Quality improvement lessons learned from National Implementation of the "Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook".

OBJECTIVE: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them. DATA SOURCES AND STUDY SETTING: Qualitative data collected from key informants at 18 geographically diverse VA facilities across 17 Veterans Integrated Services Networks (VISNs). STUDY DESIGN: We conducted semi-structured interviews from 2019 to 2022 with VISN Patient Safety Officers (PSOs) and VA facility patient safety and quality managers (PSMs and QMs) and VA Facility Community Care (CC) staff to assess lessons learned by examining organizational contextual factors affecting Guidebook implementation based on the Consolidated Framework for Implementation Research (CFIR). DATA COLLECTION/EXTRACTION METHODS: Interviews were conducted virtually with 45 facility staff and 10 VISN PSOs. Using directed content analysis, we identified CFIR factors affecting implementation. These factors were mapped to the Expert Recommendations for Implementing Change (ERIC) strategy compilation to identify lessons learned that could be useful to our operational partners in improving implementation processes. We met frequently with our partners to discuss findings and plan next steps. PRINCIPAL FINDINGS: Six CFIR constructs were identified as both facilitators and barriers to Guidebook implementation: (1) planning for implementation; (2) engaging key knowledge holders; (3) available resources; (4) networks and communications; (5) culture; and (6) external policies. The two CFIR constructs that were only barriers included: (1) cosmopolitanism and (2) executing implementation. CONCLUSIONS: Our findings suggest several important lessons: (1) engage all collaborators involved in implementation; (2) ensure end-users have opportunities to provide feedback; (3) describe collaborators' purpose and roles/responsibilities clearly at the start; (4) communicate information widely and repeatedly; and (5) identify how multiple high priorities can be synergistic. This evaluation will help our partners and key VA leadership to determine next steps and future strategies for improving Guidebook implementation through collaboration with VA staff.

Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA).

BACKGROUND: Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. METHODS: In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. RESULTS: A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). CONCLUSION: Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.

Adverse Patient Safety Events During the COVID-19 Epidemic.

METHODS: A retrospective descriptive analysis of patient safety events related to COVID-19 was performed on data that were submitted in the Joint Patient Safety Event Reporting System and Root Cause Analysis databases to the VHA National Center for Patient Safety from March 2020 to February 2021. Events were coded for type of event, location, and cause of event. RESULTS: Delays in care and staff/patients exposed to COVID-19 were the most common types of patient safety events, followed by COVID-19-positive patients eloping, laboratory processing errors, and one wrong procedure. The most frequently cited locations where events took place were emergency departments, medical units, community living centers, and intensive care units. Confusion over procedures, care not provided because of COVID-19, and failure to identify COVID-positive patient before they exposed others to COVID were the most common causes for patient safety events. DISCUSSION: Our results are similar to other studies of patient safety during the first year of the COVID-19 pandemic. Based on these results, we recommend the following: (1) focus on patient safety culture, leadership, and governance; (2) proactively develop competency checklists, cognitive aids, and other tools for healthcare staff who are working in new or unfamiliar clinical settings; (3) augment or enhance communication efforts with patient safety huddles or briefings at all levels within a healthcare organization to proactively uncover risk and mitigate fear by explaining changes in policies and procedures; and (4) maximize the use of quality and patient safety experts who are knowledgeable in system and human factor theories as well as change management to assist in redesigning clinical workflows and processes.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

INTRODUCTION: Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. MATERIALS AND METHODS: A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. RESULTS: Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. CONCLUSIONS: It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

Delays in Care During the COVID-19 Pandemic in the Veterans Health Administration.

OBJECTIVES: The purpose of this study was to review patient safety reports in the Veterans Health Administration (VHA) related to delays during an 11-month period that included months of the COVID-19 pandemic. DESIGN: A retrospective descriptive analysis of COVID-19 patient safety reports related to delays that were submitted in the Joint Patient Safety Event Reporting System database to the VHA National Center of Patient Safety from January 01, 2020 to November 15, 2020 was conducted. There were 897 COVID-19 patient safety events related to delays; 200 cases were randomly selected for analysis, with 148 meeting inclusion criteria. RESULTS: The results showed delays in laboratory results, level of care, treatment and interventional procedures, specific aspects of care, radiology treatment, and diagnosis. Causes for delays included poor communication between staff, problems in getting laboratory results, confusion over policy, and misunderstanding of COVID-19-specific rules. CONCLUSIONS: Healthcare delays can be reduced during a pandemic by proactively standardizing medical processes/procedures when testing for infection, improving staff to staff communication teaching the SBAR (situation, background, assessment, and recommendations) communication model, and using simulation to identify latent safety issues and educating medical personnel on new protocols related to the pandemic. Simulation can be used to test new protocols developed during the pandemic.

Veterans Health Administration response to 2021 recall of Philips Respironics devices: A case study.

This case study describes, for the time frame of June 2021 through August 2022, the U.S. Veterans Health Administration (VHA) organizational response to a manufacturer's recall of positive airway pressure devices used in the treatment of sleep disordered breathing. VHA estimated it could take over a year for Veterans to receive replacement devices. Veterans awaiting a replacement faced a dilemma. They could continue using the recalled devices and bear the product safety risks that led to the recall, or they could stop using them and bear the risks of untreated sleep disordered breathing. Using a program monitoring approach, we report on the processes VHA put in place to respond to the recall. Specifically, we report on the strategic, service, and operational plans associated with VHA's response to the recall for Veterans needing replacement devices. In program monitoring, the strategic plan reflects the internal process objectives for the program. The service plan articulates how the delivery of services will intersect the customer journey. The operational plan describes how the program's resources and actions must support the service delivery plan. VHA's strategic plan featured a clinician-led, as opposed to primarily legal or administrative response to the recall. The recall response team also engaged with VHA's medical ethics service to articulate an ethical framework guiding the allocation of replacement devices under conditions of scarcity. This framework proposed allocating scarce devices to Veterans according to their clinical need. The service plan invited Veterans to schedule visits with sleep providers who could assess their clinical need and counsel them accordingly. The operational plan distributed devices according to clinical need as they became available. Monitoring our program processes in real time helped VHA launch and adapt its response to a recall affecting more than 700,000 Veterans.

