within the nursing profession. We have to  trust each other because of the critical nature of passing patients from  one shift to another.
Nurse 2: The only group I worry about is Clerical. Their work is frontline  and high-stress, but it’s entry level, so they may have never worked in a  hospital before. We have to double-check their work because there’s no  system in the clinic to verify orders, as there is in the hospital.
Nurse 3: We trust those we work with. The exception is Housekeeping.  We have to continually call to complain about the cleanliness of the  clinic.
Nurse 4: Nurses have a value system in which we “eat our young,” which  undercuts comfort in reporting errors. Traditionally, older nurses taught  younger ones their way of doing things, and the younger ones were  punished when they failed to do things that way. Now, we must allow  nurses to do things a new way without punishment.
Nurse 5: I keep hearing that we’re looking to learn and not blame.  Nursing culture is a blaming culture, and  is  helping to stop this.
Nurse 6: The model in nursing is “a nun with a ruler.”
Physician 1: The culture is changing, but it’s taking a while. I’m  impressed with administration here that tries to say, “How can we learn  from this?”
Physician 2: To promote the Program, you have to have a change to a  no-blame culture.
Physician 3: Clinicians have to stop blaming each other and learn from  their mistakes.
VA clinicians explained that nurses see themselves as the patients’ first  and last guard against harm during care. Nurses are expected to be double- checking physicians’ orders, medicines, and dressings and, for example,  preventing falls or suicide attempts. Generally speaking, in their traditional  role, nurses feel personally responsible for patients’ welfare and are  designated to fulfill that role. They hold fast to protocols as safety devices,  follow rules, and double-check work orders. Some spoke favorably of a  bygone era when nurses could be counted on to back up one another,  while many others thought this described their current work environment.  In contrast, VA staff told us that physicians have thought of themselves as  taking more original and independent actions but not as part of a  multidisciplinary team. Their actions, based on traditional professional  values, would thus undercut mutual trust. Physicians told us that patient  safety would be improved if they were better trained to work on teams.
Both nurses and physicians face many obstacles to improving patients’  safety in the increasingly complex and ever changing world of medicine.  VA clinicians take seriously their mission as caretakers of the nation’s  veterans, many of whom are older and have multiple chronic diseases,  making these efforts to improve patient safety even more challenging.  Many told us that they feel ethically and morally bound as frontline  caretakers to keep their patients safe by reducing the number of adverse  events and close calls.
section_title: Improving Assessment of, Familiarity with, Participation in, and Cultural Support for the Program
paragraphs: Although VA conducted a cultural assessment survey in 2000 and plans to  resurvey VA staff in the near future, it has not measured staff familiarity  with, participation in, and cultural support for the Program. For example,  it did not ask about staff knowledge and understanding of key concepts  (close call reporting, RCAs, and VA’s confidential reporting system to  NASA) or RCA participation. Although the 2000 survey did describe some  important attitudes about patient safety, such as shame and punishment  related to reporting adverse events, it did not explicitly measure mutual  trust among staff, a central theme of VA clinicians in describing what  affected patient safety and a supportive culture. Finally, while NCPS staff  asked each facility to administer the survey to a random sample, many  facilities did not follow their directions. The VA survey may serve as a  baseline measure of national local trends, but it could not be used to  identify facility-level improvements or interventions.
section_title: Using Storytelling to Promote Culture Change
paragraphs: VA leaders at some facilities we studied showed staff they support the  Program by telling stories. They used the stories to publicly demonstrate a  changed and open atmosphere for learning from adverse events and close  calls, for example. While leaders must still distinguish episodes that  warrant professional accountability, they must fairly draw the line  between system fixes and performance issues. One way to do this is by  repeating stories that demonstrate that VA leaders encourage a culture  that supports the Program and an atmosphere of open reporting and  learning from past close calls and adverse events.
