July 11, 2005
U.S. News and World Report
Military Might - Today's VA hospitals are models of top-notch care
By Christopher J. Gearon
That they do, say healthcare experts. Routinely criticized for decades for indifferent care, attacked by Oliver Stone in Born on the Fourth of July, the VA health system has performed major surgery on itself. The care provided to 5.2 million veterans by the nation's largest healthcare system has improved so much that often it is the best around. And in the new VA, patient safety is a particular priority. Before making the first incision, for example, surgeons conduct a five-step audit to be sure they don't cut into the wrong body part or person. Doctors and nurses are unusually conscientious about hand hygiene, to reduce infections caused by carrying germs from one patient to another.
Technology helps, as would be expected. Martinez is particularly impressed by the computerization of patient records. When he visits, his doctors and nurses instantly call up his medical records, including test results (his cholesterol is high and he suffers from asthma), CT scans, and medications via laptop, which has become as ubiquitous a tool at VA facilities as a stethoscope.
Paper delay. But computerized records are more than a convenience. If all patient information could be reviewed on a computer screen and updated with each new test and observation, studies suggest that many of the medical errors that kill hospital patients would be prevented. Keeping everything on paper has been shown to delay care, force 1 in every 5 lab tests to be repeated, and cause unnecessary hospitalizations. But switching to computerized records can cost millions of dollars at a single hospital, so relatively few medical centers outside the VA have changed over.
"The information is right at your fingertips, right at the bedside, right when you're making decisions," Wren says. Besides giving her a quick snapshot of a patient's progress, the system automatically displays the latest and best studies and guidelines for that patient's condition. The screen also prompts her about preventive measures. If she calls up the record of a diabetic patient, for example, she is reminded to perform or schedule foot and eye exams, which diabetics must have regularly to prevent amputation or blindness.
Such prompting is largely why the VA vaccinates 92 percent of patients ages 65 and older against pneumonia versus 29 percent 10 years ago, says Jonathan Perlin, the top doctor in the Department of Veterans Affairs. Outside the VA, he says, the rate averages below 55 percent. "The increase not only has saved the lives of 6,000 patients with emphysema," says Perlin; "we've halved hospitalizations for [patients with] community-acquired pneumonia."
And the computerized system reduces medication errors, blamed for thousands of deaths in hospitalized patients, by flagging an order if there's a possible drug interaction, if the dosage doesn't match a doctor's order, or if there is a potential allergic reaction. Retired Army Sgt. Maj. Lance Sweigart of Laurel, Md., takes six medications for arthritis, high cholesterol, and depression. The 61-year-old Sweigart says he has "never gotten the wrong medication" at VA facilities in Baltimore.
All drugs carry bar codes, as do patients' ID bracelets. Both are scanned before a medication is administered to make sure the drug and patient match and last-minute order changes are caught. It's not yet sophisticated enough to offer the appropriate dosage, but Isabel Sotomayor, a nurse at the VA Medical Center in Washington, D.C., says the system snags one or two potential errors every day during her medication rounds.
The impact of such changes is real, says Harvard School of Public Health professor and renowned patient-safety advocate Lucian Leape. "Recent evidence shows [that care at the VA system] is at least as good as, if not better," he says, than care delivered elsewhere. In the 1990s, for example, the VA began using a new way--since adopted by the American College of Surgeons--to evaluate surgical quality. It enabled VA surgeons to reduce postoperative deaths by 27 percent and post-surgical complications by 45 percent. Recently published studies have found that the VA rates much better than Medicare fee-for-service providers in 11 basic measures of quality, such as regular mammograms and counseling for smokers. Late last year, the Annals of Internal Medicine published a study showing that the VA had "substantially better quality of care" than other providers in many of nearly 350 indicators of quality, such as screening and treating depression, diabetes, and hypertension.
Overhauling a system of 157 hospitals, 134 nursing homes, and 887 clinics is never finished. Recent reports by the inspector general of the Department of Veterans Affairs have highlighted such problems as cancellation of surgeries, unexpected deaths, and radiology backups at VA facilities in Florida. Surgeries have had to be canceled at some facilities because surgical supplies were unavailable or improperly sterilized. But John Daigh, who as assistant inspector general for healthcare inspections is responsible for exposing such flaws, says that VA top brass haven't retreated into denial. They "have stepped up to the plate and fixed the problems" that his investigators uncover.
That, too, is evidence of a seismic shift, brought about not by high-tech breakthroughs but by a fundamental change in VA culture. A new emphasis, on patient safety and on a work ethic that stresses constant examination of the processes and procedures that go into caregiving, arrived in 1994 when Kenneth Kizer, former director of California's Department of Health Services, was tapped to run the VA health empire. His mission, as he saw it, was to remake the unwieldy system into one of the world's safest and finest. Kizer started holding doctors, administrators, and managers directly accountable for the quality of their patient care, linking, for example, how many heart-attack patients received recommended beta blockers and aspirin to job reviews. And the performance for each facility was made public, which turned out to be a major motivator. "People competed like hell," says Kizer, now president of the nonprofit National Quality Forum, which develops national standards for assessing the quality of healthcare.
