Program Profile

Background

Approximately 56,000 Veterans are diagnosed with cancer every year in the VA system. Up to 90% of survivors have at least one impairment that decreases their quality of life, but only 2-9% are receiving cancer rehabilitation. Current research in cancer care demonstrates the importance of prospective surveillance, rehabilitation, and a multidisciplinary (MultiD) approach to cancer survivorship. Multi-D treatments help mitigate the effects of cancer and its treatments as the veterans proceed through care, improve outcomes, and streamline the process to meet all rehabilitation needs for those affected by cancer. Prior to the development of this program all services except navigation were available. Those diagnosed with cancer were not receiving prehabilitation and consults to ancillary services did not occur until after active cancer treatment was completed. CCRP united existing Multi-D programs to better serve the needs of veterans with cancer. Development of the CCRP CPRS Consult menu has allowed for improved access for both providers and veterans.

Methods

Identified the need for ancillary services during cancer survivorship, regardless of Veterans treatment location within or outside the VA system. Initiated tracking via CCR consults, developed a CCRP guidebook to identify all services available and how to access them as well as the CCCRP consult menu to create easier access for providers and veterans. Tracking via Multi-D departments that allow for tracking in CPRS via CCRP Consult.

Results

Prior to FY23 no cancer rehab consults existed. Consults received since program implementation: Navigation: 144, Physical Therapy: 102, Occupational Therapy: 7, Speech: 15. All other Multi-D did not track CCRP-specific consults. Other tools for data analysis are utilized in other departments in which gaps in coordination of care have been caught/resolved, and advocacy has increased.

Conclusions

Comprehensive cancer care from diagnosis throughout survivorship improves quality of life. A Multi-D comprehensive Cancer rehabilitation provides an opportunity to streamline care via a CPRS Menu. Other VA medical centers can develop a Multi-D cancer rehabilitation program to coordinate treatments from diagnosis through survivorship. This is an opportunity to make the VA the forefront of oncology care – by providing all services within one system.

Background

Approximately 56,000 Veterans are diagnosed with cancer every year in the VA system. Up to 90% of survivors have at least one impairment that decreases their quality of life, but only 2-9% are receiving cancer rehabilitation. Current research in cancer care demonstrates the importance of prospective surveillance, rehabilitation, and a multidisciplinary (MultiD) approach to cancer survivorship. Multi-D treatments help mitigate the effects of cancer and its treatments as the veterans proceed through care, improve outcomes, and streamline the process to meet all rehabilitation needs for those affected by cancer. Prior to the development of this program all services except navigation were available. Those diagnosed with cancer were not receiving prehabilitation and consults to ancillary services did not occur until after active cancer treatment was completed. CCRP united existing Multi-D programs to better serve the needs of veterans with cancer. Development of the CCRP CPRS Consult menu has allowed for improved access for both providers and veterans.

Methods

Identified the need for ancillary services during cancer survivorship, regardless of Veterans treatment location within or outside the VA system. Initiated tracking via CCR consults, developed a CCRP guidebook to identify all services available and how to access them as well as the CCCRP consult menu to create easier access for providers and veterans. Tracking via Multi-D departments that allow for tracking in CPRS via CCRP Consult.

Results

Prior to FY23 no cancer rehab consults existed. Consults received since program implementation: Navigation: 144, Physical Therapy: 102, Occupational Therapy: 7, Speech: 15. All other Multi-D did not track CCRP-specific consults. Other tools for data analysis are utilized in other departments in which gaps in coordination of care have been caught/resolved, and advocacy has increased.

Conclusions

Comprehensive cancer care from diagnosis throughout survivorship improves quality of life. A Multi-D comprehensive Cancer rehabilitation provides an opportunity to streamline care via a CPRS Menu. Other VA medical centers can develop a Multi-D cancer rehabilitation program to coordinate treatments from diagnosis through survivorship. This is an opportunity to make the VA the forefront of oncology care – by providing all services within one system.

Background

Approximately 56,000 Veterans are diagnosed with cancer every year in the VA system. Up to 90% of survivors have at least one impairment that decreases their quality of life, but only 2-9% are receiving cancer rehabilitation. Current research in cancer care demonstrates the importance of prospective surveillance, rehabilitation, and a multidisciplinary (MultiD) approach to cancer survivorship. Multi-D treatments help mitigate the effects of cancer and its treatments as the veterans proceed through care, improve outcomes, and streamline the process to meet all rehabilitation needs for those affected by cancer. Prior to the development of this program all services except navigation were available. Those diagnosed with cancer were not receiving prehabilitation and consults to ancillary services did not occur until after active cancer treatment was completed. CCRP united existing Multi-D programs to better serve the needs of veterans with cancer. Development of the CCRP CPRS Consult menu has allowed for improved access for both providers and veterans.

Methods

Identified the need for ancillary services during cancer survivorship, regardless of Veterans treatment location within or outside the VA system. Initiated tracking via CCR consults, developed a CCRP guidebook to identify all services available and how to access them as well as the CCCRP consult menu to create easier access for providers and veterans. Tracking via Multi-D departments that allow for tracking in CPRS via CCRP Consult.

Results

Prior to FY23 no cancer rehab consults existed. Consults received since program implementation: Navigation: 144, Physical Therapy: 102, Occupational Therapy: 7, Speech: 15. All other Multi-D did not track CCRP-specific consults. Other tools for data analysis are utilized in other departments in which gaps in coordination of care have been caught/resolved, and advocacy has increased.

Conclusions

Comprehensive cancer care from diagnosis throughout survivorship improves quality of life. A Multi-D comprehensive Cancer rehabilitation provides an opportunity to streamline care via a CPRS Menu. Other VA medical centers can develop a Multi-D cancer rehabilitation program to coordinate treatments from diagnosis through survivorship. This is an opportunity to make the VA the forefront of oncology care – by providing all services within one system.

Background

Multiple responses or repeat e-consults were observed by Hematology/Oncology Department. Root cause analysis uncovered that 60% of e-consults ordered required multiple responses or repeat econsults for the same clinical situation, often due to the need for additional lab testing before the e-consult question could be addressed. Hematology/Oncology econsult ordering process did not have an order design menu to provide guidance on appropriate questions, simplified ordering of relevant tests, or ways to identify patients that were either already established in the Hem/Onc clinic or patients that would be better managed with a more urgent or in-person consultation. This quality improvement project was created to improve the appropriateness and efficiency of hematology/oncology e-consult ordering process.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a project team lead by Hematology/Oncology, Clinical Informatics, Clinical Application Coordinator and the Systems Redesign Coordinator, rebuilt menus to navigate referring providers to the appropriate e-consults. This would improve the process flow and enhance clear communication. The primary process improvement goals were 1) to decrease the number of e-consults that were better suited for inperson evaluation; 2) decrease the number of Hem/Onc e-consults that lack adequate clinical lab information and 3) decrease the number of e-consults for patients that are already established with a Hematology/Oncology provider.

Results

Baseline sample data (7-1-23-11-30-22)-revealed only 60% of e-consults placed were deemed appropriate. 13% required certain minimum lab testing, 11% were already established patients and 11% were better managed through in-person consultation. After the first PDSA cycle, from 9/21/23-3/29/24, 72% of econsults were deemed appropriate (114/158), a 12% improvement.

Conclusions

The success of the project supports the use of existing VA hospital-based program resources such as clinical informatics and utilizing frontline physician input. This input was critical to the redesigned ordering process. Ultimately, our process improvement efforts helped facilitate communication and information flow which improved our ability to better coordinate our Veteran’s care.

Background

Multiple responses or repeat e-consults were observed by Hematology/Oncology Department. Root cause analysis uncovered that 60% of e-consults ordered required multiple responses or repeat econsults for the same clinical situation, often due to the need for additional lab testing before the e-consult question could be addressed. Hematology/Oncology econsult ordering process did not have an order design menu to provide guidance on appropriate questions, simplified ordering of relevant tests, or ways to identify patients that were either already established in the Hem/Onc clinic or patients that would be better managed with a more urgent or in-person consultation. This quality improvement project was created to improve the appropriateness and efficiency of hematology/oncology e-consult ordering process.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a project team lead by Hematology/Oncology, Clinical Informatics, Clinical Application Coordinator and the Systems Redesign Coordinator, rebuilt menus to navigate referring providers to the appropriate e-consults. This would improve the process flow and enhance clear communication. The primary process improvement goals were 1) to decrease the number of e-consults that were better suited for inperson evaluation; 2) decrease the number of Hem/Onc e-consults that lack adequate clinical lab information and 3) decrease the number of e-consults for patients that are already established with a Hematology/Oncology provider.

Results

Baseline sample data (7-1-23-11-30-22)-revealed only 60% of e-consults placed were deemed appropriate. 13% required certain minimum lab testing, 11% were already established patients and 11% were better managed through in-person consultation. After the first PDSA cycle, from 9/21/23-3/29/24, 72% of econsults were deemed appropriate (114/158), a 12% improvement.

Conclusions

The success of the project supports the use of existing VA hospital-based program resources such as clinical informatics and utilizing frontline physician input. This input was critical to the redesigned ordering process. Ultimately, our process improvement efforts helped facilitate communication and information flow which improved our ability to better coordinate our Veteran’s care.

Background

Multiple responses or repeat e-consults were observed by Hematology/Oncology Department. Root cause analysis uncovered that 60% of e-consults ordered required multiple responses or repeat econsults for the same clinical situation, often due to the need for additional lab testing before the e-consult question could be addressed. Hematology/Oncology econsult ordering process did not have an order design menu to provide guidance on appropriate questions, simplified ordering of relevant tests, or ways to identify patients that were either already established in the Hem/Onc clinic or patients that would be better managed with a more urgent or in-person consultation. This quality improvement project was created to improve the appropriateness and efficiency of hematology/oncology e-consult ordering process.

Methods

Using Plan-Do-Study-Act (PDSA) quality improvement methodology, a project team lead by Hematology/Oncology, Clinical Informatics, Clinical Application Coordinator and the Systems Redesign Coordinator, rebuilt menus to navigate referring providers to the appropriate e-consults. This would improve the process flow and enhance clear communication. The primary process improvement goals were 1) to decrease the number of e-consults that were better suited for inperson evaluation; 2) decrease the number of Hem/Onc e-consults that lack adequate clinical lab information and 3) decrease the number of e-consults for patients that are already established with a Hematology/Oncology provider.

Results

Baseline sample data (7-1-23-11-30-22)-revealed only 60% of e-consults placed were deemed appropriate. 13% required certain minimum lab testing, 11% were already established patients and 11% were better managed through in-person consultation. After the first PDSA cycle, from 9/21/23-3/29/24, 72% of econsults were deemed appropriate (114/158), a 12% improvement.

Conclusions

The success of the project supports the use of existing VA hospital-based program resources such as clinical informatics and utilizing frontline physician input. This input was critical to the redesigned ordering process. Ultimately, our process improvement efforts helped facilitate communication and information flow which improved our ability to better coordinate our Veteran’s care.

Background

Cancer diagnosis and treatment can be devastating! After treatment, a person often feels tired, weak, and worried while trying to put their life back together. This transition period is known to be difficult (www.cancer.gov/about-cancer/coping/survivorship/new-normal). A Time to Heal for Veterans and their Caregivers (“wellness rehabilitation”) was created to provide support, information, and skills to help with this transition.