Leaders supported the Program by telling staff stories that demonstrated a  systems change to safeguard patients after a medical adverse event was  reported. Storytelling has a long tradition in medicine as way of teaching  newcomers about a group’s social norms. One leader shared with us the  story he used to kick off VA’s Patient Safety Program. Each time he tells  the story, he confirms the importance of changing VA’s culture and helps  transform the organization because staff remember it. Instead of  dismissing an employee who has reported not giving a patient the drug the  patient was supposed to receive, the leader judged the adverse event to be  a systems problem. In discussions with NCPS, the leader recognized that  this story was an opportunity to show his staff that the facility was  following the Program by taking a systems rather than a disciplinary  approach and to highlight that reporting close calls and adverse events  was critical in changing the patient care practice so that such problems  would not recur. “Leaders’ Effective Promotion of Patient Safety in Staff  Meetings” contains another example of storytelling to change  communication practice.
Leaders’ Effective Promotion of Patient Safety in Staff Meetings  [The Administrative Official met with a unit leader and about 20  physicians and residents.]  Administrative Official: The Patient Safety Program includes close calls  as reportable incidents. [That is, VA is accepting staff reports of close  calls.] A culture change is needed at VA, brought about by sharing a  vision of what is valuable to us. We also want to show that leadership  endorses the Program.  [He walked the meeting through an aviation example that showed that  the first officer should have challenged the captain, raising parallels with  failure to question authority—or to “cross-check”— at this facility. He  asked the group how they challenged authority effectively. Finally, he  introduced RCAs as a new type of system analysis. Physicians continued  their discussion.]  Physician 1: Cross-checking is more effective if it’s not hostile.
Physician 2: There are fewer errors in medical settings where there’s a  stable team, but recently VA has been trying to do things more quickly  with fewer staff.
Physician 3: Communication is a problem on my unit, where we have  28 contract nurses.
Physician 4: Could it be bad if one unit reported a lot of close calls?
Physician 5: : VA has 50 years of being punitive.  The Patient Safety Managers will be looking for patterns across a large  number of reports, not seeking to blame individuals.
Physician 6: Why can’t the reporting simply be open and the names of  the reporters known?  [Several members of the meeting talked about the fear of punishment  that still existed.]  Physicians 7 and 8: Are the forms discoverable? Can they be  subpoenaed? Can the reports be anonymous? (continued from previous page) [In a subsequent interview, leaders told about how the Program was  progressing.]  Leader 1: We must change doing what you’re told without questioning  orders. We tell nurses that it’s OK to challenge physicians in an  atmosphere of mutual respect. We’re establishing it as a facility goal,  keeping it on the front burner and keeping it a priority.
Leader 2: Since leaders began visiting staff meetings to get the word out  on close call reporting, we’ve noticed a change—a significant reduction  in the fear of reporting close calls. Not all fear is gone, but the close call  program is a success.
Leader 3: Leadership raised safety consciousness with the close call  airplane accident lesson. If it had been handed to us as just another  memo, it might have been thrown away, but when leaders are there in  person to answer questions, then it raises people’s awareness of patient  safety.
Physician 1: Leadership here went out and talked about patient safety.  Their support and emphasis and bringing their level of importance to it  made the Program happen.
section_title: Deliberate Teaching, Coaching, and Role Modeling
paragraphs: Staff at one facility told us that VA’s leadership supported the Program and  the patient safety culture by teaching, coaching, and role modeling patient  safety concepts to their staff in more than a hundred small meetings. VA’s  leaders had a three-part agenda in their initial staff meetings. First, they  taught a scenario in which two pilots failed to communicate well enough  to avoid a fatal crash. The first officer did not cross-check and challenge  an order from his captain to descend in a wind shear, resulting in the  plane’s crashing and killing 37 people. Facility leaders depicted the strong  parallels—-including the communication effects of unequal power  relationships and hierarchical decisionmaking discussed earlier—- between the pilots’ communication to save the plane and clinicians’  communications to save the patient.
