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VHA National Center for Patient Safety

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VHA's HRO journey officially begins

VHA Leaders attend the High Reliability Organization (HRO) Summit.

At the HRO Leadership Summit in Orlando, the 18 VAMC and VISN Directors, along with HRO co-leads, Dr. Gerry Cox and Dr. Bill Patterson, and Dr. Richard Stone, EIC, VHA.

Friday, March 29, 2019

VHA’s journey to become an enterprise-wide High Reliability Organization (HRO) kicked-off in February at the HRO Leadership Summit. The two-day Summit brought together leadership from 18 medical facilities selected to lead VHA’s HRO journey, along with VISN and central office leaders. Attendees had the opportunity to learn what it means to become an HRO and how a strong culture of safety will positively impact Veterans, their family members, and caregivers.

The HRO concept was pioneered in industries like aviation and nuclear power, that were able to reduce accidents in their complex environments. Research shows high reliability organizations experience fewer accidents despite being high-risk environments where small errors can produce catastrophic results. HROs put procedures and protocols in place that maximize safety and minimize harm.

“VA has been a leader in patient safety for years,” said VA Secretary Robert Wilkie. “Adopting high reliability principles more formally represents the next step for delivering the best health care to Veterans. Our culture is changing VHA’s HRO journey officially begins and pursuing HRO principles nationwide is our pledge to empower staff and keep Veterans the safest they can be on our watch.”

As the largest integrated health care system in the U.S., delivering care to more than nine million Veterans, VHA is on this journey as a continuing commitment to Veteran safety. By striving for high reliability in a workplace where harm prevention and process improvement are second nature to all employees, VHA will improve the way care is delivered to our Veterans.

Prior to 1999, the year that VA established the National Center for Patient Safety (NCPS), when an error occurred the focus was on individuals considered responsible for mistakes, rather than reviewing the chain of events or current systems that could address where and why an error occurred. As a result, NCPS established a systems approach to understanding vulnerabilities that could result in harm to patients instead of focusing on individual errors. NCPS’ expertise and courses will play a large part in the training that HRO sites will receive. Beginning with the 18 lead sites, all staff will receive the HRO training focused on leadership engagement, safety and continuous process improvement.

The 18 sites selected are: Manchester VA Medical Center (VAMC) (N.H.); Albany Samuel S. Stratton VAMC (N.Y.); Erie VAMC (Pa.); Beckley VAMC (W.Va.); Durham VAMC (N.C.); Ralph H. Johnson VAMC (Charleston, S.C.); James A. Haley Veterans Hospital (Tampa, Fla.); James H. Quillen VA Healthcare System (HCS) (Johnson City, Tenn.); Louis Stokes Cleveland VAMC (Ohio); William S. Middleton VA Hospital (Madison, Wis.); Kansas City VAMC (Mo.); G.V. Sonny Montgomery VAMC (Jackson, Miss.); Audie L. Murphy VA Hospital (San Antonio, Texas); Oklahoma City VA HCS (Okla.); Boise VAMC (Idaho); VA Sierra Nevada HCS (Reno, Nev.); VA San Diego HCS (Calif.); and St. Cloud VA HCS (Minn.).

VHA’s journey to become an HRO is consistent with National Patient Safety Goals (NPSGs) set forth by The Joint Commission, an independent, nonprofit organization that accredits and certifies approximately 21,000 health care organizations and programs in the U.S. In addition to a safer environment focused on reducing errors and preventing patient harm, HRO principles and values call for deference to expertise; oftentimes, the patient’s family caregiver is that expert. HRO will empower Veterans and their family caregivers, along with staff.

Veterans will continually receive care with the highest safety standards, and experience better care coordination, standardized processes, and comprehensive plans. As an HRO, leadership and staff – clinical and nonclinical – share the same vision for what is needed and expected to deliver the safest patient care. VHA’s goal is that every patient receives excellent care, every time.


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