Transforming the Veterans Health Administration into a High Reliability Organization

Solutions

A top-down and bottom-up approach for the Journey to High Reliability: We partnered with VHA to orchestrate multiple work streams; enable close collaborations, within and across teams; manage budgets; and support delivery. Our experts collaborated with VHA to design comprehensive strategies and approaches to realize the vision for transformation. We also helped hospitals define, design, implement and continuously improve the approach. Our dynamic team worked to change VHA employee behavior and its culture to advance the organization’s vision for transformation and improved patient safety.

Baseline training

Our team partnered with VA Employee Education Services to develop scripts and storyboards for eLearning modules: HRO 101 (completed by 323,917) and HRO 201 (completed by 252,970); developed and delivered VHA Central Office HRO Training (completed by 90% of Senior Executive Service, 65% of VHACO supervisors and 20% of staff members from August 2019 to present); supported the National Center for Patient Safety and Office of Systems Redesign in the administration and execution of Clinical Team Training and Lean Management training offerings; and developed and executed one-day HRO Baseline Training for executives (8 hours), supervisors (120 minutes) and frontline staff members (90 minutes).

Site-specific assessment

Together with VHA, we assessed each hospital’s application of HRO principles and practices to determine their level of HRO maturity. Our team completed 134 site-specific assessments in FY20 through FY22. Our team then delivered 134 site-specific diagnostic assessment reports, detailing site strengths and improvement opportunities. Assessment reports provided recommendations for methods, tools and strategies to drive culture change and improvements enabling fewer errors and improved patient safety (e.g., fewer infections, fewer falls and fewer medication administration errors). The team also provided implementation plans accompanied by implementation advisory support and an HRO Site-specific Implementation Plan.

Continuous learning

Our team stood up HRO learning workgroups to support the spread and sustainment of HRO principles and practices throughout VHA. We led planning, development, coordination and execution of a new education pilot — called HRO in Practice (or HIP) — which focuses on sharing and applying the foundational HRO practices across different facilities. The team is currently developing an HRO Community of Practice to provide user-friendly access to curated materials, experiential learning opportunities and a network of peer-to-peer connections. Continuous process improvement training advances staff member understanding of practical use cases and enables employees to apply that knowledge to operationalize HRO concepts through improvement projects in their everyday work, improving patient and employee safety and reliability.

We also stood up a High Reliability Academy Work Group to develop learning objectives, curriculum, content and activities for HRO foundational training for HRO leads and champions — those responsible for influencing, mentoring and coaching others to accelerate VHA’s Journey to High Reliability. This work group also examines the essential behaviors and competencies needed to lead with vulnerability, empathy and accountability while influencing, coaching and mentoring others; resolving conflicts with an HRO mindset; and modeling a non-punitive (otherwise known as Just Culture) response to mistakes. We delivered a pilot session of HRO Leads and Champions Foundational Training, with anticipated final course launch in FY23.

Strategic communications

Our team worked with VHA to develop a robust communications plan to engage and inspire VHA staff members during all phases of the Journey to High Reliability. Our team developed and maintains the VHA HRO SharePoint site for disseminating communications to leaders, front line staff members and VHA’s Central Office. We also work with VHA to launch several employee engagement campaigns to engage VHA staff members and inspire them to celebrate high reliability practices in their daily work. One such campaign, the HRO Safety Story Video Challenge, which invited individuals and groups to submit widely applicable “Good Catch” and “Close Call” stories of error avoidance, resulted in 84 videos submitted from across VHA. Our team also developed the following: a monthly HRO blog, newsletter and poster to highlight staff member success stories; fact sheets and videos to showcase HRO principles and values, foundational practices and implementation activities; and a semi-annual award ceremony to celebrate HRO successes.