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Codes, Contracts, and Commitments: Who Defines What is a Profession?
Codes, Contracts, and Commitments: Who Defines What is a Profession?
A professional is someone who can do his best work when he doesn’t feel like it.
Alistair Cooke
When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.1 That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.
There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.2 The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.
But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.2
As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.3 The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.4
There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.
The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.5
Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,6 professional societies (eg, National Association of Social Workers),7 and certifying boards (eg, National Commission on Certification of Physician Assistants).8 States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.9
In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”2 Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.10
I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.
- Wade JW. Public responsibilities of the learned professions. Louisiana Law Rev. 1960;21:130-148
- US Department of Education. Myth vs. fact: the definition of professional degrees. Press Release. November 24, 2025. Accessed December 22, 2025. https://www.ed.gov/about/news/press-release/myth-vs-fact-definition-of-professional-degrees
- Laws J. Full list of degrees not classed as “professional” by Trump admin. Newsweek. Updated November 26, 2025. Accessed December 22, 2025. https://www.newsweek.com/full-list-degrees-professional-trump-administration-11085695
- New York Academy of Medicine. Response to stripping “professional status” as proposed by the Department of Education. New York Academy of Medicine. November 24, 2025. Accessed December 22, 2025. https://nyam.org/article/response-to-stripping-professional-status-as-proposed-by-the-department-of-education
- Cruess SR, Johnston S, Cruess RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74-76. doi:10.1207/s15328015tlm1601_15
- American Association of Colleges of Nursing. Nursing is a professional degree. American Association of Colleges of Nursing. Accessed December 20, 2025. https://www.aacnnursing.org/policy-advocacy/take-action/nursing-is-a-professional-degree
- National Association of Social Workers. Social work is a profession. Social Workers. Accessed December 20, 2025. https://www.socialworkers.org
- National Commission on Certification of Physician Assistants. Accessed December 20, 2025. https://www.nccpa.net/about-nccpa/#who-we-are
- The Federation of State Boards of Physical Therapy. Accessed December 20, 2025. https://www.fsbpt.org/About-Us/Staff-Home
- Cruess SR, Cruess RL. Professionalism and medicine’s contract with social contract with society. Virtual Mentor. 2004;6:185-188. doi:10.1001/virtualmentor.2004.6.4.msoc1-040
A professional is someone who can do his best work when he doesn’t feel like it.
Alistair Cooke
When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.1 That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.
There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.2 The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.
But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.2
As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.3 The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.4
There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.
The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.5
Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,6 professional societies (eg, National Association of Social Workers),7 and certifying boards (eg, National Commission on Certification of Physician Assistants).8 States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.9
In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”2 Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.10
I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.
A professional is someone who can do his best work when he doesn’t feel like it.
Alistair Cooke
When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.1 That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.
There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.2 The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.
But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.2
As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.3 The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.4
There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.
The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.5
Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,6 professional societies (eg, National Association of Social Workers),7 and certifying boards (eg, National Commission on Certification of Physician Assistants).8 States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.9
In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”2 Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.10
I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.
- Wade JW. Public responsibilities of the learned professions. Louisiana Law Rev. 1960;21:130-148
- US Department of Education. Myth vs. fact: the definition of professional degrees. Press Release. November 24, 2025. Accessed December 22, 2025. https://www.ed.gov/about/news/press-release/myth-vs-fact-definition-of-professional-degrees
- Laws J. Full list of degrees not classed as “professional” by Trump admin. Newsweek. Updated November 26, 2025. Accessed December 22, 2025. https://www.newsweek.com/full-list-degrees-professional-trump-administration-11085695
- New York Academy of Medicine. Response to stripping “professional status” as proposed by the Department of Education. New York Academy of Medicine. November 24, 2025. Accessed December 22, 2025. https://nyam.org/article/response-to-stripping-professional-status-as-proposed-by-the-department-of-education
- Cruess SR, Johnston S, Cruess RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74-76. doi:10.1207/s15328015tlm1601_15
- American Association of Colleges of Nursing. Nursing is a professional degree. American Association of Colleges of Nursing. Accessed December 20, 2025. https://www.aacnnursing.org/policy-advocacy/take-action/nursing-is-a-professional-degree
- National Association of Social Workers. Social work is a profession. Social Workers. Accessed December 20, 2025. https://www.socialworkers.org
- National Commission on Certification of Physician Assistants. Accessed December 20, 2025. https://www.nccpa.net/about-nccpa/#who-we-are
- The Federation of State Boards of Physical Therapy. Accessed December 20, 2025. https://www.fsbpt.org/About-Us/Staff-Home
- Cruess SR, Cruess RL. Professionalism and medicine’s contract with social contract with society. Virtual Mentor. 2004;6:185-188. doi:10.1001/virtualmentor.2004.6.4.msoc1-040
- Wade JW. Public responsibilities of the learned professions. Louisiana Law Rev. 1960;21:130-148
- US Department of Education. Myth vs. fact: the definition of professional degrees. Press Release. November 24, 2025. Accessed December 22, 2025. https://www.ed.gov/about/news/press-release/myth-vs-fact-definition-of-professional-degrees
- Laws J. Full list of degrees not classed as “professional” by Trump admin. Newsweek. Updated November 26, 2025. Accessed December 22, 2025. https://www.newsweek.com/full-list-degrees-professional-trump-administration-11085695
- New York Academy of Medicine. Response to stripping “professional status” as proposed by the Department of Education. New York Academy of Medicine. November 24, 2025. Accessed December 22, 2025. https://nyam.org/article/response-to-stripping-professional-status-as-proposed-by-the-department-of-education
- Cruess SR, Johnston S, Cruess RL. “Profession”: a working definition for medical educators. Teach Learn Med. 2004;16:74-76. doi:10.1207/s15328015tlm1601_15
- American Association of Colleges of Nursing. Nursing is a professional degree. American Association of Colleges of Nursing. Accessed December 20, 2025. https://www.aacnnursing.org/policy-advocacy/take-action/nursing-is-a-professional-degree
- National Association of Social Workers. Social work is a profession. Social Workers. Accessed December 20, 2025. https://www.socialworkers.org
- National Commission on Certification of Physician Assistants. Accessed December 20, 2025. https://www.nccpa.net/about-nccpa/#who-we-are
- The Federation of State Boards of Physical Therapy. Accessed December 20, 2025. https://www.fsbpt.org/About-Us/Staff-Home
- Cruess SR, Cruess RL. Professionalism and medicine’s contract with social contract with society. Virtual Mentor. 2004;6:185-188. doi:10.1001/virtualmentor.2004.6.4.msoc1-040
Codes, Contracts, and Commitments: Who Defines What is a Profession?
Codes, Contracts, and Commitments: Who Defines What is a Profession?
The Once and Future Veterans Health Administration
The Once and Future Veterans Health Administration
He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle
Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.1
This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated.
The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.2
In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).3
Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.
The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.4
The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.5 A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.6
The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.7
The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”8
Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time
Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”9 Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.
- Quil L. Hundreds of VA clinicians warn that cuts threaten vet’s health care. National Public Radio. October 1, 2025. Accessed October 27, 2025. https://www.npr.org/2025/10/01/nx-s1-5554394/hundreds-of-va-clinicians-warn-that-cuts-threaten-vets-health-care
- Nutton V. Ancient Medicine. 2nd ed. Routledge; 2012.
- US Department of Veterans Affairs. VA History Summary. Updated June 13, 2025. Accessed October 27, 2025. https://department.va.gov/history/history-overview/
- Geppert CMA. Learning from history: the ethical foundation of VA health care. Fed Pract. 2016;33:6-7.
- US Department of Veterans Affairs. Nationwide patient survey shows VA hospitals outperform non-VA hospitals. News release. June 14, 2023. Accessed October 27, 2025. https://news.va.gov/press-room/nationwide-patient-survey-shows-va-hospitals-outperform-non-va-hospitals
- Chan DC, Danesh K, Costantini S, Card D, Taylor L, Studdert DM. Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study. BMJ. 2022;376:e068099. doi:10.1136/bmj-2021-068099
- Vigilante K, Batten SV, Shang Q, et al. Camaraderie among US veterans and their preferences for health care systems and practitioners. JAMA Netw Open. 2025;8(4):e255253. doi:10.1001/jamanetworkopen.2025.5253
- Rasmussen P, Farmer CM. The promise and challenges of VA community care: veterans’ issues in focus. Rand Health Q. 2023;10:9.
- Kierkegaard S. Journalen JJ:167 (1843) in: Søren Kierkegaards Skrifter. Vol 18. Copenhagen; 1997:306.
He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle
Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.1
This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated.
The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.2
In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).3
Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.
The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.4
The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.5 A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.6
The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.7
The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”8
Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time
Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”9 Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.
He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle
Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.1
This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated.
The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.2
In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).3
Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.
The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.4
The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.5 A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.6
The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.7
The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”8
Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time
Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”9 Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.
- Quil L. Hundreds of VA clinicians warn that cuts threaten vet’s health care. National Public Radio. October 1, 2025. Accessed October 27, 2025. https://www.npr.org/2025/10/01/nx-s1-5554394/hundreds-of-va-clinicians-warn-that-cuts-threaten-vets-health-care
- Nutton V. Ancient Medicine. 2nd ed. Routledge; 2012.
- US Department of Veterans Affairs. VA History Summary. Updated June 13, 2025. Accessed October 27, 2025. https://department.va.gov/history/history-overview/
- Geppert CMA. Learning from history: the ethical foundation of VA health care. Fed Pract. 2016;33:6-7.
- US Department of Veterans Affairs. Nationwide patient survey shows VA hospitals outperform non-VA hospitals. News release. June 14, 2023. Accessed October 27, 2025. https://news.va.gov/press-room/nationwide-patient-survey-shows-va-hospitals-outperform-non-va-hospitals
- Chan DC, Danesh K, Costantini S, Card D, Taylor L, Studdert DM. Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study. BMJ. 2022;376:e068099. doi:10.1136/bmj-2021-068099
- Vigilante K, Batten SV, Shang Q, et al. Camaraderie among US veterans and their preferences for health care systems and practitioners. JAMA Netw Open. 2025;8(4):e255253. doi:10.1001/jamanetworkopen.2025.5253
- Rasmussen P, Farmer CM. The promise and challenges of VA community care: veterans’ issues in focus. Rand Health Q. 2023;10:9.
- Kierkegaard S. Journalen JJ:167 (1843) in: Søren Kierkegaards Skrifter. Vol 18. Copenhagen; 1997:306.
- Quil L. Hundreds of VA clinicians warn that cuts threaten vet’s health care. National Public Radio. October 1, 2025. Accessed October 27, 2025. https://www.npr.org/2025/10/01/nx-s1-5554394/hundreds-of-va-clinicians-warn-that-cuts-threaten-vets-health-care
- Nutton V. Ancient Medicine. 2nd ed. Routledge; 2012.
- US Department of Veterans Affairs. VA History Summary. Updated June 13, 2025. Accessed October 27, 2025. https://department.va.gov/history/history-overview/
- Geppert CMA. Learning from history: the ethical foundation of VA health care. Fed Pract. 2016;33:6-7.
