Case Study

Management Consulting

VHA Quality and Safety Management – Safety Science Publishing Program

Problem

VHA embarked on its Journey to becoming a High Reliability Organization and wanted to contribute to the knowledgebase and science of High Reliability through scholarly publications and presentations to share their results and lessons learned.

Solution

Created a Co-Publication / Co-Presentation Work Group to educate VHA staff on publication / presentation processes and co-author scholarly articles with VHA HRO Leaders.

Outcome

Established VHA as a thought leader in High Reliability contributing the state of science and practice sharing. Since 2021, VHA has had 16 scholarly articles accepted for publication in peer-reviewed journals and presented 50+ poster/podium presentations. Supported inter-agency Just Culture training to ~3000 Department of Justice personnel.

Related Blogs

Case Study – VHA Quality and Safety Management – VHA Tiered Safety Huddles

Case Study Management Consulting VHA Quality and Safety Management – VHA Tiered Safety Huddles Problem The VHA needed to establish an omni-directional communication process across it’s 172 VA Medical Centers, 18 VISNs, and Central Office Programs that enabled teams to identify safety concerns and efficiently escalate concerns that could not…

Case Study – VHA Quality and Safety Management – Safety Science Publishing Program

Case Study Management Consulting VHA Quality and Safety Management – Safety Science Publishing Program Problem VHA embarked on its Journey to becoming a High Reliability Organization and wanted to contribute to the knowledgebase and science of High Reliability through scholarly publications and presentations to share their results and lessons learned.…

Case Study – VHA Quality and Safety Management – Introduction to Just Culture

Case Study Management Consulting VHA Quality and Safety Management – Introduction to Just Culture Problem Committing to a long-term journey towards High Reliability and a Just Culture - focused on Veteran and staff safety and transparency - VHA wanted to implement the infrastructure necessary to sustain a baseline level of…

Case Study – VHA Quality and Safety Management – HRO Leader Coaching

Case Study Management Consulting VHA Quality and Safety Management – HRO Leader Coaching Problem In 2019, the Veterans Health Administration recognized a need to renew focus on the pursuit of zero preventable harm while facing historic grow and transformation. With added system complexity and volume, the priority to ensure safe…

Case Study – VHA Quality and Safety Management – HRO Assessment and Planning

Case Study Management Consulting VHA Quality and Safety Management – HRO Assessment and Planning Problem The Joint Commission estimates that over 60,000 patients per year die due to preventable harm in the U.S. VA hired rockITdata to assess ongoing operations across their 18 Networks, 171 VA Medical Centers, and over…

Case Study – VHA Nurse Standards and Qualifications Modernization

Case Study Management Consulting VHA Nurse Standards and Qualifications Modernization Problem The Veterans Health Administration (VHA) has a large, diverse and geographically dispersed nursing workforce and needed a comprehensive plan to modernize the outdated nurse qualification standards and performance management processes. Solution Combined change management, communications and training expertise, focusing…

Case Study – VHA National Center for Patient Safety – Teams Training

Case Study Management Consulting VHA National Center for Patient Safety – Teams Training Problem VHA National Center for Patient Safety (NCPS) developed a very sophisticated multi-disciplinary educational program designed to create high functioning clinical teams across 167 medical centers and 1100 outpatient clinics. The training met significant resistance and experienced…

Case Study – VHA Lean Curriculum Development

Case Study Management Consulting VHA Lean Curriculum Development Problem VHA needed a Lean Community of Practice structure to standardize, grow, and sustain continuous process improvement across the enterprise. Forward movement was stalled due to the COVID-19 Pandemic Restrictions. Solution Developed Green Belt, Black Belt and a Master Black Belt training…

Case Study – VHA High Reliability Organization – Outreach and Change Management

Case Study Management Consulting VHA High Reliability Organization – Outreach and Change Management Problem The Veteran Health Administration needed to align and integrate the portfolio of HRO activities and educational products across the 350,000 enterprise. Solution Created hundreds of video and written products to include eight HRO Dashboard educational videos,…

