Veteran’s Health Administration is the nation’s largest integrated health care system with over 1,300 locations. To address concerns about the quality of care provided the administration decided to undergo a “broad organizational transformation.” This transformation included many things to improve patient and employee satisfaction, as well as, safety. Resource redistribution, reevaluation of quality and value standards, and creation of a department-wide database to enable patients, clinicians, and administrators were the top priorities for this change (McCarthy and Blumenthal, 2006). The National Center for Patient Safety was quickly developed to encourage and enforce all of the new modifications. The foremost goal of the Veteran’s Health Administration
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Assessment in the change process includes creating a culture of safety in the U.S Department of Veterans Affairs health care system, starting with adopting a nonpunitive approach to patient safety (McCarthy and Blumenthal, 2006). In assessment the problem is identified, then data is collected and analyzed (Sullivan, 2013). The next portion starts with asking who, what, when, where and how. This helps to collect the data needed for the problem. After collecting data the next step is to begin analyzing it and to determine which direction to go. In this case study a problem with patient safety was discovered.
This brings us to the planning phase, which involves developing a plan for change; including resources, identifying supporters, opposers; and building a coalition. The proposed areas of change were the organizational culture and empowering local facilities and staff with tools, methods, and initiatives for patient safety improvement (McCarthy and Blumenthal, 2006). “The VA sought the cooperation of Congress, the Joint Council on Accreditation of Healthcare Organizations (JCAHO), and the unions that helped to define what acts would be subject to blame or punitive action” (McCarthy and Blumenthal, 2006, pp. …show more content…
This includes helping others prepare for change and how to handle resistance. There were many strategies implemented to improve patient safety. First, criminal acts were defined by certain parameters including: involvement of alcohol, substance abuse, patient abuse, or a purposefully unsafe act. The VA described that these were culpable acts that needed to be handled administratively and not within the patient safety system. Also, the National Center explained that employees should report all adverse events and close calls to the facilities patient safety manager, who would then use a computer system to centrally report these incidents (McCarthy and Blumenthal, 2006). Close calls can be more serious than adverse events. They also provide useful information to help diagnose dormant system weaknesses, which can lead to errors. Along with the implementation stage, the National Center conducted three-day training programs to teach the staff how to use these tools and provide them with ongoing support through calls and site visits (McCarthy and Blumenthal, 2006). The last step is the evaluation; including a feedback mechanism to keep everyone informed of the process, evaluation, and success of the change (Sullivan, 2013, p. 59). The case study they evaluated the process of change by doing a root cause analysis. The root cause analysis was presented to the facility’s CEO, who could choose to approve recommendations for corrective action or propose
Assessment in the change process includes creating a culture of safety in the U.S Department of Veterans Affairs health care system, starting with adopting a nonpunitive approach to patient safety (McCarthy and Blumenthal, 2006). In assessment the problem is identified, then data is collected and analyzed (Sullivan, 2013). The next portion starts with asking who, what, when, where and how. This helps to collect the data needed for the problem. After collecting data the next step is to begin analyzing it and to determine which direction to go. In this case study a problem with patient safety was discovered.
This brings us to the planning phase, which involves developing a plan for change; including resources, identifying supporters, opposers; and building a coalition. The proposed areas of change were the organizational culture and empowering local facilities and staff with tools, methods, and initiatives for patient safety improvement (McCarthy and Blumenthal, 2006). “The VA sought the cooperation of Congress, the Joint Council on Accreditation of Healthcare Organizations (JCAHO), and the unions that helped to define what acts would be subject to blame or punitive action” (McCarthy and Blumenthal, 2006, pp. …show more content…
This includes helping others prepare for change and how to handle resistance. There were many strategies implemented to improve patient safety. First, criminal acts were defined by certain parameters including: involvement of alcohol, substance abuse, patient abuse, or a purposefully unsafe act. The VA described that these were culpable acts that needed to be handled administratively and not within the patient safety system. Also, the National Center explained that employees should report all adverse events and close calls to the facilities patient safety manager, who would then use a computer system to centrally report these incidents (McCarthy and Blumenthal, 2006). Close calls can be more serious than adverse events. They also provide useful information to help diagnose dormant system weaknesses, which can lead to errors. Along with the implementation stage, the National Center conducted three-day training programs to teach the staff how to use these tools and provide them with ongoing support through calls and site visits (McCarthy and Blumenthal, 2006). The last step is the evaluation; including a feedback mechanism to keep everyone informed of the process, evaluation, and success of the change (Sullivan, 2013, p. 59). The case study they evaluated the process of change by doing a root cause analysis. The root cause analysis was presented to the facility’s CEO, who could choose to approve recommendations for corrective action or propose