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Transforming the Veterans Health Administration into a High Reliability Organization


How does an agency of 400,000 employees create systemic change to provide better care for Veterans?

The Veterans Health Administration (VHA) is the largest health care system in the United States, employing close to 400,000 health care professionals and providing medical care to nearly 9 million Veterans. Inspired by proven safety practices in the nuclear and aviation industries, VHA is on a “journey” to become a High Reliability Organization (HRO). HROs experience fewer accidents despite operating in highly complex, high-risk environments by cultivating and spreading procedures and protocols to maximize safety and minimize harm. VHA is transforming its culture by ingraining principles and practices of high reliability and specific safety behaviors.


VHA was ready for a seismic cultural shift

VHA maintains hospitals and health care systems across the United States and its territories. In such a large, complex system, hospitals develop different processes and procedures. In the health care industry, where people care for the lives and well-being of others, a lack of standard processes creates an environment for inconsistent care, errors and patient harm (e.g., falls and hospital acquired infections).

To maximize safety and minimize harm to Veterans and employees, VHA embarked on a journey to transform its culture by embracing safety practices and the following five principles of high reliability:

  • Deference to Expertise — Value expertise and diversity of perspectives and insights, relying on those with the most knowledge of the situation at hand, regardless of rank, hierarchy, position or other factors
  • Reluctance to Simplify — Get to the root cause of a problem rather than settling for simple explanations
  • Sensitivity to Operations — Be mindful of people, processes and systems that impact patient care
  • Commitment to Resilience — Bounce back from mistakes, get back on track and prevent those mistakes from happening again
  • Preoccupation with Failure — Have a laser-sharp focus on catching errors before they happen and predicting and eliminating risks before they cause harm

Employing these guiding HRO principles, organizations that manage high-risk operations significantly reduce error and patient harm. VHA’s partnership with our team (Artemis and Aptive) provides comprehensive, evidence-based expertise to support enterprise-wide HRO transformation and implementation efforts that focus on clinical and nonclinical end-user needs and feasibility.


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.


VHA is embracing the Journey to High Reliability

VHA’s Journey to High Reliability continues to accelerate and expand. Reception was so successful at VHA hospitals that leadership decided to roll out the journey to VHA Central Office (VHACO) program offices as well.

We stood up and facilitated the VHACO Journey to High Reliability Work Group to plan, develop and execute a pilot to expand and integrate HRO activities across VHACO program offices. During the planning phase, we conducted stakeholder interviews with VHACO representatives to refine the pilot approach, develop training materials (e.g., VHACO Journey to High Reliability Quick Start Guide and pilot SharePoint) and partner with VHA leadership to identify pilot offices and HRO pilot champions. We also launched the pilot with nine program offices and approximately 1,880 participants via targeted communications and kickoff sessions. As of November 2022, we hosted facilitated leader training for 250 plus leaders, launched HRO improvement projects to enhance internal operations and service delivery in five offices, distributed 31 weekly HRO learning videos with resources, and conducted approximately 60 listening sessions and eight action plans to identify HRO opportunities to integrate HRO principles and practices into VHACO culture and operations.

VHA staff members are embracing the change on VHA’s Journey to High Reliability that will provide a stronger culture of safety and better patient care.

Results at a Glance

  • 300,000 employees completed the first HRO training
  • 90% of executives completed their curriculum
  • VHA hospitals nationwide are implementing their tailored plans


  • Enterprise-wide transformation
  • System evaluation
  • Training


  • Clinical subject matter experts
  • Thought leadership
  • High reliability expertise

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