VHA's Movement for Change: Implementing High-Reliability Principles and Practices.

Abstract

Motivated by research showing that high-reliability organizations (HROs) in high-risk environments experience fewer adverse events (Anderson & Abrahamson, 2017), we at the Veterans Health Administration (VHA) set out to transform our culture, improve our systems, and empower our workforce to keep veterans safe. Patients are too often harmed because of preventable errors during their care. Even small errors can have devastating results, so we initiated an enterprise-wide journey to integrate HRO principles and practices into operations across our central office, regional networks, and medical centers (VAMCs). We wanted the VHA to gain the complete trust of our patients while implementing evidence-based practices, becoming a learning organization, and implementing robust process improvements. These goals align with the mission of the VHA—to provide exceptional care that improves the health and well-being of America’s veterans—and help advance the system toward zero harm. We believe that an HRO can realize: