Systems Thinking

Finally, our ethnographic research approach was systemic. We looked not only at the Program’s key  elements, in the darkly shaded boxes in figure 2, but also at what  surrounds them—the context of the medical facilities’ culture—and  whether the culture supports the adoption of the Program. In fiscal year 1999, NCPS defined three major initiatives: (1) a  more focused system for mandatory close call and adverse event  reporting, including a renewed focus on close calls; (2) reviews of close  calls and adverse events, including RCAs, using interdisciplinary teams at  each facility to discover system flaws and recommends redesign to  prevent harm to patients; and (3) staff feedback on system changes and  communication about improvements to patient safety. Chapter 3 is an examination of  whether the culture at the four facilities supports the Patient Safety  Program and chapter 4 provides examples of management practices that  promote patient safety. In general, we found progress in clinicians’ understanding and  participation in the Patient Safety Program. Of the staff who  had participated in RCAs, many indicated that it was a positive learning  experience, but facilities varied in ensuring clinicians’ broad participation. At one facility, we found broad  participation by physicians because management required it. For example, nurses told us that they had to speak up when they  disagreed with the medication or dosage doctors had ordered. Improving Assessment of, Familiarity with, Participation in, and Cultural Support for the Program

Although VA conducted a cultural assessment survey in 2000 and plans to  resurvey VA staff in the near future, it has not measured staff familiarity  with, participation in, and cultural support for the Program. Although the 2000 survey did describe some  important attitudes about patient safety, such as shame and punishment  related to reporting adverse events, it did not explicitly measure mutual  trust among staff, a central theme of VA clinicians in describing what  affected patient safety and a supportive culture. One way to do this is by  repeating stories that demonstrate that VA leaders encourage a culture  that supports the Program and an atmosphere of open reporting and  learning from past close calls and adverse events. Nurse 1: People are rewarded for reporting close calls and adverse  events—and not punished. Recommendations for Executive Action

To better assess the adequacy of clinicians’ familiarity with, participation  in, and cultural support for the Program, we recommend that the Secretary  of Veterans Affairs direct the Under Secretary for Health to take the  following three actions:  1.  set goals for increasing staff  familiarity with the Program’s major concepts (close call reporting,  confidential reporting program with NASA, root cause analysis),    participation in root cause analysis teams, and    cultural support for the Program by measuring the extent to which  each facility has mutual trust and comfort in reporting close calls and  adverse events;  2.  develop tools for measuring goals by facility; and  3.  develop interventions when goals have not been met.
Why GAO Did This Study

The Department of Veterans Affairs (VA) introduced its Patient Safety Program in 1999 in order to discover and fix system flaws that could harm patients. The Program process relies on staff reports of close calls and adverse events. GAO found that achieving success requires a cultural shift from fear of punishment for reporting close calls and adverse events to mutual trust and comfort in reporting them. GAO used ethnographic techniques to study the Patient Safety Program from the perspective of direct care clinicians at four VA medical facilities. This approach recognizes that what people say, do, and believe reflects a shared culture. The focus included (1) the status of VA's efforts to implement the Program, (2) the extent to which a culture exists that supports the Program, and (3) practices that promote patient safety. GAO combined more traditional survey methods with those from ethnography, including in-depth interviews and observation.

What GAO Found

GAO found progress in staff familiarity with and participation in the VA Patient Safety Program's key initiatives, but these achievements varied substantially in the four facilities we visited. In our study conducted from November 2002 through August 2004, three-fourths of the clinicians across the facilities were familiar with the concepts of teams investigating root causes of unintentional adverse events and close calls. One-third of the staff had participated in such teams, and most who participated in these teams found it a positive learning experience. The cultural support clinicians expressed for the Program also differed. At three of four facilities, GAO found a supportive culture, but at one facility the culture blocked participation for many clinicians. Clinicians articulated two themes that could stimulate culture change: leadership actions and open communication. For example, nurses need the confidence to disagree with physicians when they find an unsafe situation. Although VA has conducted a cultural survey, it has not set goals or explicitly measured, for example, staff familiarity and mutual trust. Clinicians reported management practices at one facility that had helped them adopt the Program, including (1) story-telling techniques such as leaders telling about a case in which reporting an adverse event resulted in system change, (2) management efforts to coach staff, and (3) reward systems. The Patient Safety Program Process shows how ideally (1) clinicians have cultural support for reporting adverse events and close calls, (2) teams investigate root causes, (3) systems are changed, (4) feedback and reward systems encourage reporting, and (5) patients are safer.