- US Department of Veterans Affairs. Nationwide patient survey shows VA hospitals outperform non-VA hospitals. News release. June 14, 2023. Accessed October 27, 2025. https://news.va.gov/press-room/nationwide-patient-survey-shows-va-hospitals-outperform-non-va-hospitals
- Chan DC, Danesh K, Costantini S, Card D, Taylor L, Studdert DM. Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study. BMJ. 2022;376:e068099. doi:10.1136/bmj-2021-068099
- Vigilante K, Batten SV, Shang Q, et al. Camaraderie among US veterans and their preferences for health care systems and practitioners. JAMA Netw Open. 2025;8(4):e255253. doi:10.1001/jamanetworkopen.2025.5253
- Rasmussen P, Farmer CM. The promise and challenges of VA community care: veterans’ issues in focus. Rand Health Q. 2023;10:9.
- Kierkegaard S. Journalen JJ:167 (1843) in: Søren Kierkegaards Skrifter. Vol 18. Copenhagen; 1997:306.
The Once and Future Veterans Health Administration
The Once and Future Veterans Health Administration
VHA Facilities Report Severe Staffing Shortages
VHA Facilities Report Severe Staffing Shortages
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
For > 10 years, the US Department of Veterans Affairs (VA) Office of Inspector General (OIG) has annually surveyed Veterans Health Administration (VHA) facilities about staffing. Its recently released report is the 8th to find severe shortages—in this case, across the board. There were 4434 severe staffing shortages reported across all 139 VHA facilities in fiscal year (FY) 2025, a 50% increase from FY 2024.
In the OIG report lexicon, a severe shortage refers to "particular occupations that are difficult to fill," and is not necessarily an indication of vacancies. Vacancy refers to a "specific unoccupied position and is distinct from the designation of a severe shortage." For example, a facility could identify an occupation as a severe occupational shortage, which could have no vacant positions or 100 vacant positions.
Nearly all facilities (94%) had severe shortages for medical officers, and 79% had severe shortages for nurses even with VHA's ability to make noncompetitive appointments for those occupations. Psychology was the most frequently reported severe clinical occupational staffing shortage, reported by 79 facilities (57%), down slightly from FY 2024 (61%). One facility reported 116 clinical occupational shortages.
The report notes that the OIG does not verify or otherwise confirm the questionnaire responses, but it appears to support other data. In the first 9 months of FY 2024, the VA added 223 physicians and 3196 nurses compared with a deficit of 781 physicians and 2129 nurses over the same period in FY 2025.
VHA facilities are finding it hard to reverse the trend. According to internal documents examined by ProPublica, nearly 4 in 10 of the roughly 2000 doctors offered jobs from January through March 2025 turned them down, 4 times the rate in the same time period in 2024. VHA also lost twice as many nurses as it hired between January and June. Many potential candidates reportedly were worried about the stability of VA employment.
VA spokesperson Peter Kasperowicz did not dispute the ProPublica findings but accused the news outlet of bias and "cherry-picking issues that are mostly routine." A nationwide shortage of health care workers has made hiring and retention difficult, he said.
Kasperowicz said the VA is "working to address" the number of doctors declining job offers by speeding up the hiring process and that the agency "has several strategies to navigate shortages." Those include referring veterans to telehealth and private clinicians.
In a statement released Aug. 12, Sen Richard Blumenthal (D-CT), ranking member of the Senate Committee on Veterans' Affairs, said, "This report confirms what we've warned for months—this Administration is driving dedicated VA employees to the private sector at untenable rates."
The OIG survey did not ask about facilities' rationales for identifying shortages. Moreover, the OIG says the responses don't reflect the possible impacts of "workforce reshaping efforts," such as the Deferred Resignation Program announced on January 28, 2025.
In response to the OIG report, Kasperowicz said it is "not based on actual VA health care facility vacancies and therefore is not a reliable indicator of staffing shortages." In a statement to CBS News, he added, "The report simply lists occupations facilities feel are difficult for which to recruit and retain, so the results are completely subjective, not standardized, and unreliable." According to Kasperowicz, the system-wide vacancy rates for doctors and nurses are 14% and 10%, respectively, which are in line with historical averages.
The OIG made no recommendations but "encourages VA leaders to use these review results to inform staffing initiatives and organizational change."
VHA Facilities Report Severe Staffing Shortages
VHA Facilities Report Severe Staffing Shortages
VA Workforce Shrinking as it Loses Collective Bargaining Rights
VA Workforce Shrinking as it Loses Collective Bargaining Rights
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
The US Department of Veterans Affairs (VA) is on pace to cut nearly 30,000 positions by the end of fiscal year 2025, an initiative driven by a federal hiring freeze, deferred resignations, retirements, and normal attrition. According to the VA Workforce Dashboard, health care experienced the most significant net change through the first 9 months of fiscal year 2025. That included 2129 fewer registered nurses, 751 fewer physicians, and drops of 565 licensed practical nurses, 564 nurse assistants, and 1294 medical support assistants. In total, nearly 17,000 VA employees have left their jobs and 12,000 more are expected to leave by the end of September 2025.
According to VA Secretary Doug Collins, the departures have eliminated the need for the "large-scale" reduction-in-force that he proposed earlier in 2025.
The VA also announced that in accordance with an Executive Order issued by President Donald Trump, it is terminating collective bargaining rights for most of its employees, including most clinical staff not in leadership positions. The order includes the National Nurses Organizing Committee/National Nurses United, which represents 16,000 VA nurses, and the American Federation of Government Employees, which represents 320,000 VA employees. The order exempted police officers, firefighters, and security guards. The Unions have indicated they will continue to fight the changes.
VA staffing has undergone significant reversals over the past year. The VA added 223 physicians and 3196 nurses in the first 9 months of fiscal year 2024 before reversing course this year. According to the Workforce Dashboard, the VA and Veterans Health Administration combined to hire 26,984 employees in fiscal year 2025. Cumulative losses, however, totaled 54,308.
During exit interviews, VA employees noted a variety of reasons for their departure. "Personal/family matters" and "geographic relocation" were cited by many job categories. In addition, medical and dental workers also noted "poor working relationship with supervisor or coworker(s)," "desired work schedule not offered," and "job stress/pressure" among the causes. The VA has lost 148 psychologists in fiscal year 2025 who cited "lack of trust/confidence in senior leaders," as well as "policy or technology barriers to getting the work done," and "job stress/pressure" among their reasons for departure.
VA Workforce Shrinking as it Loses Collective Bargaining Rights
VA Workforce Shrinking as it Loses Collective Bargaining Rights
AVAHO Encourages Members to Make Voices Heard
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
Advocacy for veterans with cancer has always been a central part of the Association for VA Hematology/Oncology (AVAHO) mission, but that advocacy has now taken on a new focus: the fate of US Department of Veterans Affairs (VA) employees. The advocacy portal provides templated letters, a search function to find local Senators and Members of Congress, a search function to find regional media outlets, updates on voting and elections, and information on key legislation relevant to VA health care.
To ensure its members’ concerns are heard, AVAHO is encouraging members, in their own time and as private citizens, to contact their local representatives to inform them about the real impact of recent policy changes on VA employees and the veterans they care for. Members can select any of 4 letters focused on reductions in force, cancellation of VA contracts, the return to office mandate, and the National Institutes of Health’s proposed cap on indirect cost for research grants: “AVAHO recognizes the power of the individual voice. Our members have an important role in shaping the health care services provided to veterans across our nation.”
"The contracts that have been canceled and continue to be canceled included critical services related to cancer care," AVAHO notes on its Advocacy page. "We know these impacted contracts have hindered the VA’s ability to implement research protocols, process and report pharmacogenomic results, manage Electronic Health Record Modernization workgroups responsible for safety improvements, and execute new oncology services through the Close to Me initiative, just to name a few."
VA Choice Bill Defeated in the House
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
A U.S. House of Representatives appropriation to fund the Veterans Choice Program surprisingly went down to defeat on Monday. The VA Choice Program is set to run out of money in September, and VA officials have been calling for Congress to provide additional funding for the program. Republican leaders, hoping to expedite the bill’s passage and thinking that it was not controversial, submitted the bill in a process that required the votes of two-thirds of the representatives. The 219-186 vote fell well short of the necessary two-thirds, and voting fell largely along party lines.
Many veterans service organizations (VSOs) were critical of the bill and called on the House to make substantial changes to it. Seven VSOs signed a joint statement calling for the bill’s defeat. “As organizations who represent and support the interests of America’s 21 million veterans, and in fulfillment of our mandate to ensure that the men and women who served are able to receive the health care and benefits they need and deserve, we are calling on Members of Congress to defeat the House vote on unacceptable choice funding legislation (S. 114, with amendments),” the statement read.
AMVETS, Disabled American Veterans , Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign Wars, Vietnam Veterans of America, and Wounded Warrior Project all signed on to the statement. The chief complaint was that the legislation “includes funding only for the ‘choice’ program which provides additional community care options, but makes no investment in VA and uses ‘savings’ from other veterans benefits or services to ‘pay’ for the ‘choice’ program.”
The bill would have allocated $2 billion for the Veterans Choice Program, taken funding for veteran housing loan fees, and would reduce the pensions for some veterans living in nursing facilities that also could be paid for under the Medicaid program.
The fate of the bill and funding for the Veterans Choice Program remains unclear. Senate and House veterans committees seem to be far apart on how to fund the program and for efforts to make more substantive changes to the program. Although House Republicans eventually may be able to pass a bill without Democrats, in the Senate, they will need the support of at least a handful of Democrats to move the bill to the President’s desk.
Managing Resistance to Change Along the Journey to High Reliability
Managing Resistance to Change Along the Journey to High Reliability
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
- Merchant NB, O’Neal J, Dealing-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/JMQ.0000000000000086
- Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18:e320-e328. doi:10.1097/PTS.0000000000000768
- Murray JS, Baghdadi A, Dannenberg W, et al. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Ford J, Isaacks DB, Anderson T. Creating, executing and sustaining a high-reliability organization in health care. The Learning Organization: An International Journal. 2024;31:817-833. doi:10.1108/TLO-03-2023-0048
- Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/JHM-D-00056
- Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
- Nilsen P, Seing I, Ericsson C, et al. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. doi:10.1186/s12913-020-4999-8
- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
- Warrick DD. Revisiting resistance to change and how to manage it: what has been learned and what organizations need to do. Bus Horiz. 2023;66:433-441. doi:10.1016/j.bushor.2022.09.001
- Sverdlik N, Oreg S. Beyond the individual-level conceptualization of dispositional resistance to change: multilevel effects on the response to organizational change. J Organ Behav. 2023;44:1066-1077. doi:10.1002/job.2678
- Khaw KW, Alnoor A, Al-Abrrow H, et al. Reactions towards organizational change: a systematic literature review. Curr Psychol. 2022;13:1-24. doi:10.1007/s12144-022-03070-6
- Pomare C, Churruca K, Long JC, et al. Organisational change in hospitals: a qualitative case-study of staff perspectives. BMC Health Serv Res. 2019;19:840. doi:10.1186/s12913-019-4704-y
- DuBose BM, Mayo AM. RtC: a concept analysis. Nurs Forum. 2020;55:631-636. doi:10.1111/nuf.12479
- Sahay S, Goldthwaite C. Participatory practices during organizational change: rethinking participation and resistance. Manag Commun Q. 2024;38(2):279-306. doi:10.1177/08933189231187883
- Damawan AH, Azizah S. Resistance to change: causes and strategies as an organizational challenge. ASSEHR. 2020;395(2020):49-53. doi:10.2991/assehr.k.200120.010
- Wong Q, Lacombe M, Keller R, et al. Leading change with ADKAR. Nurs Manage. 2019;50:28-35. doi:10.1097/01.NUMA.0000554341.70508.75
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.1 HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.1-3
Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).5
Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.6 Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.7 Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.
