Development of a Systems Safety Program for a Large Healthcare System

We describe a new program element in our Veterans Health Administration (VHA) healthcare system. The purpose is to pursue opportunities for efforts to complement existing VHA safety work with an emphasis on understanding how things go right and supporting activities or structures that contribute to system success. The program takes a holistic systems approach to safety by promoting system lifecycle activities that explore context of use and Work-As-Done, recognizing that the way work is performed reflects realities of the work environment, demands, resources, and organizational value system. It seeks to increase human factors capabilities with a goal of empowering design teams to understand and document current state prior to proposing changes and to explore opportunities and conduct risk assessments for current state, proposed redesigned state, and post-implementation state. An outcome should be enhanced staff ability to understand and adapt to changing demands and conditions that affect how they deliver care.