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Excellence in Action

Shared Governance — Shifting the Focus on Improving Quality and Safety

In response to VA being placed on the Government Accountability Office's High-Risk List, the Office of Quality, Safety and Value (QSV) has taken steps to re-invigorate and support performance improvement in VA's health care system. In early 2018, the Veterans Integrated Service Network (VISN) 10 piloted the implementation of a quality and safety shared governance framework at two VAMCs: the Aleda E. Lutz VA Medical Center, Saginaw and the VA Ann Arbor Healthcare System.

A shared governance framework provides empowerment to employees who are providing direct services to Veterans by giving them a voice and role in oversight and improvement activities around quality and safety. According to Karen Maudlin, Health Systems Specialist, QSV, who oversees the project, "When I reviewed the pre- and post-survey results from the pilot and saw the increased scores for the perception of shared accountability for patient safety and clinical quality between leadership and clinical teams, I knew we were onto something good."

The pilot focused on improving communication, collaboration and accountability between leadership and frontline VA employees delivering care and services to Veterans. During the pilot, leadership was charged with setting expectations and providing resources necessary for their frontline teams to deliver the highest quality and safest care possible. Using the industry-standard performance improvement process "PDCA" — Plan, Do, Check, Act, leaders focused on delivering care that engages and respects the Veteran and family. The medical centers' frontline teams were first provided data and other types of feedback to show how they were doing with regard to quality, safety, access and satisfaction outcomes. These teams combined that information with an assessment of their own observations and experience in caring for Veterans and identified issues that they wanted to improve. Improvement experts then helped them understand how to monitor and measure changes while they were trying new interventions.

After each cycle of improvement, the team reflected and decided how to move forward; that is, whether to spread and share the intervention with others, continue to tweak it, or cease using the intervention altogether because it wasn't working as planned. According to Sara Schroeder, Patient Safety Manager at Aleda E. Lutz VA Medical Center, "The conversations among frontline staff all the way to the Service Chief changed significantly with the pilot, with the focus now on how to improve care."

The next step was for hospital leadership to attend a quality and safety meeting where each department shared what was working well and should be implemented across the facility. Staff were also given the opportunity to request additional resources from leadership to address problems. "Lessons learned from a VISN leadership perspective is that quality is owned, implemented and improved upon at the frontlines," says Jane Johnson, VISN 10 Quality Management Officer. "It is a change of culture to go from quality departments reporting for other departments on quality, to quality teams in each department working with frontline staff toward outstanding outcomes for Veterans. Real innovation and advancement occurs when leadership, care and diffusion come together. It is challenging, but we are excited to continue to spread the shared governance approach."

In late August, the shared governance project team kicked off phase two by sharing the tools and processes that were developed during the pilot with three more VA medical centers in VISN 10 — Cleveland, Cincinnati and Chillicothe. These three new sites will allow the project team to test these tools and processes in different environments. "Similar to the cycle of the learning and improvement philosophy we are instilling at our facilities, we are using that same philosophy to develop and spread our shared governance model," Karen Maudlin added.

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