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HRO “Commit to Zero Harm in a Culture of Excellence” is a quarterly newsletter designed to support HRO Champions, Leads, and workgroups by featuring high reliability actions and initiatives.
HRO Links:
VHA's Journey to High Reliability (sharepoint.com)
VISN 22 Systems Redesign - V22 High Reliability Journey (sharepoint.com)
VISN 22 HRO Community of Practice Teams Channel
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Leadership Commitment |
Message from your VISN 22 Network Director
Mr. Michael W. Fisher
Without Employee Engagement to Commit to a Culture of Excellence, we will not be able to create Exceptional Patient Experience in a High Reliability Organization and so THANK YOU for providing input during our 2022 All Employee Survey (AES) Campaign June 6 - 28, 2022.
I appreciate you taking the time to provide your valuable feedback and while the results will not be available until August 29, 2022, we ask that you continue to engage in discussion on how we can live up to Lincoln’s vision of caring for our nation’s Veterans!
How do we stay engaged?
Taking the AES is just one step. We know that engaging workplaces don’t just happen – it takes all of us working together to create a great place to work! We need a diverse workforce that is inclusive of the many different knowledge, skills, abilities, and perspectives. We all have a natural desire to learn and grow. Explore growth/development opportunities and schedule time on a weekly basis.
In a learning organization, everyone experiences growth and learns from the experiences of others. So, speak up! See something we can do better to serve Veterans, say something! Engage your thinking brain and be creative in imagining a brighter future, then share it! Participate in process improvement ideas/teams. Explore other areas of the healthcare system and meet someone new today. Talk about how what we do connects to the mission of the VA. We are better together!
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VISN 22 Story: Interview with the VA San Diego Health Care System HRO Lead- Eusebio Rodriguez
Tell us about yourself? What is your background? I joined VA San Diego in February 2011 after serving 21 years in the United States Marine Corps. My hobbies are watching movies and eating dinner with my wife and daughters. I also enjoy watching football during the NFL season.
How long have you been the HRO Lead? I have been the HRO Lead, in an acting role, since the kick-off of the HRO journey at VA San Diego in February 2019.
How is the SDVAHCS making high reliability a part of its culture? VA San Diego had been working on high reliability and creating a Culture of Excellence way before being selected as a lead site for HRO. A primary focus, in terms of culture, has been on ensuring alignment of local cultural transformation efforts with all initiatives (e.g., VISN, VHA, VA, etc.). Through alignment of all initiatives within our Culture of Excellence framework, we have been able to reduce silos and maintained a consistent message to our employees of one journey. A Culture of Excellence!
How is high reliability embedded into your leadership rounding, safety values, and continuous process improvement? I would say that high reliability is being embedded through training and use of standard work. We have focused on training our staff on HRO Baseline Training, Clinical Team Training, and Lean Training where we emphasize the goal of zero harm, psychological safety, just culture, and continuous improvement. Our training programs have dedicated and committed trainers who drive home the need to “Stop the Line” when it’s called for and use standardized tools, such as huddles and daily management system (DMS) to report issues. Problem solving is just as important, so our staff are highly encouraged to participate in our Lean program which includes Lean training, annual Lean 5S projects, and improving processes within their units or participating in Lean projects as part of their self-development.
What high reliability best practices have you implemented? The best practice I am most proud of is the creation of our local virtual DMS boards. During our planning to implement DMS two to three years ago, the topic of a virtual DMS board did not exist. It was during our implementation, which occurred a few months before the COVID-19 pandemic started, that we quickly identified the need for a virtual DMS board. The pandemic also introduced challenges to holding face-to-face huddles because employees were being sent home to telework and others were being displaced. As a result, with the help of our local DMS implementation workgroup, we were able to create a virtual DMS board using Microsoft Power Apps that has been adopted widely across the organization and is now a primary tool for communicating issues, announcements, and celebrations or recognitions. The Leader Rounding and Continuous Process Improvement (CPI) features are now being added and will further enhance the tool’s capabilities. The virtual DMS board has now been spread to other VA facilities, including VA Denver and VA New York Harbor.
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Culture of Safety |
Interview with the VISN 22 Patient Safety Officer- Brittany L. Cato
Tell us about yourself? What is your background? I joined the VA in 2013, after working as a float pool Registered Nurse in the private sector. My most recent position was serving as the Atlanta VA Health Care System Patient Safety Manager for 3 years. I previously served at VA North Texas Health Care System, Dallas, Texas holding positions as staff nurse, patient safety specialist and patient safety manager. I focus on health care quality and patient safety, while promoting proactivity and strategies for achieving large scale change and approaches to improving organizational value. While I am not a Veteran, I have several family members who served in the military. My hobbies include traveling, attending, and hosting family functions and volunteering with my sorority community service projects.