Methods

This 9-week program is based on a successful, well documented, evidence-based book and protocol developed in 2005, that has been updated and adapted for specific populations. The VA program has a customized participant book and is facilitated by a VA social worker and a VA oncology nurse. It includes weekly protocols of research-based educational presentations on the following topics: Building Resilience, Physical Side Effects, Calming Worries and Fears, Nutrition and Exercise for Cancer Survivors, Relationships After Cancer, Nurturing Inner Strength, Planning for the Future, and Happiness Going Forward. It also includes facilitated discussions to share experiences, demonstration/ practices of simple strategies for relaxation or health, and journaling/affirmation writing. The program is held in person at the VA for locals and via Zoom for non-local participants (hybrid format).

Results

A Time to Heal program for Veterans has been offered since 2016. In 2020 it was shortened from 12 weeks to 9 weeks. Since then, 24 veterans and 8 caregivers have completed the program and 13 have completed the evaluation/survey. On a scale of 1 (below expectations) to 5 (exceeded expectations), the program and book have consistently received rating averages of 4.5/5.0. Testimonials include: “Awesome program!” “Was hesitant at first, but so glad I decided to participate. I was able to open up my feelings and express them. I am grateful for the VA to have these resources.”

Conclusions

Recruitment for the program has relied on fliers and education from oncology staff. The feedback received from veterans with cancer, caregivers, and providers indicates a positive impact of this program. More study is needed to evaluate specific aspects of the program, guide participant recruitment, and determine best delivery methods for participants.

Background

Cancer diagnosis and treatment can be devastating! After treatment, a person often feels tired, weak, and worried while trying to put their life back together. This transition period is known to be difficult (www.cancer.gov/about-cancer/coping/survivorship/new-normal). A Time to Heal for Veterans and their Caregivers (“wellness rehabilitation”) was created to provide support, information, and skills to help with this transition.

Methods

This 9-week program is based on a successful, well documented, evidence-based book and protocol developed in 2005, that has been updated and adapted for specific populations. The VA program has a customized participant book and is facilitated by a VA social worker and a VA oncology nurse. It includes weekly protocols of research-based educational presentations on the following topics: Building Resilience, Physical Side Effects, Calming Worries and Fears, Nutrition and Exercise for Cancer Survivors, Relationships After Cancer, Nurturing Inner Strength, Planning for the Future, and Happiness Going Forward. It also includes facilitated discussions to share experiences, demonstration/ practices of simple strategies for relaxation or health, and journaling/affirmation writing. The program is held in person at the VA for locals and via Zoom for non-local participants (hybrid format).

Results

A Time to Heal program for Veterans has been offered since 2016. In 2020 it was shortened from 12 weeks to 9 weeks. Since then, 24 veterans and 8 caregivers have completed the program and 13 have completed the evaluation/survey. On a scale of 1 (below expectations) to 5 (exceeded expectations), the program and book have consistently received rating averages of 4.5/5.0. Testimonials include: “Awesome program!” “Was hesitant at first, but so glad I decided to participate. I was able to open up my feelings and express them. I am grateful for the VA to have these resources.”

Conclusions

Recruitment for the program has relied on fliers and education from oncology staff. The feedback received from veterans with cancer, caregivers, and providers indicates a positive impact of this program. More study is needed to evaluate specific aspects of the program, guide participant recruitment, and determine best delivery methods for participants.

Background

Cancer diagnosis and treatment can be devastating! After treatment, a person often feels tired, weak, and worried while trying to put their life back together. This transition period is known to be difficult (www.cancer.gov/about-cancer/coping/survivorship/new-normal). A Time to Heal for Veterans and their Caregivers (“wellness rehabilitation”) was created to provide support, information, and skills to help with this transition.

Methods

This 9-week program is based on a successful, well documented, evidence-based book and protocol developed in 2005, that has been updated and adapted for specific populations. The VA program has a customized participant book and is facilitated by a VA social worker and a VA oncology nurse. It includes weekly protocols of research-based educational presentations on the following topics: Building Resilience, Physical Side Effects, Calming Worries and Fears, Nutrition and Exercise for Cancer Survivors, Relationships After Cancer, Nurturing Inner Strength, Planning for the Future, and Happiness Going Forward. It also includes facilitated discussions to share experiences, demonstration/ practices of simple strategies for relaxation or health, and journaling/affirmation writing. The program is held in person at the VA for locals and via Zoom for non-local participants (hybrid format).

Results

A Time to Heal program for Veterans has been offered since 2016. In 2020 it was shortened from 12 weeks to 9 weeks. Since then, 24 veterans and 8 caregivers have completed the program and 13 have completed the evaluation/survey. On a scale of 1 (below expectations) to 5 (exceeded expectations), the program and book have consistently received rating averages of 4.5/5.0. Testimonials include: “Awesome program!” “Was hesitant at first, but so glad I decided to participate. I was able to open up my feelings and express them. I am grateful for the VA to have these resources.”

Conclusions

Recruitment for the program has relied on fliers and education from oncology staff. The feedback received from veterans with cancer, caregivers, and providers indicates a positive impact of this program. More study is needed to evaluate specific aspects of the program, guide participant recruitment, and determine best delivery methods for participants.

Background

Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.

Methods

The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.

Results

During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.

Conclusions

This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.

Background

Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.

Methods

The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.

Results

During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.

Conclusions

This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.

Background

Purpose: to review the number of genetic testing referrals for breast cancer at the Stratton VA Medical Center and identify barriers that hinder testing, aiming to improve risk reduction strategies and therapeutic options for patients. National guidelines recommend genetic testing for breast cancer susceptibility genes in specific patient populations, such as those under 50, those with a high-risk family history, high-risk pathology, male breast cancer, or Ashkenazi Jewish ancestry. Despite efforts to adhere to these guidelines, several barriers persist that limit testing rates among eligible patients.

Methods

The medical oncology team selected breast cancer as the focus for reviewing adherence to germline genetic testing referrals in the Stratton VA Medical Center. With assistance from cancer registrars, a list of genetics referrals for breast cancer from January to December 2023 was compiled. Descriptive analysis was conducted to assess referral rates, evaluation visit completion rates, genetic testing outcomes, and reasons for non-completion of genetic testing.

Results

During the study period, 32 patients were referred for germline genetic testing for breast cancer. Of these, 26 (81%) completed the evaluation visit, and 11 (34%) underwent genetic testing. Of these, 7 patients had noteworthy results, and 2 patients (6%) were found to carry pathogenic variants: BRCA2 and CDH1. Reasons for non-completion included perceived irrelevance without biological children, need for additional time to consider testing, fear of exacerbating self-harm thoughts, and fear of losing service connection. Additionally, 2 patients did not meet the guidelines for testing per genetic counselor.

Conclusions

This project marks the initial step in identifying barriers to germline genetic testing for breast cancer based on an extensive review of patients diagnosed and treated at a single VA site. Despite the removal of the service connection clause from the consent form, some veterans still declined testing due to fear of losing their service connection. The findings emphasize the importance of educating providers on counseling techniques and education of veterans to enhance risk reduction strategies and patient care. Further research is essential to quantify the real-world outcomes and longterm impacts of improving genetic counseling rates on patient management and outcomes.

Background

The care of veterans with head and neck cancers requires a team approach among multiple disciplines throughout the entire trajectory of their cancer treatment course. Veterans with head and neck cancer have complicated treatments including surgery, radiation, chemotherapy and reconstructive surgery which can affect swallow function, speech, taste and physical appearance. Many patients who get treated for head and neck cancer will have lasting side effects of treatment. Veterans with cancer are more likely than the general population to have mental health comorbidities such as anxiety, depression and PTSD. Many head and neck cancer patients have used tobacco and/or alcohol as coping mechanisms for these issues. A new diagnosis of cancer may exacerbate their mental illness. Tobacco cessation may exacerbate anxiety for patients who have used tobacco as a coping mechanism. Ongoing alcohol use can complicate treatment. All of these issues can create delays in care.

Methods

In August 2019, a task force (“the ENT Multidisciplinary Workgroup”) was formed at VA Connecticut Healthcare System (“VACHS”) including representatives from ENT, Speech Pathology, Nutrition, Palliative Care and Oncology with the specific goal of improved coordination of care for head and neck cancer patients. Regular weekly meetings began in September 2019 to identify and track patients and to make referrals for appropriate diagnostic testing, treatment and supportive care.

Discussion

Weekly meeting among the core members of the ENT workgroup led to identification of patient needs earlier in the illness course than was observed prior to this workgroup initiative. Each week several opportunities are identified to improve patient care. This is a dynamic, ongoing process that has improved communication among key members of the interdisciplinary team that cares for these very complex patients and has led to the development of quality improvement initiatives that are reproducible at other VA sites.

Background

The care of veterans with head and neck cancers requires a team approach among multiple disciplines throughout the entire trajectory of their cancer treatment course. Veterans with head and neck cancer have complicated treatments including surgery, radiation, chemotherapy and reconstructive surgery which can affect swallow function, speech, taste and physical appearance. Many patients who get treated for head and neck cancer will have lasting side effects of treatment. Veterans with cancer are more likely than the general population to have mental health comorbidities such as anxiety, depression and PTSD. Many head and neck cancer patients have used tobacco and/or alcohol as coping mechanisms for these issues. A new diagnosis of cancer may exacerbate their mental illness. Tobacco cessation may exacerbate anxiety for patients who have used tobacco as a coping mechanism. Ongoing alcohol use can complicate treatment. All of these issues can create delays in care.

Methods

In August 2019, a task force (“the ENT Multidisciplinary Workgroup”) was formed at VA Connecticut Healthcare System (“VACHS”) including representatives from ENT, Speech Pathology, Nutrition, Palliative Care and Oncology with the specific goal of improved coordination of care for head and neck cancer patients. Regular weekly meetings began in September 2019 to identify and track patients and to make referrals for appropriate diagnostic testing, treatment and supportive care.

Discussion

Weekly meeting among the core members of the ENT workgroup led to identification of patient needs earlier in the illness course than was observed prior to this workgroup initiative. Each week several opportunities are identified to improve patient care. This is a dynamic, ongoing process that has improved communication among key members of the interdisciplinary team that cares for these very complex patients and has led to the development of quality improvement initiatives that are reproducible at other VA sites.

Background

The care of veterans with head and neck cancers requires a team approach among multiple disciplines throughout the entire trajectory of their cancer treatment course. Veterans with head and neck cancer have complicated treatments including surgery, radiation, chemotherapy and reconstructive surgery which can affect swallow function, speech, taste and physical appearance. Many patients who get treated for head and neck cancer will have lasting side effects of treatment. Veterans with cancer are more likely than the general population to have mental health comorbidities such as anxiety, depression and PTSD. Many head and neck cancer patients have used tobacco and/or alcohol as coping mechanisms for these issues. A new diagnosis of cancer may exacerbate their mental illness. Tobacco cessation may exacerbate anxiety for patients who have used tobacco as a coping mechanism. Ongoing alcohol use can complicate treatment. All of these issues can create delays in care.

Methods

In August 2019, a task force (“the ENT Multidisciplinary Workgroup”) was formed at VA Connecticut Healthcare System (“VACHS”) including representatives from ENT, Speech Pathology, Nutrition, Palliative Care and Oncology with the specific goal of improved coordination of care for head and neck cancer patients. Regular weekly meetings began in September 2019 to identify and track patients and to make referrals for appropriate diagnostic testing, treatment and supportive care.

Discussion

Weekly meeting among the core members of the ENT workgroup led to identification of patient needs earlier in the illness course than was observed prior to this workgroup initiative. Each week several opportunities are identified to improve patient care. This is a dynamic, ongoing process that has improved communication among key members of the interdisciplinary team that cares for these very complex patients and has led to the development of quality improvement initiatives that are reproducible at other VA sites.

