VA Medical Center Quality Assurance Program: Systems Theory

Introduction

Today, the Department of Veterans Affairs (VA) operates a system of 167 medical centers across the country that provides tertiary healthcare services to eligible veteran patients. Each of these medical centers has a quality assurance service responsible for identifying opportunities for improving patient care through a rigorous patient incident reporting system. The results of these monitoring activities are reported at the medical center level, as well as regionally and nationally. By analyzing this aggregated data, quality assurance services can help reduce the incidence of serious patient incidents such as medication errors, patient falls, and patient abuse. This paper provides a description of quality assurance services in a VA medical center from a systems theory perspective. A summary of the research and important findings concerning using a systems theory approach to reducing patient incidents is provided in the conclusion.

A wide range of events qualify for a patient incident report in the VA healthcare system, including patient falls (with and without injury), medication errors (with and without injury), and surgical misadventures. Other events such as fires and patient abuse are also reportable. In all cases, patient incident data is trended locally and forwarded to regional offices and ultimately to VA Central Office for national comparisons. When patient events are sufficiently serious, they may warrant peer review, and adverse personnel actions can result from these reviews. An open system concept of this process is set forth in the table below.

Open Systems Framework for VA Peer Review

Open System Concept of Department of Veterans Affairs Peer Review

Inputs: Incident reports of medication errors — especially those sufficiently severe to trigger a peer review — serve as the primary inputs. In any VA healthcare setting, incident reports can be generated by anyone. In nursing services, these inputs typically involve medication errors or patient abuse cases.

Throughput: A computer-based reporting system is available that allows for the reporting of all types of incidents (e.g., falls, medication errors, fires), which are then trended by ward and shift and weighted by patient days of care. Results of incident analyses are reported in the medical center's weekly QA report and discussed by all medical center committees as the data relates to them. Various initiatives have been used to reduce patient incidents; for example, posters reminding nurses about eliminating medication errors resulted in a 30% reduction.

Output: Patient incident data is transmitted to a regional office and subsequently to VA Central Office in Washington, DC, for aggregation and further analysis. All VA medical centers receive aggregated reports concerning their patient incident reporting regimens and where they stand compared to all other VA medical centers. A single event can include more than one type of patient incident (Walshe & Boaden, 2006). Patient incidents are inevitable, but steps can be taken to reduce them. In one medical center, the decision was made to reduce the number of falls a patient experienced to just one before qualifying for fall prevention protocols.

Systems as cycles of events: Patient incident reporting is an ongoing program. Renewal is generated through internal audits as well as Joint Commission reviews. Outputs include reductions in patient incidents and the achievement of accreditation.

Negative feedback: Trended analyses of patient incidents can help identify patterns of activity that may involve just one or two staff members. Reports from medical center services and committees concerning patient incidents are used to develop appropriate interventions. Trended data on patient incidents can also point to the shifts and dates on which most incidents occur.

Desired Outcome: A 50% reduction in the number of medication errors of all types over the next 12 months.

The overarching goal of this program is to reduce the number of medication errors in general, with particular attention to those wards and shifts with the highest numbers of medication errors over the past 12 months. The objectives in support of this goal include:

Goals, Objectives, and Policies

1. Developing awareness campaign materials — such as locally prepared newsletter articles, posters, and brochures — concerning the goal to reduce medication errors.

2. Conducting a medication error theme seminar that provides basic guidelines for avoiding medication errors (the "5 Ps").

The above-described goals and objectives would be codified in a center memorandum signed by the director, translating them into formal policies and procedures.

Conclusion

Tertiary healthcare facilities are replete with patient interactions that can result in patient incidents, including falls and medication errors. By keeping track of these events and identifying patterns of occurrence, quality assurance professionals can help improve the quality of care being delivered to veteran patients in VA healthcare facilities. Because the information is frequently sensitive and can have implications for the career development of the individuals involved, it is vitally important that any such initiative be implemented and administered in a thoughtful fashion that ensures anonymity in aggregated data analyses. In sum, quality assurance professionals have a number of useful tools at their disposal, including chart review, peer review, and patient incident reporting systems that can identify opportunities for improving patient care.