We are committed to continuing to build on the great strides we have made with improving safety and quality of care. VHA has been a leader in the patient safety movement for more than 20 years. 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. 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. 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. HRO leaders empower all staff to lead continuous process improvements within their own workspace. HROs establish trust amongst leaders and staff by creating a Just Culture that balances individual accountability with systems thinking. At the center of this modernization is a culture change that will be realized throughout VHA –our transformation into a high reliability organization (HRO).Īn 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. 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. Lieberman, MD, MBA, FACHE, Acting Deputy Under Secretary for Health, Veterans Health Administration, Washington, DC Stone, MD, Executive in Charge, and Steven L. Preventing Suicide among Veterans (03-2021).Advancing VA Telehealth and Virtual Care (06-2021).Helping Veterans Cope with and Conquer Pain (09-2021).HSR&D Advances Research in Providing Healthcare for Veterans in Rural Settings (12-2021).HSR&D Research on Social Determinants (03-2022).05/2020: Spring 2020: Substance Use Disorders.08/2020: Summer 2020: Becoming a High Reliability Organization.Search for Published Research and Experts: Dimensions for VA.Women Veterans Reproductive Health Conference.
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