Increasing complexities within health care systems are significant impediments to the consistent delivery of safe and effective patient care. These impediments include an increase in specialization of care, staff shortages, burnout, poor coordination of services and access to care, as well as rising costs.1 High reliability organizations (HROs) provide safe, high-quality, and effective care in highly complex and risk-prone environments without causing harm or experiencing catastrophic events.2
Within the US Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) operates the nation’s largest integrated health care system, providing care to > 9 million veterans. The VHA formally launched plans for an enterprise-wide HRO in February 2019. During the first year, 18 medical facilities comprised cohort1 of the journey to high reliability. Cohort 2 began in October 2020 and consisted of 54 facilities. Cohort 3 started in October 2021 with 67 facilities.3
Health care organizations seeking high reliability exercise a philosophy aimed at learning from errors and addressing system failures. High reliability is accomplished by implementing 5 principles: (1) sensitivity to operations (a heightened understanding of the current state of systems); (2) preoccupation with failure (striving to anticipate risks that might suggest a much larger system problem); (3) reluctance to simplify (avoiding making any assumptions regarding the causes of failures); (4) commitment to resilience (preparing for potential failures and bouncing back when they occur); and (5) deference to expertise (deferring to individuals with the skills and proficiency to make the best decisions).2 The VHA also recognized that a successful journey to high reliability—in addition to achieving a culture of safety—relies on the implementation of foundational HRO practices: leader rounding, visual management systems, safety forums, and safety huddles. This article describes an initiative for how these foundational practices were implemented in a large integrated health care system.
BACKGROUND
The VHA has focused on 4 foundational components as part of its enterprise activities and support structure to implement HRO principles and practices. These components were selected based on pilot activities that preceded the enterprise-wide effort, reviews of the literature, and expert consultation with both government and private sector health systems. To support the implementation of these practices, the VHA provided training, toolkits, HRO executive leader coaching, and peer-to-peer mentoring. As the VHA enters its fifth year seeking high reliability, we undertook an initiative to reflect on our own experiences and refine our practices based on an updated literature review.
As part of this enterprise-wide initiative, we conducted a literature review from 2018 to March 2023 seeking recent evidence describing the value of implementing the 4 foundational HRO practices to advance high reliability and improve patient safety. A 5-year period was used to ensure recency and value of evidence.
Eligible literature was identified in PubMed, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, Scopus, the Cochrane Library, and ProQuest Dissertations & Theses Global. Inclusion and exclusion criteria were peer-reviewed interdisciplinary documents(eg, publications, dissertations, conference proceedings, and grey literature) written in English. Search terms included high reliability organizations, foundational practices, and patient safety. Boolean operators (AND, OR) were also used in the search. The search resulted in a dearth of evidence that addressed implementation of all 4 foundational practices across a health care system. Retrieved evidence focused on the implementation of only 1 particular foundational practice in a specific health care setting. In addition to describing the formal processes for the implementation of each foundational HRO practice, a brief description of representative examples of strong practices within the VHA is provided.