Veteran's Health Administration Case Study

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 …show more content…
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 …show more content…
For example, active errors are errors nurses, physicians, or technicians make who are providing direct patient care (Giddens, 2013). In this article, they describe the importance of a medication barcoding system to improve patient safety. This system helps to reduce errors by preventing drawing up wrong medications or administering medications to the wrong patient. In this case study, The Quality and Safety Education for Nurses (QSEN) attribute would be the nurse’s attitude of collaboration. With inadequate collaboration, communication gaps between nurses and physicians will increase. This case study states, “…many nurses say they do not see the value of participating in patient rounds with physicians” (McCarthy and Blumenthal, 2006). Nurses are not satisfied with the teamwork, collaboration, or communication between physicians. With better precieved teamwork and lower nursing staff burnout, an increase in patient satisfaction will occur. Just culture is the best theoretical link that relates to this case study. Employees must report all adverse events and near misses. Although, some people are afraid to be identified, all identifier information is stripped from the record after the incident is under control. Just culture is a balance of learning from mistakes and taking disciplinary action (Giddens,