Postponing surgeries was about doing the right thing for Veterans

Veterans have been waiting anxiously since May to hear what I am about to share – surgeries at Rocky Mountain Regional VA Medical Center resumed normal operations on August 12. I want to take this opportunity to give a firsthand account of why we postponed surgeries and why it took so long to resume.

You may have heard of high reliability organizations (HRO). In industries where errors can have devastating consequences, such as nuclear power and air travel, the idea of HRO was born to ensure that safety always comes first. HROs experience fewer than anticipated accidents or events of harm, despite operating in complex, high-risk environments. At VAECHCS, we are committed to the journey to high reliability, and HRO principles form the foundation of our operations. It is an ongoing process to ensure our nation’s heroes receive the high-quality care they deserve.

HRO principles guided the decision to postpone surgeries due to the residue on our equipment. “Preoccupation with failure” is a risk-based concept, in that our employees look for things that could go wrong and identify ways to prevent the risks from causing harm to patients. Our staff in the Operating Room stopped the line when they identified the risk to Veterans with our surgical instrumentation. The HRO principle "deference to expertise” means listening to our subject matter experts when the Infection Control team raised concerns about the residue. “Reluctance to simplify” means digging into a problem until we find the root causes and address them.

It was a difficult decision. It was hard knowing that we had highly qualified, specially trained staff unable to do the surgeries that they are trained to do. Those staff members continued to support clinical operations during this time, including working with the impacted Veterans to ensure that they received the care that they needed. While we want those highly qualified staff members doing the surgeries that they were hired to do, we couldn’t continue doing surgeries until we knew that our sterilized equipment was truly safe.

We spent the summer as an Incident Management Team made up of experts on engineering, sterilization, infection control and surgery focusing on all aspects of the steam sterilization system. We worked through ensuring that the pH of the steam was on target. We replaced pipes and filters throughout the system, exceeding safety standards. We worked with regional and national experts to implement every recommendation to solve this problem, but ultimately, we had to go beyond what anybody expected. We worked with the manufacturer of the equipment to fully dismantle and refurbish the equipment. That step was vitally important to ensuring we could get back to business, providing the care that we do best.
The reason that I’m writing this is to set the record straight. While it was painful for us to stand down many of our surgery services, we did it because it was the right thing to do. We value patient safety above all else, and we could not in good conscience continue to do these surgeries until we knew that the issue was resolved. We will continue applying HRO principles to ensure that we are ever moving towards that goal of zero harm. Veterans deserve the best care, and their trust in us means that we must do everything in our power to provide them the care they deserve. I am proud to say in this instance and in many more, we have done just that.

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