Background

Assess implementation outcomes of the National Tele-Oncology’s first high-risk breast clinic program, part of the Breast and Gynecological System of Excellence (BGSOE). Women Veterans are the fastest-growing demographic in the Veteran population. Breast cancer (BC) is the most prevalent cancer among women. An estimated 15% of women will be considered high risk for BC at some point during their lifetime. For these reasons, the BGSOE high-risk breast clinic offers screening and risk reduction care to women with an increased risk for BC.

Methods

We described the patients seen in the BGSOE high-risk breast clinic since its implementation in 2023. We collected demographic and geographic information, genetic testing status, imaging, and risk-reducing agents (RRA) use. We reported percentages for categorical variables, followed by the total number of patients in parenthesis.

Results

There are a total of 124 patients served since 2023 (123 female, 1 male). The average age was 44.6 years. 61.3% (76) of patients lived in an urban setting, while 38.7% (48) lived in rural areas. Most patients were White at 63.7% (79), followed by African American 20.2%(25), Other 5.6% (7), and Unknown/declined 10.5%(13). Regarding ethnicity, 9% (12) were Hispanic. The most common reasons for referral to the clinic were a family history of breast cancer 89.2% (111), followed by high-risk genetic pathogenic variants 5.6% (7), mammary dysplasia 3.2% (4), inconclusive imaging 0.8% (1) and personal history of radiation 0.8%(1). 2 patients were started on RRAs. 56% (70) of patients had genetic testing discussions. The clinic coordinated 50 mammograms and 10 breast MRIs.

Conclusions

We demonstrated the successful implementation of the BGSOE high-risk breast program. We reached multiple historically underserved populations, including a high percentage of rural and African American patients. We also facilitated breast MRIs. Similar to other studies, there was a low uptake of RRA in our clinic. BGSOE is now working on a clinical pathway to standardize RRA and breast imaging recommendations for high-risk women. There are many more women Veterans at risk for BC and future expansion of the highrisk breast clinic could further raise awareness of lifetime breast cancer risk and risk-reducing and surveillance options in Veterans.

Background

Assess implementation outcomes of the National Tele-Oncology’s first high-risk breast clinic program, part of the Breast and Gynecological System of Excellence (BGSOE). Women Veterans are the fastest-growing demographic in the Veteran population. Breast cancer (BC) is the most prevalent cancer among women. An estimated 15% of women will be considered high risk for BC at some point during their lifetime. For these reasons, the BGSOE high-risk breast clinic offers screening and risk reduction care to women with an increased risk for BC.

Methods

We described the patients seen in the BGSOE high-risk breast clinic since its implementation in 2023. We collected demographic and geographic information, genetic testing status, imaging, and risk-reducing agents (RRA) use. We reported percentages for categorical variables, followed by the total number of patients in parenthesis.

Results

There are a total of 124 patients served since 2023 (123 female, 1 male). The average age was 44.6 years. 61.3% (76) of patients lived in an urban setting, while 38.7% (48) lived in rural areas. Most patients were White at 63.7% (79), followed by African American 20.2%(25), Other 5.6% (7), and Unknown/declined 10.5%(13). Regarding ethnicity, 9% (12) were Hispanic. The most common reasons for referral to the clinic were a family history of breast cancer 89.2% (111), followed by high-risk genetic pathogenic variants 5.6% (7), mammary dysplasia 3.2% (4), inconclusive imaging 0.8% (1) and personal history of radiation 0.8%(1). 2 patients were started on RRAs. 56% (70) of patients had genetic testing discussions. The clinic coordinated 50 mammograms and 10 breast MRIs.

Conclusions

We demonstrated the successful implementation of the BGSOE high-risk breast program. We reached multiple historically underserved populations, including a high percentage of rural and African American patients. We also facilitated breast MRIs. Similar to other studies, there was a low uptake of RRA in our clinic. BGSOE is now working on a clinical pathway to standardize RRA and breast imaging recommendations for high-risk women. There are many more women Veterans at risk for BC and future expansion of the highrisk breast clinic could further raise awareness of lifetime breast cancer risk and risk-reducing and surveillance options in Veterans.

Background

Assess implementation outcomes of the National Tele-Oncology’s first high-risk breast clinic program, part of the Breast and Gynecological System of Excellence (BGSOE). Women Veterans are the fastest-growing demographic in the Veteran population. Breast cancer (BC) is the most prevalent cancer among women. An estimated 15% of women will be considered high risk for BC at some point during their lifetime. For these reasons, the BGSOE high-risk breast clinic offers screening and risk reduction care to women with an increased risk for BC.

Methods

We described the patients seen in the BGSOE high-risk breast clinic since its implementation in 2023. We collected demographic and geographic information, genetic testing status, imaging, and risk-reducing agents (RRA) use. We reported percentages for categorical variables, followed by the total number of patients in parenthesis.

Results

There are a total of 124 patients served since 2023 (123 female, 1 male). The average age was 44.6 years. 61.3% (76) of patients lived in an urban setting, while 38.7% (48) lived in rural areas. Most patients were White at 63.7% (79), followed by African American 20.2%(25), Other 5.6% (7), and Unknown/declined 10.5%(13). Regarding ethnicity, 9% (12) were Hispanic. The most common reasons for referral to the clinic were a family history of breast cancer 89.2% (111), followed by high-risk genetic pathogenic variants 5.6% (7), mammary dysplasia 3.2% (4), inconclusive imaging 0.8% (1) and personal history of radiation 0.8%(1). 2 patients were started on RRAs. 56% (70) of patients had genetic testing discussions. The clinic coordinated 50 mammograms and 10 breast MRIs.

Conclusions

We demonstrated the successful implementation of the BGSOE high-risk breast program. We reached multiple historically underserved populations, including a high percentage of rural and African American patients. We also facilitated breast MRIs. Similar to other studies, there was a low uptake of RRA in our clinic. BGSOE is now working on a clinical pathway to standardize RRA and breast imaging recommendations for high-risk women. There are many more women Veterans at risk for BC and future expansion of the highrisk breast clinic could further raise awareness of lifetime breast cancer risk and risk-reducing and surveillance options in Veterans.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Discussion

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. For example, the Very Low Risk flow map has seven unique Veterans entered, whereas the Molecular Testing flow map has over 3,900 unique Veterans entered. One clear reason for this disparity in pathway documentation use is that local prostate cancer is managed by urology and their documentation of the PCCP is not as widespread as the medical oncologists. The National Oncology Program developed clinical note templates to document PCCP that medical oncologist use which has increased utilization. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator. The UPCN will function as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. The UPCN is in the testing phase at three pilot test sites and is scheduled to be deployed summer 2024. The collaborative effort is aligned with the VHA directives outlined in the Cleland Dole Act.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Discussion

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. For example, the Very Low Risk flow map has seven unique Veterans entered, whereas the Molecular Testing flow map has over 3,900 unique Veterans entered. One clear reason for this disparity in pathway documentation use is that local prostate cancer is managed by urology and their documentation of the PCCP is not as widespread as the medical oncologists. The National Oncology Program developed clinical note templates to document PCCP that medical oncologist use which has increased utilization. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator. The UPCN will function as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. The UPCN is in the testing phase at three pilot test sites and is scheduled to be deployed summer 2024. The collaborative effort is aligned with the VHA directives outlined in the Cleland Dole Act.

Background

Prostate cancer is the most common non-cutaneous malignancy diagnosis within the Department of Veterans Affairs (VA). The Prostate Cancer Clinical Pathways (PCCP) were developed to enable providers to treat all Veterans with prostate cancer at subject matter expert level.

Discussion

The PCCP was launched in February 2021; however, provider documentation of PCCP is variable across the VA healthcare system and within the PCCP, specific flow maps have differential use. For example, the Very Low Risk flow map has seven unique Veterans entered, whereas the Molecular Testing flow map has over 3,900 unique Veterans entered. One clear reason for this disparity in pathway documentation use is that local prostate cancer is managed by urology and their documentation of the PCCP is not as widespread as the medical oncologists. The National Oncology Program developed clinical note templates to document PCCP that medical oncologist use which has increased utilization. To increase urology specific flow map use, a collaboration between the National Surgery Office and National Oncology Program was established to develop a Urology Prostate Cancer Note (UPCN). The UPCN was designed by urologists with assistance from a medical oncologist and a clinical applications coordinator. The UPCN will function as a working clinical note for urologists and has the PCCPs embedded into reminder dialog templates, which when completed generate health factors. The health factors that are generated from the UPCN are data mined to record PCCP use and to perform data analytics. The UPCN is in the testing phase at three pilot test sites and is scheduled to be deployed summer 2024. The collaborative effort is aligned with the VHA directives outlined in the Cleland Dole Act.

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

The emergency department (ED) is estimated to provide half of all medical care in the United States, serving as a conduit between ambulatory care and inpatient settings.¹ According to the Centers for Disease Control and Prevention, around 11 million antibiotic prescriptions were written in EDs in 2021.² A previous study conducted at a US Department of Veterans (VA) Affairs medical center found that about 40% of all antimicrobial use in the ED was inappropriate.³ The ED is a critical and high-yield space for antimicrobial stewardship efforts.⁴

Urinary tract infections (UTIs) are one of the most common reasons for ED visits.⁴ In 2018, there were about 3 million UTI discharge diagnoses reported in the US.⁵ Diagnosis and management of UTIs can vary depending on patient sex, upper or lower urinary tract involvement, and the severity of the infection.⁶ Most UTIs are uncomplicated and can be safely treated with oral antibiotics at home; however, if mismanaged, they can lead to increased morbidity and mortality.⁶

Antimicrobial prescribing in the ED is predominantly empiric with challenges such as diverse patient needs, rising antimicrobial resistance, and limited microbiologic data at the time of discharge.⁶ The lack of a standardized process for urine culture follow-up after discharge represents another major complicating factor in the outpatient management of UTIs. Studies have shown that ED pharmacists play a vital role in providing quality follow-up care by optimizing antimicrobial use, resulting in improved patient outcomes in various infectious syndromes, including UTIs.^7-13

Program Description

In June 2021, the VA Greater Los Angeles Healthcare System (VAGLAHS) piloted an ED pharmacist-led aftercare program to optimize postdischarge antimicrobial therapy management of UTIs. After a patient is discharged from the ED, the clinical pharmacist reviews urine culture results, interprets available antimicrobial susceptibility, conducts patient interviews, adjusts for patient-specific factors, and addresses potential antibiotic-associated adverse events. The ED pharmacist is then responsible for managing therapy changes in consultation with an ED health care practitioner (HCP).

Methods

This single center, retrospective chart review included veterans who were discharged with an oral antibiotic for UTI treatment from the VAGLAHS ED and evaluated by clinical pharmacists between June 1, 2021, and June 30, 2022. For patients with multiple ED visits, only the initial ED encounter was reviewed. Patients were excluded if they had a complicated UTI diagnosis requiring intravenous antibiotics or if they were admitted to the hospital. Data were generated through the Corporate Data Warehouse by VAGLAHS Pharmacy Informatics Service. Each patient was assigned a random number using the Microsoft Excel formula =RAND( ) and then sorted in chronological order to ensure randomization at baseline prior to data collection.

The primary aim of this quality improvement project was to characterize the impact of ED pharmacist-led interventions by evaluating the proportion of empiric to targeted therapy adjustments, antibiotic therapy discontinuation, and unmodified index treatment. The secondary objectives evaluated time to ED pharmacist aftercare follow-up, days of antibiotic exposure avoided, 30-day ED visits related to a urinary source, and transition of care documentation. Descriptive statistics were performed; median and IQR were calculated in Microsoft Excel.

