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July 29, 2026
By Marcus Henry
VA Research Communications
Leadership matters to how teams perform, and so we need to take care of our front-line clinical leaders. (Dr. Heather Gilmartin)
The physician introduces himself as the chief of hospital medicine, amongst his other positions in outpatient care, the community living center, and the pharmacy. The national average for a health care executive is seven years – he’s the third chief of the facility in that amount of time.
In rural VA hospitals, this is often what leadership looks like: executive leaders wearing several hats, with few peers to lean on, who turn over so often that no mission has time to set. This in turn leads to burnout from competing initiatives, not enough time, and low levels of trust within small facilities already stretched thin.
VA’s Office of Rural Health knew the struggle happening in the field, and they searched for a solution. They found Dr. Heather Gilmartin, a supervisory research health scientist at the Denver-Seattle Center of Innovation, and her program: AIM-HI, short for the Acute Inpatient Medicine - High Reliability Learning Environment and Workforce Development Initiative.
The engine of AIM-HI is a toolkit called the Relational Playbook: roughly 50 evidence-based practices for the hard work of building a positive culture, focusing on teamwork, servant leadership, joy in work, communication, and high reliability.
She assembled it during a VA Career Development Award through the Office of Research and Development, after spending five years inside VA’s highest-performing cardiac catheterization labs, cataloging the habits and practices that set the best teams apart. What she found were not medical secrets, they were timeless management and high-reliability practices, adapted for busy clinical teams.
The plan was to keep the work in cardiology.
The Office of Rural Health thought it could work for them.
So Gilmartin’s team did something researchers rarely do with a leadership program: they tested the Playbook in the field and rigorously evaluated every aspect.
Their findings, published in the Journal of Rural Health, come from the front end of that work, what the field calls a pre-implementation study. The team visited three VA hospitals that serve mostly rural Veterans and sat with leaders across medicine, nursing, social work, and pharmacy.
What rural hospitals said they needed, Gilmartin recalled, were tools they could use immediately to get quick wins.
So, the team kept the Relational Playbook simple and low burden: just 30 minutes a week over six months. Practices include Humble Inquiry, where a leader trades having the answer to every problem for asking better questions, and Appreciative Inquiry, which asks a spiraling team to name one thing it did well today, and then another.
Others are just as concrete: Three Good Things, where staff write down three things that went right each day for a week; Stop, Start, Continue, where a team decides what processes to quit, what to try, and what to keep; and the Gratitude Huddle, a few minutes for a team to name what it is thankful for. All small moves that, when repeated, create positive team cultures open to learning new things.
The pre-implementation study also reshaped who gets invited to the training. In a large urban hospital the chief of medicine is a physician, but in a rural one that chief might be a nurse practitioner or a physician assistant. So the team widened the door to all the clinical leaders who hold a small hospital together.
The team has already seen AIM-HI’s success at changing culture. One site that had hit a hard, public stretch – Gilmartin remembered the chief of nursing said, “All we have is up” – has become one of the program’s strongest sites. At another site, a pharmacy leader who enrolled in AIM-HI to sharpen his resume on his way out of the VA was instead changed as a leader and helped his team become more positive and supportive. He found joy in the work again. He stayed in VA.
As an assessment of how the Playbook could help VA’s rural facilities, this wasn’t a causal study measuring Veteran outcomes – determining exactly how a stable and happier workforce benefits rural Veterans is still ahead.
Measuring that benefit is the team’s next frontier: future work will track team functioning, clinician well-being, and what any of it means for Veterans. Gilmartin is candid that she does not yet have a good way to draw a direct line from a high-performing team to better Veterans’ health, and she is asking for help finding one.
Meanwhile, AIM-HI is recruiting more rural hospitals and is testing the Relational Playbook with national VA leaders from the VA Office of Nursing Services and the Office of Rural Health. The team has also secured VA technology-transfer clearance to carry the Relational Playbook beyond VA’s walls. Gilmartin aims for it to become a permanent, standing program for clinical leaders across the system.
“Leadership matters to how teams perform, and so we need to take care of our front-line clinical leaders,” Gilmartin said. “If we can support our front-line leaders, then teams can focus on what matters most to them, which is learning, innovating, finding joy in work, and providing excellent clinical care to Veterans.”
The study appeared in the Journal of Rural Health.
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