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 be resolved at the local level.

Solution

Developed a TSH/VMS Instructional Guide and Toolkit defining a recommended implementation approach of a 5/6 tier safety huddle – included 23 custom designed tools. Deployed enterprise-wide by 50+ HRO Leader Coaches supporting 116 VA Medical Centers, 14 VISNs, and 12 VHA Program Offices (84% of VHA).

Outcome

Supported the implementation of Safety Huddles at 97% of VHA Facilities receiving HRO Leader Coaching between September 2000 to September 2023 and set the conditions to systematically connect thousands of work settings each day across the VHA with an intense focus on harm prevention.

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…

duta76 perihoki pola mahjong wild 2 terbaru sering dipakai pemain duta76 saat modal tipis sicbo gates of olympus trik rahasia mahjong ways 2 pgsoft scatter hitam baccarat duta76 tanpa banyak risiko starlight princess pola mahjong wins 3 pragmatic blackjack paling konsisten menurut data duta76 hari ini sweet bonanza analisis jitu perihoki tren bermain dan arah kemenangan pada mahjong ways 2 pgsoft roulette wild west gold bongkar faktor kemenangan mahjong wins 3 pragmatic blackjack dikupas tuntas perihoki aztec gems metode bermain mahjong wild deluxe sicbo perihoki mudah dapatkan jepe berlimpah gates of olympus penguraian faktor kemenangan mahjong ways 2 pgsoft baccarat dibahas secara menyeluruh perihoki lucky neko skema terbaru mahjong wins 3 pragmatic blackjack bisa bikin permainan perihoki lebih menguntungkan wild bounty hunter cara membaca arah permainan duta76 pola mahjong ways 2 dari data rtp live terkini roulette sabung ayam sv388 mahjong wins 3 pragmatic blackjack bikin banjir kemenangan pola cepat duta76 bikin pemain sbobet88 terkejut aws alur bermain seimbang mahjong ways 2 aws analisis aktivitas bermain mahjong pg soft aws dampak inovasi pg soft industri game aws evaluasi tekanan psikologis mahjong wins 3 aws evolusi desain mahjong ways pg soft aws evolusi desain pola ritme mahjong ways aws inovasi desain visual mahjong ways pg soft aws mekanisme internal mahjong ways pg soft aws membaca momentum putaran mahjong wins 3 aws mengatur risiko konsisten mahjong ways aws metodologi analisis log putaran mahjong wins 3 aws pemilahan risiko fase sesi mahjong wins 3 aws perbandingan dinamika mahjong ways aws perubahan pola grid mahjong ways aws pola bermain berkelanjutan saldo mahjong ways 2 aws pola menang mahjong ways 2 2026 aws stabilitas sistem mahjong ways pg soft aws strategi rtp terbaru mahjong ways 2 aws studi statistik waktu mahjong ways 2 aws trik simbol emas mahjong ways 2