Frequently Asked Questions - Quality, Safety & Value
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Quality, Safety & Value

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Frequently Asked Questions

Q-1: What is the Stop the Line for Patient Safety initiative?

A-1: The Stop the Line for Patient Safety initiative was established in 2013 with the goal of empowering VA employees to identify and report their concerns about patient safety without fear of reprisal.  More specifically, it refers to a measured response from VA staff when detecting errors or identifying areas of concern in the health care delivery process.

Q-2: Where did the phrase “Stop the Line” come from?

A-2: “Stop the Line” is a concept that originated in the manufacturing industry.  Management gave all employees working at the plant the power to stop a production line if they saw a mistake.

Q-3: How does “Stop the Line” apply to the care provided Veterans?

A-3: Stopping the line is about creating a Culture of Safety and a Just Culture, thereby empowering VA staff, whether they are clinical staff in the intensive care unit or engineering staff at the boiler plant, to feel safe and protected when voicing concerns about safety.

Q-4: What are the 3Ws©?

A-4: The 3Ws© refer to a tool that encourages employees to speak up: “Say what you see; Say what you are concerned about; and, Say what you want to happen to keep things safe.” 

Q-5: What is a Culture of Safety and a Just Culture?

A-5: Culture of Safety is characterized by an organization where leaders openly focus on safety as a top priority, where system-wide learning occurs as the causes of adverse events are openly shared, where investments are made in the resources and training to ensure safe practices, and where employees freely report and communicate safety concerns.

In a Just Culture, leaders do not rush to judge and punish employees involved in medical errors, but seek first to examine the care delivery systems as a whole in order to find hidden failures and vulnerabilities.