As part of a systemwide transformation, the VA formed its National Center for Patient Safety to foster an organizational culture of safety within its nationwide network of hospitals and outpatient clinics. A recent medical team training program designed to improve communication among operating room staff was associated with a reduction in surgical mortality and improvements in quality of care, on-time surgery starts, and staff morale. The program is now being expanded to other clinical units, along with a patient engagement program that prevents errors by facilitating communication relating to patients' daily care plans. A recognition program stimulated facilities to conduct timelier and higher-quality root-cause analyses of reported safety events to identify stronger actions for preventing their recurrence. Other initiatives have reduced rates of health care -- associated infections, patient mortality, and post-operative complications. Success factors include leadership accountability for performance and organizational support for testing, expanding, and adopting improvements.
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Title: Advancing Patient Safety in the U.S. Department of Veterans Affairs
Publication date 2011-03-15
Publication Year 2011
Authors
Deborah Chase
, Douglas McCarthy
Copyright holder(s)
Commonwealth Fund
Geographical Focus
North America / United States
Keywords
patient
, safety
, medical team
, NCPS
, checklist
Document type
CaseStudy
Language
English
URL: http://joiningforces.issuelab.org/resource/advancing-patient-safety-in-the-u-s-department-of-veterans-affairs.html
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