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Called the preoperative briefing, the rundown typically only takes a minute or two at nearly 130 Veterans Affairs hospitals around the country. The clinicians around the operating table introduce themselves to each other, including sometimes to the patient before anesthesia has begun.

They verify that all of the necessary supplies and instruments are ready, that the right blood type is on standby. Clinicians also can raise any last-minute concerns. Perhaps the patient bled a little more than anticipated during a prior surgery, says Lisa Mazzia, M.D., who runs the Medical Team Training program at the VA's National Center for Patient Safety. "It all turned out okay," she says. "But somebody remembers that."

The benefits of adding that briefing, integral to the national safety center's medical team training program, soon became self-evident, Mazzia says. During the first year that the new approach was used at 110 VA hospitals, 144 potential patient safety concerns were caught. They tended to fall into one of three categories, according to Mazzia: wrong patient or wrong medical chart (but right patient); concerns with an aspect of the patient's condition, such as a missing or worrisome laboratory result; and missing equipment.

"These are good facilities," Mazzia says. "And they were all pretty horrified. They all thought they had really, really iron-clad, iron-tight preoperative processes. It just shows you that we are all human. And [the briefing] is just another way to block that Swiss cheese model of how errors occur."

In regard to patient safety, or at least its public perception, the Veterans Affairs health system has developed a bit of a split personality in recent years.

The federally funded system for veterans, with 153 hospitals and more than 1,400 other clinical treatment sites, has been the focus of various newspaper and congressional investigations. Most recently, they have primarily involved concerns about sterilization or reprocessing of medical equipment for such procedures as colonoscopies and dental care. Early this year, VA officials reported that four veterans who had received dental care at the St. Louis VA Medical Center had tested positive for hepatitis, although at press time they've been unable to determine whether the infection is related to sterilization practices.

At the same time, the VA's national safety center, launched in 1999 from Ann Arbor, Mich., continues to spearhead quality and safety improvement efforts that have received kudos in national peer-reviewed journals. Among their initiatives: strict adherence to presurgical briefings and debriefings; training to break down clinical hierarchies that can inhibit frank conversations; and sifting through the VA's database of past life-threatening errors to figure out how to prevent the next one.

The VA has shown how improvement efforts can succeed across very large health systems, helping to pave the way for others, says David Nash, M.D., dean of the Jefferson School of Population Health in Philadelphia and an expert in quality improvement. "The VA is a national leader in having a centralized leadership team committed to the quality and safety agenda," he says.

Through studies and during interviews, VA officials have provided data that they say illustrate the quality influence of their national safety center. As one example, a study published in 2010 in the Journal of the American Medical Association found that the center's medical team training approach, first introduced in 2006, significantly has reduced surgical mortality. Among the 74 hospitals that had completed the training, patient deaths declined by 18 percent during the first year after training compared with the prior baseline year numbers. Among the 34 hospitals that hadn't yet been trained, the mortality reduction was 7 percent during the same period.

Still, the center is only one component of the sprawling health system, which also relies on other tools, including patient safety managers at the individual hospital and regional level, senior VA officials say. Size matters, too. As a publicly funded entity, one that's treating an expanding and aging veteran population, the VA's safety and quality stumbles are more likely to be put on display, including at congressional hearings.

And therein lies the Catch-22: how to foster disclosure amid public scrutiny, says George Arana, M.D., the VA's assistant deputy undersecretary for health for clinical operations. But Arana cites signs of progress.

"I think the message is, 'If you see something, tell us,'" he says. "I think it took a while for that to really happen. But I think it clearly has started happening."

Building Better Teams

In describing their work, the leaders at the VA's patient safety center frequently reference some of the safety lessons derived by the aviation industry and applied by the center's founding director, James Bagian, M.D. A former astronaut, Bagian led the center until he stepped down in 2010.