Second, they discussed the importance of communications in medical  care, coaching lower-level staff to speak up when they saw adverse events  and emphasized the importance of two-way communication. Finally, they  introduced a new close call reporting program at the facility and modeled  for staff that they supported this type of reporting in introducing the new  Program and its elements. “Leaders’ Effective Promotion of Patient Safety  in Staff Meetings” presents a portion of one such meeting and also  interviews with VA staff when they discussed how the staff meetings had  raised their consciousness about patient safety.  “Leaders’ Effective Promotion” represents more than a hundred small  meetings conducted at one facility that successfully demonstrated that  patient safety was a priority for the organization. When top leaders  attended staff meetings, staff listened to their message. It may be no  coincidence that this facility had the highest rating for comfort in  reporting, according to the findings of our survey. Many staff at this facility  told us that because their top leaders spoke to them about the Program,  they concluded that the Program and its culture change were a priority for  their leaders. Midlevel staff also acknowledged progress but admitted to  some remaining fear.
Participants heard their leaders say that challenging authority—here  called “cross-checking”—was important for patient safety. They were  asked to compare their own communication patterns with the aviation  crew’s communication in a similarly high-risk setting that depended on  teamwork. The administrative official at the medical facility meeting,  drawing an analogy between the aviation example and participants’ work,  noted that an RCA had found that an adverse event could have been  prevented if authority had been challenged. His message to the meeting’s  participants was that VA’s leadership saw cross-checking as acceptable  and necessary.
section_title: Rewarding Close Call Reporting
paragraphs: The same facility that held small meetings for staff developed a close call  reward system that reinforced the idea that reporting a close call not only  did not result in punishment but was actually rewarded. Staff feared a  negative atmosphere when the close call program was first established,  with staff telling on one another, but this did not occur. The number of  close calls at this facility was few before the reward program began. In the  first 6 months of the program, 240 close calls were reported. While we  were visiting the Patient Safety Managers, many staff called them to report  close calls; each staff member was given a $4 cafeteria certificate.
Patient Safety Managers at this facility told us that they rewarded  reporting, no matter who reported or how trivial the report. The unit with  the month’s best close call received a plate of cookies. The Patient Safety  Manager reported that a milestone had been reached when a chief of  surgery reported a close call—a first for surgery leadership. “Rewarding  Close Call Reporting” paraphrases leaders and clinicians on the success of  the close call program at their facility.
Leader 1: With the close call program, the wards do not feel as secretive.  VA leadership thought the new close call program might cause staff to  turn on one another and begin to blame one another for reporting close  calls, but this has not happened.
Nurse 1: People are rewarded for reporting close calls and adverse  events—and not punished.
Nurse 2: I feel comfortable about reporting close calls and adverse  events. When management first introduced the close call program, we  thought everyone was going to tell on each other. If everyone starts to  find out things about you, you could lose your job, because it could be on  your record. You would have to ask yourself, “Is this something I would  really want to tell someone about?” We thought it would be like “Big  Brother Is Watching You.” But that is not what it’s like. I feel comfortable  reporting close calls and adverse events.
Administrative Official: To promote patient safety, we did a lot of  reward and recognition to let staff know that what they have done   is important.
Other facilities did not have as extensive a reward system. At one facility,  the Patient Safety Manager had recently given a certificate to someone  who had done a good job in describing an adverse event. However, at  another facility, the quality manager who supervised Patient Safety  Managers told us that she thought it improper to reward staff for  reporting: She did not want to reward people for almost making a mistake.  Clinicians in our interviews, however, pointed to the need to develop  reward programs around patient safety. For example, one nurse said that  if she were the director, she would call staff to thank them for reporting  close calls and adverse events and would develop a reward system.
section_title: Measuring Clinicians’ Familiarity with and Cultural Support for the Program
paragraphs: Clinicians’ familiarity with the Program and opportunities to participate in  RCAs could be measured at each facility in order to identify facilities that  require specific interventions. Because low familiarity or participation can  hinder the success of the Program, VA could attempt to measure and  improve basic staff familiarity with the Program’s core concepts and  ensure opportunities to participate in RCA teams. Our study developed  measures of familiarity with and participation in the Program by analyzing  responses from interviews of a small random sample of clinicians, and  these could be further developed into useful measures in a larger study.  These measures could also be developed into goals to be achieved  nationally and, more importantly, locally for each facility.
