What Safer Care Actually Requires: Lessons from Three Health System Leaders on Patient Safety, Quality and Culture
Insights from leaders at Henry Ford Health, Nemours Children’s Health and Nicklaus Children’s Health System
Healthcare has never had more data. What we still struggle with is visibility, especially hearing what frontline teams, patients and families are already telling us and acting on it before harm reaches a patient. The signals exist. The question is whether we capture them early and connect them across silos to turn them into decisions that make care safer.
At a recent RLDatix Executive Exchange event, three health system leaders shared what is working inside their organizations right now. Vanessa Mona, Vice President of Consumer Insights and Experience at Henry Ford Health; Dr. Jared Capouya, Chief Quality and Patient Safety Officer at Nemours Children’s Health; and Randy Harmatz, Chief Quality Officer at Nicklaus Children’s Health System, spoke candidly about the progress they are making, the resistance they have navigated and the conditions that make improvement stick.
Three very different organizations discussed the same three imperatives underneath it all: reliable care, resilient operations and a ready culture enabling them to learn and adapt together.
Reliable Care: See risk clearly. Deliver safer care, consistently.
Using connected data and proactive learning to prevent harm before it happens
Reliable care depends on seeing risk as it actually shows up in the care delivered every day. That may sound simple, but it takes intentional effort: standardizing how information is captured, connecting it across silos and building learning into the way teams respond.
At Henry Ford Health, that work started by bringing patient experience and complaint data into the same view for the first time. What patients and families described became a source of operational learning, not simply experience measurement. Those insights then informed a frontline training program built around the issues patients identified most often.
“We trained 1,700 nurses and MAs, taking the actual data, actual insights, actual direct feedback. That’s how we created our training program.”
Vanessa Mona, Vice President of Consumer Insights and Experience, Henry Ford Health
Nemours Children’s Health has taken the same principle and hard-wired it into how they learn from safety events. Rather than treating root cause analysis as a retrospective exercise done for families, Dr. Capouya and his team are bringing families directly into the process.
“If we can shift our learnings from ‘yes, something bad really happened’ to ‘what were the ingredients that led to that thing, what was the context’ — those ingredients are there every day.”
Dr. Jared Capouya, Chief Quality and Patient Safety Officer, Nemours Children’s Health
Family engagement in root cause analysis is a concrete move from a Safety I mindset (counting what went wrong) to a Safety II mindset (understanding how care usually goes right, and where it almost does not, under real-world conditions).
When patient, family and frontline signals are captured consistently and connected across teams to feed back into how care is designed, reliability stops being an abstract goal and starts showing up in everyday decisions.
Resilient Operations: Build operations that bend without breaking
Recognizing and responding to emerging risk before it becomes harm
Resilient operations depend on an organization’s ability to see what is changing on the frontline and respond before small issues become larger ones.
Some signals show up in safety events while others appear in staffing challenges, patient concerns, workflow friction or workarounds teams create simply to get through the day. The challenge is not whether those signals exist. The challenge is making them visible to the people who can act on them.
At Nicklaus Children’s Health System, Randy Harmatz described one way her organization is creating that visibility: bringing board members into safety rounding. One board member, a financial professional who initially wondered whether he had anything to contribute to quality discussions, rounded in the PICU. Harmatz described the shift:
“It was amazing for him to be able to talk to the frontline nurses, see the patients, see the conflict, the complexity. He had not only the perspective of a board member, but he also saw from the perspective of the patient, as well as the staff.”
Randy Harmatz, Chief Quality Officer, Nicklaus Children’s Health System
The value was not simply board engagement. It was creating a clearer understanding of the realities experienced every day on the frontlines. A family’s request for a refrigerator on a long-stay oncology unit might seem like a small operational issue. Instead, it became a window into the experience of extended hospitalization and highlighted needs that were not visible through traditional reporting.
Resilience is not the absence of disruption. It is the ability to be agile and adapt safely when disruption occurs. The organizations that perform best are not those that avoid surprises altogether, but those that recognize emerging risk early and have clear pathways for escalating concerns and coordinating action, ultimately leading to learning from their findings.
Those moments matter because resilience is built long before a crisis occurs.
“My org chart is going to have AI and agents as part of it, because it’s the world we’re moving into. The human is never going to go away from healthcare, but how do we use the technology to help us become more proactive.”