More often than not, the center's initiatives and programs stem from patterns or concerns identified in the VA's growing database of adverse events — incidents which harmed or nearly harmed a patient. Subsequently, the center conducts an analysis, dubbed a root cause analysis by VA officials (see sidebar). Moving forward, they tend to apply one or more of several unifying philosophies:

  • Identify and fix the error pattern, rather than become embroiled in a blame game, says Douglas Paull, M.D., the center's director of patient safety curriculum. "Instead of asking who is at fault, the office as a whole asks one simple question: Why? Why did something happen?"
  • Strive to boost communication and break down hierarchical barriers. As an analogy, Robin Hemphill, M.D., the center's new director, points out that all hands scour the deck of an aircraft carrier, looking for even one loose screw that might inflict damage. "If somebody picks up a screw, they don't say, 'That screw doesn't matter because you just fill the gas can.'"
  • Verify, verify, verify. Is all of the surgical equipment handy? In a knee replacement, for example, one of several key replacement pieces can differ depending upon whether the operation is on the right or the left knee, Mazzia says. "If you are doing three knees in a row, it's possible to get that mixed up."

The medical team training, implemented at nearly all of the 130 VA hospitals that perform surgery, weaves together those strategies in an effort to encourage team camaraderie and candor. The half-day of training typically involves numerous surgical players, including doctors, nurses, anesthesia providers and, frequently, housekeeping and imaging specialists. The goal is to implement the new approach within several days, Mazzia says.

According to last year's JAMA results, the mortality benefits increased over time, the longer the surgical teams were able to put the training into practice. Noted safety proponent Peter Pronovost, M.D., who co-authored the accompanying JAMA editorial, lauded the approach along with the results. "Teams did not solely check off items on the checklist, they used the checklist to trigger a conversation," he wrote.

Some surgeons have been slower to adapt, but none have failed to make the transition, says Paull, a surgeon himself. He's particularly excited that medical residents at the VA are being trained in the more interactive communication style, essentially reframing the definition of a good doctor beyond sheer technical prowess.

"In fact, you can be very good at those things and be a relatively poor health care provider," Paull says. "You could be doing a perfect central line on the wrong side of the chest, because you didn't listen to the nurse who was standing right next to you who had important information."

Speaking Up

Encouraging nurses to step forward more frequently with patient safety concerns is one of the driving passions of Gary Sculli, R.N., a safety program manager at NCPS. A former pilot, Sculli returned to health care and nursing following the airline industry downsizing after 9/11.

"I wanted to target that group [of nurses], who are laying their hands on patients the most," he says. "If there are subtle [patient] changes to detect, they are going to be the first to detect them."

Last year, Sculli helped to launch the pilot for a new program, Nurse Crew Resource Management. By midsummer, more than 20 units in the VA health system either had undergone the training or are scheduled to do so. The curriculum, which includes six hours of learning sessions and two hours of clinical simulations, walks nurses through better communication strategies, including assertiveness techniques.

Practice does help, according to a VA survey of the 14 units involved with the pilot phase. Prior to training, 60 percent of the participants agreed with the following statement: "It is difficult to speak up if I perceive a problem with patient care."

Six months later, just 20 percent of the group agreed.

Each unit also implements at least one improvement project. One unit decided to focus on more frequent patient turning to reduce hospital-acquired pressure ulcers, Sculli says. Other units have taken steps to shield nursing staffers who are performing key critical patient care tasks — similar to protecting a pilot during the takeoff process.

In one unit, nursing assistants have been given more protected time to check patients' blood glucose. In another, at Boise (Idaho) VA Medical Center's inpatient psychiatric unit, the medication administration nurse pulls on a red vest that clearly states: "Med Nurse. Do Not Disturb. Please."

With the exception of a medical crisis, that nurse isn't supposed to be sidetracked or interrupted, says Judy Area, the unit's nurse manager. Patients are accordingly educated. "The feedback I get from the nurses is that they are more focused on the patient and focused on the medication itself, rather than thinking the phone might ring or somebody might show up," she says. "They don't feel guilty if the phone just rings, rings, rings."

