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The New Generation Risk Tool for VA HFMEA

The Proactive Assessment for Safer Systems (PASS) Logo

The Proactive Assessment for Safer Systems (PASS) is an electronic tool created to help VA hospitals perform and document Healthcare Failure Mode and Effect Analysis (HFMEA).

Thursday, January 5, 2017

Failure Mode and Effect Analysis (FMEA) is a method that engineers across industries use to systematically detect and prevent process and product problems before they occur. VA has adapted the FMEA methodology to health care processes in order to reduce the frequency of unanticipated adverse events and ensure safer care for Veterans.1 VA Healthcare Failure Mode and Effect Analysis (HFMEA) also helps VA facilities comply with The Joint Commission standards, which require accredited hospitals to select a high-risk health care process and perform at least one risk assessment every 18 months.2

Currently, teams at VA hospitals carry out the HFMEA methodology manually using white boards, easel paper and large printed worksheets to organize ideas. Later, they transcribe the information into electronic documents and propose actions to leadership.

In early 2016, the VA National Center for Patient Safety (NCPS) began brainstorming the next generation of the VA HFMEA in collaboration with the Veterans Engineering Resource Center (VERC) Data Engineering Resources team in Indianapolis and developed a prototype called the Proactive Assessment for Safer Systems (PASS).

What is PASS?
PASS is an electronic tool created to help VA hospitals perform and document HFMEAs. The goal of PASS is to empower clinical and patient safety staff across VA to carry out proactive risk assessments more simply and effectively. The features of the PASS web-based application will be structured around the HFMEA methodology and designed to ensure ease of use for beginners and experts alike. PASS will streamline HFMEA facilitation by providing a platform for teams to electronically input the five HFMEA steps:

1) Selecting the process
2) Assembling the team
3) Identifying process steps
4) Identifying failure modes
5) Identifying actions.

This will eliminate the need for paper worksheets, but more importantly, it will allow for an enterprise view throughout VA to help facilities standardize processes nationally. The PASS tool will promote organizational learning by maintaining a searchable database. Users will be able to search for completed HFMEAs by topic area, allowing for the innovations and outcome measures generated at one site to benefit teams at all VA medical centers. HFMEA teams will be able to review items such as process steps and sub-steps, failure modes, actions and outcome measures that other teams across the country have previously entered into the PASS system. This ability adds a new and exciting layer to HFMEA that will enhance the quality and consistency of analyses and increase the effectiveness of planned actions and outcome measures.

The application will be accessible anywhere within the VA network, requiring no software installation. Embedded tips, a user manual and reference materials will be available to guide users through the methodology. Each team’s designated HFMEA coordinator will have access-granting rights so that they can invite team members to view and edit ongoing analyses.

Developing and Testing PASS
In order to best translate existing practices into the electronic tool, the development team will work with teams of clinical and patient safety staff in the field to introduce, explore and evaluate the new features of PASS. The development team plans to facilitate pilot sessions during facility level HFMEAs to gain valuable insight from end users.

A phased development and implementation plan will create opportunities for discussion, analysis and mid-course improvement. The first version of PASS will feature full HFMEA functionality. Users will be able to construct static process diagrams, conduct basic searches of archived HFMEAs, and print completed process diagrams and HFMEA worksheets. The second version of PASS will equip users with more advanced features including a “drag-and-drop” flow diagram, a personalized “dashboard” to view and resume HFMEAs, and the ability to print isolated HFMEA components. Finally, in a third release, PASS will enable VA service chiefs to develop standard health care process templates that are either specific to one service line or span multiple service lines. This will create an opportunity for service chiefs to lead large scale, multidisciplinary, multi-facility HFMEAs leveraging the insight of staff from numerous sites and service areas. Aggregate HFMEA findings will strengthen VA’s capacity to proactively identify vulnerabilities and take corrective actions.

The Future of VA Proactive Risk Assessments
Reliance on reactive, piecemeal improvements to small elements of a complex system ultimately cannot help identify or remediate the things that could go wrong. Alternatively – when we study how processes intertwine, thoughtfully determine which vulnerabilities we can control, and challenge ourselves to acknowledge our weaknesses – we empower each other to overcome those weaknesses and proactively address broken systems before they cause harm. PASS, with its broad accessibility, user and team-friendly interface, and database of solutions, will provide a pathway for teams in the field to accelerate VA’s proactive approach to building safer systems.

References
1. VA National Center for Patient Safety. The Basics of Healthcare Failure Mode and Effect Analysis. 2002. http://www.patientsafety.va.gov/docs/hfmea/FMEA2.pdf.
2. VHA Handbook 1050.01. VHA National Patient Safety Improvement Handbook. 2011. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2389.

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