Summary

This correspondence responds to follow-up questions to GAO's July 27, 2000, testimony before Congress on patient safety and quality of care at the Department of Veterans' Affairs (VA). The Patient Safety Centers of Inquiry and VA's Office of Research and Development are not directly linked organizationally. The four centers of Inquiry do not report to and are not funded by the Office of Research and Development. The Directors of the four centers report to either the Veterans Integrated Service Networks or Medical Center manager where they are located. The work at the Centers of Inquiry address some but not all of the known principal adverse and sentinel events at VA medical facilities. The key challenges to improving patient safety include setting goals, planning, and communicating the priority of patient safety to its employees. VA's patient safety program has not been fully implemented, because it is too early to predict whether, in the final analysis, it will be a model for other health care organizations.