A total of 548 ED UTI encounters were identified, including 449 patients with an index ED UTI aftercare follow-up evaluation. Of the 246 randomly screened patients, 200 veterans met inclusion criteria. The median age of included patients was 73 years and most (83.0%) were male (Table 1). One hundred thirty-two patients (66.0%) had a cystitis diagnosis, followed by complicated UTI (14.0%) and catheter-associated UTI (11.0%). The most frequently isolated uropathogen was Escherichia coli (30.5%). ß-lactams were prescribed for empiric treatment to 121 patients (60.5%), followed by 36 fluoroquinolones prescriptions (18.0%). The median treatment duration was 7 days.

The median time to ED pharmacist UTI aftercare evaluation was 2 days (Table 2). Sixty-seven cases required pharmacist intervention, which included 34 transitions to targeted therapy (17.0%) and 33 antibiotic discontinuations (16.5%). A total of 144 days of antibiotic exposure was avoided (ie, days antibiotic was prescribed minus days therapy administered). The majority of cases without modification to index therapy were due to appropriate empiric treatment selection (49.0%). Twelve (6.0%) patients had a subsequent urinary-related ED visit within 30 days due to 8 cases of persistent and/or worsening urinary symptoms (66.7%) and 2 cases of recurrent UTI (16.7%).

Discussion

Outpatient antibiotic prescribing for UTI management in the ED is challenging due to the absence of microbiologic data at time of diagnosis and lack of consistent transition of care follow-up.⁶ The VAGLAHS ED UTI aftercare program piloted a pharmacist-driven protocol for review of all urine cultures and optimization of antibiotic therapy.

Most ED UTI discharges that did not require pharmacist intervention had empiric treatment selection active against the clinical isolates. This suggests that the ED prescribing practices concur with theVAGLAHS antibiogram and treatment guidelines. Clinical pharmacists intervened in about one-third of UTI cases, which included modification or discontinuation of therapy. Further review of these cases demonstrated that about half of those with a subsequent 30-day ED visit related to a urinary source had therapy modification. Most patients with a 30-day ED visit had persistent and/or worsening urinary symptoms, prompting further exploratory workup.

Although this project did not evaluate time from urine culture results to aftercare review, the VAGLAHS ED pharmacists had a median follow-up time of 48 hours. This timeline mirrors the typical duration for urine culture results, suggesting that the pilot program allowed for real time pharmacist review and intervention. Consequently, this initiative resulted in the avoidance of 144 unnecessary days of antibiotic exposure.

While the current protocol highlights the work that ED pharmacists provide postdischarge, there are additional opportunities for pharmacist intervention. For example, one-third of these clinical encounters were completed without HCP notification, indicating an ongoing need to ensure continuity of care. Additionally, all 16 patients diagnosed with asymptomatic bacteriuria were discharged with an oral antibiotic, highlighting an opportunity to further optimize antibiotic prescribing prior to discharge. ED pharmacists continue to play an important role in mitigating inappropriate and unnecessary antibiotic use, which will reduce antibiotic-related adverse drug reactions, Clostridioides difficile infection, and antimicrobial resistance.

Limitations

Inconsistent and incomplete documentation of clinical data in the electronic health record made the characterization of patient encounters challenging. Furthermore, ED HCPs varying clinical practices may have impacted the heterogeneity of UTI diagnosis and management at VAGLAHS.

Conclusions

Implementation of an ED pharmacist-driven UTI aftercare program at VAGLAHS reduced unnecessary antimicrobial exposure, improved antibiotic management, and ensured continuity of care postdischarge. Findings from our project implicate possible future pharmacist involvement predischarge, such as targeting inappropriate asymptomatic bacteriuria treatment.^14-16 This pilot program suggested the feasibility of integrating antimicrobial stewardship practices within the ED setting in an ongoing effort to improve the quality of care for veterans.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Health care organizations began implementing Lean management and high reliability organization (HRO) principles in the 1990s to improve quality and efficiency by aligning leaders and staff to a shared vision, fostering a culture of continuous improvement, identifying the root causes of complex problems, and engaging frontline staff as drivers of improvement efforts.¹ There are 4 components for establishing a Lean management system: (1) leader standard work; (2) visual management; (3) daily accountability; and (4) discipline to institute the first 3 components.² Leader standard work promotes continuous improvement by setting a standard routine of behaviors, actions, and tools consistently performed by leadership. These include routine and frequent frontline check-ins (ie, Gemba walks) as well as standardization of employee onboarding, training, and evaluations. Visual management refers to the process of making problems and abnormal conditions readily apparent to staff and leadership.³

The US Department of Veterans Affairs (VA) is committed to implementing similar principles of HROs, which focus on error analysis and process improvement to foster a culture of safety, leadership commitment, and staff engagement.^4,5 Visual management is an important tool for HROs; it reflects the mindset of promoting transparency, teamwork, and openness.^6,7

Visual management boards (VMBs), such as huddle boards, Gemba boards, or visibility walls, are critical tools that can promote daily accountability and the core principles of Lean thinking and HROs.^1,6,8,9 Accountability is enhanced through frequent real-time, data-driven feedback between staff and leadership. This is often facilitated with a huddle, a structured and disciplined team meeting that provides bidirectional information.¹ Frequently, a VMB is incorporated into the structure and flow of the huddle.

In a literature review of 20 years of implementation of Lean management systems in health care, Winner and colleagues report that while the frequency and duration of huddles vary, they are often united by several characteristics, including the involvement of the unit team, focus on feedback, problem identification and solutions, and central location around a visual board.¹ VMBs most often take the form of a magnetic, dry-erase board located in a hall or conference room central to the work area.¹ In addition to identifying and tracking problems in the place of work, VMBs can also provide a representation of key performance indicators and metrics, disseminate essential unit information, and acknowledge the work and successes of staff and leaders.^6,8-12

This article outlines the commitment of the Lieutenant Colonel Charles S. Kettles VA Medical Center (VAMC) within the VA Ann Arbor Healthcare System (VAAAHS) to the HRO principle of visual management. We describe the incorporation of VMBs throughout VAAAHS and provide a detailed report of the development and use at a large outpatient subspecialty clinic.

Implementation

The goal of implementing visual management tools at VAAAHS was to empower staff members to identify problems and process improvements, enhance teamwork, and improve communication between staff and section leadership. The Systems Redesign and Improvement Program (SR), which supports Veteran Health Administration high reliability initiatives, helped implement VMBs in VAAAHS departments. Each board was designed to meet the specialized needs of each respective team and could be a physical board, virtual board, or combination. However, all boards sought to create standardized work and identify department needs.

The VAAAHS outpatient cardiology section VMB complemented an existing daily huddle framework. The cardiology section is large and diverse, with 6 subspecialty clinics, and team members who work in multiple locations. The clinic team includes 19 faculty physicians, 14 cardiology fellow physicians,9 nurse care managers, 13 nurse practitioners, 2 licensed practical nurses, and 5 medical support assistants at both the Lieutenant Colonel Charles S. Kettles VAMC and Toledo, Ohio, community based outpatient clinic. Prior to VMB implementation, a morning huddle with clinic team members led by a cardiology manager was an unstructured group discussion about clinic operations for the day. While the daily huddle had a positive impact on staff orientation to daily goals, it did not fully meet the aims of staff empowerment, problem identification and tracking, and knowledge distribution. The VMB was codeveloped with cardiology and the SR program with these goals in mind.

Cardiology was the first VAAAHS outpatient subspecialty clinic to institute a VMB. Two boards were created: a large standard VMB (Figure 1) and a smaller kudos board (Figure 2), which were placed in a central hallway in which staff members and patients pass frequently throughout the day. This location was chosen to promote engagement and promote the VAAAHS commitment to continuous improvement. The VMB focused on identifying and tracking problems, information sharing, and metric monitoring. The goal of the smaller kudos board was to highlight staff achievements and provide an opportunity for patient feedback.

The SR program required that the board incorporate problem identification and a uniform VAAAHS ticket tracking system. Each department could customize the VMB to fit its needs. Staff members are asked to define a problem, complete a ticket describing the issue, consider possible root causes, and suggest solutions. This approach empowers staff to take ownership, make a problem visible, and identify a solution. The problem is then discussed in group huddles using an Impact and Effort Matrix, a tool focused on categorizing and prioritizing those interventions that require low effort and lead to high impact.¹³

Tickets move along the board as they are addressed using a Plan-Do-Study-Act problem-solving model.¹⁴ Plan involves identifying and assigning leadership for the problem and understanding its root causes. Do involves implementing an action plan. Study involves evaluating the results. Finally, Act involves determining whether the plan was successful, and if so, standardizing the improvement and using it regularly.¹⁴ Complicated projects that require higher effort or additional resources are moved to the roll-up and parking lot, so they may be addressed by leadership at an appropriate time. Roll up is the escalation of process improvement tickets that frontline staff are unable to resolve with their current resources. The parking lot is for tickets that staff want to address later based on priority determined using an impact vs effort matrix. This allows for enhanced bidirectional communication between the department and high-level leadership, showing a commitment to HRO principles at all levels. The cardiology department customized its board to include essential clinic information, such as faculty staffing for the clinic that day and clinic metric information (eg, patient satisfaction scores, and appointment wait times). The kudos board, a space for patient feedback and to celebrate staff accomplishments, was located across the hall closest to the waiting area.

After the VMB was implemented as a new component to the daily team huddle, the group discussion physically moved to just in front of the board; pertinent clinic information is discussed daily, and the ticketing system is discussed 1 to 3 times per week, depending on ticket progress. Open and unresolved tickets are reviewed for updates on the status by the responsible team member, who receives ongoing feedback and assistance.

Program Impact

A total of 55 improvement opportunity tickets were submitted by staff members during the initial 23 months after the implementation of the outpatient cardiology clinic VMB. Most were submitted by nurse practitioners, although there were contributions from all faculty and staff. The high percentage of ticket submissions by nurse practitioners may be related to their full-time daily presence in the clinic, whereas some other staff members are part-time (most physicians are present 1 day each week). Improvement opportunities were noted within a variety of areas, including clinic facilities (eg, clinic equipment), communication between the clinic and patients (eg, telephone calls from patients or appointment letters), and patient care (eg, medication reconciliation and laboratory requisition).

In an improvement opportunity ticket, a staff member identified that the low seating in the patient waiting area was a fall risk and not diversified for varying body types. They posted a ticket, and the issue was discussed as a group. This staff member assumed ownership of the problem and placed an interior design request for taller chairs and bariatric options. The ticket was resolved when the waiting area was upgraded to include safer and more inclusive seating options for patients. Of 55 tickets submitted by staff as of June 2024, 45 have identified solutions, 4 are in process, and 6 have been placed in the parking lot. On average, the morning huddle spends about 5 to 10 minutes addressing tickets, but on occasion, more complex topics require additional time. The kudos board receives feedback from patients who express their gratitude, and serves as a space to celebrate awards received by staff members.

Implementing a VMB into daily huddles within the cardiology clinic led to increased staff engagement and ownership of challenges, as well as improved communication between frontline workers and leadership. VMBs have proven to be useful for annual staff performance evaluations because staff members who engaged in the board and volunteered to take accountability for ticket resolution could use those accomplishments in their assessments. Finally, VMBs made quality improvement and safety work accessible by normalizing frequent conversations. This empowered staff to engage in improvement projects and even led some members to enroll in formal Lean training.

The outpatient cardiology clinic VMB at the VAAAHS was identified as a best practice during a site visit by the Promising Practice Team in the Veterans Health Administration Office of Integrated Veteran Care. The outpatient cardiology clinic leadership team, including the authors of this article, was invited to present our visual management work as a main topic at the January 2024 Office of Integrated Veteran Care collaborative meeting.

Further Implementation

The SR program has collaborated with additional VAAAHS teams to implement VMBs. Forty-four physical VMBs and 20 virtual VMBs are currently in use throughout the VAAAHS. Virtual VMB content is similar to a physical board and can be modified by each team to meet its particular needs. Several virtual VMBs have been implemented at the VAAAHS and can achieve the same goals of staff teamwork, empowerment, and engagement. Each team can choose the format of the VMB that best fits their needs, which may be partially influenced by the team’s overall interaction style (on-site teams may function better with a physical VMB, and off-site teams may find a virtual VMB works best). VMBs have been implemented in various work areas, including laboratories, inpatient wards, subspecialty outpatient clinics, procedural areas, and the engineering department. In fiscal year 2024, 180 tickets were electronically submitted by teams across the VAAAHS, of which 170 identified solutions and were marked completed. Ticket counts may be underestimated since not all physical board tickets are reported in the electronic system. The SR program periodically attends morning huddles of various teams and obtains feedback on their VMBs, a practice that highlights its contribution to staff engagement, transparency, teamwork, and continuous improvement (Table). A goal of the SR program is to identify areas of the VAAAHS in which VMBs would add value to the team and implement them as necessary.

Discussion

VMBs are common in health care and are implemented to promote the core principlesof Lean thinking and HROs, including visual management and daily accountability. The goals of a visual management tool are to make problems visible and document their management. A VMB can serve as a focal point for team discussion and a physical space to track each problem through its initial identification, understanding of root causes, consideration of potential solutions, and recording of intervention results.

A VMB can foster a culture of safety, leadership commitment, and continuous process improvement when designed and implemented to reflect team needs. VMBs can empower staff members to share work concerns and openly promote engagement. As a central place for discussion between staff and leaders, VMBs can also foster teamwork and communication. The daily huddle provides a safe, productive working environment by ensuring that lines of communication are open among all team members, regardless of role or leadership designation.

Limitations

This article focused on the implementation of 1 type of visual management tool. It provides an in-depth discussion of the development, implementation, and experience with a VMB at multiple clinics of a single section in 1 health care system. These reported experiences may not represent other VA facilities. Perceptions of the impact and usefulness of the VMB were mostly anecdotal. Further evaluation of the VMB implementation experience and utility at other VA health care systems would provide additional insight into the optimal implementation of VMBs.

Conclusions

Through increased transparency, empowerment, and communication, VMBs are an important tool in the visual management tool belt for organizations committed to HROs and Lean management. Given the successful institution of VMBs at the VAAAHS, the description of our experience may aid other VA systems for the incorporation of visual management into the daily culture of their respective health care teams.

Increasing complexities within health care systems are significant impediments to the consistent delivery of safe and effective patient care. These impediments include an increase in specialization of care, staff shortages, burnout, poor coordination of services and access to care, as well as rising costs.¹ High reliability organizations (HROs) provide safe, high-quality, and effective care in highly complex and risk-prone environments without causing harm or experiencing catastrophic events.²

Within the US Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) operates the nation’s largest integrated health care system, providing care to > 9 million veterans. The VHA formally launched plans for an enterprise-wide HRO in February 2019. During the first year, 18 medical facilities comprised cohort1 of the journey to high reliability. Cohort 2 began in October 2020 and consisted of 54 facilities. Cohort 3 started in October 2021 with 67 facilities.³

Health care organizations seeking high reliability exercise a philosophy aimed at learning from errors and addressing system failures. High reliability is accomplished by implementing 5 principles: (1) sensitivity to operations (a heightened understanding of the current state of systems); (2) preoccupation with failure (striving to anticipate risks that might suggest a much larger system problem); (3) reluctance to simplify (avoiding making any assumptions regarding the causes of failures); (4) commitment to resilience (preparing for potential failures and bouncing back when they occur); and (5) deference to expertise (deferring to individuals with the skills and proficiency to make the best decisions).² The VHA also recognized that a successful journey to high reliability—in addition to achieving a culture of safety—relies on the implementation of foundational HRO practices: leader rounding, visual management systems, safety forums, and safety huddles. This article describes an initiative for how these foundational practices were implemented in a large integrated health care system.

BACKGROUND

The VHA has focused on 4 foundational components as part of its enterprise activities and support structure to implement HRO principles and practices. These components were selected based on pilot activities that preceded the enterprise-wide effort, reviews of the literature, and expert consultation with both government and private sector health systems. To support the implementation of these practices, the VHA provided training, toolkits, HRO executive leader coaching, and peer-to-peer mentoring. As the VHA enters its fifth year seeking high reliability, we undertook an initiative to reflect on our own experiences and refine our practices based on an updated literature review.

As part of this enterprise-wide initiative, we conducted a literature review from 2018 to March 2023 seeking recent evidence describing the value of implementing the 4 foundational HRO practices to advance high reliability and improve patient safety. A 5-year period was used to ensure recency and value of evidence.

Eligible literature was identified in PubMed, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scopus, the Cochrane Library, and ProQuest Dissertations & Theses Global. Inclusion and exclusion criteria were peer-reviewed interdisciplinary documents(eg, publications, dissertations, conference proceedings, and grey literature) written in English. Search terms included high reliability organizations, foundational practices, and patient safety. Boolean operators (AND, OR) were also used in the search. The search resulted in a dearth of evidence that addressed implementation of all 4 foundational practices across a health care system. Retrieved evidence focused on the implementation of only 1 particular foundational practice in a specific health care setting. In addition to describing the formal processes for the implementation of each foundational HRO practice, a brief description of representative examples of strong practices within the VHA is provided.

To support the implementation of HROs, the VHA paired HRO executive leader coaches with select medical center directors and their leadership teams. Executive leader coaches also support an organization’s HRO Lead and HRO Champion. The HRO Lead coordinates and facilitates the implementation of HRO principles and practices in pursuit of no harm across an organization. The HRO Champion supports the same as the HRO Lead, but typically has a different specialty background. For example, if the HRO Lead has an administrative background, the HRO Champion would have a clinical background.

Coaching focuses heavily on supporting site-specific implementation and sustainment of the 4 HRO foundational practices. The aim is to accelerate change, build enduring capacity, foster a safety culture, and accelerate HRO maturity. To measure change, HRO executive leader coaches track the progress of their aligned VA medical centers (VAMCs) using the Organizational Learning Tool (OLT). This tool was developed to provide information such as a facility summary and relationships between a medical center director, HRO Lead, HRO Champion, and the executive leader coach (Figure 1). The OLT also serves as a structured process to measure leader coaching performance against mutually agreed upon objectives that ultimately contribute to enterprise outcomes. It also collects data on the progress in implementing foundational practices, strong practices, needs and gaps, and more (Figure 2). Data collected from facilities supported by HRO executive leader coaches on whether foundational practices are in place are briefly described.

Leader Rounding

Leader rounding for high reliability ensures effective, bidirectional communication and collaboration among all disciplines to improve patient safety. It is an essential feature of a robust patient safety culture and an important method for demonstrating leadership engagement with high reliability.^4,5 These rounds are conducted by organizational leadership (eg, executive teams, department/service chiefs, or unit managers) and frontline staff from different areas. They are specifically focused on high reliability, patient and staff safety, and improvement efforts. The aim is to learn about daily challenges that may contribute to patient harm.⁴

Leader rounding has been found to be highly effective at improving leadership visibility across the organization. It enhances interaction and open communication with frontline staff, fostering leader-staff collaboration and shared decision-making,as well as promoting leadership understanding of operational, clinical, nonclinical (eg, administrative, nutrition services, or facilities management), and patient/family experience issues.⁴ Collaboration among team members fosters the delivery of more effective and efficient care, increases staff satisfaction, and improves employee retention.⁶ Leader rounding for high reliability significantly contributes to the breakdown of power barriers by giving team members voice and agency, ultimately leading to deeper engagement.⁷

It is important that leader rounding for high reliability occurs as planned and when possible, scheduled in advance. This helps to avoid rounding at peak times when care activities are being performed.^4,6 When scheduling conflicts arise, another leader should be sent to participate in rounds.⁴ Developing a list of questions in advance allows leadership to prepare messaging to share with staff as it relates to high reliability and patient safety (Table).^4,6,8

Closing the loop improves bidirectional communication and is critical to leader rounding for high reliability. Closed-loop communication and following up on and/or closing out issues raised during rounding empowers the sharing of information, which is critical for advancing a culture of safety.^4,8 Enhanced feedback is also associated with greater workforce engagement, staff feeling more connected to quality improvement activities, and lower rates of employee burnout.⁷ It is important to recognize that senior leaders are not responsible for resolving all issues. If a team or manager can resolve concerns that are raised, this should be encouraged and supported. Maintaining accountability at the lowest level of the organization promotes principles and practices of high reliability (Figure 3).^4,8

The VA Bedford Healthcare System created and implemented a strong practice for leader rounding for high reliability. This phased implementation involved creating an evidence-based process, deciding on an appropriate cadence, developing a tracking tool, and measuring impact to determine the overall effectiveness of leader rounding for high reliability.⁴

A visual management system (VMS) displays clinical and operational performance aligned with HRO goals and practices. It is used to view and guide discussions between interdisciplinary teams during tiered safety huddles, leader rounds for high reliability, and frontline staff on the current status and safety trends in a particular area.^8,9 A VMS is highly effective in creating an environment where all staff members, especially frontline workers, feel empowered to voice their concerns related to safety or to identify improvement opportunities.^8,10 Increased leader engagement in patient safety and heightened transparency of information associated with the use of a VMS improves staff morale and professional satisfaction.¹⁰

A VMS may be a dry-erase or whiteboard display, paper-based display, or electronic status board.⁸ VMSs are usually located in or near work settings (eg, nurses’ station, staff break room, or conference room).⁸ Although they can take different forms and display several types of information, a VMS should be easy to update and meet the specific needs of a work area. In the VHA, a VMS displays: (1) essential information for staff members to effectively perform their work; (2) improvement project ideas; (3) current work in progress; (4) tracking of implemented improvement activities; (5) strong practices that have been effective; and (6) staff recognition for those who have enhanced patient safety, including the reporting of close calls and near misses.

The VHA uses the MESS (methods, equipment, staffing, and supplies) VMS format. This format empowers staff to identify whether proper procedures and practices are in place, essential equipment and supplies are readily available in the quantity needed, and appropriate staffing is on hand to provide safe, high-quality patient care.⁸ Colored magnets are used as visual cues in a stoplight classification system to identify low or no safety risks (green), at risk (yellow), or high risk (red). Green coded issues are addressed locally by a manager or supervisor. Yellow coded concerns require increased staff and leadership vigilance. Red coded issues indicate that patient care would be impacted that day and therefore need to be immediately escalated and addressed with senior leaders to mitigate the threat.^4,11 Dayton VAMC successfully implemented a VMS, using both physical and electronic visual management boards. The Dayton VAMC VMS boards are closely tied to tiered safety huddles and leader rounding for high reliability.   

Safety Forums

Safety forums are another foundational practice of VHA health care organizations seeking high reliability. Recurring monthly, safety forums focus on reinforcing HRO principles and practices, safety programs, the importance and appreciation of reporting, and just culture. The emphasis on just culture reminds staff that adverse events in the organization are viewed as valuable learning opportunities to understand the factors leading to the situation as opposed to immediately assigning blame.¹²

Psychological safety is another important focus. When individuals feel psychologically safe, they are more likely to voice concerns and act without fear of reprisal, which supports a culture of safety.¹³ Safety forums are open to all members of the health care organization, including both clinical and nonclinical staff. Forums can be conducted by an HRO Lead, HRO Champion, Patient Safety Manager, or even executive leadership. Rotating the responsibility of leading these forums demonstrates that high reliability and safety are everyone’s responsibility.

