Driving to zero: Birmingham VA holds first Patient Safety/High Reliability Stand Down

The aim was to reinforce regulatory safety standards, improve processes, and provide staff with information and tools to assist them in providing safe and excellent care.

Representatives from Quality, Safety and Value, Patient Care Service, Infection Control, Pharmacy, Hospital Safety, Sterile Processing, Mental Health, and Primary Care provided staff with information and tools to assist them in providing safe and high-quality health care.

“The Birmingham VA is a highly reliable organization,” said Dr. Shawana Barnes, Birmingham VA Interim Quality Manager, and safety stand down organizer. “We work hard to avoid failure and do not need a specific incident to trigger a response or identify areas of opportunity. We work tirelessly to improve our processes and want only to ensure that staff have all the tools they need to continue providing safe and excellent care to our nation’s Veterans.”

The first of its kind

Although the Birmingham VA has hosted patient safety fairs, this was the first time High Reliability was included, to include Veterans Clinics participating virtually. 

Experts provided presentations and reports from various clinics during education segments titled “Stop the Line.” Staff from Huntsville, Bessemer, and Guntersville Community Based Outpatient Clinics shared their safety stories with the audience, allowing other VA staff to learn from positive experiences with “see something-say something,” a national safety initiative.

During simulated inspections or accreditations, health care professionals must be prepared to articulate how they perform their daily care of Veterans. Generally, they operate within established policies and procedures. Still, events such as the safety stand-down prepare them to increase awareness by offering example responses to various scenarios.

“Patient safety is our number one priority,” said Dr. Oladipo Kukoyi, Birmingham VA Health Care System, Executive Director. “When a Veteran visits our facilities, we expect for them to get nothing but the best possible health care, with zero harm from our staff. This focus on safety allows us to get back to the basics and renew our commitment to foster a safety culture in our organization.”

Praised by the network director

During an hour-long employee roundtable, Dr. David Walker, VA Southeast Network Director and National High Reliability Steering Committee member commended Birmingham VA on achieving a 77.4 percent participation rate in its annual All Employee Survey.

“Part of being a highly reliable organization requires people feeling comfortable to speak up,” he said. “Leadership cannot order employees to participate in AES, so the results tell an important story about the culture of your organization—people want to share their ideas in making changes where needed.”

The AES is an annual, anonymous, and voluntary organizational climate report card. It gives employees a voice in what is going well and a chance to identify opportunities for improvement. Birmingham VA scored the highest percent participation rate in VISN 7 and ranked 35 out of 140 nationwide VA medical centers.

Walker discussed the three pillars of High Reliability: Leadership Commitment, Culture of Safety, and Continuous Process Improvement. 

“Leadership not only plays an important role at the executive level but throughout the entire organization. Today’s event focuses on the culture of safety-using values and practices to prevent harm and learn from mistakes.”  Walker added, “Continuous process improvement is the most challenging. Process improvement should be constant and part of our daily culture. Always seek out ideas for improvement from new employees and frontline staff.”

Providing continuous learning opportunities

After its inaugural success, Birmingham VA leadership plans to conduct a Patient Safety/High Reliability stand down annually, using specific elements to provide continuous learning opportunities for staff throughout the year.

Although the event took two months of planning, coordinating, and collaborating with participating services, Barnes insists the efforts will provide a hefty return on investment.

“It’s about the Veteran,” she said. “We are grateful to VA Southeast Network and Birmingham VA leadership for their support and for encouraging our entire staff to learn, inquire, and improve.”