[Congressional Record Volume 147, Number 174 (Friday, December 14, 2001)]
[Senate]
[Pages S13295-S13296]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
VA COMMENDED FOR PATIENT SAFETY INITIATIVE
Mr. ROCKEFELLER. Mr. President, today I am proud to highlight the
recognition given to the Department of Veterans Affairs for the high
level of attention they have paid to patient safety in recent years.
The Institute for Government Innovation at Harvard University has
announced that VA's National Center for Patient Safety (NCPS) will be
one of five winners of the annual Innovations in American Government
awards. An article in yesterday's Washington Post brings this
achievement to national attention and details why VA's Center was the
only federal recipient of the award.
It's apparent that the NCPS has cultivated a culture within VA that
promotes communication and therefore enables health care staff to feel
more comfortable about reporting medical errors or even concerns that
they have about patient safety. VA launched this initiative in 1998,
but it received a major push in 1999 when the Institute of Medicine
released a report estimating that 44,000 to 98,000 Americans die each
year due to medical mistakes.
This award demonstrates how VA has pioneered the establishment of the
type of culture which must exist. According to the article, many health
care providers in the private sector have started to model their
patient safety models around that of the NCPS. This was a driving force
behind the Institute for Government Innovation's decision to recognize
VA's efforts by giving them this honor.
For a long time now, I have pushed VA to pay closer attention to
patient safety, as it has been an issue of concern in the past. This is
why I am glad to finally see VA on the cutting edge of patient safety,
and being acknowledged for it. Our veterans deserve nothing less than
highest standards of health care.
I ask unanimous consent that an article from The Washington Post,
detailing VA's patient safety program and the award, be printed in the
Record.
There being no objection, the article was ordered to be printed in
the Record, as follows:
[From the Washington Post, Dec. 13, 2001]
VA Medical System To Get Harvard Innovation Award
Reporting, Handling of Health Care Errors To Be Cited
(By Ben White)
The Department of Veterans Affairs health care system, long
derided as a bloated bureaucratic mess, will be singled out
for praise today for its efforts to improve the way medical
errors and close calls are reported by health care workers
and handled by hospital administrators.
VA's National Center for Patient Safety (NCPS) will be the
only federal program among five winners of the annual
Innovations in American Government awards from the Institute
for Government Innovation at Harvard University. The awards
are to be announced today.
Gail Christopher, executive director of the institute, said
the NCPS is helping foster a ``healthier culture of
communication'' in which health care workers at VA's 173
medical centers are far more likely to report mistakes or
close calls than in years past.
``It's sort of a breath of fresh air for workers who are
used to being in an adversarial or litigious climate,''
Christopher said. ``It meets a basic set of human needs, to
strive for excellence while at the same time acknowledging
the potential for human error. Its genius is really its
simplicity.''
VA officials say the program, begun in 1998, produced a 30-
fold increase in the number of accident reports in just 16
months and a 900-fold increase in the number of reported
close calls over the same period. These numbers reflect not
an increase in mistakes, they say, but rather a big jump in
the willingness of doctors, nurses and other workers to
report problems.
The agency began to focus on the issue after a 1999 report
by the Institute of Medicine estimated that 44,000 to 98,000
Americans die each year as a result of medical errors.
VA Secretary Anthony J. Principi said NCPS has created a
centralized mistake-reporting system that helps staff analyze
and address repeat problems while also establishing a new
culture in which the emphasis is on addressing the root
causes of errors rather than punishing those who make them.
``We look at entire systems now, not just, say, a nurse who
[makes a mistake] because she is pressed for time,'' Principi
said in an interview yesterday. He noted, however, that VA
will still punish anyone who ``intentionally and criminally
hurts a patient.''
In addition to the improved, confidential mistake-reporting
system, NCPS has set up a voluntary external system, modeled
after a NASA program, that allows any individual to report
medical mistakes or close calls anonymously.
NCPS Director James P. Bagian said the anonymous system
serves as a safety valve to make sure serious problems that
VA health workers might feel uncomfortable reporting, even
confidentially, do not slip unnoticed.
Bagian cited a flawed pacemaker and a potentially deadly
ventilator as examples of problems the NCPS regime has helped
identify and correct. But he said the biggest success has
been the change in culture. VA health care workers now know
they will be identified publicly and punished only if they
deliberately cause harm to a patient, according to Bagian. If
a worker simply makes a mistake, he can report it
confidentially and a team will assess the case, addressing
the cause of the error rather than the individual
responsible.
``We no longer focus on whose fault it is,'' Bagian said,
noting that the handbook explaining the new approach is
written in plain
[[Page S13296]]
English, rather than in the legalese of the past. ``Instead
we ask: What happened? How did it happen? And what can we do
to prevent it in the future?''
The award carries a $100,000 grant to help VA further the
program and let others know about it. Harvard's Christopher
said VA earned the award in part because so many private
health care and hospital companies are already seeking to
emulate NCPS.
``Clearly, the problem this program addresses is of
monumental significance,'' she said. ``and word has spread
rapidly within the health care community.''
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