Safety forums publicly review and discuss errors, adverse events, close calls, and near misses. Time is also spent discussing root cause analysis trends and highlighting continuous process improvement principles and current projects. During safety forums, leaders should recognize individuals for safety behaviors and reward reporting through a safety awards program.¹⁴ All forums should conclude with a question-and-answer session. Forums typically occur in virtual 30-minute sessionsbut can last up to 60 minutes when guest speakers attend and continuing education credit is offered.

The Jesse Brown VAMC in Chicago developed an interactive monthly safety forum appealing to a broad audience. Each forum is attended by about 200 staff members and includes leader engagement and panel discussions led by the chief medical officer, with topics on both patient and team safety connecting with HRO principles. A planning committee prepares guest speakers and offers continuing education credits.

Based on the processes of high reliability industries like aviation and nuclear power, tiered safety huddles have been increasingly adopted in health care. Huddles (health care, utilizing, deliberate, discussion,linking, and events) are department-level interdisciplinary meetings that last no more than 15 minutes.¹⁵ Their purpose is to improve communication by sharing day-to-day information across multiple disciplines, identify issues that may impact the delivery of care (eg, patient and staff safety concerns, staffing issues, or inadequate supplies) and resolve problems.

Tiered safety huddles are gaining popularity, especially in organizations seeking high reliability. They are more complex than traditional huddles because of the mechanics of elevating safety issues (eg, bedside to executive leadership teams), feedback loops, and sequencing, among other factors.^15,16

Tiered safety huddles are focused, transparent forums with multidisciplinary staff, including frontline workers, along with senior leadership.^15,16 When initially implemented, tiered safety huddles may take longer than the suggested 15 minutes; however, as teams become more experienced, huddles become more efficient.¹⁵ The goal of tiered safety huddles is to proactively identify, share, address, and resolve problems that have the potential to impact the delivery of safe and quality patient care. This may include addressing staffing shortfalls, inadequate allocation of supplies and equipment, operational issues, etc.^8,15 Critical to theeffective utilization of tiered safety huddles is the appropriate escalation of issues between tiers. The most critical issues are elevated to higher tiers so they are addressed by the most qualified person in the organization.

Deciding on the number of tiers typically depends on the size and scope of services provided by the health care organization or integrated system.For example, tiered huddles in the VHA originate at the point of service (eg, critical care unit). Tier 1 includes staff members at the unit/team level along with immediate supervisors/managers. Tier 2 involves departments and service lines (eg, pharmacy, podiatry, or internal medicine) including their respective leadership. Tier 3 is the executive leadership team. This process allows for bidirectional communication instead of the traditional hierarchical communication pathway (Figure 4). Issues identified that cannot be addressed at a particular tier are elevated to the next tier. Elevated issues typically involve systems or processes requiring attention and resolution by senior leadership.¹⁵ Tier 4 huddles at the Veterans Integrated Services Network level and Tier 5 huddles at the VHA Central Office level are being initiated. These additional levels will more effectively identify system-level risks and issues that may impact multiple VHA facilities and may be addressed through centralized functions and resources.

Tiered safety huddles have been found to be instrumental to ensuring the flow of information across organizations, improving multidisciplinary and leadership engagement and collaboration, as well as increasing accountability for safety.Tiered safety huddles increase situational awareness, which improves an organization’s ability to appropriately respond to safety concerns.Furthermore, tiered safety huddles enhance teamwork and interprofessional collaboration, and have been found to significantly increase the reporting of patient safety events.^15-19

The VA Connecticut Healthcare System tiered huddles followed a pilot testing implementation process. After receiving executive-level commitment, an evidence-based process was enacted, including staff education, selecting a VMS, determining tier interaction, and deciding on metrics to track.¹⁵

Implementing Foundational Practices

To examine the progress of the implementation of the 4 foundational HRO practices, quarterly metrics derived from the OLT are reviewed to determine whether each is being implemented and sustained. The OLT also tracks progress over time. For example, at the 27 cohort 2 and lead sites that initiated leader coaching in 2021 and continued through 2022, coaches observed a 27% increase in leader rounding for high reliability and a 46% increase in the use of VMSs. For the 66 cohort 3 sites that began leader coaching in 2022, coaches documented similar changes, ranging from a 40% increase in leader rounding for high reliability to a 66% increase in the use of safety forums. Additional data continue to be collected and analyzed to publish more comprehensive findings.

DISCUSSION

Incorporating leader rounding for high reliability, VMSs, safety forums, and tiered safety huddles into daily operations is critical to building and sustaining a robust culture of safety.⁸ The 4 foundational HRO practices are instrumental in providing psychologically safe forums for staff to share concerns and actively participate. These practices also promote continual, efficient bidirectional communication throughout organizational lines and across services. The increased visibility and transparency of leaders demonstrate the importance of fostering trust, enhancing closed-loop communication with issues that arise, and building momentum to achieve high reliability. The interconnectedness of the foundational HRO practices identified and implemented by the VHA helps foster teamwork and collaboration built on trust, respect, enthusiasm for improvement, and the delivery of exceptional patient care.

CONCLUSIONS

Incorporating the 4 foundational practices into daily operations is beneficial to the delivery of safe, high-quality health care. This effective and sustained application can strengthen a health care organization on its journey to high reliability and establishing a culture of safety. To be effective, these foundational practices should be personalized to support the unique circumstances of every health care environment. While the exact methodology by which organizations implement these practices may differ, they will help organizations approach patient safety in a more transparent and thoughtful manner.

Acknowledgments

The authors thank Aaron M. Sawyer, PhD, PMP, and Jessica Fankhauser, MA, for their unwavering administrative support, and Jeff Wright for exceptional graphic design support.

Increasing complexities within health care systems are significant impediments to the consistent delivery of safe and effective patient care. These impediments include an increase in specialization of care, staff shortages, burnout, poor coordination of services and access to care, as well as rising costs.¹ High reliability organizations (HROs) provide safe, high-quality, and effective care in highly complex and risk-prone environments without causing harm or experiencing catastrophic events.²

Within the US Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) operates the nation’s largest integrated health care system, providing care to > 9 million veterans. The VHA formally launched plans for an enterprise-wide HRO in February 2019. During the first year, 18 medical facilities comprised cohort1 of the journey to high reliability. Cohort 2 began in October 2020 and consisted of 54 facilities. Cohort 3 started in October 2021 with 67 facilities.³

Health care organizations seeking high reliability exercise a philosophy aimed at learning from errors and addressing system failures. High reliability is accomplished by implementing 5 principles: (1) sensitivity to operations (a heightened understanding of the current state of systems); (2) preoccupation with failure (striving to anticipate risks that might suggest a much larger system problem); (3) reluctance to simplify (avoiding making any assumptions regarding the causes of failures); (4) commitment to resilience (preparing for potential failures and bouncing back when they occur); and (5) deference to expertise (deferring to individuals with the skills and proficiency to make the best decisions).² The VHA also recognized that a successful journey to high reliability—in addition to achieving a culture of safety—relies on the implementation of foundational HRO practices: leader rounding, visual management systems, safety forums, and safety huddles. This article describes an initiative for how these foundational practices were implemented in a large integrated health care system.

BACKGROUND

The VHA has focused on 4 foundational components as part of its enterprise activities and support structure to implement HRO principles and practices. These components were selected based on pilot activities that preceded the enterprise-wide effort, reviews of the literature, and expert consultation with both government and private sector health systems. To support the implementation of these practices, the VHA provided training, toolkits, HRO executive leader coaching, and peer-to-peer mentoring. As the VHA enters its fifth year seeking high reliability, we undertook an initiative to reflect on our own experiences and refine our practices based on an updated literature review.

As part of this enterprise-wide initiative, we conducted a literature review from 2018 to March 2023 seeking recent evidence describing the value of implementing the 4 foundational HRO practices to advance high reliability and improve patient safety. A 5-year period was used to ensure recency and value of evidence.

Eligible literature was identified in PubMed, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scopus, the Cochrane Library, and ProQuest Dissertations & Theses Global. Inclusion and exclusion criteria were peer-reviewed interdisciplinary documents(eg, publications, dissertations, conference proceedings, and grey literature) written in English. Search terms included high reliability organizations, foundational practices, and patient safety. Boolean operators (AND, OR) were also used in the search. The search resulted in a dearth of evidence that addressed implementation of all 4 foundational practices across a health care system. Retrieved evidence focused on the implementation of only 1 particular foundational practice in a specific health care setting. In addition to describing the formal processes for the implementation of each foundational HRO practice, a brief description of representative examples of strong practices within the VHA is provided.

To support the implementation of HROs, the VHA paired HRO executive leader coaches with select medical center directors and their leadership teams. Executive leader coaches also support an organization’s HRO Lead and HRO Champion. The HRO Lead coordinates and facilitates the implementation of HRO principles and practices in pursuit of no harm across an organization. The HRO Champion supports the same as the HRO Lead, but typically has a different specialty background. For example, if the HRO Lead has an administrative background, the HRO Champion would have a clinical background.

Coaching focuses heavily on supporting site-specific implementation and sustainment of the 4 HRO foundational practices. The aim is to accelerate change, build enduring capacity, foster a safety culture, and accelerate HRO maturity. To measure change, HRO executive leader coaches track the progress of their aligned VA medical centers (VAMCs) using the Organizational Learning Tool (OLT). This tool was developed to provide information such as a facility summary and relationships between a medical center director, HRO Lead, HRO Champion, and the executive leader coach (Figure 1). The OLT also serves as a structured process to measure leader coaching performance against mutually agreed upon objectives that ultimately contribute to enterprise outcomes. It also collects data on the progress in implementing foundational practices, strong practices, needs and gaps, and more (Figure 2). Data collected from facilities supported by HRO executive leader coaches on whether foundational practices are in place are briefly described.

Leader Rounding

Leader rounding for high reliability ensures effective, bidirectional communication and collaboration among all disciplines to improve patient safety. It is an essential feature of a robust patient safety culture and an important method for demonstrating leadership engagement with high reliability.^4,5 These rounds are conducted by organizational leadership (eg, executive teams, department/service chiefs, or unit managers) and frontline staff from different areas. They are specifically focused on high reliability, patient and staff safety, and improvement efforts. The aim is to learn about daily challenges that may contribute to patient harm.⁴

Leader rounding has been found to be highly effective at improving leadership visibility across the organization. It enhances interaction and open communication with frontline staff, fostering leader-staff collaboration and shared decision-making,as well as promoting leadership understanding of operational, clinical, nonclinical (eg, administrative, nutrition services, or facilities management), and patient/family experience issues.⁴ Collaboration among team members fosters the delivery of more effective and efficient care, increases staff satisfaction, and improves employee retention.⁶ Leader rounding for high reliability significantly contributes to the breakdown of power barriers by giving team members voice and agency, ultimately leading to deeper engagement.⁷

It is important that leader rounding for high reliability occurs as planned and when possible, scheduled in advance. This helps to avoid rounding at peak times when care activities are being performed.^4,6 When scheduling conflicts arise, another leader should be sent to participate in rounds.⁴ Developing a list of questions in advance allows leadership to prepare messaging to share with staff as it relates to high reliability and patient safety (Table).^4,6,8

Closing the loop improves bidirectional communication and is critical to leader rounding for high reliability. Closed-loop communication and following up on and/or closing out issues raised during rounding empowers the sharing of information, which is critical for advancing a culture of safety.^4,8 Enhanced feedback is also associated with greater workforce engagement, staff feeling more connected to quality improvement activities, and lower rates of employee burnout.⁷ It is important to recognize that senior leaders are not responsible for resolving all issues. If a team or manager can resolve concerns that are raised, this should be encouraged and supported. Maintaining accountability at the lowest level of the organization promotes principles and practices of high reliability (Figure 3).^4,8

The VA Bedford Healthcare System created and implemented a strong practice for leader rounding for high reliability. This phased implementation involved creating an evidence-based process, deciding on an appropriate cadence, developing a tracking tool, and measuring impact to determine the overall effectiveness of leader rounding for high reliability.⁴

A visual management system (VMS) displays clinical and operational performance aligned with HRO goals and practices. It is used to view and guide discussions between interdisciplinary teams during tiered safety huddles, leader rounds for high reliability, and frontline staff on the current status and safety trends in a particular area.^8,9 A VMS is highly effective in creating an environment where all staff members, especially frontline workers, feel empowered to voice their concerns related to safety or to identify improvement opportunities.^8,10 Increased leader engagement in patient safety and heightened transparency of information associated with the use of a VMS improves staff morale and professional satisfaction.¹⁰

A VMS may be a dry-erase or whiteboard display, paper-based display, or electronic status board.⁸ VMSs are usually located in or near work settings (eg, nurses’ station, staff break room, or conference room).⁸ Although they can take different forms and display several types of information, a VMS should be easy to update and meet the specific needs of a work area. In the VHA, a VMS displays: (1) essential information for staff members to effectively perform their work; (2) improvement project ideas; (3) current work in progress; (4) tracking of implemented improvement activities; (5) strong practices that have been effective; and (6) staff recognition for those who have enhanced patient safety, including the reporting of close calls and near misses.

