Case Study

Management Consulting

VHA Quality and Safety Management – VHA Tiered Safety Huddles


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.


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).


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.