Prevention of veteran suicide in community settings: Patient safety resources.

As a recently retired Army Nurse Corps officer with almost 30 years of service to my country, I want to ensure that my fellow nurse practitioners (NPs) are aware of their role in ensuring high quality and safe patient care to all veterans who are accessing care outside of the Veterans Health Administration (VHA). Specifically, NPs who work outside the VHA have an opportunity to participate in patient safety efforts aimed at reducing veteran suicide. On June 6, 2018, Congress passed Public Law 115-182 or the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. A goal of the MISSION Act is to ensure that veterans have access to health care by streamlining eligibility criteria for community care. A veteran who drives more than 30 minutes or waits more than 20 days for a primary care or mental health appointment may be eligible to be sent to a community care provider such as an NP. Therefore, NPs and other providers who work in community settings have an obligation to know more about the mental and physical health care needs of veterans as well as the resources that have been developed by the VHA to assist them.

The Role of Army Nurse Practitioners Supporting Wars in Iraq and Afghanistan.

Family nurse practitioners are an essential member of the military medical team. They were incorporated into the Army medical system almost as soon as there was an academic program to develop the role in primary care settings. The role for nurse practitioners during deployment has not been as clear. Even though they have been around for 50 years, the specific role nurse practitioners provide is still evolving. This article explores the incorporation of nurse practitioners into Army medicine with a focus on deployed medicine. Nurse practitioners have been shown to be very versatile providers with the requisite skill sets to meet the demands of the combat environment and are able to substitute for other medical assets that are critically short due to sustained conflict. Clarifying the value a nurse practitioner brings to medical care in the combat environment is essential to insure all assets are being employed to provide the best medical care to the US fighting force.

Improving the adoption of evidence-based practice among nurses in Army outpatient medical treatment facilities.

This quality improvement project implemented and evaluated an evidence-based practice (EBP) program at two Army outpatient health care facilities. The EBP program consisted of five implementation strategies that aimed to inculcate EBP into organizational culture as well as nursing practice and culture. A conceptual model of the "Diffusion of Innovations" theory was adapted to explain the application of the program. The Institutional Review Boards at Walter Reed National Military Medical Center and Duke University School of Medicine reviewed and exempted this quality improvement project. A pretest-posttest design was used with four instruments at each facility. The EBP program was successful in enhancing organizational culture and readiness for EBP (p < 0.01) and nursing staff's belief about the value of EBP and their ability to implement it (p < 0.05). Another indicator that the EBP program achieved its goals was the significant difference (p = 0.002) in the movement of the outpatient health care facilities toward an EBP culture. These results suggest that this EBP program may be an effective method for empowering outpatient nursing staff with the knowledge and tools necessary to use evidence-based nursing practice.

A nurse-facilitated depression screening program in an Army primary care clinic: an evidence-based project.

BACKGROUND: Depression, sometimes with suicidal manifestations, is a medical condition commonly seen in primary care clinics. Routine screening for depression and suicidal ideation is recommended of all adult patients in the primary care setting because it offers depressed patients a greater chance of recovery and response to treatment, yet such screening often is overlooked or omitted. OBJECTIVE: The purpose of this study was to develop, to implement, and to test the efficacy of a systematic depression screening process to increase the identification of depression in family members of active duty soldiers older than 18 years at a military family practice clinic located on an Army infantry post in the Pacific. METHODS: The Iowa Model of Evidence-Based Practice to Promote Quality Care was used to develop a practice guideline incorporating a decision algorithm for nurses to screen for depression. A pilot project to institute this change in practice was conducted, and outcomes were measured. RESULTS: Before implementation, approximately 100 patients were diagnosed with depression in each of the 3 months preceding the practice change. Approximately 130 patients a month were assigned a 311.0 Code 3 months after the practice change, and 140 patients per month received screenings and were assigned the correct International Classification of Diseases, Ninth Revision Code 311.0 at 1 year. The improved screening and coding for depression and suicidality added approximately 3 minutes to the patient screening process. The education of staff in the process of screening for depression and correct coding coupled with monitoring and staff feedback improved compliance with the identification and the documentation of patients with depression. Nurses were more likely than primary care providers to agree strongly that screening for depression enhances quality of care. DISCUSSION: Data gathered during this project support the integration of military and civilian nurse-facilitated screening for depression in the military primary care setting. The decision algorithm should be adapted and tested in other primary care environments.

Expanding the role of the nurse practitioner in the deployed setting.

Today's military is experiencing rapid advances in technology and in manpower utilization. The Army Medical Department is redesigning the structure and function of deployable hospital systems as part of this effort. The transformation of deployable hospital systems requires that a critical analysis of manpower utilization be undertaken to optimize the employment of soldier-medics. The objective of this article was to describe the use of nurse practitioners as primary care providers during deployment. The lived experiences of five nurse practitioners deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the literature clearly support expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.

An activity calendar program for children who are overweight.

Sedentary lifestyle activities, such as computer use and television viewing, are modifiable causes of overweight among children. There are many recommendations in the literature that suggest the number of children who are overweight must be decreased; however, none of the research describes an instrument to achieve this goal. This article describes the use of a home-based physical activity calendar and its successes and failures.