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Implementation of High Reliability Organization Principles in a Nationally Integrated Healthcare System: Initial
R Neal Axon1, Ralph Ward1, Ahmed Mohamed1
1Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Healthcare System, Charleston, South Carolina, USA.
Health Services Research
|August 11, 2026
Summary
Implementing High Reliability Organization (HRO) programs in Veterans Affairs (VA) medical centers was associated with significant improvements in employee retention and reductions in turnover. These findings suggest HRO initiatives positively impact workforce stability within the VA system.
Area of Science:
- Healthcare Management
- Organizational Psychology
- Public Health Policy
Background:
- The Veterans Health Administration (VA) initiated a national High Reliability Organization (HRO) program in 2018.
- The program aimed to enhance patient safety culture and quality of care across VA medical centers (VAMCs).
- Understanding the impact of HRO implementation on workforce dynamics, specifically employee turnover and retention, is crucial.
Purpose of the Study:
- To analyze the association between the implementation of High Reliability Organization (HRO) programs.
- To examine the impact of HRO programs on employee turnover and retention rates within Veterans Affairs (VA) medical centers (VAMCs).
- To evaluate changes in workforce stability following HRO program rollout.
Main Methods:
- Retrospective cohort study including 723,290 VA employees across 125 VAMCs (January 2018 - June 2024).
- Interrupted time series analyses (ITSA) were employed to assess pre- and post-HRO implementation changes.
- Analyses considered both calendar time of program rollout and HRO training completion thresholds.
Main Results:
- Prior to HRO implementation, VA employee turnover was increasing annually by 0.5%, while retention was decreasing by 0.8%.
- Post-HRO implementation, turnover rates decreased by 1.04% annually, and retention rates increased by 1.6% annually.
- These changes translated to an average of 16 fewer positions lost and 24 additional employees retained per VAMC annually.
Conclusions:
- High Reliability Organization (HRO) program implementation demonstrated a statistically significant, albeit temporary, positive impact on employee retention and turnover rates.
- The findings suggest a potential association between HRO initiatives and improved workforce stability in the Veterans Health Administration.
- Further research is needed to explore potential confounding factors and long-term effects.
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