How does organizational culture affect patient safety? Patient safety culture should be a priority in any organization. A positive safety culture can encourage employees to report and analyze errors. Analyzation allows us to truly assess the type of errors occurring and develop an action plan to prevent recurrence. If we have a positive safety culture, we are improving the beliefs, perceptions, and values of the organization.
What impact do you think your Patient Safety Officer role has had on the quality of the delivery of service to Veterans? Guiding and implementing interventions to promote a positive safety culture. Promoting feedback and communication about errors to lead to organizational learning. Quality, Patient Safety and Process Improvement are all aligned. My goal is to integrate our data with improvement initiatives to decrease harm/adverse events…STRIVING FOR ZERO HARM
What can front line staff do, or even non-clinical staff do to support / reinforce / strengthen Patient Safety? Speak up for any patient safety concern. Patient Safety is everyone’s responsibility. Speaking up is at the heart of improvement and keeping our patients safe. How will we know there is a problem if you don’t speak up?
What is one lesson you have learned from a Veteran that you remember/apply to your work or personal life today? “Change is uncomfortable”. Uncomfortable can be due to fear and anxiety of the unknown, but anything you’re scared of is an opportunity. Change begins at the end of your comfort zone.
VISN 22 Patient Safety Officer Call to Action
My charge to you, how will you speak up for patient safety?
To become and remain an HRO, we must promote Just Culture and develop environments where all staff feel safe to speak up about potential safety issues and identify areas that need improvement. Just Culture means, we recognize we are not perfect and enable learning on process breakdown and health system issues instead of blaming others. To monitor our progress in creating a Just Culture, we are reviewing patient safety culture survey results from the All-Employee Survey (AES), assessing Root Cause Analysis (RCA) reporting trends, analyzing JPSR events and most importantly providing feedback on actions taken to reporters.
VISN 22, What Does Safety Mean to You?
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 Throughout our organization, safety values and practices are used to prevent harm and learn from mistakes. This quarter we focus on the following HRO principles. (July) Support a Safety Culture is about creating a Just Culture where it is safe for employees to make mistakes and to speak up for safety. (August) Commit to Zero Harm means zero harm does not mean zero mistakes. We are going to make mistakes, but our collective mindfulness and process improvements we put in place to prevent mistakes from causing harm are what will make us a High Reliability Organization. (September) Learn, Inquire and Improve is about creating a learning organization is essential to becoming a High Reliability Organization—it is what will enable us to continually improve our processes and provide better and safer care for our Veterans.
Clinical Team Training (CTT) program offers an opportunity for clinicians to improve patient safety and job satisfaction by facilitating clear and timely communication through collaborative teamwork in the clinical workplace. The fundamental paradigm of CTT is that front-line clinicians are taught specific behaviors to manage human error before patients are harmed. Human errors are trapped before they reach the patient through effective teamwork, communication, and higher levels of team situational awareness.
This quarter’s recommended safety article comes from ErgoPlus where author Mark Middlesworth identifies the 25 signs you have an awesome safety culture.
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Continuous Process Improvement |
Across our organization, we use effective tools for continuous learning and improvement. By striving for Zero Harm in a Culture of Excellence, where harm prevention and continuous process improvement are second nature to all staff members, we can dramatically improve the way we delivery care to our Veterans.
Seeking improvements aligns with the continuous journey to become a High Reliability Organization. This effort includes promoting an improvement culture that focuses on safety and zero harm.
VHA Standardized Lean Training curricula applies Lean thinking and methods to enhance organizational effectiveness by improving processes and reducing waste. Lean is widely used globally across settings to support efficient health care.
To learn more about how to implement daily continuous improvement management systems, tracking of improvement efforts and learn a deep exploration of Lean methodologies, click the link to the QuITT repository (below) or contact the VISN 22 Systems Redesign Health Systems Specialist Scott McRoberts, scott.mcroberts@va.gov.
HeRO Awards
The National HeRO Award is the highest level of HRO recognition available within VHA and is reserved to honor staff members who advance VHA's journey to High Reliability through demonstration of VHA's HRO Principles in action.
These awards reinforce the ADKAR Change Model. Nominees are recognized based on demonstration of the following 5 HRO Principles: 1) Sensitivity to Operations, 2) Preoccupation with Failure, 3) Reluctance to Simplify, 4) Commitment to Resilience, and 5) Deference to Expertise.
Calendar Year 2022 3rd quarter HeRO Award submissions are open effective July 1, 2022 and will close on September 1, 2022. Nominee names are forwarded to VA Central Office for nationwide competition. To nominate your facility staff for the HeRO Award Program, visit our VISN 22 submission portal. For more information about the HeRO Award, please visit the national HRO SharePoint.
