The recent release of Safer Together: A National Action Plan to Advance Patient Safety marks the latest contribution of William Gunnar, MD, JD, FACHE, to a better healthcare system. Dr. Gunnar, director of the U.S. Department of Veterans Affairs (VA) National Center for Patient Safety, also is a member of the National Steering Committee for Patient Safety, which established the National Action Plan’s core values.
The Institute for Healthcare Improvement (IHI) brought together leaders from influential national organizations, including the VA and the American College of Healthcare Executives, to create this new National Action Plan to guide healthcare leaders’ efforts to prevent medical harm. (The plan is accessible through www.ache.org/SaferTogether.)
In an interview shortly after the National Action Plan’s release, Dr. Gunnar spoke with Eric W. Ford, PhD, editor of the Journal of Healthcare Management. Their conversation, edited here for format and clarity, covered his groundbreaking work with the VA and tapped into his thoughts on the value of high reliability and just culture in the delivery of care.
Dr. Ford: What led to your career pivot from cardiac surgeon to the top leadership role of the VA National Center for Patient Safety?
Dr. Gunnar: I came to the National Center for Patient Safety after several years in the VA’s National Surgery Office, where I was director of surgery from 2008 to 2018. A major part of that role was oversight of the VA’s National Surgical Quality Improvement Program (NSQIP).
Originally, the NSQIP was limited to noncardiac surgical cases, and a separate VA program focused on continuous improvement in cardiac surgery. They played foundational roles for the American College of Surgeons’ safety programs and the Society of Thoracic Surgeons’ safety database. In fact, the people who originated the American College of Surgeons programs and the Society of Thoracic Surgeons database were also instrumental in forming the VA’s databases and logistic regression model that generated the initial NSQIP scores.
When I was the VA’s national director of surgery and had oversight of those two programs, I knew the historical reason for their separation but could not see the functional reason. Why should cardiac and noncardiac be considered separately? I merged those two surgical quality improvement programs into one that looks at noncardiac and cardiac together, and then began to build a quarterly and rolling-year report for quality improvement data in all of the VA’s 137 surgical programs.
All along, I had been collaborating with the leadership of the VA National Center for Patient Safety, and I had written a number of papers on incorrect surgical procedures and other topics with them. When the center’s director position opened in 2018, I applied for it. Gratefully, I was selected. I have always viewed the role as a challenge and as an opportunity to make a difference in this space.
Actually, my path to a leadership position in the VA followed a midlife interest in health law. In 2002, I was accepted to Loyola University Chicago’s law school. For 4 years, I was a cardiac surgeon by day and a law student by night. I passed the Illinois Bar in 2006.
Dr. Ford: How have you been able to apply your legal training to your current role?
Dr. Gunnar: VA leadership positions are grounded not only in operations but also in policy—that is how you can drive quality and patient safety in a large, integrated healthcare system. A legal background helps me understand the policies and statutes that guide the VA’s work.
Dr. Ford:How did the new National Action Plan come together?
Dr. Gunnar: To answer that question, I need to connect the dots between the VA and the efforts of the IHI’s National Safety Council to roll out the National Action Plan. The VA’s National Center for Patient Safety and the VA have shared an interest in high-reliability organization (HRO) transformations for some time.
In 2018, the Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri, was completing work on an HRO framework. The project began in 2015 when staff from this office engaged the leadership at Truman; in 2016, they deployed a fairly comprehensive plan for transformation to an HRO that was implemented over the next 3 years. When I started at this position, our office began studying the impact of that transformation on outcomes—in the development of a patient safety culture as well as quality at the facility.
In the meantime, the leadership in the Veterans Health Administration changed. In February 2019, Dr. Rich Stone, who is now our executive in charge, implemented a national initiative to transform the Veterans Health Administration to an HRO. The HRO Journey to Zero Harm program followed principles set forth by the Agency for Healthcare Research and Quality and The Joint Commission. This leadership commitment for generating a culture of safety and continuous process improvement (CPI) was foundational to the VA’s systemwide HRO effort. We took what we learned at our high-reliability hospital at Truman and expanded the model to 18 lead sites, one in each of our veterans integrated service networks.
