Stop the Line
A VA-wide initiative that empowers VHA employees to speak up immediately if they see a risk to patient safety.
Quality of Healthcare
VA strives to provide the highest quality care possible every day. This site will tell you how we’re doing!
I CARE at VA
The I CARE Core Characteristics define "what we stand for," and what VA strives to be as an organization.
Predicting and Preventing Delirium
Could a nine cent set of earplugs prevent a patient safety emergency, avoid an extended hospital stay, and support a better health outcome for Veterans?
Delirium is a patient safety emergency that is common and vastly under recognized. It occurs in 25 percent of medical inpatients, half of surgical patients, and 75 percent of ICU patients. These patients often incur higher costs, longer hospitalizations, loss of function, and the need for rehabilitation or nursing home care. Prevention strategies, however, can be effective, particularly for individuals at elevated delirium risk. In fact, targeted interventions can reduce the incidence of delirium up to 40 percent.
In the past, the average amount of time required to assess a patient for delirium was 21 minutes. More recently, two tests - the MOYB (Months of Year Backward) and mRASS (Modified Richmond Agitation and Sedation Scale) – have been found to identify high risk patients in only six minutes. Today, there’s the promise of a new electronic system– the e-NICE rule – which has been shown to cut assessment time to ten seconds. Developed by the Delirium Patient Safety Center of Inquiry and the QSV’s New England Veterans Engineering Resource Center, the e-NICE rule uses standard data elements from VistA and CPRS.
Now that we have much greater ability to assess patients for risk of delirium, we can also take advantage of an array of simple tools and strategies to prevent it. Pocket amplifiers, reading glasses and magnifiers can enrich the patient’s sensory input. Puzzles, modeling clay and playing cards can provide mental stimulation. Relaxing music, sleep masks and, yes, those nine cent earplugs can promote restful sleep – and help prevent delirium.
Bright Idea Award
On June 6, VA’s National Center for Patient Safety, in partnership with the VA Healthcare Technology Management (HTM) Office, received the Association for the Advancement of Medical Instrumentation (AAMI) 2015 Bright Idea Award for A Systems Approach to Patient Safety. The award, which recognizes the top innovation profiled in AAMI’s peer-reviewed journal Biomedical Instrumentation and Technology (BI&T), was presented during the association’s annual conference in Denver, Colorado.
VA’s “Bright Idea” was a systems-based, multidisciplinary training initiative to enhance patient safety across the entire healthcare system. NCPS ‘translated’ its patient safety curriculum and geared it directly towards newly hired HTM professionals entitling it Patient Safety Boot Camp. This training program focuses on a systems approach to patient safety to ensure adverse events as well as close calls are fully understood in the field and that vulnerabilities are removed from the system. These new recruits then can share important patient safety principles with other VA HTM staff, who in turn build stronger working relationships with their respective facility patient safety managers in order to enhance patient safety and ensure safe operations across all VA facilities.
Biomedical engineers also learn how to conduct their own root cause analyses of adverse medical device events, as well as how to assess risk prior to purchasing complex devices.
This training was profiled in the Jan/Feb 2014 issue of BI&T. Four Patient Safety Boot Camps have been held since the program began in October 2012. After the release of the article in BI&T, NCPS, in partnership with HTM, has expanded patient safety training to more senior-level biomedical engineering professionals to create a mission-focused, systems-focused team at every VHA facility.
Risk Management Boot Camp
Earlier this year, QSV’s Risk Management Program sponsored the third of four Risk Manager Boot Camps to be held in 2015. Designed primarily for recently assigned risk managers (those who have been at their position less than two years), each boot camp features interactive sessions and group discussion as well as lectures by Risk Management staff and guest faculty from QSV. During the most recent session (last March), 25 participants from VAMCs nationwide gathered at the VISN 22 offices in Long Beach to learn about peer review for quality management, disclosure of adverse events to patients, and tort claims processing, among other topics. Guest faculty participants were David Sine, Chief Risk Officer, who provided a presentation on Enterprise Risk Management; Kate Enchelmayer, Director, Medical Staff Affairs, who provided an overview of the Credentialing and Privileging process; and Gary Sculli, Director of Clinical Training Programs, NCPS, who presented on Just Culture and Culture of Safety.
EMMT Wins 2015 ‘Igniting Innovation Award’
Working with experts across the VA, QSV’s Office of Health Systems Innovation and Office of System Design and Improvement (SR) developed the Emergency Medicine Management Tool (EMMT), an innovation that helps VHA emergency departments (EDs) improve performance. The EMMT works with emergency department integration software (EDIS) to help VHA EDs and urgent care clinics monitor and compare performance on key metrics such as wait times, length of stay, service quality and productivity. By enabling facilities to assess performance in real time, the EMMT improves Veterans’ care through the reduction of patient waiting times, more efficient use of emergency medicine resources, and standardization of operations across VHA facilities. Earlier this year, the EMMT was named winner of the 2015 “Igniting Innovation” High Risk/High Reward Dynamite Award. Sponsored by the American Council for Technology and Industry’s Council (ACT-IAC) Institute for Innovation, the Igniting Innovation awards honor cutting-edge solutions to federal government IT challenges. The EMMT was also named among the competition’s top 30 government IT innovations.
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