According to the clinicians we interviewed, the supportive culture of  individual facilities plays a critical role in clinicians’ participation in the  Program and warrants VA leadership’s priority. In one of the three  facilities where staff had above average familiarity with the Program, staff  told us that fear prevented them from fully participating in the Program.  From the clinicians’ vantage point, their leaders need not accept given  levels of mutual trust or comfort in reporting close calls and adverse  events; instead, once facilities are identified as having low cultural support  for the Program, that can be a starting point for change. In our  conversational interviews with clinicians, they consistently pointed to  specific workplace conditions that fostered their mutual trust and comfort  in reporting. Notably, management can take actions to stimulate culture  change by developing a work environment that reinforces patient safety.  Drawing from their own experience, clinicians had views that were  consistent with many studies of culture change in organizations, indicating  that leaders’ actions and open communication are important in the  transformation sought under the Program.
We were able to directly observe practices that have convinced frontline  workers that the Program is a priority for VA, that it is worth their while to  participate in it, and that by doing so medical facilities are safer for  patients. These practices included leadership’s demonstrating to staff that  patient safety is an organizational priority—for example, by coaching and  by communicating safety stories in face-to-face meetings with all staff— and that the organization values reporting close calls because it rewards  and does not punish staff for reporting them.
section_title: Recommendations for Executive Action
paragraphs: To better assess the adequacy of clinicians’ familiarity with, participation  in, and cultural support for the Program, we recommend that the Secretary  of Veterans Affairs direct the Under Secretary for Health to take the  following three actions:  1.  set goals for increasing staff  familiarity with the Program’s major concepts (close call reporting,  confidential reporting program with NASA, root cause analysis),    participation in root cause analysis teams, and    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;  2.  develop tools for measuring goals by facility; and  3.  develop interventions when goals have not been met.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for its review.  The Secretary of  Veterans Affairs stated in a December 3, 2004, letter that the department  concurs with GAO’s recommendations and will provide an action plan to  implement them. VA also commented that the report did not address the  question of whether VA’s work in patient safety improvement serves as a  model for other healthcare organizations. GAO’s study was not designed to  evaluate whether VA’s program was a model, compared with other  programs, but was limited to how the program had been implemented in  four medical facilities. VA also provided several technical comments that  we incorporated as appropriate.
section_title: Appendix I: Content Analysis, Statistical Tests, and Intercoder Reliability
subsections: section_title: Content Analysis
paragraphs: To analyze the data we collected, we used content analysis, a technique  that requires that the data be reduced, classified, and sorted. In content  analysis, analysts look for, and sometimes quantify, patterns in the data.  We conducted tests on clinicians’ responses to our key variables and  found a number of significant differences. We also conducted intercoder  reliability tests—that is, we assessed the degree to which coders agreed  with one another. The tests showed that the consistency among the coders  was satisfactory.
section_title: Ethnography
paragraphs: Ethnography is a social science method, embracing qualitative and  quantitative techniques, developed within cultural anthropology for  studying a wide variety of communities in natural settings. It allowed us to  study the Program in VA’s medical facilities. Ethnography is particularly  suited to exploring unknown variables, such as studying what in VA’s  culture at the four facilities affected the Program. In our open-ended  questions, we did not supply the respondents with any answer choices. We  allowed them to talk at length, and therefore the interviews lasted  anywhere from a half hour to an hour or more.
Ethnography is also useful for giving respondents the confidence to talk  about sensitive topics. We anticipated that clinicians would find the study  of VA’s medical facility culture, including staff views of close calls and  adverse events, a sensitive subject. Therefore, we gave full consideration  to the format and context of the interviews. Although ethnography is  commonly associated with lengthy research aimed at understanding  remote cultures, it can also be used to inform the design, implementation,  and evaluation of public programs. Governments have used ethnography  to gain a better understanding of the sociocultural life of groups whose  beliefs and behavior are important to federal programs. For example, the  U.S. Census Bureau used ethnographic techniques to understand  impediments to participation in the census among certain urban and rural  groups that have long been undercounted.
section_title: Data Collection
paragraphs: We conducted fieldwork for approximately a week at each of two  facilities, for 3 weeks at a third, and for 25 days at the fourth. Although  ethnographers traditionally conduct fieldwork over a year or more, we  used a more recent rapid assessment process (RAP). RAP is an intensive,  team-based ethnographic inquiry using triangulation and iterative data  analysis and additional data collection to quickly develop a preliminary  understanding of a situation from the insider’s perspective.