Within each veterans integrated service network, three additional facilities will be included in the next rollout. By early 2022, 72 sites will receive the HRO curriculum, which will include HRO training for leaders, supervisors, and frontline staff. The National Center for Patient Safety will participate in communicating the principles of a just culture to leadership throughout the VA and in establishing clinical team training, starting with clinical team training master training. The idea is to train the trainer through a series of interactive engagements with the HRO lead sites. That way, we can build a cadre of local master trainers to do all-staff clinical team preparation, a process that will repeat on a 2-year basis. In the middle of that cycle, each local unit will engage in CPI efforts.
The CPI efforts are built upon foundational topics such as briefing/debriefing, standardizing processes, examining the local environment and infrastructure, identifying opportunities for improvement, using checklists, and so on. Drawing from a series of seven or eight topics, each unit can pick the ones that they believe would be most beneficial, based on their own environmental review. So, there is ongoing collection of data, and we are reporting these process improvement efforts in a shared database.
Because the VA is the largest integrated healthcare system in the country and delivers a phenomenal amount of care, our sizable denominator enables us to track even the rarest patient safety events. There are 9.2 million veterans enrolled in the VA health system, and 6.5 million of them use VA health services each year. We can evaluate outcomes even at low rates. For example, we have published data on our wrong-site surgery and retained surgical item rates. For reference, in 2019, we had approximately 20 wrong-site procedures out of a total of 422,000 surgical procedures and an equal number of retained surgical items in that same period. The benefit I see is the opportunity to enhance policy and measure impact even though the rate of events is low.
Dr. Ford:Those are phenomenal numbers. How have they led to your participation on the National Patient Safety Council?
Dr. Gunnar: As a federal partner, I consider it an absolute pleasure to be a part of the National Patient Safety Council and to engage in this ongoing conversation. I came to the council after work had already begun. Tejal Gandhi, then senior fellow at IHI, and Jeff Brady, director of the Agency for Healthcare Research and Quality’s Center for Quality Improvement and Patient Safety, were well into formatting what is now Safer Together: A National Action Plan to Advance Patient Safety.
Dr. Ford: My colleagues and I have published several articles using your hospital safety culture survey. I think we were one of the few groups that received permission to use the identified data, and we were able to use the data to great effect. We really appreciated the VA’s willingness to put all that information out there. How can other researchers gain access to the quality data?
Dr. Gunnar: Frankly, it is a lot easier if you are in the VA in some capacity. Most of the data are based in our National Center for Organization Development. The policy is that you must have an appointment in the VA to gain access. That is because of the privacy and security training that is attached to a data-use agreement.
Dr. Ford:What are you reading these days that other healthcare administrators would find useful for their careers?
Dr. Gunnar: I am in the midst of trying to educate myself on the evidence and literature that supports the implementation of an HRO framework and describes its impact on patient safety culture and clinical outcomes. Not a lot exists.
I am also trying to dig into the relationship between patient safety culture and quality outcomes. Quality improvement has been going on for decades without HRO implementation. I see a direct impact of HRO implementation on patient safety culture—on transparency of reporting harm events and the feeling that you work in a just culture that allows you to report and not be burdened by blame. I am a surgeon. I know that, for years, healthcare drove quality through a culture of blame. There was a “we will not fail” attitude, as opposed to an approach that allows the examination of systems and issues. We make mistakes; we are not perfect. The future of healthcare should be based on approaching our mortality and complication rates and then examining those rates in a way that is based in process change and risk mitigation.
High reliability is the foundation for quality improvement, but it also propels patient safety. So, I am trying to identify the point of nexus for high reliability, direct impact, patient safety culture, and patient safety event reporting. Over time, people do improve quality outcomes as measured by NSQIP or a VA surgical quality improvement program. It is amazing to watch facilities that have been identified as outliers make the necessary corrections.
I think it is right to drive an organization to become an HRO, to drive CPI and a better culture of safety. The thought that you can reach zero harm in complex healthcare is aspirational and appropriate, but not really obtainable. Instead, think about how you drive your system. How do you make your staff know that they can be comfortable reporting events? Look for ways to ensure that the system they work in is corrected and be alert to practices that would make the environment as safe as possible.
Dr. Ford: How do you deal with the stress of your job?
Dr. Gunnar: I am honored to be in the position I am in. Coming to work is fun. I also have a wonderful home life with my wife and children. I spend a lot of time at my daughter’s tennis competitions and my son’s baseball games. My own passions are baseball and tennis, so participating in those sports with the family is wonderful, too.