REASONS FOR RESISTANCE TO CHANGE
RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.8 While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.8
Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.9 To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.
Individual
An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.9
Interpersonal
Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.11 Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.8 Employees’ understanding of changes through communication between other members of the organization is critical to success.11
Organizational
How organizational leaders introduce change affects the extent to which staff respond.10 RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.8,13
MANAGING RESISTANCE TO CHANGE
RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.8
Communication
Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.9 Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.15 The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.3
Employee Participation
Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.7,14,15
Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.14
Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.3
Education and Training
Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.8 For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.16
Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.3 In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.
Engaging Managers
Managers are pivotal to the successful implementation of organizational change.8 They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.
CONCLUSIONS
Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.
- Merchant NB, O’Neal J, Dealing-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/JMQ.0000000000000086
- Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18:e320-e328. doi:10.1097/PTS.0000000000000768
- Murray JS, Baghdadi A, Dannenberg W, et al. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Ford J, Isaacks DB, Anderson T. Creating, executing and sustaining a high-reliability organization in health care. The Learning Organization: An International Journal. 2024;31:817-833. doi:10.1108/TLO-03-2023-0048
- Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/JHM-D-00056
- Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
- Nilsen P, Seing I, Ericsson C, et al. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. doi:10.1186/s12913-020-4999-8
- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
- Warrick DD. Revisiting resistance to change and how to manage it: what has been learned and what organizations need to do. Bus Horiz. 2023;66:433-441. doi:10.1016/j.bushor.2022.09.001
- Sverdlik N, Oreg S. Beyond the individual-level conceptualization of dispositional resistance to change: multilevel effects on the response to organizational change. J Organ Behav. 2023;44:1066-1077. doi:10.1002/job.2678
- Khaw KW, Alnoor A, Al-Abrrow H, et al. Reactions towards organizational change: a systematic literature review. Curr Psychol. 2022;13:1-24. doi:10.1007/s12144-022-03070-6
- Pomare C, Churruca K, Long JC, et al. Organisational change in hospitals: a qualitative case-study of staff perspectives. BMC Health Serv Res. 2019;19:840. doi:10.1186/s12913-019-4704-y
- DuBose BM, Mayo AM. RtC: a concept analysis. Nurs Forum. 2020;55:631-636. doi:10.1111/nuf.12479
- Sahay S, Goldthwaite C. Participatory practices during organizational change: rethinking participation and resistance. Manag Commun Q. 2024;38(2):279-306. doi:10.1177/08933189231187883
- Damawan AH, Azizah S. Resistance to change: causes and strategies as an organizational challenge. ASSEHR. 2020;395(2020):49-53. doi:10.2991/assehr.k.200120.010
- Wong Q, Lacombe M, Keller R, et al. Leading change with ADKAR. Nurs Manage. 2019;50:28-35. doi:10.1097/01.NUMA.0000554341.70508.75
- Merchant NB, O’Neal J, Dealing-Perez C, et al. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/JMQ.0000000000000086
- Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. 2022;18:e320-e328. doi:10.1097/PTS.0000000000000768
- Murray JS, Baghdadi A, Dannenberg W, et al. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Ford J, Isaacks DB, Anderson T. Creating, executing and sustaining a high-reliability organization in health care. The Learning Organization: An International Journal. 2024;31:817-833. doi:10.1108/TLO-03-2023-0048
- Cox GR, Starr LM. VHA’s movement for change: implementing high-reliability principles and practices. J Healthc Manag. 2023;68:151-157. doi:10.1097/JHM-D-00056
- Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf. 2022;31:845-848. doi:10.1136/bmjqs-2021-014141
- Nilsen P, Seing I, Ericsson C, et al. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. doi:10.1186/s12913-020-4999-8
- Cheraghi R, Ebrahimi H, Kheibar N, et al. Reasons for resistance to change in nursing: an integrative review. BMC Nurs. 2023;22:310. doi:10/1186/s12912-023-01460-0
- Warrick DD. Revisiting resistance to change and how to manage it: what has been learned and what organizations need to do. Bus Horiz. 2023;66:433-441. doi:10.1016/j.bushor.2022.09.001
- Sverdlik N, Oreg S. Beyond the individual-level conceptualization of dispositional resistance to change: multilevel effects on the response to organizational change. J Organ Behav. 2023;44:1066-1077. doi:10.1002/job.2678
- Khaw KW, Alnoor A, Al-Abrrow H, et al. Reactions towards organizational change: a systematic literature review. Curr Psychol. 2022;13:1-24. doi:10.1007/s12144-022-03070-6
- Pomare C, Churruca K, Long JC, et al. Organisational change in hospitals: a qualitative case-study of staff perspectives. BMC Health Serv Res. 2019;19:840. doi:10.1186/s12913-019-4704-y
- DuBose BM, Mayo AM. RtC: a concept analysis. Nurs Forum. 2020;55:631-636. doi:10.1111/nuf.12479
- Sahay S, Goldthwaite C. Participatory practices during organizational change: rethinking participation and resistance. Manag Commun Q. 2024;38(2):279-306. doi:10.1177/08933189231187883
- Damawan AH, Azizah S. Resistance to change: causes and strategies as an organizational challenge. ASSEHR. 2020;395(2020):49-53. doi:10.2991/assehr.k.200120.010
- Wong Q, Lacombe M, Keller R, et al. Leading change with ADKAR. Nurs Manage. 2019;50:28-35. doi:10.1097/01.NUMA.0000554341.70508.75
Managing Resistance to Change Along the Journey to High Reliability
Managing Resistance to Change Along the Journey to High Reliability
Negotiating the VUCA World Through Tiered Huddles
Negotiating the VUCA World Through Tiered Huddles
To see what is in front of one’s nose needs a constant struggle.
George Orwell (1946)1
In 2019, the Veterans Health Administration (VHA) initiated a process to become a high reliability organization (HRO).2 The COVID-19 pandemic has been described in medical literature as a volatile, uncertain, complex, and ambiguous (VUCA) event, underscoring the necessity of resilient communication strategies.3 Challenges posed by 2024 Hurricanes Helene and Milton further highlighted the need for resilient communication strategies within HRO implementation.
Central to the HRO journey within the VHA has been the development of tiered huddles, an evolution of the safety huddle concept.4 Emerging organically as an effective communication mechanism across multiple facilities between 2019 and 2020, tiered huddles were, in part, spurred by the onset of COVID-19. Tiered huddles represent a proactive approach to identifying and addressing organizational threats in their early stages, thereby preventing their escalation to a VUCA-laden crisis.5 When conditions evolve beyond the horizon of tractability, where challenges are easily identified and resolved, tiered huddles serve as a resilient mechanism to restore dynamic equilibrium within the organization.6,7
This article describes how tiered huddles were integrated within Veterans Integrated Service Network (VISN) 4 and explores why these huddles are essential, particularly in the context of VUCA events. What began as a local-level tactic has now gained widespread acceptance and continues to evolve across the VHA with full support from the US Department of Veterans Affairs (VA) Under Secretary for Health.8
The VHA is divided into 18 VISNs. Nine VA Medical Centers (VAMCs) and 46 outpatient clinics across Pennsylvania, Delaware, and parts of Ohio, New York, and New Jersey make up VISN 4. Disseminating vital information across VISN 4, in addition to the 17 other VISNs—including 170 VAMCs and 1193 clinics—presents a formidable challenge. As the largest integrated system in the US, the VHA is realigning its workforce to address organizational inefficiencies. An enterprise of this scale, shaped by recurrent organizational change, faces ongoing challenges in sustaining clear communication across all levels. These transitions create uncertainty for staff as roles and resources shift, underscoring the need for dependable vertical and horizontal information flow. Tiered huddles offer a steady means to support coordinated communication and strengthen the system’s ability to adapt.9
ERIE VA MEDICAL CENTER HRO JOURNEY
In 2019, John Gennaro, the Erie VAMC executive director, attended a presentation that showcased the Cleveland Clinic’s tiered huddle process, with an opportunity to observe its 5-tiered system.10 Erie VAMC already had a 3-tiered huddle system, but the Cleveland Clinic’s more robust model inspired Gennaro to propose a VISN 4 pilot program. Tiered huddles were perceived as innovative, yet not fully embraced within the VHA; nonetheless, VISN 4, much like several other VISNs, moved forward and established a VISN-level (Tier 4) huddle.8 It is important to note that there was a notional fifth-tier capability as VISN and program office leaders already participated in daily VHA-wide meetings under the auspices of the Hospital Operations Center (HOC).
Expanding the Tiered Huddle Process
The Erie VAMC huddle process begins with the unit level Managers and Frontline Staff (Tier 1), then moves to Service Chiefs and Managers (Tier 2). Tier 3 involves facility executive leadership team and service chiefs, clinical directors and top VAMC administrators (these configurations may vary depending on context). The sequencing and flow of information is bidirectional across levels, reflecting the importance of closed-loop communication to ensure staff at all levels understand that issues raised are followed up on and/or closed out (Figure 1).2
Tier 4 composition may vary among VISNs depending on size and unique mission requirements.8,11 The VISN 4 Tier 4 huddle includes the VISN director, 9 VAMC directors, and key network administrators and clinical experts. The Tier 5 huddle includes 18 VISN 4 directors with the VHA HOC (Figure 2). The tiered huddle process emphasizes team-based culture and psychological safety.12-15 Staff at all levels are encouraged to identify and transparently resolve issues, fostering a proactive and problem-solving environment across the organization. A more nuanced and detailed process across tier levels is depicted in the Table.
The vetting and distillation of information can present challenges as vital information ascends and spreads across organization levels. Visual management systems (VMS), whether a whiteboard or a digital platform, are key to facilitate decision-making related to what needs to be prioritized and disseminated at each tier level.2,8 At Tier 5, the HOC uses a digital VMS to provide a structured, user-friendly format for categorizing issues and topics and enhances clarity and accessibility (Figure 3). The Tier 5 VMS also facilitates tracking and reciprocal information exchange, helping to close the loop on emerging issues by monitoring their progression and resolution up and across tiers.2,8 The Tier 5 huddle process and technology supporting continue to evolve offering increasing sophistication in organizational situational awareness and responsiveness.