We drew two samples, one judgmental and one random. To understand  how the Program was implemented at each medical facility, we conducted  approximately a hundred nonrandom interviews with facility leaders,  Patient Safety Managers, and a variety of facility employees at all levels,  from maintenance workers, security officers, nursing aides, and  technicians to department heads. This allowed us a detailed understanding  of how the Program was implemented at each facility.
To ensure that we represented clinicians’ views at all four facilities, we  selected a random sample of 80, using computer-generated random  numbers from an employee roster of clinicians, yielding 10 physicians and  10 nurses at each facility. While this provided us with a representative  sample of clinicians (physicians and nurses) from each facility, the size of  this sample was too small to provide a statistical basis for  generalizing from our survey results to the entire facility or to all facilities.  For both samples, we used a similar semistructured questionnaire (see  app. III). It consisted of mostly open-ended questions and a few questions  with yes-or-no responses. At every interview, we asked staff for their  ideas, and we incorporated a number of their perspectives into this report.
A hallmark of ethnography is its observation of behavior, attitudes, and  values. Observation is conducted for a number of purposes. One is to  allow ethnographers to place the specific issue or program they are  studying in the context of the larger culture. Another, in our case, was to  allow some facility staff to feel more comfortable with us as we  interviewed them. Both purposes worked for us in this study.
Because we had observed meetings and RCA teams at work, we could  better understand respondents’ answers. Respondents noted how  comfortable they were in talking to us and how different our  conversational interviews were from other interviews they had  experienced in the past. We observed staff in their daily activities. For  example, we accompanied a nurse while she administered medication  using bar code technology that scans the medication and the patient’s  wristband. We also observed staff at numerous meetings, including RCA  team meetings, patient safety conferences, patient safety training sessions,  staff meetings in which patient safety was discussed, and daily leadership  meetings.
Our methodology included collecting data from facility records. We  examined all close calls and adverse events reported for a 1-month period  and all RCA reports conducted at each facility, and we reviewed  administrative boards and rewards programs. We read minutes from  patient safety committees and other committees that addressed safety  issues.
section_title: Data Analysis
paragraphs: Our data were mostly recorded, but some interviews were written,  depending on respondents’ permission to record. Using AnnoTape,  qualitative data analysis software, we coded the interviews for both  qualitative and quantitative patterns, and we used the software to capture  paraphrases for our analysis.
We developed a prescriptive codebook to guide the coders in identifying  interviews and classifying text relevant to our variables. After several  codebook drafts, we agreed on common definitions and uses for the  codes. In the content analysis of our random sample data, we looked for  patterns, associations, and trends. AnnoTape allowed us to mark a digital  recording or transcribed text with our codes and then sort and display all  the marked audio or text bites by these codes. Because all the coders  operated from a common set of rules, we achieved a satisfactory  intercoder rater reliability score. AnnoTape also allowed us to record  prose summaries of the interviews, some of which paraphrased what the  clinicians said; the paraphrases we present in the report reflect the range  of views and perceptions of VA staff at the four medical facilities. A rough  gauge of the importance of their views is discernible in the extent to which  certain opinions or perceptions are repeatedly expressed or endorsed.
Using the statistical package SAS, we analyzed the variables with two- choice and three-choice answers and transferred them to an SAS file for  quantitative analysis. Among the quantifiable variables were five yes-or-no  questions asking about respondents’ familiarity with key elements of the  Patient Safety Program. We created a new variable that reflected a  composite familiarity score for the Program, using the five questions about  familiarity with the key elements (the questions are listed in the note to   fig. 4). We also assessed respondents’ levels of comfort in reporting close  calls and adverse events and mutual trust among staff at each facility,  based on each whole interview. We used these two assessments, rated  high, middle, or low to characterize cultural support for the Patient Safety  Program.