Kizer was immersed in studies of patient safety years before the Institute of Medicine's jolting report in 1999 of hospital errors that kill tens of thousands of patients. To cultivate a "culture of safety" at the VA, he created a National Center for Patient Safety, and to head it up he brought in James Bagian, a former astronaut who had investigated the space shuttle Challenger accident for NASA.
Bagian's hire was "one of the smartest things [Kizer] did," says Leape. Both an engineer and physician, Bagian brought to the VA unique skills and a zealous commitment to safety. "It was like being in two different worlds," Bagian says of the move from NASA to the VA. "One had a very constructive and methodical approach to how we identify problems, decide whether they are worth fixing and then fix them versus one that was done much more like a cottage industry, where decisions are based on what's my opinion or how do I feel about it today, which is not how you should run healthcare today."
Out loud. Bagian wanted people to report mistakes or close calls in treating patients. Such intelligence was crucial if safety was to be improved, because many errors happen because of a flawed system rather than a careless individual--a chart mix-up that could have ended in surgery on the wrong patient, the incorrect medication given to a patient because it was stored next to another one with nearly the same name. At today's VA hospitals, patient safety teams identify every step that led up to a blunder or close call to determine needed changes. For example, the VA has instituted a process to ensure that surgeons operate on the correct person or body part. One step includes asking patients to say their full names and birth dates out loud and to identify the body part to be cut.
Bagian's greatest challenge was shifting the attitudes of VA staffers. Few people reported a gaffe, for fear that they or the person who made it would suffer. "The VA had the most punitive, hardest culture I had ever seen," says Kizer; he and Bagian wanted to change the VA's punishment-oriented ways to an open, nonpunitive environment. But the staff didn't begin to respond until top managers showed they were serious. In the new VA, for example, managers could be fired, fined, and even jailed for retaliating against workers who file mistake reports.
Reports began coming in. More than 200,000 close-call and error reports have been filed at the VA without anyone being punished. "Staff gets to have input about how to provide better care," says Sotomayor, a VA nurse for 15 years. "The attitudes of people have changed." They take pride in the results, such as a decline in patient falls and a pacemaker redesigned by the manufacturer because of a close call. And other hospitals have noticed. Jennifer Daley, chief medical officer and senior vice president of clinical quality at Tenet Healthcare Corp., is using the VA as a blueprint to improve performance at the nation's second-largest for-profit hospital operator.
"There is room for improvement," says Bagian. "We're not perfect, make no mistake about it." But now the drive to enhance safety has become an accepted part of the VA. Caregivers on the front lines turn in a steady flow of ideas, such as requiring that doctors key in the full name rather than the first few letters when ordering a prescription. That minimizes the chance, say, that a patient who needs clonidine, a blood-pressure medicine, will get clozapine, an antipsychotic.
Augustin Martinez simply appreciates that he took his brother's advice. "I was fortunate I was a veteran. Otherwise, I don't know what else I would have done," Martinez says. "I don't think I would be here today."
Small steps that made a difference
These are a few of the changes the VA has put in place to make patients safer.
Problem: In older patients, falls were the top cause of injury and the No. 1 cause of deaths resulting from injury.
Solution: Bedside floor mats. Putting the bedside table, call button, and light switch within easy patient reach. Outfitting at-risk patients with hip protectors.
Did it work? In a six-month trial at 31 VA facilities, there were 62 percent fewer major injuries from falls.
Problem: Infections caused by an antibiotic-resistant strain of Staphylococcus aureus, largely spread by healthcare workers' hands, were killing patients or making them very ill.
Solution: In 2001, the VA's Pittsburgh Healthcare System mounted a hand hygiene campaign, raising awareness of the need for disinfecting hands and for gloving and using gowns and masks, and making sure such supplies were always at hand. At the same time, infection monitoring was increased.
Did it work? Such infections have been cut 85 percent in the general surgical unit, 50 percent in the surgical ICU.
Problem: Delays in follow-up care for discharged patients taking blood thinners such as warfarin, which can cause bleeding complications if patients are not carefully monitored.
Solution: The VA Ann Arbor Healthcare System in Michigan recently required doctors to ensure that these discharged patients are seen within a week in one of its clinics. Their blood levels and medication dosage can be checked, and they can be counseled about diet, because certain foods interfere with blood thinners.
Did it work? It's too early for clinical results, but reportedly all such patients have had follow-ups, lab tests, and counseling within one week of discharge.