VUCA: A Lens for Health Care Challenges
First introduced by social scientists at the US Army War College in 1995, VUCA describes complex and unpredictable conditions often encountered in military operations.16,17 Prompted by the COVID-19 pandemic, the acronym VUCA gained recognition in health care, as leaders acknowledged the challenge of navigating rapidly changing environments. van Stralen, Byrum and Inozu, recognized authorities in high reliability, cited VUCA as the rationale for implementing HRO principles and practices. They argued that “HRO solves the problem of operations and performance in a volatile, uncertain, complex, ambiguous environment.” 18 To fully appreciate the VUCA environment and its relevance to health care, it is essential to unpack the 4 components of the acronym: volatile, uncertain, complex, and ambiguous.
Volatile refers to the speed and unpredictability of change. Health care systems are interactively complex and tightly coupled, meaning that changes in 1 part of the system can rapidly impact others.6,18,19 This high degree of interdependence amplifies volatility, especially when unexpected events occur. The rapid spread of COVID- 19 and the evolving nature of its transmission challenged health care systems’ ability to respond swiftly and effectively. Volatility also may emerge in acute medical situations, such as the rapid deterioration of a patient’s condition.
Uncertain captures the lack of predictability inherent in complex systems. In health care, uncertainty arises when there is insufficient information or when an excess of data make it difficult to discern meaningful patterns. COVID-19 and recent natural disasters have introduced profound uncertainty, as the disease’s behavior, transmission, and impact were initially unknown. Health care practitioners struggled to make decisions in real time, lacking clear guidance or precedent.3,20 While health care planning and established protocols are grounded in predictability, the COVID-19 pandemic revealed that as complexity increases, predictability diminishes. Moreover, complexity can complicate protocol selection, as situations may arise in which multiple protocols conflict or compete. The cognitive challenge of operating in this environment is analogous to what military strategists call the fog of war, where situational awareness is low and decision-makers must navigate without clarity.21 Tiered huddles, a core practice in HROs, mitigate uncertainty by fostering real-time communication and shared situational awareness among teams.20
Complex refers to the intricate interplay of multiple, interconnected factors within a system.22 In health care, this complexity is heightened by the sociotechnical nature of the field—where human, technology, and organizational elements all converge.19 Systems designed to prevent failures, such as redundancies and safety protocols, can themselves contribute to increased complexity. HRO practices such as tiered huddles are implemented to mitigate the risk of catastrophic failure by fostering collaborative sensemaking, enhanced situational awareness, and rapid problem-solving.5,20,23
Ambiguous refers to situations in which multiple interpretations, causes, or outcomes are possible. It explains how, despite following protocols, failure can still occur, or how individuals may reach different conclusions from the same data. Ambiguity does not offer binary solutions; instead, it presents a murky, multifaceted reality that requires thoughtful interpretation and adaptive responses. In these moments, leaders must act decisively, even in the absence of complete information, making trade-offs that balance immediate needs with long-term consequences.
MANAGING VUCA ENVIRONMENTS WITH TIERED HUDDLES
The tiered huddle process provides several key benefits that enable real-time issue resolution. These include the rapid dissemination of vital information, enhanced agility and resilience, and improved sensemaking within a VUCA environment. Additionally, tiered huddles prevent organizational drift by fostering heightened situational awareness. The tiered huddle process also supports leadership development, as unit-level leaders gain valuable insights into strategic decision-making through active participation. Each component is outlined in the following section.
Spread: The Challenge of Communicating
“The hallmark of a great organization is how quickly bad news travels upward,” argued Jay Forrester, the father of system dynamics.24 Unfortunately, steep power gradients and siloed organizational structures inhibit the flow of unfavorable information from frontline staff to senior leadership. This suppression is not necessarily intentional but is often a byproduct of organizational culture. Tiered huddles address the weakness of top-down communication models by promoting a reciprocal, bidirectional information exchange, with an emphasis on closed-loop communication. Open communication can foster a culture of trust and transparency, allowing leaders to make more informed decisions and respond quickly to emerging risks.
Enhancing Agility and Resilience
Tiered huddles contribute to a mindful infrastructure, an important aspect of maintaining organizational awareness and agility.21,25 A mindful infrastructure enables an organization to detect early warning signs of potential disruptions and respond to them before they escalate. In this sense, tiered huddles serve as a signal-sensing mechanism, providing the agility needed to adapt to changing circumstances and prevent patient harm. Tiered huddles facilitate self-organization, a concept from chaos theory known as autopoiesis. 26 This self-organizing capability allows teams to develop novel solutions in response to unforeseen challenges, exemplifying the adaptability and resilience needed in a VUCA environment. The diverse backgrounds of tiered huddle participants—both cognitively and culturally—enable a broader range of perspectives, which is critical for making sound decisions in complex and uncertain situations. “HROs cultivate diversity not just because it helps them notice more in complex environments, but also because it helps them adapt to the complexities they do spot,” argues Weick et al.27 This diversity of thought and experience enhances the organization’s ability to respond to complexity, much like firefighters continually adapt to the VUCA conditions they face.
Sensemaking and Sensitivity to Operations
Leaders at all levels must be attuned to what is happening both within and outside their organization. This continual sensing of the environment—looking for weak signals, threats, and opportunities—is important for HROs. This signal detection capability allows organizations to address problems in their nascent emerging state within a tractable horizon to successfully manage fluctuations. The horizon of tractability reflects a zone where weak signals and evolving issues can be identified, addressed, and resolved early before they evolve and cascade outside of safe operations. 7 Tiered huddles facilitate this process by creating a platform for team members to engage in respectful, collaborative dialogue. The diversity inherent in tiered huddles also supports sensemaking, a process of interpreting and understanding complex situations.27 In a VUCA environment, this multiperspective approach helps filter out noise and identify the most important signals. Tiered huddles can help overcome the phenomenon of dysfunctional momentum associated with cognitive lockup, fixation error, and tunnel vision, in which individuals or teams fixate on a particular solution, thus missing important alternative views.21,28 By fostering a common operating picture of the fluctuating environment, tiered huddles can enable more accurate decision-making and improve organizational resilience.
Avoiding Organizational Drift
One of the most significant contributions of tiered huddles is the ability to detect early signs of organizational drift, or subtle deviations from standard practices that can accumulate over time and lead to serious failures. By continuously monitoring for precursor conditions and weak signals, tiered huddles allow organizations to intervene early and prevent drift from becoming catastrophic.29,30 This vigilance is essential in health care, where complacency can lead to patient harm. Tiered huddles foster a culture of mindfulness and accountability, ensuring that staff stay engaged and alert to potential risks. This proactive approach is a safeguard against human error and the gradual erosion of safety standards.
Leadership Development
Tiered huddles serve as a powerful tool for leadership development. Effective leaders must be able to anticipate potential risks and foresee system failures. Involving future leaders in tiered huddles can facilitate the transfer of these critical skills. When emerging leaders at lower tiers participate in ascending-tier huddles, they gain a unique opportunity to engage in a structured, collaborative setting. This environment provides a safe space to develop and practice strategic skills, enhancing their ability to think proactively and manage complexity. By integrating future leaders into tiered huddles, organizations offer essential, hands-on experience in real-time decision making. This experiential learning is invaluable for preparing leaders to navigate the demands of a VUCA environment.
CONCLUSIONS
Since implementing the tiered huddle process, the Erie VAMC and VISN 4 have emerged as early adopters of VUCA, thus contributing to the expansion of this innovative communication approach across the VHA. Tiered huddles strengthen organizational resilience and agility, facilitate critical information flow to manage risk, and support the cultivation of future leaders. The Erie VAMC director and the VISN 4 network director regard the expansion of tiered huddles, including Tiers 4 and 5, as an adaptable model for the VHA. While tiered huddles have not yet been mandated across the VHA, a pilot at the Tier 5 HOC level was initiated on May 20, 2024. In a complex world in which VUCA events will continue to be inevitable, implementation of robust tiered huddles within complex health care systems provides the opportunity for improved responses and delivery of care.
- Orwell S, Angus I, eds. In Front of Your Nose, 1945-1950. Godine; 2000. Orwell G. The Collected Essays, Journalism, and Letters of George Orwell; vol 4.
- Murray JS, Baghdadi A, Dannenberg W, Crews P, Walsh ND. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22:899-906. doi:10.1136/bmjqs-2012-001467
- Pandit M. Critical factors for successful management of VUCA times. BMJ Lead. 2021;5:121-123. doi:10.1136/leader-2020-000305
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- van Stralen D, Mercer TA. High-reliability organizing (HRO) in the COVID-19 liminal zone: characteristics of workers and local leaders. Neonatology Today. 2021;16:90-101. http://www.neonatologytoday.net /newsletters/nt-apr21.pdf
- Nemeth C, Wears R, Woods D, Hollnagel E, Cook R. Minding the gaps: creating resilience in health care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol 3: Performance and Tools. Agency for Healthcare Research and Quality; 2008.
- Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs medical center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
- Starbuck WH, Farjoun M, eds. Organization at the Limit: Lessons From the Columbia Disaster. 1st ed. Wiley-Blackwell; 2005.
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- Donnelly LF, Cherian SS, Chua KB, et al. The Daily Readiness Huddle: a process to rapidly identify issues and foster improvement through problem-solving accountability. Pediatr Radiol. 2017;47:22-30. doi:10.1007/s00247-016-3712-x
- Clark TR. The 4 Stages of Psychological Safety: Defining the Path to Inclusion and Innovation. Berrett-Koehler Publishers, Inc.; 2020.
- Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. John Wiley & Sons; 2018.
- Edmondson AC. The Right Kind of Wrong: The Science of Failing Well. Simon Element/Simon Acumen; 2023.
- Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808 -810. doi:10.1093/milmed/usac041
- Barber HF. Developing strategic leadership: the US Army War College experience. J Manag Dev. 1992;11:4-12. doi:10.1108/02621719210018208
- US Army Heritage & Education Center. Who first originated the term VUCA (volatility, uncertainty, complexity and ambiguity)? Accessed November 5, 2025. https://usawc .libanswers.com/ahec/faq/84869
- van Stralen D, Byrum SL, Inozu B. High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. CreateSpace Independent Publishing Platform; 2018.
- Perrow C. Normal Accidents: Living With High-Risk Technologies. Princeton University Press; 2000.
- Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Clinical Teams. HCPro; 2021. Accessed November 5, 2025. https://hcmarketplace.com /media/wysiwyg/CRM3_browse.pdf
- Barton MA, Sutcliffe KM, Vogus TJ, DeWitt T. Performing under uncertainty: contextualized engagement in wildland firefighting. J Contingencies Crisis Manag. 2015;23:74-83. doi:10.1111/1468-5973.12076
- Sutcliffe KM. Mindful organizing. In: Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018:61-89.
- Merchant NB, O’Neal J, Dealino-Perez C, Xiang J, Montoya A Jr, Murray JS. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/jmq.0000000000000086
- Senge PM. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. Crown Currency; 1994.
- Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018.
- Coveney PV. Self-organization and complexity: a new age for theory, computation and experiment. Philos Trans A Math Phys Eng Sci. 2003;361:1057-1079. doi:10.1098/rsta.2003.1191
- Weick KE, Sutcliffe KM. Managing the Unexpected: Sustained Performance in a Complex World. 3rd ed. Wiley; 2015.
- Barton M, Sutcliffe K. Overcoming dysfunctional momentum: organizational safety as a social achievement. Hum Relations. 2009;62:1327-1356. doi:10.1177/0018726709334491
- Dekker S. Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems. Routledge; 2011.
- Price MR, Williams TC. When doing wrong feels so right: normalization of deviance. J Patient Saf. 2018;14:1-2. doi:10.1097/pts.0000000000000157
To see what is in front of one’s nose needs a constant struggle.
George Orwell (1946)1
In 2019, the Veterans Health Administration (VHA) initiated a process to become a high reliability organization (HRO).2 The COVID-19 pandemic has been described in medical literature as a volatile, uncertain, complex, and ambiguous (VUCA) event, underscoring the necessity of resilient communication strategies.3 Challenges posed by 2024 Hurricanes Helene and Milton further highlighted the need for resilient communication strategies within HRO implementation.
Central to the HRO journey within the VHA has been the development of tiered huddles, an evolution of the safety huddle concept.4 Emerging organically as an effective communication mechanism across multiple facilities between 2019 and 2020, tiered huddles were, in part, spurred by the onset of COVID-19. Tiered huddles represent a proactive approach to identifying and addressing organizational threats in their early stages, thereby preventing their escalation to a VUCA-laden crisis.5 When conditions evolve beyond the horizon of tractability, where challenges are easily identified and resolved, tiered huddles serve as a resilient mechanism to restore dynamic equilibrium within the organization.6,7
This article describes how tiered huddles were integrated within Veterans Integrated Service Network (VISN) 4 and explores why these huddles are essential, particularly in the context of VUCA events. What began as a local-level tactic has now gained widespread acceptance and continues to evolve across the VHA with full support from the US Department of Veterans Affairs (VA) Under Secretary for Health.8
The VHA is divided into 18 VISNs. Nine VA Medical Centers (VAMCs) and 46 outpatient clinics across Pennsylvania, Delaware, and parts of Ohio, New York, and New Jersey make up VISN 4. Disseminating vital information across VISN 4, in addition to the 17 other VISNs—including 170 VAMCs and 1193 clinics—presents a formidable challenge. As the largest integrated system in the US, the VHA is realigning its workforce to address organizational inefficiencies. An enterprise of this scale, shaped by recurrent organizational change, faces ongoing challenges in sustaining clear communication across all levels. These transitions create uncertainty for staff as roles and resources shift, underscoring the need for dependable vertical and horizontal information flow. Tiered huddles offer a steady means to support coordinated communication and strengthen the system’s ability to adapt.9
ERIE VA MEDICAL CENTER HRO JOURNEY
In 2019, John Gennaro, the Erie VAMC executive director, attended a presentation that showcased the Cleveland Clinic’s tiered huddle process, with an opportunity to observe its 5-tiered system.10 Erie VAMC already had a 3-tiered huddle system, but the Cleveland Clinic’s more robust model inspired Gennaro to propose a VISN 4 pilot program. Tiered huddles were perceived as innovative, yet not fully embraced within the VHA; nonetheless, VISN 4, much like several other VISNs, moved forward and established a VISN-level (Tier 4) huddle.8 It is important to note that there was a notional fifth-tier capability as VISN and program office leaders already participated in daily VHA-wide meetings under the auspices of the Hospital Operations Center (HOC).
Expanding the Tiered Huddle Process
The Erie VAMC huddle process begins with the unit level Managers and Frontline Staff (Tier 1), then moves to Service Chiefs and Managers (Tier 2). Tier 3 involves facility executive leadership team and service chiefs, clinical directors and top VAMC administrators (these configurations may vary depending on context). The sequencing and flow of information is bidirectional across levels, reflecting the importance of closed-loop communication to ensure staff at all levels understand that issues raised are followed up on and/or closed out (Figure 1).2
Tier 4 composition may vary among VISNs depending on size and unique mission requirements.8,11 The VISN 4 Tier 4 huddle includes the VISN director, 9 VAMC directors, and key network administrators and clinical experts. The Tier 5 huddle includes 18 VISN 4 directors with the VHA HOC (Figure 2). The tiered huddle process emphasizes team-based culture and psychological safety.12-15 Staff at all levels are encouraged to identify and transparently resolve issues, fostering a proactive and problem-solving environment across the organization. A more nuanced and detailed process across tier levels is depicted in the Table.
The vetting and distillation of information can present challenges as vital information ascends and spreads across organization levels. Visual management systems (VMS), whether a whiteboard or a digital platform, are key to facilitate decision-making related to what needs to be prioritized and disseminated at each tier level.2,8 At Tier 5, the HOC uses a digital VMS to provide a structured, user-friendly format for categorizing issues and topics and enhances clarity and accessibility (Figure 3). The Tier 5 VMS also facilitates tracking and reciprocal information exchange, helping to close the loop on emerging issues by monitoring their progression and resolution up and across tiers.2,8 The Tier 5 huddle process and technology supporting continue to evolve offering increasing sophistication in organizational situational awareness and responsiveness.
VUCA: A Lens for Health Care Challenges
First introduced by social scientists at the US Army War College in 1995, VUCA describes complex and unpredictable conditions often encountered in military operations.16,17 Prompted by the COVID-19 pandemic, the acronym VUCA gained recognition in health care, as leaders acknowledged the challenge of navigating rapidly changing environments. van Stralen, Byrum and Inozu, recognized authorities in high reliability, cited VUCA as the rationale for implementing HRO principles and practices. They argued that “HRO solves the problem of operations and performance in a volatile, uncertain, complex, ambiguous environment.” 18 To fully appreciate the VUCA environment and its relevance to health care, it is essential to unpack the 4 components of the acronym: volatile, uncertain, complex, and ambiguous.
Volatile refers to the speed and unpredictability of change. Health care systems are interactively complex and tightly coupled, meaning that changes in 1 part of the system can rapidly impact others.6,18,19 This high degree of interdependence amplifies volatility, especially when unexpected events occur. The rapid spread of COVID- 19 and the evolving nature of its transmission challenged health care systems’ ability to respond swiftly and effectively. Volatility also may emerge in acute medical situations, such as the rapid deterioration of a patient’s condition.
Uncertain captures the lack of predictability inherent in complex systems. In health care, uncertainty arises when there is insufficient information or when an excess of data make it difficult to discern meaningful patterns. COVID-19 and recent natural disasters have introduced profound uncertainty, as the disease’s behavior, transmission, and impact were initially unknown. Health care practitioners struggled to make decisions in real time, lacking clear guidance or precedent.3,20 While health care planning and established protocols are grounded in predictability, the COVID-19 pandemic revealed that as complexity increases, predictability diminishes. Moreover, complexity can complicate protocol selection, as situations may arise in which multiple protocols conflict or compete. The cognitive challenge of operating in this environment is analogous to what military strategists call the fog of war, where situational awareness is low and decision-makers must navigate without clarity.21 Tiered huddles, a core practice in HROs, mitigate uncertainty by fostering real-time communication and shared situational awareness among teams.20
Complex refers to the intricate interplay of multiple, interconnected factors within a system.22 In health care, this complexity is heightened by the sociotechnical nature of the field—where human, technology, and organizational elements all converge.19 Systems designed to prevent failures, such as redundancies and safety protocols, can themselves contribute to increased complexity. HRO practices such as tiered huddles are implemented to mitigate the risk of catastrophic failure by fostering collaborative sensemaking, enhanced situational awareness, and rapid problem-solving.5,20,23
Ambiguous refers to situations in which multiple interpretations, causes, or outcomes are possible. It explains how, despite following protocols, failure can still occur, or how individuals may reach different conclusions from the same data. Ambiguity does not offer binary solutions; instead, it presents a murky, multifaceted reality that requires thoughtful interpretation and adaptive responses. In these moments, leaders must act decisively, even in the absence of complete information, making trade-offs that balance immediate needs with long-term consequences.
MANAGING VUCA ENVIRONMENTS WITH TIERED HUDDLES
The tiered huddle process provides several key benefits that enable real-time issue resolution. These include the rapid dissemination of vital information, enhanced agility and resilience, and improved sensemaking within a VUCA environment. Additionally, tiered huddles prevent organizational drift by fostering heightened situational awareness. The tiered huddle process also supports leadership development, as unit-level leaders gain valuable insights into strategic decision-making through active participation. Each component is outlined in the following section.
Spread: The Challenge of Communicating
“The hallmark of a great organization is how quickly bad news travels upward,” argued Jay Forrester, the father of system dynamics.24 Unfortunately, steep power gradients and siloed organizational structures inhibit the flow of unfavorable information from frontline staff to senior leadership. This suppression is not necessarily intentional but is often a byproduct of organizational culture. Tiered huddles address the weakness of top-down communication models by promoting a reciprocal, bidirectional information exchange, with an emphasis on closed-loop communication. Open communication can foster a culture of trust and transparency, allowing leaders to make more informed decisions and respond quickly to emerging risks.
Enhancing Agility and Resilience
Tiered huddles contribute to a mindful infrastructure, an important aspect of maintaining organizational awareness and agility.21,25 A mindful infrastructure enables an organization to detect early warning signs of potential disruptions and respond to them before they escalate. In this sense, tiered huddles serve as a signal-sensing mechanism, providing the agility needed to adapt to changing circumstances and prevent patient harm. Tiered huddles facilitate self-organization, a concept from chaos theory known as autopoiesis. 26 This self-organizing capability allows teams to develop novel solutions in response to unforeseen challenges, exemplifying the adaptability and resilience needed in a VUCA environment. The diverse backgrounds of tiered huddle participants—both cognitively and culturally—enable a broader range of perspectives, which is critical for making sound decisions in complex and uncertain situations. “HROs cultivate diversity not just because it helps them notice more in complex environments, but also because it helps them adapt to the complexities they do spot,” argues Weick et al.27 This diversity of thought and experience enhances the organization’s ability to respond to complexity, much like firefighters continually adapt to the VUCA conditions they face.
Sensemaking and Sensitivity to Operations
Leaders at all levels must be attuned to what is happening both within and outside their organization. This continual sensing of the environment—looking for weak signals, threats, and opportunities—is important for HROs. This signal detection capability allows organizations to address problems in their nascent emerging state within a tractable horizon to successfully manage fluctuations. The horizon of tractability reflects a zone where weak signals and evolving issues can be identified, addressed, and resolved early before they evolve and cascade outside of safe operations. 7 Tiered huddles facilitate this process by creating a platform for team members to engage in respectful, collaborative dialogue. The diversity inherent in tiered huddles also supports sensemaking, a process of interpreting and understanding complex situations.27 In a VUCA environment, this multiperspective approach helps filter out noise and identify the most important signals. Tiered huddles can help overcome the phenomenon of dysfunctional momentum associated with cognitive lockup, fixation error, and tunnel vision, in which individuals or teams fixate on a particular solution, thus missing important alternative views.21,28 By fostering a common operating picture of the fluctuating environment, tiered huddles can enable more accurate decision-making and improve organizational resilience.
