Case Study

Management Consulting

VHA Quality and Safety Management – HRO Leader Coaching


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 delivery of high quality, patient-centered care across the VHA became paramount.


The VHA pursued a multi-tiered plan to establish key activities for a successful HRO journey. Through HRO Leader Coaching, the VHA set the conditions for a system focused on individual accountability and systems thinking across a high complexity and high-risk environment by providing experts to guide organizations through this journey.


Operationalized HRO Leader Coaching through a detailed logic model and blueprint that guided 52k hours of direct mentoring and 216 on-site visits to 13 VISNs and 116 VA Facilities. More than 90% of VA Facilities receiving HRO Leader Coaching implemented the four Foundational HRO Practices leading to a 28% reduction in close call to adverse event ratio over two years, as reported by VHA’s NCPS.