Abstract
BACKGROUND: The Veterans Health Administration is the largest integrated health care system in the United States, and becoming an enterprise-wide high reliability organization (HRO). In extremely complex and risk-prone environments, HROs provide safe, high-quality patient care without causing harm or adverse events. Integral to this work is psychological safety-the belief that team members can comfortably speak up when they have questions, voice concerns (especially regarding safety), take risks, and suggest ways of doing things differently. These actions are taken without undue fear of negative consequences, such as humiliation or criticism. Although progress has been made, much still needs to be done to promote psychological safety in all health care systems-especially HROs. OBSERVATIONS: In its journey to become an enterprise-wide HRO, the Veterans Health Administration has implemented initiatives to develop and foster psychological safety as a means to promote patient safety and improve outcomes. In this article, we describe strategies that can be implemented to promote psychological safety. CONCLUSIONS: Psychological safety is critical to providing safe, quality health care within an HRO. However, achieving and cultivating psychological safety in this setting requires time and patience and must be actively promoted and supported. It also requires thoughtful and purposeful attention to strategies that promote a culture where individuals feel safe to speak up when they have safety concerns.