Case Study – DoD Medical Research and Development Financial Model

Case Study Management Consulting DoD Medical Research and Development Financial Model Problem USAMRDC Laboratories are overly dependent on research reimbursements to provide critical and unique Department of Defense (DoD) readiness capabilities. The indirect costs across the system are not sustainable or competitive. Solution Conducted a five-month assessment and synthesized input…

perihokislot kunci menang besar gates of olympus auto spin 30x bikin jackpot gede mengungkap keuntungan besar mahjong wins 3 game gacor panduan tak tertandingi mahjong ways rahasia sukses waktu yang tepat pgsoft tak lagi biasa begini cara anak magang buat jadi menang starlight princess 1000 semua yang perlu kamu tau fitur wild putaran gratis berburu jackpot mahjong ways 2 rtp tinggi dapat scatter hitam buktikan keberuntunganmu di wild west gold panduan main teknik menang menguasai dunia zeus strategi pola fitur gacor olympus mengungkap keuntungan besar mahjong wins 3 game gacor peluang menang lebih besar 5 game pgsoft rtp tertinggi dari keberuntungan hingga strategi cermat mahjong wins panduan lengkap menang mahjong ways teknik rahasia pecahkan gerbang olympus menangkan hadiah besar pgsoft menguak alasan kenapa game gacor ini jadi favorit starlight princess cara menang sensasional pakai pola jitu berani menghadapi naga hitam cara menang mahjong wins 3 mahjong ways fitur scatter hitam mengubah setiap putaran petir zeus maxwin gacor rahasia menjadi sultan cuan instan pgsoft panduan lengkap manfaatkan strategi terbaru menang sweet bonanza mengungkap rahasia rtp tertinggi menang beruntun dari modal receh ke kemenangan gede strategi cerdas starlight princess jangan lewatkan cara jitu manfaatkan scatter hitam mahjong wins 3 kuasai mahjong ways dengan pola sakti terbukti teknik tips ampuh menjadi jutawan modal kecil gates of olympus kemenangan gacor peluang menang besar 5 game pgsoft rtp tertinggi pola gacor kakek zeus lagi gacor temukan pola kemenangan gates of olympus kunci menang wild west gold pola gacor terbaik tips ampuh raih menang maxwin di mahjong wins 3 bisa jadi milikmu trik cerdas pola naga pgsoft buka rahasia 5 trik menang mahjong ways bawa kamu ke jackpot tantangan baru mahjong ways 2 tips kemenangan jadi juara keterampilan bocoran pgsoft panduan lengkap menang terus
menang lebih sering di gates of olympus pakai scatter tersembunyi
tantangan kejutan mahjong wins 3 cara tepat menang besar
teknik mahir mahjong ways 2 cara gunakan power up menang beruntun
terungkap trik jitu bang dika untuk menang instan starlight princess
cara terbaik menang sweet bonanza teknik memahami pola mengatur modal
keterampilan bocoran pgsoft panduan lengkap menang terus
meningkatkan peluang menang mahjong ways 2 pola pusat efektif
menjadi pemain pgsoft yang cerdas tips strategi menang mudah
tren kemenangan besar di game olympus tips terbaru pasti jackpot
4 shio akan wd malam ini mahjong ways kunci kemenangan mahjong ways rtp akurat mahjong ways mudah menang scatter emas mahjong ways viral starlight princess pragmatic play mahjong mudah maxwin pola jackpot mahjong mudah menang pg soft gacor pola maxwin mahjong ways modal receh pola jackpot mudah menang pg soft mudah menang rtp tertinggi pola scatter gates of olympus rtp pragmatic play anti rungkad game online mahjong ways rtp akurat gates of olympus maxwin game online modal receh scatter hitam pola maxwin mahjong ways 2 pola gacor rtp akurat scatters hitam mahjong ways scatter hitam modal receh pola gacor rtp akurat banjir scatter starlight princess x1000 mencapai puncak kemenangan mahjong wins3 trik tertinggi menang jackpot bang roy bisnis kontrakan dari scatter hitam mahjong ways mahjong ways 2 anti rungkad pola pasti menang pola mahjong ways scatter hitam naga hitam rtp akurat deposit qris mudah jackpot pakai modal kecil rtp pgsoft mudah maxwin rtp akurat tertinggi akun pro maxwin mahjong ways strategi kemenangan mahjong wins 3 algoritma baru pgsoft terbaru mahjong ways 2025 naga hitam scatter pink pola scatter hitam mahjong wins 3 naga hitam rtp pragmatic play terbaru gates of olympus alasan kenapa mahjong ways 2 bikin semua gamer ketagihan gacor langkah kecil menuju jackpot raksasa menaklukkan gates of olympus x1000 pgsoft luncurkan program maxwin lucky neko cara baru peluang cuan starlight princess fitur gokil bikin saldo melejit trik ampuh jackpot trik jitu menggunakan pola free spin tak terbatas mahjong wins 3 dari pemula jadi pro gates of olympus temukan cara menang beruntun gali cuan maksimal di wild west gold tips jitu pola rahasia menang terus mengungkap keberuntungan mahjong wins 3 strategi dan tips menang petualangan sertu tanpa henti mengungkap fitur gacor mahjong ways 2 teknik kejutan besar di balik game pgsoft dengan rtp tinggi panduan lengkap