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Implementation of High Reliability Organization Principles in a Nationally Integrated Healthcare System: Initial Associations With Staff Turnover and Retention
Journal article   Peer reviewed

Implementation of High Reliability Organization Principles in a Nationally Integrated Healthcare System: Initial Associations With Staff Turnover and Retention

R Neal Axon, Ralph Ward, Ahmed Mohamed, Patrick Mauldin, Casey Buchanan, Michelle Mengeling, James Rudolph, Amjed Baghdadi and Jennifer L Sullivan
Health services research, Vol.61(4), e70156
08/2026
DOI: 10.1111/1475-6773.70156
PMID: 42576436

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Abstract

To analyze associations between implementation of high reliability organization (HRO) programs at Veterans Health Administration (VA) medical centers (VAMC) and measures of employee turnover and retention. In 2018, VA began a phased multi-year national implementation of HRO principles to foster improvements in safety culture and quality of care. Interrupted time series analyses (ITSA) were used to estimate changes in employee turnover and retention pre- and post-HRO implementation. Primary analyses focused on each site's calendar time for program rollout. Secondary analyses estimated changes after training thresholds were attained based on the proportion of employees completing HRO training modules. A retrospective cohort of 723,290 VA employees working at 125 VAMCs between January 2018 through June 2024 was included. Baseline and post-implementation (intercept and slope) rates of employee turnover and retention were estimated. ITSA model estimates showed prior to HRO rollout, VA turnover was increasing from 12.3% at baseline at an annual rate of +0.5% (95% CI: 0.2%, 1.0%, p < 0.001), and after HRO implementation the annual rate dropped by -1.04% (95% CI: -0.8%, -1.3%, p < 0.001). Similarly, retention across the VA was dropping from 86.8% at baseline at an annual rate of -0.8% (95% CI: -0.5%, -1.3%, p < 0.001), and after HRO implementation, the annual rate increased by +1.6% (95% CI: 1.0%, 2.1%, p < 0.001). For an "average" VAMC of 3056 employees at baseline, these changes in retention and turnover translated to 16 fewer positions lost and 24 additional employees retained per year. Models analyzing HRO training thresholds found similar results. HRO implementation was associated with temporary, modest but statistically significant reversals in the slope of employee turnover and retention rates. Although unobserved factors may have contributed to these results, this work provides initial information regarding potential associations between HRO implementation and workforce outcomes.
 United States Delivery of Health Care, Integrated - organization & administration Hospitals, Veterans - organization & administration Humans Interrupted Time Series Analysis Organizational Culture Personnel Turnover - statistics & numerical data Quality of Health Care - organization & administration Retrospective Studies United States Department of Veterans Affairs - organization & administration

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