Becoming a High Reliability Organization: Structural Limitations to Continuous Quality Improvement in a Large Health Care System

OBJECTIVES: The Veterans Health Administration (VHA) aims to improve patient safety by becoming a high reliability organization (HRO), which requires a culture of continuous quality improvement (CQI). Despite national HRO emphasis, conditions supporting or hindering frontline staff engagement in CQI efforts, especially skill development, are not well understood. METHODS: We conducted semistructured interviews at VHA sites participating in one of 3 randomized trials to improve clinical outcomes by engaging staff in quality improvement (QI). We conducted interviews with primary care and mental health staff and leaders to assess local context, including barriers and facilitators to engaging in QI training and initiatives. Interviews were coded using the updated Consolidated Framework for Implementation Research and analyzed for cross-cutting themes. RESULTS: Analysis of 56 interviews revealed that despite high-level leadership support for HRO principles, including patient safety, most sites lacked adequate infrastructure and leadership engagement necessary to support participation in QI training and projects. Barriers included limited time, unclear direction, burnout, and lingering COVID-19 pandemic effects. These challenges often prevented staff from developing foundational QI skills critical for entering a positive feedback loop of engagement and empowerment. Opportunities for improvement varied based on leadership style, team cohesion, role clarity, and location. CONCLUSIONS: To advance as HROs, health systems must go beyond high-level endorsement and invest in skill development and provide protected time to enable local leaders and frontline providers to do QI. Future work should explore how leaders can create sustainable conditions for improvement efforts and better align system-level goals with local realities.