VHA’s vast network of hospitals and outpatient sites served nearly nine million Veterans annually. Despite shared goals, inconsistent processes across facilities created variability in patient experiences and increased potential for harm. VHA committed to a systemwide adoption of five high reliability principles to reduce this risk — requiring cultural, behavioral and operational transformation at scale.
Arrow led multiple interconnected workstreams that translated VHA’s high reliability goals into practice. The team introduced frameworks, tools and coordination strategies that helped accelerate change while maintaining alignment with leadership expectations.
Working closely with VA Employee Education Services, Arrow designed and deployed tailored training programs for leaders and staff. More than 300,000 personnel completed core eLearning courses, while executives, managers and clinical teams participated in targeted learning sessions. Complementary offerings, including Lean and Clinical Team Training, extended the impact of foundational content.
From FY20 to FY22, Arrow completed assessments at 134 hospitals to identify strengths, gaps and improvement opportunities. Each facility received a customized report with clear implementation strategies. Arrow also enhanced VHA’s HRO Maturity Matrix to better support continuous measurement across departments.
To maintain momentum, Arrow launched national learning resources including a peer-to-peer Community of Practice, a High Reliability Academy and the HRO in Practice pilot. These environments helped HRO champions and frontline teams apply principles in daily operations and accelerate improvements.
Arrow built a centralized SharePoint hub for guidance, updates and tools. Internal campaigns, such as a systemwide video challenge highlighting near-miss stories, promoted learning and accountability. The team also produced content that supported behavior change and aligned with mission-critical service delivery goals.
The initiative resulted in broad adoption of high reliability practices across the enterprise. Training reached over 300,000 staff and nearly all executives, while customized plans were implemented at every assessed facility.
Following early successes, VHA expanded the initiative to Central Office programs. Arrow led the rollout to nine offices, engaging more than 1,800 participants through executive briefings, staff interviews, leader training and implementation planning.
These efforts helped standardize safety practices, enhance coordination and reinforce VHA’s commitment to delivering consistent, high-quality care to Veterans.