Avoiding Organizational Drift
One of the most significant contributions of tiered huddles is the ability to detect early signs of organizational drift, or subtle deviations from standard practices that can accumulate over time and lead to serious failures. By continuously monitoring for precursor conditions and weak signals, tiered huddles allow organizations to intervene early and prevent drift from becoming catastrophic.29,30 This vigilance is essential in health care, where complacency can lead to patient harm. Tiered huddles foster a culture of mindfulness and accountability, ensuring that staff stay engaged and alert to potential risks. This proactive approach is a safeguard against human error and the gradual erosion of safety standards.
Leadership Development
Tiered huddles serve as a powerful tool for leadership development. Effective leaders must be able to anticipate potential risks and foresee system failures. Involving future leaders in tiered huddles can facilitate the transfer of these critical skills. When emerging leaders at lower tiers participate in ascending-tier huddles, they gain a unique opportunity to engage in a structured, collaborative setting. This environment provides a safe space to develop and practice strategic skills, enhancing their ability to think proactively and manage complexity. By integrating future leaders into tiered huddles, organizations offer essential, hands-on experience in real-time decision making. This experiential learning is invaluable for preparing leaders to navigate the demands of a VUCA environment.
CONCLUSIONS
Since implementing the tiered huddle process, the Erie VAMC and VISN 4 have emerged as early adopters of VUCA, thus contributing to the expansion of this innovative communication approach across the VHA. Tiered huddles strengthen organizational resilience and agility, facilitate critical information flow to manage risk, and support the cultivation of future leaders. The Erie VAMC director and the VISN 4 network director regard the expansion of tiered huddles, including Tiers 4 and 5, as an adaptable model for the VHA. While tiered huddles have not yet been mandated across the VHA, a pilot at the Tier 5 HOC level was initiated on May 20, 2024. In a complex world in which VUCA events will continue to be inevitable, implementation of robust tiered huddles within complex health care systems provides the opportunity for improved responses and delivery of care.
To see what is in front of one’s nose needs a constant struggle.
George Orwell (1946)1
In 2019, the Veterans Health Administration (VHA) initiated a process to become a high reliability organization (HRO).2 The COVID-19 pandemic has been described in medical literature as a volatile, uncertain, complex, and ambiguous (VUCA) event, underscoring the necessity of resilient communication strategies.3 Challenges posed by 2024 Hurricanes Helene and Milton further highlighted the need for resilient communication strategies within HRO implementation.
Central to the HRO journey within the VHA has been the development of tiered huddles, an evolution of the safety huddle concept.4 Emerging organically as an effective communication mechanism across multiple facilities between 2019 and 2020, tiered huddles were, in part, spurred by the onset of COVID-19. Tiered huddles represent a proactive approach to identifying and addressing organizational threats in their early stages, thereby preventing their escalation to a VUCA-laden crisis.5 When conditions evolve beyond the horizon of tractability, where challenges are easily identified and resolved, tiered huddles serve as a resilient mechanism to restore dynamic equilibrium within the organization.6,7
This article describes how tiered huddles were integrated within Veterans Integrated Service Network (VISN) 4 and explores why these huddles are essential, particularly in the context of VUCA events. What began as a local-level tactic has now gained widespread acceptance and continues to evolve across the VHA with full support from the US Department of Veterans Affairs (VA) Under Secretary for Health.8
The VHA is divided into 18 VISNs. Nine VA Medical Centers (VAMCs) and 46 outpatient clinics across Pennsylvania, Delaware, and parts of Ohio, New York, and New Jersey make up VISN 4. Disseminating vital information across VISN 4, in addition to the 17 other VISNs—including 170 VAMCs and 1193 clinics—presents a formidable challenge. As the largest integrated system in the US, the VHA is realigning its workforce to address organizational inefficiencies. An enterprise of this scale, shaped by recurrent organizational change, faces ongoing challenges in sustaining clear communication across all levels. These transitions create uncertainty for staff as roles and resources shift, underscoring the need for dependable vertical and horizontal information flow. Tiered huddles offer a steady means to support coordinated communication and strengthen the system’s ability to adapt.9
ERIE VA MEDICAL CENTER HRO JOURNEY
In 2019, John Gennaro, the Erie VAMC executive director, attended a presentation that showcased the Cleveland Clinic’s tiered huddle process, with an opportunity to observe its 5-tiered system.10 Erie VAMC already had a 3-tiered huddle system, but the Cleveland Clinic’s more robust model inspired Gennaro to propose a VISN 4 pilot program. Tiered huddles were perceived as innovative, yet not fully embraced within the VHA; nonetheless, VISN 4, much like several other VISNs, moved forward and established a VISN-level (Tier 4) huddle.8 It is important to note that there was a notional fifth-tier capability as VISN and program office leaders already participated in daily VHA-wide meetings under the auspices of the Hospital Operations Center (HOC).
Expanding the Tiered Huddle Process
The Erie VAMC huddle process begins with the unit level Managers and Frontline Staff (Tier 1), then moves to Service Chiefs and Managers (Tier 2). Tier 3 involves facility executive leadership team and service chiefs, clinical directors and top VAMC administrators (these configurations may vary depending on context). The sequencing and flow of information is bidirectional across levels, reflecting the importance of closed-loop communication to ensure staff at all levels understand that issues raised are followed up on and/or closed out (Figure 1).2
Tier 4 composition may vary among VISNs depending on size and unique mission requirements.8,11 The VISN 4 Tier 4 huddle includes the VISN director, 9 VAMC directors, and key network administrators and clinical experts. The Tier 5 huddle includes 18 VISN 4 directors with the VHA HOC (Figure 2). The tiered huddle process emphasizes team-based culture and psychological safety.12-15 Staff at all levels are encouraged to identify and transparently resolve issues, fostering a proactive and problem-solving environment across the organization. A more nuanced and detailed process across tier levels is depicted in the Table.
The vetting and distillation of information can present challenges as vital information ascends and spreads across organization levels. Visual management systems (VMS), whether a whiteboard or a digital platform, are key to facilitate decision-making related to what needs to be prioritized and disseminated at each tier level.2,8 At Tier 5, the HOC uses a digital VMS to provide a structured, user-friendly format for categorizing issues and topics and enhances clarity and accessibility (Figure 3). The Tier 5 VMS also facilitates tracking and reciprocal information exchange, helping to close the loop on emerging issues by monitoring their progression and resolution up and across tiers.2,8 The Tier 5 huddle process and technology supporting continue to evolve offering increasing sophistication in organizational situational awareness and responsiveness.
VUCA: A Lens for Health Care Challenges
First introduced by social scientists at the US Army War College in 1995, VUCA describes complex and unpredictable conditions often encountered in military operations.16,17 Prompted by the COVID-19 pandemic, the acronym VUCA gained recognition in health care, as leaders acknowledged the challenge of navigating rapidly changing environments. van Stralen, Byrum and Inozu, recognized authorities in high reliability, cited VUCA as the rationale for implementing HRO principles and practices. They argued that “HRO solves the problem of operations and performance in a volatile, uncertain, complex, ambiguous environment.” 18 To fully appreciate the VUCA environment and its relevance to health care, it is essential to unpack the 4 components of the acronym: volatile, uncertain, complex, and ambiguous.
Volatile refers to the speed and unpredictability of change. Health care systems are interactively complex and tightly coupled, meaning that changes in 1 part of the system can rapidly impact others.6,18,19 This high degree of interdependence amplifies volatility, especially when unexpected events occur. The rapid spread of COVID- 19 and the evolving nature of its transmission challenged health care systems’ ability to respond swiftly and effectively. Volatility also may emerge in acute medical situations, such as the rapid deterioration of a patient’s condition.
Uncertain captures the lack of predictability inherent in complex systems. In health care, uncertainty arises when there is insufficient information or when an excess of data make it difficult to discern meaningful patterns. COVID-19 and recent natural disasters have introduced profound uncertainty, as the disease’s behavior, transmission, and impact were initially unknown. Health care practitioners struggled to make decisions in real time, lacking clear guidance or precedent.3,20 While health care planning and established protocols are grounded in predictability, the COVID-19 pandemic revealed that as complexity increases, predictability diminishes. Moreover, complexity can complicate protocol selection, as situations may arise in which multiple protocols conflict or compete. The cognitive challenge of operating in this environment is analogous to what military strategists call the fog of war, where situational awareness is low and decision-makers must navigate without clarity.21 Tiered huddles, a core practice in HROs, mitigate uncertainty by fostering real-time communication and shared situational awareness among teams.20
Complex refers to the intricate interplay of multiple, interconnected factors within a system.22 In health care, this complexity is heightened by the sociotechnical nature of the field—where human, technology, and organizational elements all converge.19 Systems designed to prevent failures, such as redundancies and safety protocols, can themselves contribute to increased complexity. HRO practices such as tiered huddles are implemented to mitigate the risk of catastrophic failure by fostering collaborative sensemaking, enhanced situational awareness, and rapid problem-solving.5,20,23
Ambiguous refers to situations in which multiple interpretations, causes, or outcomes are possible. It explains how, despite following protocols, failure can still occur, or how individuals may reach different conclusions from the same data. Ambiguity does not offer binary solutions; instead, it presents a murky, multifaceted reality that requires thoughtful interpretation and adaptive responses. In these moments, leaders must act decisively, even in the absence of complete information, making trade-offs that balance immediate needs with long-term consequences.
MANAGING VUCA ENVIRONMENTS WITH TIERED HUDDLES
The tiered huddle process provides several key benefits that enable real-time issue resolution. These include the rapid dissemination of vital information, enhanced agility and resilience, and improved sensemaking within a VUCA environment. Additionally, tiered huddles prevent organizational drift by fostering heightened situational awareness. The tiered huddle process also supports leadership development, as unit-level leaders gain valuable insights into strategic decision-making through active participation. Each component is outlined in the following section.
Spread: The Challenge of Communicating
“The hallmark of a great organization is how quickly bad news travels upward,” argued Jay Forrester, the father of system dynamics.24 Unfortunately, steep power gradients and siloed organizational structures inhibit the flow of unfavorable information from frontline staff to senior leadership. This suppression is not necessarily intentional but is often a byproduct of organizational culture. Tiered huddles address the weakness of top-down communication models by promoting a reciprocal, bidirectional information exchange, with an emphasis on closed-loop communication. Open communication can foster a culture of trust and transparency, allowing leaders to make more informed decisions and respond quickly to emerging risks.