The VHA uses the MESS (methods, equipment, staffing, and supplies) VMS format. This format empowers staff to identify whether proper procedures and practices are in place, essential equipment and supplies are readily available in the quantity needed, and appropriate staffing is on hand to provide safe, high-quality patient care.⁸ Colored magnets are used as visual cues in a stoplight classification system to identify low or no safety risks (green), at risk (yellow), or high risk (red). Green coded issues are addressed locally by a manager or supervisor. Yellow coded concerns require increased staff and leadership vigilance. Red coded issues indicate that patient care would be impacted that day and therefore need to be immediately escalated and addressed with senior leaders to mitigate the threat.^4,11 Dayton VAMC successfully implemented a VMS, using both physical and electronic visual management boards. The Dayton VAMC VMS boards are closely tied to tiered safety huddles and leader rounding for high reliability.   

Safety Forums

Safety forums are another foundational practice of VHA health care organizations seeking high reliability. Recurring monthly, safety forums focus on reinforcing HRO principles and practices, safety programs, the importance and appreciation of reporting, and just culture. The emphasis on just culture reminds staff that adverse events in the organization are viewed as valuable learning opportunities to understand the factors leading to the situation as opposed to immediately assigning blame.¹²

Psychological safety is another important focus. When individuals feel psychologically safe, they are more likely to voice concerns and act without fear of reprisal, which supports a culture of safety.¹³ Safety forums are open to all members of the health care organization, including both clinical and nonclinical staff. Forums can be conducted by an HRO Lead, HRO Champion, Patient Safety Manager, or even executive leadership. Rotating the responsibility of leading these forums demonstrates that high reliability and safety are everyone’s responsibility.

Safety forums publicly review and discuss errors, adverse events, close calls, and near misses. Time is also spent discussing root cause analysis trends and highlighting continuous process improvement principles and current projects. During safety forums, leaders should recognize individuals for safety behaviors and reward reporting through a safety awards program.¹⁴ All forums should conclude with a question-and-answer session. Forums typically occur in virtual 30-minute sessionsbut can last up to 60 minutes when guest speakers attend and continuing education credit is offered.

The Jesse Brown VAMC in Chicago developed an interactive monthly safety forum appealing to a broad audience. Each forum is attended by about 200 staff members and includes leader engagement and panel discussions led by the chief medical officer, with topics on both patient and team safety connecting with HRO principles. A planning committee prepares guest speakers and offers continuing education credits.

Based on the processes of high reliability industries like aviation and nuclear power, tiered safety huddles have been increasingly adopted in health care. Huddles (health care, utilizing, deliberate, discussion,linking, and events) are department-level interdisciplinary meetings that last no more than 15 minutes.¹⁵ Their purpose is to improve communication by sharing day-to-day information across multiple disciplines, identify issues that may impact the delivery of care (eg, patient and staff safety concerns, staffing issues, or inadequate supplies) and resolve problems.

Tiered safety huddles are gaining popularity, especially in organizations seeking high reliability. They are more complex than traditional huddles because of the mechanics of elevating safety issues (eg, bedside to executive leadership teams), feedback loops, and sequencing, among other factors.^15,16

Tiered safety huddles are focused, transparent forums with multidisciplinary staff, including frontline workers, along with senior leadership.^15,16 When initially implemented, tiered safety huddles may take longer than the suggested 15 minutes; however, as teams become more experienced, huddles become more efficient.¹⁵ The goal of tiered safety huddles is to proactively identify, share, address, and resolve problems that have the potential to impact the delivery of safe and quality patient care. This may include addressing staffing shortfalls, inadequate allocation of supplies and equipment, operational issues, etc.^8,15 Critical to theeffective utilization of tiered safety huddles is the appropriate escalation of issues between tiers. The most critical issues are elevated to higher tiers so they are addressed by the most qualified person in the organization.

Deciding on the number of tiers typically depends on the size and scope of services provided by the health care organization or integrated system.For example, tiered huddles in the VHA originate at the point of service (eg, critical care unit). Tier 1 includes staff members at the unit/team level along with immediate supervisors/managers. Tier 2 involves departments and service lines (eg, pharmacy, podiatry, or internal medicine) including their respective leadership. Tier 3 is the executive leadership team. This process allows for bidirectional communication instead of the traditional hierarchical communication pathway (Figure 4). Issues identified that cannot be addressed at a particular tier are elevated to the next tier. Elevated issues typically involve systems or processes requiring attention and resolution by senior leadership.¹⁵ Tier 4 huddles at the Veterans Integrated Services Network level and Tier 5 huddles at the VHA Central Office level are being initiated. These additional levels will more effectively identify system-level risks and issues that may impact multiple VHA facilities and may be addressed through centralized functions and resources.

Tiered safety huddles have been found to be instrumental to ensuring the flow of information across organizations, improving multidisciplinary and leadership engagement and collaboration, as well as increasing accountability for safety.Tiered safety huddles increase situational awareness, which improves an organization’s ability to appropriately respond to safety concerns.Furthermore, tiered safety huddles enhance teamwork and interprofessional collaboration, and have been found to significantly increase the reporting of patient safety events.^15-19

The VA Connecticut Healthcare System tiered huddles followed a pilot testing implementation process. After receiving executive-level commitment, an evidence-based process was enacted, including staff education, selecting a VMS, determining tier interaction, and deciding on metrics to track.¹⁵

Implementing Foundational Practices

To examine the progress of the implementation of the 4 foundational HRO practices, quarterly metrics derived from the OLT are reviewed to determine whether each is being implemented and sustained. The OLT also tracks progress over time. For example, at the 27 cohort 2 and lead sites that initiated leader coaching in 2021 and continued through 2022, coaches observed a 27% increase in leader rounding for high reliability and a 46% increase in the use of VMSs. For the 66 cohort 3 sites that began leader coaching in 2022, coaches documented similar changes, ranging from a 40% increase in leader rounding for high reliability to a 66% increase in the use of safety forums. Additional data continue to be collected and analyzed to publish more comprehensive findings.

DISCUSSION

Incorporating leader rounding for high reliability, VMSs, safety forums, and tiered safety huddles into daily operations is critical to building and sustaining a robust culture of safety.⁸ The 4 foundational HRO practices are instrumental in providing psychologically safe forums for staff to share concerns and actively participate. These practices also promote continual, efficient bidirectional communication throughout organizational lines and across services. The increased visibility and transparency of leaders demonstrate the importance of fostering trust, enhancing closed-loop communication with issues that arise, and building momentum to achieve high reliability. The interconnectedness of the foundational HRO practices identified and implemented by the VHA helps foster teamwork and collaboration built on trust, respect, enthusiasm for improvement, and the delivery of exceptional patient care.

CONCLUSIONS

Incorporating the 4 foundational practices into daily operations is beneficial to the delivery of safe, high-quality health care. This effective and sustained application can strengthen a health care organization on its journey to high reliability and establishing a culture of safety. To be effective, these foundational practices should be personalized to support the unique circumstances of every health care environment. While the exact methodology by which organizations implement these practices may differ, they will help organizations approach patient safety in a more transparent and thoughtful manner.

Acknowledgments

The authors thank Aaron M. Sawyer, PhD, PMP, and Jessica Fankhauser, MA, for their unwavering administrative support, and Jeff Wright for exceptional graphic design support.

Increasing complexities within health care systems are significant impediments to the consistent delivery of safe and effective patient care. These impediments include an increase in specialization of care, staff shortages, burnout, poor coordination of services and access to care, as well as rising costs.¹ High reliability organizations (HROs) provide safe, high-quality, and effective care in highly complex and risk-prone environments without causing harm or experiencing catastrophic events.²

Within the US Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) operates the nation’s largest integrated health care system, providing care to > 9 million veterans. The VHA formally launched plans for an enterprise-wide HRO in February 2019. During the first year, 18 medical facilities comprised cohort1 of the journey to high reliability. Cohort 2 began in October 2020 and consisted of 54 facilities. Cohort 3 started in October 2021 with 67 facilities.³

Health care organizations seeking high reliability exercise a philosophy aimed at learning from errors and addressing system failures. High reliability is accomplished by implementing 5 principles: (1) sensitivity to operations (a heightened understanding of the current state of systems); (2) preoccupation with failure (striving to anticipate risks that might suggest a much larger system problem); (3) reluctance to simplify (avoiding making any assumptions regarding the causes of failures); (4) commitment to resilience (preparing for potential failures and bouncing back when they occur); and (5) deference to expertise (deferring to individuals with the skills and proficiency to make the best decisions).² The VHA also recognized that a successful journey to high reliability—in addition to achieving a culture of safety—relies on the implementation of foundational HRO practices: leader rounding, visual management systems, safety forums, and safety huddles. This article describes an initiative for how these foundational practices were implemented in a large integrated health care system.

BACKGROUND

The VHA has focused on 4 foundational components as part of its enterprise activities and support structure to implement HRO principles and practices. These components were selected based on pilot activities that preceded the enterprise-wide effort, reviews of the literature, and expert consultation with both government and private sector health systems. To support the implementation of these practices, the VHA provided training, toolkits, HRO executive leader coaching, and peer-to-peer mentoring. As the VHA enters its fifth year seeking high reliability, we undertook an initiative to reflect on our own experiences and refine our practices based on an updated literature review.

As part of this enterprise-wide initiative, we conducted a literature review from 2018 to March 2023 seeking recent evidence describing the value of implementing the 4 foundational HRO practices to advance high reliability and improve patient safety. A 5-year period was used to ensure recency and value of evidence.

Eligible literature was identified in PubMed, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scopus, the Cochrane Library, and ProQuest Dissertations & Theses Global. Inclusion and exclusion criteria were peer-reviewed interdisciplinary documents(eg, publications, dissertations, conference proceedings, and grey literature) written in English. Search terms included high reliability organizations, foundational practices, and patient safety. Boolean operators (AND, OR) were also used in the search. The search resulted in a dearth of evidence that addressed implementation of all 4 foundational practices across a health care system. Retrieved evidence focused on the implementation of only 1 particular foundational practice in a specific health care setting. In addition to describing the formal processes for the implementation of each foundational HRO practice, a brief description of representative examples of strong practices within the VHA is provided.