Sharing the Plan

VA officials also are trying to increase patients' participation in their own care, including catching errors, by literally keeping them more in the loop.

Beth King, R.N., NCPS program manager, recalls how she was relatively new at the center and reading through root cause analysis reports from around the country. "You see things and you think, 'My gosh, why didn't the patient speak up?''' Perhaps the patient didn't know what treatment to anticipate, she says.

The result was an initiative called The Daily Plan, a name that VA officials have since trademarked. Launched in 2007 on a pilot basis, the idea is to provide patients in participating units a short summary each day, typically two or three pages, outlining medical procedures, laboratory tests, medication and other treatment details.

As of this spring, 52 VA hospitals were using the plan approach in at least a portion of the hospital, King says. Initially, some nurses worried about the time involved. But the plan review takes five to 10 minutes and may save time later in the shift, she says. "If I can have 10 minutes and I can go through everything, it's easier for both of us than for [the patient] to nickel and dime you as a staff member with questions every half an hour."

A two-week analysis at five pilot sites found that nurses identified at least one error of omission, such as a medication that wasn't given, in 35 percent of their end-of-shift summaries, according to data provided by VA officials. (Each summary incorporates all of the patients with whom the nurse has reviewed the plan during that shift.) At least one error of commission, in which a medical procedure or drug was provided that shouldn't have been, was cited in 21 percent of the summaries.

Reviewing the treatment plan each day improves patient trust and the nurse-patient relationship, says Rosanne Zawinski, R.N., nurse manager of an acute inpatient unit at the VA Pittsburgh Healthcare System, which has been using the approach since 2008.

As with many of the national patient safety center initiatives, individual units can tailor The Daily Plan to meet that site's needs. At the Pittsburgh unit, the first plan they developed took an average of 18 minutes for a newly admitted patient, making it too time-consuming, Zawinski says. She worried that "the nurses would run through it very quickly, leaving the patients more confused." In 2009 they trimmed it down, so now it only requires 11 minutes for a newly admitted patient and roughly four minutes on subsequent days, she says.

Looking Ahead

In its pursuit of patient safety, the VA health system has some built-in advantages over other hospitals, starting with its fully employed culture, says Nash, of the Jefferson School of Population Health. "Outside of the VA, the physician culture is clearly dominant and may make it more difficult in certain circumstances to implement these changes."

But the patient safety and quality concerns that have emerged in the last few years serve as a reminder that the VA system is far from immune from the cultural challenges that can impact other hospital systems, Nash says.

In short, how do you get patient safety ingrained at the hospital unit level? Arana talks about some steps that VA officials have taken to guard against future sterilization problems. One change is that the responsibility for sterile processing now falls under direct clinical oversight, specifically a nurse executive at each hospital, rather than under an administrative area, he says.

Hemphill, who started this spring as NCPS director, also has clearly mulled over the intersection between patient safety and human nature. Ideally, housekeepers should view their role as not just to clean patient rooms, but to keep them free of dangerous bacteria. If they did, they'd be more likely to report concerns, she says.

"We want people to talk about near misses," Hemphill says. "The things that almost happened that are often tomorrow's [root cause analyses], if we don't do anything about it."

Meanwhile, the VA's adverse events database continues to provide fodder for new initiatives.

One analysis, according to Paull, determined that so-called wrong-site procedures — in which the wrong body part is involved — occurred about as frequently in areas of the hospital outside of the operating room, as they did within. Many common procedures are performed outside the operating room, including colonoscopies,

CT-guided needle biopsies and cardiac catheterizations, among others, he says.

In mid-2009, the VA's national patient safety center launched the second phase of its medical team training program. This phase, which is voluntary, broadens its net to include emergency rooms, intensive care units and interventional radiology, just to name a few. By early summer, nearly three dozen VA facilities had participated in yet another effort to improve patient safety.

Charlotte Huff is a writer in Fort Worth, Texas.

Sidebar - Rooting Out Errors with 'Why?'