Leadership Pillar
Provides leaders and the organization a pulse of the where we are with the Journey to HRO, opens communication between the frontline and leadership, contributes to a just culture, positively impacts employee morale and provides opportunity for recognition.
What is Leadership Rounding?
The centralized electronic reporting system that is used by all VA employees to report near misses, good catches, and adverse events.
What is JPSR?
This is a cycle used for testing a small change when completing a PI project.
What is a PDSA Cycle (Plan-Do-Study-Act)?
Our goal as an HRO.
What is Zero Harm?
All five VISN 9 facilities and the VISN 9 Office are committed to this.
What is the commitment to implementing a VHA High Reliability Organization (HRO)?
The first question asked when an error or adverse event is reported instead of asking “who did it”
What is "what happened"?
These are shared at the start of meetings to share a safety issue of a real-life event to drive learning and awareness.
What is a safety story?
It is one of the seven HRO Values which tells staff if you see something which is a safety concern, staff need to say something.
What is "Duty to Speak Up?
The just culture response to console the parties involved and review the system for improvement to prevent future errors.
What is a leader's response to human error?
An atmosphere of trust where people are encouraged for providing essential safety-related information.
What is a Just Culture?
These are progressive levels of process improvement trainings to teach staff tools and techniques to use to drive process improvement.
What is White, Yellow, Green, and Black Belt training courses?
The HRO Principle that gets to the root cause of a problem rather than settling for simple explanations.
What is reluctance to simplify?
Leader Rounding, Safety Huddles, Patient Safety Forums and Visual Management Systems.
What are the VHA HRO four foundational practices?
The individual responsible for reporting safety events, patient incidents, close calls, or near misses into the JPRS.
Who is everyone?
A tool that provides a venue for teams to problem solve and have clear active and visual communications about process concerns.
What is a Visual Management System?
The HRO principle that anticipates Risk- every staff member is a problem-solver.
What is Preoccupation with Failure?
The just culture response to console the parties involved and review the system for improvement to prevent future errors.
What is a leader's response to human error?
This practice provides an opportunity to communicate patient safety goals, establish a just culture and reinforce the importance and appreciation of reporting.
What are Safety Forums?
It is what staff should do when they want to improve a process but are unsure how to use PI tools and processes.
What is contact their Supervisor or facility Systems Redesign Coordinator?
The HRO Value that says whenever we make a decision we should ask, “What does this have to do with helping a Veteran.”
What is “It’s About the Veteran”?