Ivy Latoja Pacis is the High Reliability Organization (HRO) Officer for the Veterans Affairs Capitol Health Care Network, where she leads efforts to reduce preventable harm and builds a Just Culture for nearly 14,000 staff members serving 700,000 Veterans across Maryland, West Virginia, and Washington, DC. She launched HRO University to expand employee capabilities and established the Safety Story and Strong and Promising Practices Portal, which increased safety reporting and improved the close-to-adverse event ratio. Her Coin of Excellence Award Program improved employee engagement, raising organizational health index ranking from 16th to the top 5 nationwide, with three facilities in the national Top 20 for psychological safety. Her pioneering programs are being adopted across the VHA, benefiting Veterans and employees. She also serves as an adjunct faculty at Johns Hopkins School of Nursing, was the inaugural chair of the VHA Network HRO Leads and led 23 national specialty care program offices toward high reliability. Dr. Pacis is a Fellow of the American College of Healthcare Executives and holds a BSN from Central Philippine University, MSN and MHA from the University of Phoenix, and a DNP Executive from Johns Hopkins. She was recently accepted into Harvard Medical School’s Safety, Quality, Informatics, and Leadership program.