AHRQ WebM&M Looks at the Safety Transformation Within the Veterans Health Administration
MedSun: Newsletter #9, November 2006

The September 2006 “Perspectives on Safety” in the Agency for Healthcare Research and Quality (AHRQ) WebM&M focuses on the notable safety transformation at the Veterans Health Administration within the U.S. Department of Veterans Affairs (VA).

In an interview with WebM&M Editor Dr. Robert Wachter, James P. Bagian—physician, mechanical engineer, and two-time space shuttle astronaut—describes the life experiences that prepared him for his position as Director of the VA National Center for Patient Safety and the path to improvement at the VA. From an early age, Dr. Bagian, the 2001 winner of the American Medical Association’s Nathan S. Davis Award for outstanding public service in the advancement of public health, was interested in “trying to do things the most effective way.” This attitude continued in medical school, where, based on his understanding of device designs and metallurgical properties, he many times suggested alternative surgical techniques to his professors. In addition to his medical training, his engineering education and the leadership skills he developed at the National Aeronautics and Space Administration inform Dr. Bagian’s attitude toward safety improvement. On arrival at the VA, Dr. Bagian concentrated on changing the institutional culture, one that varied considerably from that of the “high reliability” aerospace world.

He stressed the importance of having a staff who could analyze problems and devise feasible solutions that were user-friendly and that produced tangible results, all in a context in which employees felt safe enough to speak the truth.

In “What Can the Rest of the Health Care System Learn From the VA’s Quality and Safety Transformation?,” Ashish K. Jha, M.D., M.P.H., of the Harvard School of Public Health and the VA Boston Healthcare System, discusses the lessons learned from the VA experience and analyzes the most important modifications—those to decisionmaking, data collection and feedback, performance contract incentives, and the electronic records system—that account for the remarkable improvements in the VA health care system.

Additional Information:

For the full interview with Dr. Bagian, go to

What Can the Rest of the Health Care System Learn From the VA’s Quality and Safety Transformation?

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