VISN 22 Calendar Year 2022 2nd Quarter HeRO Award Nominees
Let's celebrate and applaud the VISN 22 Calendar Year 2022 2nd quarter HeRO Award nominations sent up to national for review. Thank you for capturing the great work being done in VISN 22!
VA Greater Los Angeles Healthcare System, MyHealtheVet Alerts.
Ashley Ingram-T’Siobbel
Southern Arizona VA Health Care System, ALS Clinic
Shaun Rudh Cristina Matei Mark Bradley Adnan Abbasi Laura Rivera
LaTanya Cotton Cheryl Wortzel Shayne Barker Anna Johnson Justine Enderlin
James Nance Clare Stanford Juliana Hall
Southern Arizona VA Health Care System, Bed Management System Log Sheet
Jamie Elbedawi
VA San Diego Healthcare System, Attending to a Veteran
Faviola Inzunza Phillip Mixon
To view all of the VISN 22 Calendar Year 2022 1st quarter submissions, click the Repository of HeRO Nominations!
VHA Shark Tank Competition identifies field-developed innovations that promote positive outcomes and improved experiences for Veterans and employees. The competition spotlights dedicated VHA employees who are addressing some of the toughest challenges across VHA and provides a platform to bring exposure from all levels of leadership.
Congratulations to the VISN 22 VHA Shark Tank Competition 2022 Semifinalists!
VA Long Beach Healthcare System
Sandra Park (Remote Occupancy Sensors to Improve Clinic Utilization and Increase Access to Care for our Veterans)
Michael Hollifield (SGB for PTSD Innovation Program-SPIP)
Phoenix VA Health Care System
Ryan Pinick (Community Care Mammography Results Using DICOM Importer III)
Southern Arizona VA Health Care System
Todd Thompson (Post-Acute Home Care Initiative: New Directions in Transitional Care for High Utilizers)
New Mexico VA Health Care System
Sarah Baron (Heart Function Clinic)
Northern Arizona VA Health Care System
Janee Lai (Diabetes Technology Education and Monitoring Program)
To see all 2022 Shark Tank Finalist, click HERE!
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QUITT is VHA's centralized improvement project tracking repository managed by the Office of Systems Redesign and Improvement.
Link to QuITT Repository
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Communications to Support HRO Behaviors
Is there specific change management training I can take to help me understand how to apply change management strategies?
VISN HRO Leads and Champions and two representatives from each medical center were provided an opportunity to participate in Change Practitioner training. This training focused on Prosci® Change Management methodology and provided a baseline understanding of how to apply change management strategies. There are a number of tools and resources available to you and to inquire about future change management training, please look at the Smart Change Toolkit.
What tools can I use to begin implementing change management within my organization?
- Use the Smart Change Toolkit to align your organizational goals to a formal change management strategy tailored to your organization
- Identify critical roles that will help support your change management plan by using the Sponsor Roadmap template
- Develop a communication plan for your facility on how to effectively communicate about changes related to HRO
- Pro-actively develop a plan to help your organization effectively plan for and manage potential resistance
VISN 22/Facility HRO Information
Get involved today, contact your facility HRO POC!
Note: All completions are current through June 30, 2022.
         What is the purpose of the HRO Site-specific Assessment?
The HRO Site-specific Assessment is a collaborative learning process intended to establish a mutual understanding of each facility’s current HRO maturity. The purpose of an assessment is to identify improvement opportunities and generate site-specific strategies to build or improve capabilities across the three Pillars of High Reliability: Leadership Commitment, Culture of Safety, and Continuous Process Improvement. It is a critical part of progressing on the Journey to High Reliability.
Who will conduct the assessment?
The HRO Support Team will conduct the assessment. Assessment activities are coordinated by the HRO Support Team in partnership with an impartial, external third party of HRO subject matter experts to provide objective observations/recommendations. Any feedback or responses shared during the assessment will be used solely to document observational themes and will be shared only at the summary level with VHA leaders and program managers.
What are HRO Maturity Statuses, and how are they used?
The HRO assessment approach is designed with the goal of supporting each facility in building and/or sustaining HRO Principles in day-to-day processes and operations. The HRO Support Team uses HRO Maturity Statuses to provide VAMCs with a qualitative understanding of where their facility is on the path to high reliability and to guide decisions on future VAMC HRO activities. HRO Maturity Statuses are used as internal benchmarks; they are not designed to be punitive.
What support do facilities and VISNs have after the assessment ends?
Following the completion of the assessment, the VISN HRO Leads, and Champions will be provided with an Implementation Specialist. The Implementation Specialist will be an HRO Support team member who will help assist in the execution of action plans/projects the facility identifies in the Implementation Workshop. They will also assist the VISN to identify what is going well or identify possible risks and barriers that facilities may encounter during implementation.
For additional information, click the site-specific assessment and planning FAQs link (below).
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