Enhancing Agility and Resilience
Tiered huddles contribute to a mindful infrastructure, an important aspect of maintaining organizational awareness and agility.21,25 A mindful infrastructure enables an organization to detect early warning signs of potential disruptions and respond to them before they escalate. In this sense, tiered huddles serve as a signal-sensing mechanism, providing the agility needed to adapt to changing circumstances and prevent patient harm. Tiered huddles facilitate self-organization, a concept from chaos theory known as autopoiesis. 26 This self-organizing capability allows teams to develop novel solutions in response to unforeseen challenges, exemplifying the adaptability and resilience needed in a VUCA environment. The diverse backgrounds of tiered huddle participants—both cognitively and culturally—enable a broader range of perspectives, which is critical for making sound decisions in complex and uncertain situations. “HROs cultivate diversity not just because it helps them notice more in complex environments, but also because it helps them adapt to the complexities they do spot,” argues Weick et al.27 This diversity of thought and experience enhances the organization’s ability to respond to complexity, much like firefighters continually adapt to the VUCA conditions they face.
Sensemaking and Sensitivity to Operations
Leaders at all levels must be attuned to what is happening both within and outside their organization. This continual sensing of the environment—looking for weak signals, threats, and opportunities—is important for HROs. This signal detection capability allows organizations to address problems in their nascent emerging state within a tractable horizon to successfully manage fluctuations. The horizon of tractability reflects a zone where weak signals and evolving issues can be identified, addressed, and resolved early before they evolve and cascade outside of safe operations. 7 Tiered huddles facilitate this process by creating a platform for team members to engage in respectful, collaborative dialogue. The diversity inherent in tiered huddles also supports sensemaking, a process of interpreting and understanding complex situations.27 In a VUCA environment, this multiperspective approach helps filter out noise and identify the most important signals. Tiered huddles can help overcome the phenomenon of dysfunctional momentum associated with cognitive lockup, fixation error, and tunnel vision, in which individuals or teams fixate on a particular solution, thus missing important alternative views.21,28 By fostering a common operating picture of the fluctuating environment, tiered huddles can enable more accurate decision-making and improve organizational resilience.
Avoiding Organizational Drift
One of the most significant contributions of tiered huddles is the ability to detect early signs of organizational drift, or subtle deviations from standard practices that can accumulate over time and lead to serious failures. By continuously monitoring for precursor conditions and weak signals, tiered huddles allow organizations to intervene early and prevent drift from becoming catastrophic.29,30 This vigilance is essential in health care, where complacency can lead to patient harm. Tiered huddles foster a culture of mindfulness and accountability, ensuring that staff stay engaged and alert to potential risks. This proactive approach is a safeguard against human error and the gradual erosion of safety standards.
Leadership Development
Tiered huddles serve as a powerful tool for leadership development. Effective leaders must be able to anticipate potential risks and foresee system failures. Involving future leaders in tiered huddles can facilitate the transfer of these critical skills. When emerging leaders at lower tiers participate in ascending-tier huddles, they gain a unique opportunity to engage in a structured, collaborative setting. This environment provides a safe space to develop and practice strategic skills, enhancing their ability to think proactively and manage complexity. By integrating future leaders into tiered huddles, organizations offer essential, hands-on experience in real-time decision making. This experiential learning is invaluable for preparing leaders to navigate the demands of a VUCA environment.
CONCLUSIONS
Since implementing the tiered huddle process, the Erie VAMC and VISN 4 have emerged as early adopters of VUCA, thus contributing to the expansion of this innovative communication approach across the VHA. Tiered huddles strengthen organizational resilience and agility, facilitate critical information flow to manage risk, and support the cultivation of future leaders. The Erie VAMC director and the VISN 4 network director regard the expansion of tiered huddles, including Tiers 4 and 5, as an adaptable model for the VHA. While tiered huddles have not yet been mandated across the VHA, a pilot at the Tier 5 HOC level was initiated on May 20, 2024. In a complex world in which VUCA events will continue to be inevitable, implementation of robust tiered huddles within complex health care systems provides the opportunity for improved responses and delivery of care.
- Orwell S, Angus I, eds. In Front of Your Nose, 1945-1950. Godine; 2000. Orwell G. The Collected Essays, Journalism, and Letters of George Orwell; vol 4.
- Murray JS, Baghdadi A, Dannenberg W, Crews P, Walsh ND. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22:899-906. doi:10.1136/bmjqs-2012-001467
- Pandit M. Critical factors for successful management of VUCA times. BMJ Lead. 2021;5:121-123. doi:10.1136/leader-2020-000305
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- van Stralen D, Mercer TA. High-reliability organizing (HRO) in the COVID-19 liminal zone: characteristics of workers and local leaders. Neonatology Today. 2021;16:90-101. http://www.neonatologytoday.net /newsletters/nt-apr21.pdf
- Nemeth C, Wears R, Woods D, Hollnagel E, Cook R. Minding the gaps: creating resilience in health care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol 3: Performance and Tools. Agency for Healthcare Research and Quality; 2008.
- Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs medical center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
- Starbuck WH, Farjoun M, eds. Organization at the Limit: Lessons From the Columbia Disaster. 1st ed. Wiley-Blackwell; 2005.
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- Donnelly LF, Cherian SS, Chua KB, et al. The Daily Readiness Huddle: a process to rapidly identify issues and foster improvement through problem-solving accountability. Pediatr Radiol. 2017;47:22-30. doi:10.1007/s00247-016-3712-x
- Clark TR. The 4 Stages of Psychological Safety: Defining the Path to Inclusion and Innovation. Berrett-Koehler Publishers, Inc.; 2020.
- Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. John Wiley & Sons; 2018.
- Edmondson AC. The Right Kind of Wrong: The Science of Failing Well. Simon Element/Simon Acumen; 2023.
- Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808 -810. doi:10.1093/milmed/usac041
- Barber HF. Developing strategic leadership: the US Army War College experience. J Manag Dev. 1992;11:4-12. doi:10.1108/02621719210018208
- US Army Heritage & Education Center. Who first originated the term VUCA (volatility, uncertainty, complexity and ambiguity)? Accessed November 5, 2025. https://usawc .libanswers.com/ahec/faq/84869
- van Stralen D, Byrum SL, Inozu B. High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. CreateSpace Independent Publishing Platform; 2018.
- Perrow C. Normal Accidents: Living With High-Risk Technologies. Princeton University Press; 2000.
- Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Clinical Teams. HCPro; 2021. Accessed November 5, 2025. https://hcmarketplace.com /media/wysiwyg/CRM3_browse.pdf
- Barton MA, Sutcliffe KM, Vogus TJ, DeWitt T. Performing under uncertainty: contextualized engagement in wildland firefighting. J Contingencies Crisis Manag. 2015;23:74-83. doi:10.1111/1468-5973.12076
- Sutcliffe KM. Mindful organizing. In: Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018:61-89.
- Merchant NB, O’Neal J, Dealino-Perez C, Xiang J, Montoya A Jr, Murray JS. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/jmq.0000000000000086
- Senge PM. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. Crown Currency; 1994.
- Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018.
- Coveney PV. Self-organization and complexity: a new age for theory, computation and experiment. Philos Trans A Math Phys Eng Sci. 2003;361:1057-1079. doi:10.1098/rsta.2003.1191
- Weick KE, Sutcliffe KM. Managing the Unexpected: Sustained Performance in a Complex World. 3rd ed. Wiley; 2015.
- Barton M, Sutcliffe K. Overcoming dysfunctional momentum: organizational safety as a social achievement. Hum Relations. 2009;62:1327-1356. doi:10.1177/0018726709334491
- Dekker S. Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems. Routledge; 2011.
- Price MR, Williams TC. When doing wrong feels so right: normalization of deviance. J Patient Saf. 2018;14:1-2. doi:10.1097/pts.0000000000000157
- Orwell S, Angus I, eds. In Front of Your Nose, 1945-1950. Godine; 2000. Orwell G. The Collected Essays, Journalism, and Letters of George Orwell; vol 4.
- Murray JS, Baghdadi A, Dannenberg W, Crews P, Walsh ND. The role of high reliability organization foundational practices in building a culture of safety. Fed Pract. 2024;41:214-221. doi:10.12788/fp.0486
- Goldenhar LM, Brady PW, Sutcliffe KM, Muething SE. Huddling for high reliability and situation awareness. BMJ Qual Saf. 2013;22:899-906. doi:10.1136/bmjqs-2012-001467
- Pandit M. Critical factors for successful management of VUCA times. BMJ Lead. 2021;5:121-123. doi:10.1136/leader-2020-000305
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- van Stralen D, Mercer TA. High-reliability organizing (HRO) in the COVID-19 liminal zone: characteristics of workers and local leaders. Neonatology Today. 2021;16:90-101. http://www.neonatologytoday.net /newsletters/nt-apr21.pdf
- Nemeth C, Wears R, Woods D, Hollnagel E, Cook R. Minding the gaps: creating resilience in health care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches. Vol 3: Performance and Tools. Agency for Healthcare Research and Quality; 2008.
- Merchant NB, O’Neal J, Montoya A, Cox GR, Murray JS. Creating a process for the implementation of tiered huddles in a Veterans Affairs medical center. Mil Med. 2023;188:901-906. doi:10.1093/milmed/usac073
- Starbuck WH, Farjoun M, eds. Organization at the Limit: Lessons From the Columbia Disaster. 1st ed. Wiley-Blackwell; 2005.
- Mihaljevic T. Tiered daily huddles: the power of teamwork in managing large healthcare organisations. BMJ Qual Saf. 2020;29:1050-1052. doi:10.1136/bmjqs-2019-010575
- Donnelly LF, Cherian SS, Chua KB, et al. The Daily Readiness Huddle: a process to rapidly identify issues and foster improvement through problem-solving accountability. Pediatr Radiol. 2017;47:22-30. doi:10.1007/s00247-016-3712-x
- Clark TR. The 4 Stages of Psychological Safety: Defining the Path to Inclusion and Innovation. Berrett-Koehler Publishers, Inc.; 2020.
- Edmondson AC. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. John Wiley & Sons; 2018.
- Edmondson AC. The Right Kind of Wrong: The Science of Failing Well. Simon Element/Simon Acumen; 2023.
- Murray JS, Kelly S, Hanover C. Promoting psychological safety in healthcare organizations. Mil Med. 2022;187:808 -810. doi:10.1093/milmed/usac041
- Barber HF. Developing strategic leadership: the US Army War College experience. J Manag Dev. 1992;11:4-12. doi:10.1108/02621719210018208
- US Army Heritage & Education Center. Who first originated the term VUCA (volatility, uncertainty, complexity and ambiguity)? Accessed November 5, 2025. https://usawc .libanswers.com/ahec/faq/84869
- van Stralen D, Byrum SL, Inozu B. High Reliability for a Highly Unreliable World: Preparing for Code Blue Through Daily Operations in Healthcare. CreateSpace Independent Publishing Platform; 2018.
- Perrow C. Normal Accidents: Living With High-Risk Technologies. Princeton University Press; 2000.
