Full CIRCLE: VA leadership at the forefront of patient safety

Authors   Carlos Lott, Henry Grinvalsky, Jeanette Criswell, Thomas Pishioneri, Molly Lyons, Jackie Westerfield, Amanda Eisenlohr, Marta Render. Marta.Render@med.va.gov (513) 475-6366

Summary  Sustained improvement in patient safety required development of a safety culture (justice, reporting, learning, flexibility) created by visible leadership and involving all organizational layers.

Objectives   To develop and implement an organizational plan to create components of a safety culture at the Cincinnati VA.

Intervention  Full CIRCLE, the program acronym, was implemented at the Cincinnati VAMC in January 2002: Celebrates recovery (Sharp-end staff submit stories of near misses). Incentivizes safety (nominal prizes to each reporter or workgroup that improves patient safety). Reports hazard (near-misses are collected, analyzed, and staff receives feedback about RCAs, prizewinners and system changes).  Creates conversations (SafetyMinutes cases are presented by leadership create teachable moments). Led by Leadership (program implemented presents safety an organization priority equal to production pressures and resource constraints). And Educates about Safety (Safety Fairs for all staff; and Performance Experts in Safety master’s class in human and organizational factors of safety).

Results  Over the first seven months, leadership delivered 40 SafetyMinutes stories, recognized 84 ndividual winners for reporting near miss and 7 groups for most reports in a month. A total of 217 reports were submitted and 25 work groups reported incidents/accident avoidance. Facility Director reported follow-ups with detailed actions taken to the units.

Conclusions  Near miss reports attributable to Full CIRCLE spurred concrete actions, including steps to reduce error in medication orders, revision of telephone triage process, unnecessary transfusion prevention, follow-up of abnormal lab results, and pharmacy addressing issues with bar coded medication administration interface.

Lessons Learned  Safety is an organizational value that requires a cultural shift. Deeply embedded issues of mistrust, fatigue and communication gaps undermine cultural shift toward safety. Highly visible leadership is critical in establishing genuine commitment throughout the organization where safety issues are discussed regularly, incentivized staff report near misses, and the organization responds with information about resulting actions.

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