Today's VA hospitals are models of top-notch care
Kizer was immersed in studies of patient safety years before the Institute of Medicine's jolting report in 1999 of hospital errors that kill tens of thousands of patients. To cultivate a "culture of safety" at the VA, he created a National Center for Patient Safety, and to head it up he brought in James Bagian, a former astronaut who had investigated the space shuttle Challenger accident for NASA.
Bagian's hire was "one of the smartest things [Kizer] did," says Leape. Both an engineer and physician, Bagian brought to the VA unique skills and a zealous commitment to safety. "It was like being in two different worlds," Bagian says of the move from NASA to the VA. "One had a very constructive and methodical approach to how we identify problems, decide whether they are worth fixing and then fix them versus one that was done much more like a cottage industry, where decisions are based on what's my opinion or how do I feel about it today, which is not how you should run healthcare today."
Out loud. Bagian wanted people to report mistakes or close calls in treating patients. Such intelligence was crucial if safety was to be improved, because many errors happen because of a flawed system rather than a careless individual--a chart mix-up that could have ended in surgery on the wrong patient, the incorrect medication given to a patient because it was stored next to another one with nearly the same name. At today's VA hospitals, patient safety teams identify every step that led up to a blunder or close call to determine needed changes. For example, the VA has instituted a process to ensure that surgeons operate on the correct person or body part. One step includes asking patients to say their full names and birth dates out loud and to identify the body part to be cut.
Bagian's greatest challenge was shifting the attitudes of VA staffers. Few people reported a gaffe, for fear that they or the person who made it would suffer. "The VA had the most punitive, hardest culture I had ever seen," says Kizer; he and Bagian wanted to change the VA's punishment-oriented ways to an open, nonpunitive environment. But the staff didn't begin to respond until top managers showed they were serious. In the new VA, for example, managers could be fired, fined, and even jailed for retaliating against workers who file mistake reports.
Reports began coming in. More than 200,000 close-call and error reports have been filed at the VA without anyone being punished. "Staff gets to have input about how to provide better care," says Sotomayor, a VA nurse for 15 years. "The attitudes of people have changed." They take pride in the results, such as a decline in patient falls and a pacemaker redesigned by the manufacturer because of a close call. And other hospitals have noticed. Jennifer Daley, chief medical officer and senior vice president of clinical quality at Tenet Healthcare Corp., is using the VA as a blueprint to improve performance at the nation's second-largest for-profit hospital operator.