Review of Veterans Health Administration’s Multi-Tiered Patient Safety Program

The VA Office of Inspector General (OIG) conducted national surveys of Veterans Integrated Service Network (VISN) patient safety officers (PSO) and facility patient safety managers (PSM). Both surveys focused on patient safety topics, including oversight, culture, staffing, and training. The OIG also conducted interviews with Veterans Health Administration (VHA) Quality and Patient Safety leaders and PSOs.The OIG identified opportunities for VHA to strengthen patient safety programs at VISNs and facilities. Variability in PSO oversight related to site visit frequency and volume, and unclear expectations for PSO follow-up of facility patient safety program deficiencies, exist. PSOs reported barriers to meeting with community care third-party administrators to discuss quality and safety concerns. A majority of PSOs reported responsibilities for areas outside of the patient safety program while a high percentage of PSMs reported feelings of burnout. Facilities that have a PSM and additional staff achieved a higher level of compliance with completing patient safety requirements.Inclusion of an analysis of patient safety data within National Center for Patient Safety (NCPS) published quarterly reports would help staff drive improvement. Both PSOs and PSMs identified that patient safety is not always considered in decision making. Lastly, although PSO and PSM training is recommended, no formalized training requirements are available.The OIG made one recommendation to the VHA Under Secretary for Health related to evaluating PSO and PSM communication with community care third-party administrators and two recommendations to the VHA Assistant Under Secretary for Quality and Patient Safety related to establishing facility patient safety program oversight requirements and evaluating barriers that limit VISN and facility leaders’ engagement with PSOs and PSMs. The OIG made six recommendations to the VHA NCPS Executive Director related to evaluating quarterly reports, PSO and PSM burnout, patient safety program staffing, and implementing formalized training.