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Commentary

VHA's Vision for a High Reliability Organization

 The Veterans Health Administration (VHA) is undergoing a transformational modernization at a scale and scope not experienced since General Omar Bradley’s leadership of the Veterans Administration in the 1940s. At the center of this modernization is a culture change that will be realized throughout VHA –our transformation into a high reliability organization (HRO).

An HRO is an organization that experiences fewer than anticipated accidents or events of harm despite operating in highly complex, high-risk environments where even small errors can lead to tragic results. HROs establish trust amongst leaders and staff by creating a Just Culture that balances individual accountability with systems thinking. HRO leaders empower all staff to lead continuous process improvements within their own workspace. Creating an environment where employees feel safe to report harm or near misses requires our leaders to focus on the why, not the who, when errors occur. Leaders must fairly distinguish between conduct deserving of discipline versus the much more common unintentional human error or drift from protocol that can lead to harm despite the best efforts and intentions of staff.

The work to become an HRO not only unleashes the incredible talent and commitment within our system to do great things, but it also supports our efforts to strengthen the trust of Veterans and the American people in VA.

 VHA has been a leader in the patient safety movement for more than 20 years. We are committed to continuing to build on the great strides we have made with improving safety and quality of care. In February 2019, VHA launched an enterprise-wide HRO transformation effort and made a long-term commitment to pursuing a goal of Zero Harm. As Veterans Integrated Service Networks (VISNs) and VA Medical Centers (VAMCs) advance toward HRO maturity, leaders are applying an organization-wide commitment to Zero Harm by developing a strong safety culture featuring empowered, collaborative frontline teams supported by engaged leadership within a climate of trust and continuous improvement.

VHA’s HRO Journey to Date

Our renewed focus on becoming an HRO over the last year builds on efforts led by VHA’s National Center of Patient Safety (NCPS) starting in the 1990s. This transformation is being led by the VHA HRO Steering Committee (whose members include select VISN and Medical Center Directors, Chiefs of Staff, Nurses, Patient Safety Experts, and Quality Managers), as well as an HRO Leadership Coalition comprised of all VISN Directors and national leaders within VHA. We are building on our organization’s existing safety and high reliability practices and developing an enterprise-wide strategy that was launched with 18 VAMCs in early 2019. This phased approach, with 18 “lead sites” in the first year, is expanding to include all VHA facilities. The foundational work of becoming an HRO includes developing leadership commitment to the goal of Zero Harm, establishing a positive safety culture, and engaging and supporting all employees in a continuous process improvement culture.

VHA’s 2020 HRO activities are focused on the following six areas.

1. HRO Baseline Training for all frontline staff, supervisors, and executive leaders to develop behaviors that foster a Just Culture, error prevention, and continuous improvement.
2. Clinical Team Training (CTT) on how to integrate team-based error prevention and management practices to improve patient safety and job satisfaction by facilitating clear and timely communication through collaborative teamwork in the clinical workplace.
3. Implementation of daily continuous process improvement (CPI) management systems and tracking of improvement efforts including expanded training in Lean methodologies.
4. Site-specific assessments and planning will help each facility continue to strengthen their safety culture and practices.
5. HRO leadership coaching provides facility leaders with opportunities to work with a coach to target site-specific HRO practices to help reach the next level in their journey to high reliability
6. Experiential learning where site leaders and teams collaborate and interact with other VAMCs within and across VISNs on HRO practices, challenges, and innovations.

HRO Research Questions

In keeping with VHA’s goal of becoming a learning organization and our commitment to continuous process improvement, VHA’s Health Services Research and Development Service (HSR&D) is evaluating the impact of VHA’s HRO implementation at the 18 lead sites. New insights will be gleaned from this evaluation to improve ongoing system-wide implementation of HRO activities.

As VHA continues HRO implementation across the system, we are also reviewing the literature on HRO frameworks, metrics, and evidence of effects within and outside VHA. Despite widespread adoption of HRO practices and principles across numerous U.S. healthcare systems in recent years, there is still much we simply do not know. HSR&D’s May 2019 “Evidence Brief: Implementation of HRO Principles” provides a comprehensive overview of the current state of HRO science, including key gaps in our knowledge on HRO implementation. As the authors of this Evidence Brief note, the major gaps are:

1. whether we can establish a causal relationship between HRO activities and improved safety and process improvements;
2. assuming we can establish a causal relationship, which components of HRO implementation are causing observed effects and how should we most appropriately measure those effects;
3. whether certain HRO frameworks lead to better results; and
4. what contextual factors affect a successful HRO implementation.

Opportunities for researchers to help answer each of these pressing questions are increasing with the many HRO activities currently occurring and rapidly spreading to more facilities across VHA.

Creating a Just Culture

While each of the aforementioned research topics are critical to improving VHA’s approach to implementing HRO practices, perhaps no inquiry is more important than determining how to appropriately assess progress in creating a Just Culture. To become and remain an HRO, we must develop environments where all staff feel safe to speak up about potential safety issues and identify areas that need improvement. Though we must appropriately monitor progress on our journey to Zero Harm, we must also ensure that these performance metrics don’t unintentionally create a disincentive to report real or potential errors, or undermine the broader strategic goals associated with becoming an HRO.

How will we know we’re making progress in creating a Just Culture? Reviewing patient safety culture survey results from the All Employee Survey (AES) or assessing Root Cause Analysis (RCA) reporting trends may provide some insights, but are those measures sufficient? VA researchers can and hopefully will help us answer this critical question so that we may continue to improve the culture and empower VHA staff to better care for the Veterans we are privileged to serve.

In our ongoing response to the COVID-19 pandemic, adoption of HRO principles and practices is more important than ever. Some VAMCs are using Safety Forums to improve communication about COVID-19, while others use daily briefings and short newsletters to highlight how specific HRO principles and behaviors can be applied in our response. Most importantly, the adoption of Just Culture allows any employee to speak up if they have concerns or see a safety risk – such as insufficient use of personal protective equipment, or when a patient requires COVID-19 testing. VHA is demonstrating throughout COVID-19 that we do indeed have high-performing teams across our enterprise who have trust and respect for each other – hallmarks of an HRO.

Over the past decade, VHA has tackled systemic issues facing our healthcare system and we have made incremental progress. We have done so while largely continuing to achieve the quality and outcomes that VA healthcare is known for. As VHA moves forward with its journey to high reliability, we will work to reinforce HRO principles and Just Culture, from VHA Central Office to frontline clinicians and administrative staff. We look forward to partnering with and learning from the VA research community in our collective goal of restoring trust with our workforce and with Veterans, contributing to the creation of a learning organization, and supporting the modernization of VHA systems.