Case Study

Management Consulting

VHA Quality and Safety Management – Introduction to Just Culture


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 understanding of Just Culture principles throughout its ~400k employees.


Trained Executive Leadership Councils across 18 VISNs, establishing leadership commitment, and certified an average of twelve HRO Baseline Training Trainers at 139 VA Medical Centers, in a 100% virtual environment during the height of COVID-19 restrictions, to enable a sustainable pool or trainers, enterprise-wide.


358k VHA employees trained in HRO Baseline Training. 9,648 improvement projects initiated, 3,546 completed as of March 2024. Annual All Employee Survey culture measures increased between 2019-2023 in Leadership Engagement, Workgroup Psychological Safety, and Patient Safety Reporting.