VHA strives to provide the best quality care for our nations' Veterans with "quality care" defined as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." VA Health Services Researchers greatly contribute to VA's quality improvement efforts by conducting multiple quality improvement studies and disseminating findings.

Presented here are four recently completed studies that address care quality from several perspectives.

Keywords: quality, improvement, outcomes, care, safety, medical errors, hazards

1. Improving Safety Culture and Outcomes in VA Hospitals

This three-year study sought to examine the level of, and variation in, safety climate in VA hospitals, as well as targeted areas for improvement. (Study no.: IIR 03-303. David M. Gaba, MD.)

Questions

What is the strength and uniformity of the safety climate, nationwide, in a sample of VA hospitals? Is there a relationship between the level of safety climate and general organizational culture? Further, is there a relationship between the level and uniformity of safety climate and patient safety outcomes?

Results

Using a variety of data sets (VA hospital employee surveys administered in 2006 and 2007; NSQIP data and VA administrative data; and results from a safety climate survey of non-VA hospitals funded by AHRQ), investigators looked at a safety climate using a primary outcome measure of problematic response (PR) rate to the Patient Safety Climate in Health Care Organizations instrument. Investigators found:
• Perceptions of safety culture differed among hospitals, job-type, and work area, but overall, VA hospitals possessed a relatively high level of safety climate, as indicated by an 83% non-problematic response rate.
• Higher levels of group and entrepreneurial organizational cultures were associated with higher levels of safety climate, while more hierarchical cultures were associated with lower levels of safety climate.
• After multiple analyses, investigators could not find consistent or significant relationships between facility-level PR rates and patient outcomes.

Implications

The investigators' findings suggest that there was a generally positive climate of safety across all VA institutions, work groups, and types of workers. Further, they found no difference in safety climate between VA and non-VA hospitals.

2. Impact of Resident Work Hour Rules on Errors and Quality in VA Hospitals

This three-year study examined the impact of changes to work hour regulations for residents in VA hospitals. (Study no.: IIR 04-202. Kevin Volpp, MD.)

Question

Did changes to medical resident work hours (mandated in 2003) affect mortality rates, length of stay, or patient safety indicators for patients in VA teaching hospitals?

Results

Using a multiple time series design, the investigators examined whether the changes in duty hour rules impacted trends in patient outcomes in teaching hospitals. Overall, the study found that the new regulations did not have a strong impact on patient mortality rates, or the probability of experiencing a prolonged hospital stay. The patient safety indicator analysis showed duty hour reform to have no systematic impact on potential safety-related events.

Implications

Duty hour limitations had the potential to uniquely impact VA, as 70% of its hospitals are teaching hospitals in which medical residents are responsible for a considerable amount of patient care. The investigators' analyses have indicated that duty hour reform has not resulted in negative outcomes for patients. They also suggest that their study will help to further inform efforts to reduce errors in VA teaching hospitals by clarifying which mechanisms helped hospitals cope with a reduction in resident work hours. (Note: This research resulted in the following publication: "Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform." JAMA 2007 Sep 5;298(9):984-92)

3. Three Components of Stroke Care Can Improve Outcomes

Completed in 2007, this four-year study, sought to identify the processes of care given to Veterans hospitalized with acute ischemic stroke or transient ischemic attack and how those processes of care are related to outcomes. (Study no.: IIR 01-104. Dawn M. Bravata, MD.)

Question

Is it possible to identify processes of care that are independently associated with patient outcomes in stroke care?

Results

This retrospective cohort study of 1487 Veterans showed that three processes of care (speech/swallowing evaluation; deep vein thrombosis prophylaxis; treating all episodes of hypoxia with supplemental oxygen) were independently associated with a reduction in the combined outcome of in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility.

Implications

VA strives to provide excellent stroke care across the spectrum of medical centers. This study, Quality Evaluation in Stroke and TIA (QUEST), identified the processes of care associated with improved patient outcomes. Investigators suggest that medical centers caring for stroke patients may want to focus on the three components of stroke care that were shown to impact mortality in order to maximize patient outcomes. (Note: The QUEST study findings were communicated to the VA HSR&D Stroke-QUERI (Quality Enhancement Research Initiative) and VA Office of Quality and Performance, who continue working to improve the measurement and implementation of stroke care quality. Dr. Bravata is the Co-Clinical Coordinator for VA HSR&D Stroke-QUERI.)

4. Understanding Nursing Quality Improvement Using a Single Site

In this study, investigators sought to examine quality surrounding the structural and process features of nursing care. (Study no.: RRP 07-338. Lynn Soban, RN, PhD, MPH.)

Questions

Using a single-site case study, is it possible to understand the organizational, processes, and quality improvement (QI) measures of nursing activities surrounding pressure ulcer care–and to extrapolate that understanding across VA?

Results

Through semi-structured interviews across one large academic VA medical center, investigators determined that nursing quality for ulcer prevention was facilitated by adhering to certain care processes (e.g., skin assessments within 24 hours of admission; completing the Braden scale within 24 hours of admission). Research also suggested that some of the perceived barriers to nursing quality in ulcer prevention were specific to individual nursing units (teamwork deficits) and could not be extrapolated to the entire hospital.

Implications

The investigators suggest that their findings can be used to inform the development of VA nursing process measures, which in turn may inform QI interventions to improve patient outcomes for pressure ulcers. Further, the investigators believe that in addition to pressure ulcer specific features of care, they identified other aspects of care delivery (e.g., deficits in teamwork) that may affect the quality of nursing care across the VA healthcare system.