Managing an Effective Quality Assurance

Managing an Effective Quality Assurance Program at a VA Medical Center

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 that is 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 a 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 are provided in the conclusion.

Review and Discussion

A wide range of events qualify for a patient incident report in the VA healthcare system, including patient falls (without and with injury), medication errors (without and with injury) and surgical misadventures. Other events such as fires and patient abuse are also reportable. In all cases, the patient incident data is trended locally and forwarded to regional offices and ultimately VA Central Office to 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 Table 1 below.

Table 1

Open System Concept of Department of Veterans Affairs Peer Review

Concept

Definition

Application to Large-Scale Organization

Application to the Nursing Services Delivery Theory

Inputs

Incident reports of medication errors, especially those sufficiently severe to trigger a peer-review.

In any VA healthcare setting, incident reports can be generated by anyone.

In the nursing services, these inputs typically involve medication errors or patient abuse cases.

Throughput

Computer-based reporting system is available that allows for the reporting of all types of incidents (i.e., fall, medication error, fire, etc.) 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

The patient incident data is transmitted to a regional office and subsequently 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 to qualify 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: reduction in patient incidents

Activities: Accreditation achieved

Negative feedback

Trended analyses of patient incidents can help identify patterns of activity that may involve just one or two staff.

Reports from medical center services and committees concerning patient incidents are used to develop appropriate interventions.

Trended data of patient incidents can point to shift and date where most incidents occur.

Desired Outcome

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

Goals and Objectives to Facilitate Outcome

The overarching goal of this program would be to reduce the number of medication errors in general and among those wards/shifts with the highest numbers of medication errors over the past 12 months. The objectives in support of this goal include:

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

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

Translation of Goals and Objectives into Policies and Procedures

The above-described goals and objectives would be codified in a center memorandum, signed by the director.

Relevant Professional Standards

This program is congruent with VA professional standards for patient care. In this regard, Jorm and Dunbar (2009) emphasize that, "In a patient-centered health system the views, experiences and rights of the patient drive the way that care is delivered. There is now an increasing emphasis on patient-centeredness as an essential characteristic of safe and high quality care" (p. 390). The initiative also encourages the use of the new Electronic Patient Event Report (ePER) system introduced by the VA in January 2013. According to the VA, "The ability for doctors, social workers, ward staff, and administrators to report events provides the opportunity to improve care for our Veterans" (Tillman, 2013, para. 3).

Explanation Concerning How the Proposed Resolution Upholds the Organization's Mission and Values and Improves the Culture and Climate