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Perceptions of organizational commitment to safety differ between the operating rooms in high- and medium-complexity facilities of the Veterans Health Administration (VHA). The purpose of this study was to see whether medical team training (MTT) reduced this difference. The Safety Attitudes Questionnaire was administered before and at the completion of a MTT program. The study population consisted of respondents working in the operating room. Responses to the 7 safety climate items were analyzed using nonparametric tests. Before MTT, respondents working at medium-complexity facilities had more favorable perceptions of knowledge of proper channels and encouragement by colleagues to report safety concerns than respondents who work at high-complexity facilities. At completion, there was no difference in perceptions between respondents working at high- and medium-complexity facilities for these items. The VHA MTT program improved perceptions at both high- and medium-complexity facilities and eliminated differences present at baseline.

Background: The purpose of this study was to examine the outcomes of checklist-driven preoperative briefings and postoperative debriefings during the Veterans Health Administration (VHA) medical team training program., Methods: A briefing score (1, never started; 2, started then discontinued; 3, maintained on original targeted cases; 4, expanded to other services; 5, briefing all cases, all services) was established at 10.1 ± .3 months after introduction of the checklist. Outcomes included antibiotic and deep venous thrombosis prophylaxis compliance rates before and after use of the checklist., Results: Antibiotic (97.0% ± .1% vs 92.1% ± 1.5%; P = .01) and deep venous thrombosis (95.7% ± .8% vs 85.1% ± 4.6%; P = .05) prophylaxis compliance rates were higher after initiation of a surgical checklist., Conclusions: Checklist-driven preoperative briefings and postoperative debriefings are associated with improvements in patient safety for surgical patients., (Published by Elsevier Inc.)

Objectives: We quantified older (65 years and older) Veterans Health Administration (VHA) patients' use of the private sector to obtain 14 surgical procedures and assessed the potential impact of directing that care to high-performance hospitals., Methods: Using a merged VHA-Medicare inpatient database for 2000 and 2001, we determined where older VHA enrollees obtained 6 cardiovascular surgeries and 8 cancer resections and whether private-sector care was obtained in high- or low-performance hospitals (based on historical performance and determined 2 years in advance of the service year). We then modeled the mortality and travel burden effect of directing private-sector care to high-performance hospitals., Results: Older veterans obtained most of their procedures in the private sector, but that care was equally distributed across high- and low-performance hospitals. Directing private-sector care to high-performance hospitals could have led to the avoidance of 376 to 584 deaths, most through improved cardiovascular care outcomes. Using historical mortality to define performance would produce better outcomes with lower travel time., Conclusions: Policy that directs older VHA enrollees' private-sector care to high-performance hospitals promises to reduce mortality for VHA's service population and warrants further exploration.

Background: Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS)., Methods: The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned., Results: Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings., Discussion: An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.

Background: In 1998 the Veterans Health Administration (VHA) created the National Center for Patient Safety (NCPS) to lead the effort to reduce adverse events and close calls systemwide. NCPS's aim is to foster a culture of safety in the Department of Veterans Affairs (VA) by developing and providing patient safety programs and delivering standardized tools, methods, and initiatives to the 163 VA facilities., A Novel Approach: To create a system-oriented approach to patient safety, NCPS looked for models in fields such as aviation, nuclear power, human factors, and safety engineering. Core concepts included a non-punitive approach to patient safety activities that emphasizes systems-based learning, the active seeking out of close calls, which are viewed as opportunities for learning and investigation, and the use of interdisciplinary teams to investigate close calls and adverse events through a root cause analysis (RCA) process. Participation by VA facilities and networks was voluntary. NCPS has always aimed to develop a program that would be applicable both within the VA and beyond., Key Action Items and Results Related to Rca: NCPS's full patient safety program was tested and implemented throughout the VA system from November 1999 to August 2000. Program components included an RCA system for use by caregivers at the front line, a system for the aggregate review of RCA results, information systems software, alerts and advisories, and cognitive acids. Following program implementation, NCPS saw a 900-fold increase in reporting of close calls of high-priority events, reflecting the level of commitment to the program by VHA leaders and staff.

The Department of Veterans Affairs (VA) has been recognized for its patient safety initiatives. In 1998, a separate entity entitled the National Center for Patient Safety (NCPS) was established to promulgate and nurture the patient safety activities throughout the health care facilities of the VA. On the basis of a nonpunitive approach, NCPS fosters a culture of safety whereby clinicians report unsafe situations and close calls without fear of reprisals. The VA patient safety program stresses that reducing iatrogenic injury is best served through an examination of system and process vulnerabilities, with a focus on why something occurred rather than who is at fault. This article discusses the genesis of the VA patient safety program and reviews some of its successes.

An overarching principle of medicine is "First Do No Harm." Indeed, as the Institute of Medicine recently highlighted, without safety, there is no quality. The Veterans Health Administration of the Department of Veterans Affairs (VA), the nation's largest integrated health system, has made a commitment to safe patient care. Programmatic responsibility for supporting this commitment resides in the National Center for Patient Safety (NCPS).

Context: Weaving patient safety into the fabric of clinical activities is an increasingly important aspect of medical care., Objective: To detail the steps taken by the Veterans Health Administration (VHA) to integrate patient safety into its organizational structure., Design: Descriptive study., Setting: VHA., Data Sources: VHA documents, congressional testimony, the medical literature, the general press, and personal communications., Results: The VHA leadership has taken steps to promote a culture of safety by making public commitments to improving patient safety, allocating resources toward establishment of special centers, enhancing employee education on patient safety, and providing incentives to promote safety. The VHA is also establishing one mandatory and one voluntary adverse event reporting system; in the latter case, the reporter remains anonymous. Examples of nationally mandated initiatives are bar coding of all medications and use of computerized medical record that includes order entry, laboratory and imaging results, and all encounter notes., Conclusions: The VHA's initial efforts may serve as a template for other health care organizations that wish to engineer a culture of safety. Although progress has been made, patient safety efforts require constant attention to guard against becoming a new bureaucracy or simply window dressing.