In quantifying verbal answers for display and comparison purposes, we  decided that the maximum individual familiarity, trust, and comfort levels  should be 10. Thus, in each key elements question, we let “yes” equal 2 and  “no” equal 0, ensuring that an individual who knew all of the five elements  would achieve a composite score of 10. Finally, we averaged composite  scores to get an average score for each facility. In the trust and comfort  summary judgments, we let “high” equal 10, “medium” equal   5, and “low” equal 0. Rather then display these numbers, we used a scale of  high, medium, and low for 10, 5, and 0 and placed the answers accordingly.
section_title: Significance Testing
paragraphs: We were able to determine statistically significant differences in clinicians’  responses by facility and, unless otherwise noted, we report only  significant results.
First, we conducted a nonparametric statistical test, called Kruskal-Wallis,  on all possible comparisons in the subset of variables that we report in our  text. Four of these variables were central to the report: comfort summary  score, trust summary score, close call score, and root cause score. In the  Kruskal-Wallis test, each observation is replaced with its rank relative to  all observations in the four samples. Tied observations are assigned the  midrank of the ranks of the tied observations. The sample rank mean is  calculated for each facility by dividing its rank sum by its sample size.
If the four sampled populations were actually identical, we would expect  our sample rank means to be about equal—that is, we would not expect to  find any large differences among the four medical facilities. The Kruskal- Wallis test allows us to determine whether at least one of the medical  facilities differs significantly from at least one other facility. This test  showed that—for each of the comfort, trust and close call variables—at  least one of the medical facilities differed significantly from at least one of  the other medical facilities.
Next, we conducted a follow-up test to determine specifically which pairs  of medical facilities were significantly different from other pairs on key  variables. This follow-up test is a nonparametric multiple comparison  procedure called Dunn’s test. Our using Dunn’s test meant testing for  differences between six pairs of medical facilities: A vs. B, A vs. C, A vs. D,  B vs. C, B vs. D, and C vs. D.
Table 4 presents the results of Dunn’s test, along with each facility’s  sample rank mean and sample size. The pairs of facilities that are  statistically significantly different from one another are in the far right  column. Note that for the root cause characteristic, there are no  statistically significant findings from the multiple comparison testing,  which conforms to the results of the earlier Kruskal-Wallis test on root  cause.
section_title: Intercoder Reliability
paragraphs: Consistency among the three coders was satisfactory. We assessed  agreement among the coders for selected variables for interviews with  seven clinicians—that is, we assessed the extent to which they  consistently agreed that a response should be coded the same. To measure  their agreement, we used Krippendorff’s alpha reliability coefficient,  which equals 1 when coders agree perfectly or 0 when coders agree as if  chance produced the results, indicating a lack of reliability. Our  Krippendorff’s alpha values ranged from 0.636 to 1.000 for nine of the  selected variables (see table 5). Compared with Krippendorff’s guidelines  that alpha is at least 0.8 for an acceptable level of agreement and ranges  from 0.667 to 0.8 for a tentative acceptance, we believe our overall our  results are satisfactory.
section_title: Appendix II: A Timeline of the Implementation of VA’s Patient Safety Program
paragraphs: This timeline highlights the training programs and other events NCPS  completed between 1997 and 2004.
