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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
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Becoming a High Reliability Organization: Structural Limitations to Continuous Quality Improvement in a Large Health

Lacey Evans1, Claire H Robinson1, Ariel Domlyn1

  • 1VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.

Journal of Patient Safety
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Summary

Frontline staff engagement in quality improvement (QI) is crucial for health systems aiming to become high reliability organizations (HROs). However, many VHA sites lack the infrastructure and protected time needed for staff to develop essential QI skills.

Keywords:
high reliability organizationleadershipquality improvement

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Area of Science:

  • Healthcare Management
  • Patient Safety
  • Organizational Psychology

Background:

  • The Veterans Health Administration (VHA) seeks to achieve High Reliability Organization (HRO) status to enhance patient safety.
  • A culture of continuous quality improvement (CQI) is fundamental to becoming an HRO.
  • Understanding factors influencing frontline staff engagement in CQI, particularly skill development, is critical but not well-established.

Purpose of the Study:

  • To explore barriers and facilitators affecting frontline staff engagement in quality improvement (QI) training and initiatives within the VHA.
  • To assess the local context influencing participation in QI efforts at VHA sites involved in clinical outcome improvement trials.

Main Methods:

  • Conducted semistructured interviews with primary care and mental health staff and leaders across VHA sites.
  • Utilized the updated Consolidated Framework for Implementation Research (CFI R) for coding interview data.
  • Analyzed qualitative data to identify cross-cutting themes related to QI engagement.

Main Results:

  • Despite leadership support for HRO principles, many VHA sites lack essential infrastructure and leadership engagement for QI initiatives.
  • Barriers to staff engagement include limited time, unclear direction, burnout, and persistent effects of the COVID-19 pandemic.
  • These challenges impede the development of foundational QI skills, hindering staff empowerment and engagement.

Conclusions:

  • Health systems must invest in skill development and provide protected time to foster CQI among frontline staff and local leaders.
  • Effective HRO transformation requires aligning system-level goals with local realities and creating sustainable conditions for improvement.
  • Future research should focus on how leadership can cultivate environments conducive to continuous quality improvement.