Radical transparency: A case study in the application of high reliability organisation principles at a complex Veterans Administration Medical Centre

Author's Biography

James Doelling MS, BSN, NE-BC, was appointed CEO/Director of Edward Hines Jr. VA Hospital in March 2020. Until then he had served as the CEO/Director at the Battle Creek VA. Doelling has more than 35 years of healthcare experience, with over 22 years at VA. He held a series of nursing leadership roles at VAMC Providence, Rhode Island, VA Boston Health Care System and Hines VA Hospital before being named CNO/Nurse Executive at the Los Angeles VA, where he served for three years. He has an MS degree in Organisational Management and a BSN. Doelling serves as the Chairperson for the VHA Senior Executive Orientation Programme and as the Chairperson for the VISN 12 HRO Committee and Chairperson of the VISN 12 Veteran Experience sub-Committee.

Adam Butusov is a US Army Veteran and has 16 years of experience in the Federal Government in a variety of roles. Adam learned about VA operations, beginning as a floating clerk across all areas of the hospital where he realised that empowered individuals could make meaningful changes and impact lives. Later he worked within the Nursing Education and Graduate Medical Education programmes, receiving the Chief Resident Award for making a difference in Resident Education. In each role, Adam has been recognised for innovation and programme management, bringing strong tech experience to yield results. In 2020, Adam was selected as Hines initial High Reliability Organisation Lead.

Zerek D. Mayes , EdD, LCSW, is the Diversity, Equity, and Inclusion/Organisational Development Programme Manager at Edward Hines Jr. VA Hospital. He holds a doctorate in education and is a respected clinician and educator, bringing over 15 years of diverse experience to education and clinical environments. He focuses primarily on offering expert guidance to individuals, communities and organisations, aiming to enrich their knowledge, redefine equity and embrace transformation. With a decade of experience in education, Zerek has honed his skills in aligning organisational objectives with the creation of relevant programmes. His dedication to fostering strong relationships and advocating for evidence-based strategies to advance diversity, equity, inclusion and belonging has been crucial in reframing the organisation and creating transformative learning environments that promote just culture.

Angela Morris , MPH, LCSW, is the Associate Director for Resources at Edward Hines Jr. VA Hospital. She began her VA career in 2008 as a licensed clinical social worker in the Women’s Health Clinic at the Edward Hines Jr. VA Hospital. In 2012, she transitioned to an administrative track and since then has held a succession of senior administrative roles. Ms Morris received a bachelor of science from Xavier University of Louisiana and a master’s degree in both public health and social work from the University of Illinois-Chicago. She is a certified Lean Six Sigma Black Belt and Health Care Leadership Development Programme (HCLDP) graduate.

Michael Richardson , MD, FACP, assumed the role of Chief Medical Officer of Edward Hines Jr. VA Hospital in September 2022. He did an MA in Physiology at Oxford University, UK, acquired a medical degree from The University of the West Indies, Jamaica, and a diploma in tuberculosis and chest diseases from the University of Wales, Cardiff. He continued his education at Georgetown University Hospital Center, Washington, DC for a Pulmonary & Critical Care fellowship before joining the faculty at Georgetown Hospital as the Chief Pulmonary at DC General Hospital 1987–1994. Richardson joined the Veterans Health Administration in 2003 as Chief of Medicine in Biloxi, MS. A subsequent interim appointment as Chief Spinal Cord Injury at the Memphis VAMC led to his interest in the VHA system of care for Veterans with SCI and his appointment as Chief of SCI at Hines. Richardson has been an associate editor of the Journal of Spinal Cord Medicine since 2018.

Joyce Overman Dube , MS, RN, is a high reliability expert, serving as an executive leader coach for the VHA HRO Support Team for the past 4 years. She has over 40 years of leadership and performance improvement experience, including serving as the executive leader for the Mayo Clinic Enterprise High Reliability journey. In her over 40-year career with the Mayo Clinic, she has held progressive leadership positions focused on improving the care and safety culture for patients and employees. Joyce has a BS in nursing and an MS in nursing administration, and she holds the rank of Assistant Professor of Nursing from the Mayo Clinic College of Medicine and Science. She is also a member of Sigma Theta Tau, International. Joyce has presented nationally and internationally at many venues and has published on a variety of topics. She is a certified change management practitioner through Prosci She is currently completing her Doctor of Nursing Practice (DNP) through the University of Minnesota.