VA announces a special focus on patient safety  VA drafts patient safety handbook  VA develops Patient Safety Event Registry   Patient Safety Awards Program begins  Expert Advisory Panel is convened to look at reporting systems  Four Patient Safety Centers of Inquiry are funded  NCPS is established and funded  VA informs Joint Commission on Accreditation of Healthcare Organizations that it will go beyond JCAHO’s sentinel  event reporting system to include close calls  VA pilots RCAs at six facilities   Institute of Medicine issues To Err Is Human  VA and NASA sign interagency agreement on the confidential Patient Safety Reporting System  NCPS adverse event and close call reporting system established throughout VA  NCPS trains clinical and quality improvement staff in patient safety topics, including the RCA process   VA establishes Patient Safety Manager (hospital level) and Officer (network level) positions  Online and print newsletter Topics in Patient Safety begins publication  RCA software is rolled out  Facilities and networks are given the performance measure of completing RCAs in 45 days  Healthcare Failure Mode and Effect Analysis (HFMEA), a proactive risk assessment tool is developed by VA and  rolled out through multiple videoconferences  Aggregate RCA implementation is phased in over the year  New hires are trained in RCAs and Patient Safety Officers and Managers are given refresher training  The Veterans Health Administration’s Patient Safety Improvement Handbook, 3rd rev. ed. (VHA 1050.1), is officially  adopted  Facilities are given a new performance measure, being required to conduct proactive risk assessment, using HFMEA  to review contingency plans for failure of the electronic bar code medication administration system  The American Hospital Association (AHA) sends Program tools developed by VA to 7,000 hospitals  Rollout of confidential reporting to NASA is largely complete  Facility directors receive a day of training to reinforce what they could do to improve the success of their patient  safety programs  Facilities are given a performance measure for timely installation of software patches to critical programs  VA begins to provide training, funded by the Department of Health and Human Services, for state health departments  and non-VA hospitals as the “Patient Safety Improvement Corps, an AHRQ/VA Partnership”
From 1999 through 2004, NCPS has conducted training in the Patient  Safety Program. It was attended primarily by quality managers and Patient  Safety Officers and Managers. Typically, the training lasted 3 days and  included an introduction to the new Patient Safety Improvement  Handbook and small group training in the RCA process. Trainees,  especially Patient Safety Managers, were expected to take the Program  back to their medical facilities, collect and transmit reported adverse  events and close calls to NCPS, and guide clinicians in the RCA teams. We  observed health fairs at several of the four facilities.
Beginning in 2003, NCPS convened medical facility directors and other  managers in 1-day sessions that introduced them to the systemic approach  to improving patient safety, including a blame-free approach to adverse  events in health care.
section_title: Appendix III: Semistructured Interview Questionnaire
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: Additional staff who made major contributions to this report were Barbara  Chapman, Bradley Trainor, Penny Pickett, Neil Doherty, Jay Smale,  George Quinn and Kristine Braaten. Donna Heivilin, recently retired from  GAO, also played an important role in preparing this report.
section_title: Glossary
paragraphs: A research and development arm of NCPS’s Patient Safety Program.  The  centers concentrate on identifying and preventing avoidable, adverse  events, and each has a different focus.
subsections: section_title: Close Call
paragraphs: An event or situation that could have resulted in harm to a patient but, by  chance or timely intervention, did not. It is also referred to as a “near  miss.”
section_title: Frontline Staff
paragraphs: Staff directly involved with patient care.
section_title: Adverse Event
paragraphs: An incident directly associated with care or services provided within the  jurisdiction of a medical facility, outpatient clinic, or other Veterans  Health Administration facility.  Adverse events may result from acts of  commission or omission.
section_title: Joint Commission on Accreditation of Healthcare Organizations
paragraphs: JCAHCO is an accrediting organization for hospitals and other health care  organizations.
section_title: Medical Facility
paragraphs: A VA hospital and its related nursing homes and outpatient clinics.
section_title: National Center for Patient Safety
paragraphs: NCPS is the hub of VA’s Patient Safety Program, where approximately 30  employees work, in Ann Arbor, Michigan.  Other employees work in the  Center of Inquiry in White River Junction, Vermont, and in Washington,  D.C.
section_title: Patient Safety Reporting System
paragraphs: PSRS, a confidential and voluntary reporting system in which VA staff may  report close calls and adverse events to a database at the National  Aeronautics and Space Administration.
section_title: Root Cause Analysis Team
paragraphs: An interdisciplinary group that identifies the basic or contributing causes  of close calls and adverse events.