Sustaining a Culture of Safety in the V.A. Health Care System

The U.S. Department of Veterans Affairs (VA) formed the National Center for Patient Safety in 1999 to foster an organizational culture of patient safety within its 153 hospitals and 783 community-based clinics.  To enhance staff engagement in safety, the Center tested and then implemented a teamwork approach based on the principles of systems engineering.

A just published article describes a case study of a multi-year effort to improve safety culture in VA hospitals.  The improvement process included the following key elements:

Medical Team Training:

The VA adopted a NASA Crew Resources Management (CRM) approach to training.  This approach emphasizes that human error should be anticipated and calls for behaviors and techniques that can prevent mistakes or ameliorate their effects. During the training participants were placed in groups and asked what they would need to make sure that a surgical operation goes well.  The output of these discussions became checklists.  The checklists themselves, while valuable, were not intended for “mindless” compliance, rather as artifacts of collaborative thinking to promote mindful practice.  As explained by Dr. Jim Bagian, the VA Chief Patient Safety Director, “The briefings and debriefings create a conversation where communication can be far richer and comprehensive than simplistic use of a checklist in a rote process.”

A Culture Dedicated to Reporting:

A commitment to creating an environment in which staff report on dangerous errors and unsafe conditions helps to promote a culture of safety in which the organization learns from mistakes.

Root Cause Analysis to Understand Vulnerabilities:

Causal analyses are conducted for learning and prevention.  The VA established severity categories to identify which events would be fully investigated.  For such events investigations are performed locally.  Based on events and concerns at other facilities, additional investigations may be conducted.  From those and other analyses, alerts and advisories may be issued to the entire VA system.

The Patient’s Role in Patient Safety:

A plan of the day is established for each patient and a nurse discusses this plan daily with each patient.  Patients are encouraged to actively participate to make sure their daily treatment goes as planned and to speak up if they note any deviations from the plan or have any concerns.


By 2009, the VA had implemented the CRM approach in operating rooms and intensive care units in virtually all VA medical centers that provide surgical services, through on-site training in each facility.  In total, more than 12,000 staff members were trained.  The VA was able to evaluate the clinical effects of CRM adoption in the operating room because of existing standardized data collection.  Preliminary results include the following:

  • Teamwork and efficiency improved: 82 percent of the operating room staff surveyed using the Safety Attitude Questionnaire said teamwork improved and 79 percent said efficiency improved.
  • Quality of care improved: for example, receipt of treatments to prevent blood clots increased from 85 percent before CRM training to 95 percent of patients after CRM implementations and timely receipt of prophylactic antibiotics increased from 92 percent to 97 percent of patients.
  • Operative time per case decreased in 29 percent of 110 facilities surveyed.
  • On-time surgery starts for the first case of the day increased by 54 percent.
  • Nursing turnover decreased by 30 percent following team training in surgical intensive care units and operating rooms.

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