Vanessa Mona, Vice President of Consumer Insights and Experience, Henry Ford Health
The goal is not replacing human judgment. It is helping organizations identify patterns earlier, create ongoing learning and optimize capacity to focus on patient care.
Technology strengthens resilience when it helps organizations capture signals once, connect them across teams and reduce the burden of finding patterns manually. When those signals are connected, leaders can identify emerging risks earlier and focus attention where it is needed most.
Learn how RLDatix supports integrated healthcare operations
Ready Culture: Make safety and accountability the way work gets done
Building just culture, psychological safety and high reliability from the frontline up
Culture is not a program or a values statement. It is the collective result of how people communicate, learn and act every day.
“Culture has to be treated like a living, breathing entity. Staff watch what we do, they watch what we say, they watch how we react to particular situations. We ask amazingly talented people to often work in imperfect systems.”
Randy Harmatz, Chief Quality Officer, Nicklaus Children’s Health System
Leaders influence culture through how they respond when concerns are raised and when harm occurs. But culture is also shaped by whether frontline teams feel heard and whether patients and families are included in learning. Most importantly, it’s whether the organization actions on findings to make and move forward with real change.
Vanessa Mona described how language alone can determine whether an initiative takes hold or stalls. When her team introduced bedside shift reports as a patient experience initiative, clinical teams pulled back. Reframed as a safety and quality initiative, the same practice produced the opposite response.
“Team members don’t show up every day going, ‘Today I’m going to harm somebody.’ They go in today and say, ‘I’m going to keep my patients safe.’ If they start with that mentality, then it’s much easier for them to incorporate these initiatives.”
Vanessa Mona, Vice President of Consumer Insights and Experience, Henry Ford Health
A ready culture creates conditions where staff speak up, where their input leads to visible change and where patient safety is understood as the organizing logic of the work, not a separate lane.
A ready culture also means shifting attention to what is going well, not only what has broken. Dr. Capouya described positive rounding as a core part of the practice:
“It’s not just what’s going wrong. It’s ‘what are you celebrating, what’s working well, what do you find joy in?’ Because that really gets the conversation flowing.”
Dr. Jared Capouya, Chief Quality and Patient Safety Officer, Nemours Children’s Health
When one unit is consistently achieving strong outcomes, the conditions behind those results deserve the same rigor as a post-event investigation. Organizations that learn only from failures miss half the story. Learning from what is going right is equally central to a stronger safety system.
The Common Thread
Across the conversation, the common thread was clear: safer care starts with better visibility, but it depends on what organizations do with what they see. Healthcare is not short on signals. Frontline staff, patients, families, complaints, safety events, near misses, operational challenges and experience data are all telling part of the story.
The challenge is bringing those signals together in a way that helps organizations understand what is really happening and where risk is building. The right technology helps teams connect those signals, identify patterns sooner and focus attention where it matters most, not by replacing people, but by helping people see what matters faster.
That is what safer care actually requires. And it is how we raise the standard of care, everywhere.
Explore how RLDatix helps health systems raise the standard of care.
Key Takeaways
- Connected signals drive reliable care. Bringing patient, family and frontline input into the same view helps organizations understand where care is working, where risk is emerging and what needs to change.
- Learning from conditions, not just events, is the next frontier of patient safety. Shifting from “what went wrong” to “what ingredients were present” surfaces risks that exist every day, not only after harm occurs.
- Governance improves when it is grounded in frontline reality. Safety rounding gives leaders and board members direct exposure to the conditions staff, patients and families experience every day, turning abstract quality metrics into better-informed decisions.
- Framing influences adoption. How an initiative is positioned shapes how people prioritize it. Efforts connected to patient safety and quality are more likely to gain traction because they connect directly to clinicians’ purpose: delivering safe, high-quality care.
- Patient and family engagement in root cause analysis strengthens outcomes. Integrating family voice into the investigation and action planning process produces insights that would not otherwise surface and makes resulting actions more durable.
- Frontline voice is a resilience strategy. Positive rounding and other listening practices help organizations learn from what is working, not only from what has gone wrong.
- Technology should reduce friction, not add it. Connected safety, risk and experience data can help organizations move from reactive response toward earlier, more proactive prevention.
RLDatix is a global healthcare technology company helping more than 10,000 organizations raise the standard of care through connected solutions for patient safety, risk and compliance, credentialing and workforce management.