- Sculli G, Essen K. Soaring to Success: The Path to Developing High-Reliability Clinical Teams. HCPro; 2021. Accessed November 5, 2025. https://hcmarketplace.com /media/wysiwyg/CRM3_browse.pdf
- Barton MA, Sutcliffe KM, Vogus TJ, DeWitt T. Performing under uncertainty: contextualized engagement in wildland firefighting. J Contingencies Crisis Manag. 2015;23:74-83. doi:10.1111/1468-5973.12076
- Sutcliffe KM. Mindful organizing. In: Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018:61-89.
- Merchant NB, O’Neal J, Dealino-Perez C, Xiang J, Montoya A Jr, Murray JS. A high-reliability organization mindset. Am J Med Qual. 2022;37:504-510. doi:10.1097/jmq.0000000000000086
- Senge PM. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. Crown Currency; 1994.
- Ramanujam R, Roberts KH, eds. Organizing for Reliability: A Guide for Research and Practice. Stanford University Press; 2018.
- Coveney PV. Self-organization and complexity: a new age for theory, computation and experiment. Philos Trans A Math Phys Eng Sci. 2003;361:1057-1079. doi:10.1098/rsta.2003.1191
- Weick KE, Sutcliffe KM. Managing the Unexpected: Sustained Performance in a Complex World. 3rd ed. Wiley; 2015.
- Barton M, Sutcliffe K. Overcoming dysfunctional momentum: organizational safety as a social achievement. Hum Relations. 2009;62:1327-1356. doi:10.1177/0018726709334491
- Dekker S. Drift Into Failure: From Hunting Broken Components to Understanding Complex Systems. Routledge; 2011.
- Price MR, Williams TC. When doing wrong feels so right: normalization of deviance. J Patient Saf. 2018;14:1-2. doi:10.1097/pts.0000000000000157
Negotiating the VUCA World Through Tiered Huddles
Negotiating the VUCA World Through Tiered Huddles
As Federal Cuts Deepen Mental Health Crisis, Philanthropy Scrambles to Fill the Gap
As Federal Cuts Deepen Mental Health Crisis, Philanthropy Scrambles to Fill the Gap
It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.
Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.
"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."
Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.
Budget Cuts Reach Far and Wide
Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.
"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.
The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.
"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."
All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.
"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."
Foundations Take Emergency Measures
Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.
We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.
"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."
The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.
"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."
At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.
"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."
Some See Hope in Raised Voices
Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.
"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."
As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.
"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."
Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.
A version of this article first appeared on Medscape.com.
It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.
Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.
"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."
Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.
Budget Cuts Reach Far and Wide
Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.
"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.
The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.
"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."
All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.
"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."
Foundations Take Emergency Measures
Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.
We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.
"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."
The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.
"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."
At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.
"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."
Some See Hope in Raised Voices
Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.
"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."
As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.
"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."
Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.
A version of this article first appeared on Medscape.com.
It's hardly news that the United States is experiencing a mental health crisis -- the CDC says as much. But experts in the field say that the current administration has severely compounded the problem by eliminating agency funding and national programs, slashing research grants and data resources, and creating new barriers to behavioral health care.
Philanthropic foundations aim to do what they can to address the shortfall. The numbers, however, just don't add up.
"Some big foundations and philanthropies have said they're going to increase what they give out in the next 4 years, but they'll never be able to fill the gap," said Morgan F. McDonald, MD, national director of population health at the Milbank Memorial Fund in New York City, which works with states on health policy. "Even if every one of them were to spend down their endowments, they still couldn't."
Given the financial limitations, some foundations are taking a different tack. While looking for ways to join forces with fellow nonprofits, they are providing emergency grants to bridge funding in the short term to keep research from grinding to a halt.
Budget Cuts Reach Far and Wide
Mental health research certainly didn't escape the extensive grant cancellations at the National Institutes of Health and the National Science Foundation.
"It's already affecting our ability to stay on the cutting edge of research, best practices, and treatment approaches," said Zainab Okolo, EdD, senior vice president of policy, advocacy, and government relations at The Jed Foundation in New York City, which focuses on the emotional health of teens and young adults.
The upheaval is evident in an array of government agencies. The Health Resources and Services Administration, which last year awarded $12 billion in grants to community health centers and addiction treatment services, has seen > one-fourth of its staff eliminated. The Substance Abuse and Mental Health Services Administration has lost more than a third of its staff as federal cuts took a $1 billion bite out of its operating budget. The Education Department has halted $1 billion in grants used to hire mental health workers in school districts nationwide.
"We're very, very concerned about cuts to behavioral health systems," said Alonzo Plough, PhD, chief science officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. "Doctors and nurses working in safety-net clinics are seeing tremendous reductions."
All in all, the new tax and spending law means $1 trillion in cuts to health care programs including Medicaid -- the nation's largest payer for mental health services -- Medicare, and Affordable Care Act insurance. An estimated 10 million Americans are expected to lose their health coverage as a result.
"When accessibility to care goes down, there's a chance that more people will die by suicide," said Jill Harkavy-Friedman, PhD, senior vice president of research at the American Foundation for Suicide Prevention. "But it also means people will come into care later in the course of their difficulties. Health professionals will be dealing with worse problems."
Foundations Take Emergency Measures
Even if private dollars can't replace what's been lost, philanthropic and medical foundations are stepping up.
We're seeing a lot of foundations and funders that are shifting their funding," said Alyson Niemann, CEO of Mindful Philanthropy, an organization that works with > 1000 private funders to marshal resources for mental health. This year, in response to federal cuts, "many increased funding to health and well-being, doubling or even tripling it," Niemann noted.
"They're making a great deal of effort to respond with emergency funds, really getting in the trenches and being good partners to their grantees," she said. "We've seen them asking deliberate questions, thinking about where their funding can have the most impact."
The American Psychological Foundation (APF), a longtime supporter of research and innovation, is addressing the current crisis with 2 initiatives, Michelle Quist Ryder, PhD, the organization's CEO, explained in an email. The first is APF Director Action, which funds innovative interventions at the community level. The second, Direct Action Crisis Funding Grants, will help continue research that is at risk of stalling because of budget cuts.
"Studies that are 'paused' or lose funding often cannot simply pick back up where they left off. Having to halt progress on a project can invalidate the work already completed," Ryder wrote. "These Direct Action Crisis Grants help bridge funding gaps and keep research viable."
At the same time, collaboration between foundations is becoming more widespread as they seek to maximize their impact. Philanthropic organizations are sharing ideas and best practices as well as pooling fundings.
"The goal of philanthropy is to help people," Harkavy-Friedman said. "There's strength in numbers and more dollars in numbers."
Some See Hope in Raised Voices
Despite the emergency scrambling, many of those in the trenches remain surprisingly optimistic. Some point out that the current turmoil has put a helpful spotlight on behavioral health care. Practitioners, meanwhile, have an essential role to play.
"There's a reason that things were the way they were: People advocated for many years to get where we've gotten," Harkavy-Friedman said, citing veterans' mental health care, the national violent death reporting system, and 988 as examples. "We have to raise our voices louder -- professionals in particular, because they know the impact a person in the general public many not fully grasp."
As a growing numbers of health professionals call attention to the damage wrought by deep cuts in the federal budget, foundation executives see an opportunity.
"In the mental health field, there's a deficit in the narrative, where there's a lot of focus on crisis. What we're hoping to do is shift the narrative toward 'How do we flourish together?'" Niemann said. "Sometimes deficits are where the most incredible innovations appear."
Debbie Koenig is a health writer whose work has been published by WebMD, The New York Times, and The Washington Post.
A version of this article first appeared on Medscape.com.
As Federal Cuts Deepen Mental Health Crisis, Philanthropy Scrambles to Fill the Gap
As Federal Cuts Deepen Mental Health Crisis, Philanthropy Scrambles to Fill the Gap
Indian Health Service: Business as Usual During Shutdown
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.
Despite the ongoing shutdown of the US federal government, the Indian Health Service (IHS) continues to maintain the status quo while operating on an island of relatively insulated stability.
“IHS will continue to operate business-as-usual during a lapse of appropriations,” US Department of Health and Human Services press secretary Emily G. Hilliard said at a recent meeting with the National Congress of American Indians (NCAI). “100% of IHS staff will report for work, and health care services across Indian Country will not be impacted.”
The protective cocoon around IHS and its services provided is largely due to advance appropriations, and lessons learned from previous government shutdowns. During the historically long 35-day government shutdown in 2018 and 2019, all federal government operations had to halt operations unless they were deemed indispensable. IHS was not considered indispensable and consequently, about 60% of IHS employees did not receive a paycheck.
In preparation for another potential shutdown in 2023, IHS was more proactive. “Because of the fact that now we have advanced appropriations for Indian Health Services, on Oct. 1, whether or not there’s a federal budget in place, will continue providing services,” then-HHS Secretary Xavier Becerra, said at the time.
The safeguards have held for the current shutdown, aided by tribal pressure. As the federal shutdown loomed in September, a delegation led by NCAI spent 3 days lobbying Congress—focusing primarily on the new leadership in the Senate Indian Affairs Committee—to guarantee some protection for federal employees who work with tribal governments.
At the quarterly meeting of the United Indian Nations of Oklahoma (UINO) in Tulsa, Rear Adm. Travis Watts, director of the IHS Oklahoma City Area and a citizen of the Choctaw Nation of Oklahoma, told attendees, “The advance appropriations allow us to keep our doors open at this particular time. We want to thank the tribal nations for their advocacy for those advance appropriations.”
IHS is funded through 2026. All 14,801 IHS staff will be paid through advance appropriations, multi-year or supplemental appropriations, third-party collections, or carryover balances.
However, according to the proposed 2026 budget some key health-related funding is at risk, including about $128 million in Tribal set-aside funding for mental and behavioral health funding: $60 million from the Tribal Opioid Response Grants, $22.75 million from Tribal Behavioral Health Grants, $14.5 million from Medication-Assisted Treatment for Prescription and Opioid Addiction, and $3.4 million Tribal set-aside for the Zero Suicide program. Six IHS accounts are not funded by advance appropriations: Electronic Health Record System, Indian Health Care Improvement Fund, Contract Support Costs, Payments for Tribal Leases, Sanitation Facilities Construction, and Health Care Facilities Construction.
In a public statement, Cherokee Nation Principal Chief Chuck Hoskin Jr. said, “[W]e’re hopeful that Congress’ foresight to provide an advance appropriation for the Indian Health Service will prevent any severe disruptions as experienced during the 2013 and 2018 shutdowns. I urge both sides of the aisle to work on a path forward and reopen the government as soon as possible and call on the administration to honor the government’s Treaty and Trust responsibilities, avoid needless cuts to Tribal programs and personnel, and use its authorities to minimize harm to tribes and tribal citizens.”
Hoskin Jr. cautioned, though, that not every tribe has the same resources. Many smaller, direct-service tribes depend entirely on IHS to deliver care.
“Thank goodness for forward funding,” he said. “But we have to make that permanent in federal statute. No one in this country should be at the mercy of political dysfunction to get health care.