To support the implementation of HROs, the VHA paired HRO executive leader coaches with select medical center directors and their leadership teams. Executive leader coaches also support an organization’s HRO Lead and HRO Champion. The HRO Lead coordinates and facilitates the implementation of HRO principles and practices in pursuit of no harm across an organization. The HRO Champion supports the same as the HRO Lead, but typically has a different specialty background. For example, if the HRO Lead has an administrative background, the HRO Champion would have a clinical background.

Coaching focuses heavily on supporting site-specific implementation and sustainment of the 4 HRO foundational practices. The aim is to accelerate change, build enduring capacity, foster a safety culture, and accelerate HRO maturity. To measure change, HRO executive leader coaches track the progress of their aligned VA medical centers (VAMCs) using the Organizational Learning Tool (OLT). This tool was developed to provide information such as a facility summary and relationships between a medical center director, HRO Lead, HRO Champion, and the executive leader coach (Figure 1). The OLT also serves as a structured process to measure leader coaching performance against mutually agreed upon objectives that ultimately contribute to enterprise outcomes. It also collects data on the progress in implementing foundational practices, strong practices, needs and gaps, and more (Figure 2). Data collected from facilities supported by HRO executive leader coaches on whether foundational practices are in place are briefly described.

Leader Rounding

Leader rounding for high reliability ensures effective, bidirectional communication and collaboration among all disciplines to improve patient safety. It is an essential feature of a robust patient safety culture and an important method for demonstrating leadership engagement with high reliability.^4,5 These rounds are conducted by organizational leadership (eg, executive teams, department/service chiefs, or unit managers) and frontline staff from different areas. They are specifically focused on high reliability, patient and staff safety, and improvement efforts. The aim is to learn about daily challenges that may contribute to patient harm.⁴

Leader rounding has been found to be highly effective at improving leadership visibility across the organization. It enhances interaction and open communication with frontline staff, fostering leader-staff collaboration and shared decision-making,as well as promoting leadership understanding of operational, clinical, nonclinical (eg, administrative, nutrition services, or facilities management), and patient/family experience issues.⁴ Collaboration among team members fosters the delivery of more effective and efficient care, increases staff satisfaction, and improves employee retention.⁶ Leader rounding for high reliability significantly contributes to the breakdown of power barriers by giving team members voice and agency, ultimately leading to deeper engagement.⁷

It is important that leader rounding for high reliability occurs as planned and when possible, scheduled in advance. This helps to avoid rounding at peak times when care activities are being performed.^4,6 When scheduling conflicts arise, another leader should be sent to participate in rounds.⁴ Developing a list of questions in advance allows leadership to prepare messaging to share with staff as it relates to high reliability and patient safety (Table).^4,6,8

Closing the loop improves bidirectional communication and is critical to leader rounding for high reliability. Closed-loop communication and following up on and/or closing out issues raised during rounding empowers the sharing of information, which is critical for advancing a culture of safety.^4,8 Enhanced feedback is also associated with greater workforce engagement, staff feeling more connected to quality improvement activities, and lower rates of employee burnout.⁷ It is important to recognize that senior leaders are not responsible for resolving all issues. If a team or manager can resolve concerns that are raised, this should be encouraged and supported. Maintaining accountability at the lowest level of the organization promotes principles and practices of high reliability (Figure 3).^4,8

The VA Bedford Healthcare System created and implemented a strong practice for leader rounding for high reliability. This phased implementation involved creating an evidence-based process, deciding on an appropriate cadence, developing a tracking tool, and measuring impact to determine the overall effectiveness of leader rounding for high reliability.⁴

A visual management system (VMS) displays clinical and operational performance aligned with HRO goals and practices. It is used to view and guide discussions between interdisciplinary teams during tiered safety huddles, leader rounds for high reliability, and frontline staff on the current status and safety trends in a particular area.^8,9 A VMS is highly effective in creating an environment where all staff members, especially frontline workers, feel empowered to voice their concerns related to safety or to identify improvement opportunities.^8,10 Increased leader engagement in patient safety and heightened transparency of information associated with the use of a VMS improves staff morale and professional satisfaction.¹⁰

A VMS may be a dry-erase or whiteboard display, paper-based display, or electronic status board.⁸ VMSs are usually located in or near work settings (eg, nurses’ station, staff break room, or conference room).⁸ Although they can take different forms and display several types of information, a VMS should be easy to update and meet the specific needs of a work area. In the VHA, a VMS displays: (1) essential information for staff members to effectively perform their work; (2) improvement project ideas; (3) current work in progress; (4) tracking of implemented improvement activities; (5) strong practices that have been effective; and (6) staff recognition for those who have enhanced patient safety, including the reporting of close calls and near misses.

The VHA uses the MESS (methods, equipment, staffing, and supplies) VMS format. This format empowers staff to identify whether proper procedures and practices are in place, essential equipment and supplies are readily available in the quantity needed, and appropriate staffing is on hand to provide safe, high-quality patient care.⁸ Colored magnets are used as visual cues in a stoplight classification system to identify low or no safety risks (green), at risk (yellow), or high risk (red). Green coded issues are addressed locally by a manager or supervisor. Yellow coded concerns require increased staff and leadership vigilance. Red coded issues indicate that patient care would be impacted that day and therefore need to be immediately escalated and addressed with senior leaders to mitigate the threat.^4,11 Dayton VAMC successfully implemented a VMS, using both physical and electronic visual management boards. The Dayton VAMC VMS boards are closely tied to tiered safety huddles and leader rounding for high reliability.   

Safety Forums

Safety forums are another foundational practice of VHA health care organizations seeking high reliability. Recurring monthly, safety forums focus on reinforcing HRO principles and practices, safety programs, the importance and appreciation of reporting, and just culture. The emphasis on just culture reminds staff that adverse events in the organization are viewed as valuable learning opportunities to understand the factors leading to the situation as opposed to immediately assigning blame.¹²

Psychological safety is another important focus. When individuals feel psychologically safe, they are more likely to voice concerns and act without fear of reprisal, which supports a culture of safety.¹³ Safety forums are open to all members of the health care organization, including both clinical and nonclinical staff. Forums can be conducted by an HRO Lead, HRO Champion, Patient Safety Manager, or even executive leadership. Rotating the responsibility of leading these forums demonstrates that high reliability and safety are everyone’s responsibility.

Safety forums publicly review and discuss errors, adverse events, close calls, and near misses. Time is also spent discussing root cause analysis trends and highlighting continuous process improvement principles and current projects. During safety forums, leaders should recognize individuals for safety behaviors and reward reporting through a safety awards program.¹⁴ All forums should conclude with a question-and-answer session. Forums typically occur in virtual 30-minute sessionsbut can last up to 60 minutes when guest speakers attend and continuing education credit is offered.

The Jesse Brown VAMC in Chicago developed an interactive monthly safety forum appealing to a broad audience. Each forum is attended by about 200 staff members and includes leader engagement and panel discussions led by the chief medical officer, with topics on both patient and team safety connecting with HRO principles. A planning committee prepares guest speakers and offers continuing education credits.

Based on the processes of high reliability industries like aviation and nuclear power, tiered safety huddles have been increasingly adopted in health care. Huddles (health care, utilizing, deliberate, discussion,linking, and events) are department-level interdisciplinary meetings that last no more than 15 minutes.¹⁵ Their purpose is to improve communication by sharing day-to-day information across multiple disciplines, identify issues that may impact the delivery of care (eg, patient and staff safety concerns, staffing issues, or inadequate supplies) and resolve problems.

Tiered safety huddles are gaining popularity, especially in organizations seeking high reliability. They are more complex than traditional huddles because of the mechanics of elevating safety issues (eg, bedside to executive leadership teams), feedback loops, and sequencing, among other factors.^15,16

Tiered safety huddles are focused, transparent forums with multidisciplinary staff, including frontline workers, along with senior leadership.^15,16 When initially implemented, tiered safety huddles may take longer than the suggested 15 minutes; however, as teams become more experienced, huddles become more efficient.¹⁵ The goal of tiered safety huddles is to proactively identify, share, address, and resolve problems that have the potential to impact the delivery of safe and quality patient care. This may include addressing staffing shortfalls, inadequate allocation of supplies and equipment, operational issues, etc.^8,15 Critical to theeffective utilization of tiered safety huddles is the appropriate escalation of issues between tiers. The most critical issues are elevated to higher tiers so they are addressed by the most qualified person in the organization.

Deciding on the number of tiers typically depends on the size and scope of services provided by the health care organization or integrated system.For example, tiered huddles in the VHA originate at the point of service (eg, critical care unit). Tier 1 includes staff members at the unit/team level along with immediate supervisors/managers. Tier 2 involves departments and service lines (eg, pharmacy, podiatry, or internal medicine) including their respective leadership. Tier 3 is the executive leadership team. This process allows for bidirectional communication instead of the traditional hierarchical communication pathway (Figure 4). Issues identified that cannot be addressed at a particular tier are elevated to the next tier. Elevated issues typically involve systems or processes requiring attention and resolution by senior leadership.¹⁵ Tier 4 huddles at the Veterans Integrated Services Network level and Tier 5 huddles at the VHA Central Office level are being initiated. These additional levels will more effectively identify system-level risks and issues that may impact multiple VHA facilities and may be addressed through centralized functions and resources.

Tiered safety huddles have been found to be instrumental to ensuring the flow of information across organizations, improving multidisciplinary and leadership engagement and collaboration, as well as increasing accountability for safety.Tiered safety huddles increase situational awareness, which improves an organization’s ability to appropriately respond to safety concerns.Furthermore, tiered safety huddles enhance teamwork and interprofessional collaboration, and have been found to significantly increase the reporting of patient safety events.^15-19

The VA Connecticut Healthcare System tiered huddles followed a pilot testing implementation process. After receiving executive-level commitment, an evidence-based process was enacted, including staff education, selecting a VMS, determining tier interaction, and deciding on metrics to track.¹⁵

Implementing Foundational Practices

To examine the progress of the implementation of the 4 foundational HRO practices, quarterly metrics derived from the OLT are reviewed to determine whether each is being implemented and sustained. The OLT also tracks progress over time. For example, at the 27 cohort 2 and lead sites that initiated leader coaching in 2021 and continued through 2022, coaches observed a 27% increase in leader rounding for high reliability and a 46% increase in the use of VMSs. For the 66 cohort 3 sites that began leader coaching in 2022, coaches documented similar changes, ranging from a 40% increase in leader rounding for high reliability to a 66% increase in the use of safety forums. Additional data continue to be collected and analyzed to publish more comprehensive findings.

DISCUSSION

Incorporating leader rounding for high reliability, VMSs, safety forums, and tiered safety huddles into daily operations is critical to building and sustaining a robust culture of safety.⁸ The 4 foundational HRO practices are instrumental in providing psychologically safe forums for staff to share concerns and actively participate. These practices also promote continual, efficient bidirectional communication throughout organizational lines and across services. The increased visibility and transparency of leaders demonstrate the importance of fostering trust, enhancing closed-loop communication with issues that arise, and building momentum to achieve high reliability. The interconnectedness of the foundational HRO practices identified and implemented by the VHA helps foster teamwork and collaboration built on trust, respect, enthusiasm for improvement, and the delivery of exceptional patient care.

CONCLUSIONS

Incorporating the 4 foundational practices into daily operations is beneficial to the delivery of safe, high-quality health care. This effective and sustained application can strengthen a health care organization on its journey to high reliability and establishing a culture of safety. To be effective, these foundational practices should be personalized to support the unique circumstances of every health care environment. While the exact methodology by which organizations implement these practices may differ, they will help organizations approach patient safety in a more transparent and thoughtful manner.

Acknowledgments

The authors thank Aaron M. Sawyer, PhD, PMP, and Jessica Fankhauser, MA, for their unwavering administrative support, and Jeff Wright for exceptional graphic design support.