Resource Library-Augmenting Annual Quality Program Reviews with High-Risk Quality Process Simulation

Video Transcription

Video Summary

Presenters from VISN 15 (VHA Heartland Network) describe adding a high-risk quality process simulation to annual quality program reviews, focusing on communication of test results and sentinel event response. Using the NAHQ competency framework and VHA high-reliability principles, they identified gaps through directives, OIG reports, and local trends (tort claims, peer review, delays in care) showing breakdowns in test-result communication and sentinel event processes (reporting, disclosures, RCA completion). They reviewed resources (VHA directives, incident reporting guidebooks, Joint Commission requirements, analytic trend data) to define an “ideal” process and required roles (quality, risk, patient safety, accreditation, systems redesign). The team built a psychologically safe, face-to-face tabletop “choose your own adventure” scenario based on a real OIG case outside the network, with role-play and decision points. Observers used a checklist and provided debrief feedback without recording findings. Outcomes included identifying silos, culture barriers, and competency weaknesses, improving collaboration and process activation across quality functions.

Asset Caption

Speakers: Melody Queenan, DNP, RN, NE-BC, Rosemarie Albers, MSN, RN, Harold Vannier, MBA, BSN, NEA-BC, LSSMBB, CCMP, CPHQ

In this session we will review the VHA VISN 15 annual network-level quality program assessment design. We will highlight the priority of review items to address directives, compliance, problem-prone and future-focused items. Finally, we will discuss using simulation to illuminate possible gaps in high-risk quality processes and identify barriers to success.

Meta Tag

Competency Tag QLI1

Competency Tag Description Direct the quality and safety infrastructure to achieve organizational objectives.

Domain Tag Quality Leadership and Integration

Keywords

VISN 15 VHA Heartland Network

high-risk quality process simulation

test result communication

sentinel event response

tabletop role-play choose your own adventure

NAHQ competency framework and high reliability principles