By: Nicholas Testa, MD | Chief Clinical Officer, Sentact
I want to start with a definition, because I think it matters more than most people realize.
When I talk with healthcare leaders about improving their organizations, I always come back to one fundamental question: what is healthcare, exactly? To improve something, you first must define it. And for me, healthcare is defined by four things: it must be safe, it must be high quality, it must provide a good patient experience, and it must be compliant.
That hierarchy is intentional. Safety comes first. Not because quality doesn’t matter, or because patient experience is secondary, but because I genuinely don’t believe we can reliably deliver any of the other three without getting safety right first. That’s the foundation.
And that brings me to what I believe is one of the most important (and most misunderstood) movements in modern healthcare: the pursuit of high reliability.
What High Reliability Actually Means
A High Reliability Organization, or HRO, is one that’s able to function through complex, dynamic systems and still produce fewer than its fair share of errors. That is achieved by doing the same things, the same way, repeatedly, even when conditions are constantly changing. Any complex system that is striving to become Highly Reliable will encounter setbacks, discover inconsistency, and, in high-risk environments, confront tragedy. Ultimately, it is how the organization responds to these events along its journey that will predict its success. To change a complex system requires resilience, curiosity, and collaboration. Too often, when discussing high reliability, we become fixated on the goal and miss that the journey is where the hard work and results live.
“High reliability has changed other industries — the airline industry, the nuclear industry — getting them toward zero deficit. The opportunity is ripe within healthcare.”
High reliability isn’t a new idea in healthcare. There’s been a significant, commendable groundswell of work throughout the industry over the past two decades. Hospitals have invested in educational programs, leadership training, unit-based teams, and countless frameworks designed to shift the culture. And much of that work has been remarkable.
So why are we still talking about it as something healthcare is “pursuing” rather than something it has “achieved”?
The Problem With Culture Alone
I’ve had the privilege of leading high reliability work in multiple health systems, including serving as the Chief Medical Officer for the California region of one of the largest healthcare systems in the country, overseeing 29 hospitals. I’ve seen what happens when these programs are done well, as well as what happens when they struggle.
The honest observation I keep coming back to: Structure tends to overly rely on the leaders who are running it. And when those leaders leave, delegate, or reprioritize, the programs themselves can quickly begin to falter. In the case of high reliability, the work often begins with intense institutional focus and early incremental gains, but over time, it can take a back seat as leadership priorities shift in response to the dynamic healthcare environment.
From my viewpoint, it’s never because the leaders don’t care. Quite the contrary — in my experience, they care deeply. But hospitals are constantly facing new priorities, mandates, and operational pressures, which means even the most committed leaders are continually forced to reprioritize and delegate.
To truly create a culture that is reliable, leadership needs to extend its influence through tools that reinforce accountability to key safety principles and make it easier to put new expectations into practice.
“There is not enough scaffolding built around it to make it durable. So, if the leader leaves, how does that program stay in place?”
Take the safety huddle, for example. It’s one of the most valuable practices you can implement in a hospital: a daily gathering of key leaders to review what happened yesterday and prepare for what’s coming. But visit almost any hospital, and you’ll still find someone standing at a whiteboard writing things down, or typing into an Excel spreadsheet, or relying on a single champion whose departure would immediately put the whole practice at risk.
Or consider rounding. We all know that leaders rounding on patients and units is one of the most powerful tools we have for improving safety, quality, and experience simultaneously. But how often does “rounding” mean someone walking the halls informally, doing their best with good intentions, with no standardized process, no accountability, and no data coming out the other side?
The healthcare industry has borrowed heavily from the airline industry’s cultural playbook — psychological safety, speaking up, checking and cross-checking. And that was the right thing to do. But here’s what I think we missed: the airline industry didn’t achieve safety just by changing culture. They paired their culture change with tangible technology that made it easier to do the right thing. They built equipment that made reliable event reporting and checklists easier and more automatic. They put systems in place that held the culture up.
Healthcare has done the first half. It’s time to focus on the second.
The Reality of the High Reliability Journey
The high reliability journey is complex. It takes years, and as your culture evolves to embrace greater transparency and psychological safety, the number of identified harm events may appear to get worse before it gets better.
If I were to advise a chief medical officer who has just been told they’re going to lead a high reliability program, I’d tell them three things: be brave, be persistent, and be patient.
Brave, because they’re almost certainly going to be confronted with things they don’t fully understand. Persistent, because the enthusiasm that surrounds a new initiative in the first few months will inevitably fade when a new organizational priority emerges. And patient, because a genuine high reliability journey takes years.
“If you’re really taking on a true high reliability journey, the first thing you’re going to see — as your staff becomes more confident and comfortable reporting — is an uptick in your serious safety events. That’s the exact opposite of what you want. But if you’re culture-changing, that’s exactly what happens first.”
At first, this can feel counterintuitive, even like a setback. But in truth, it means you’re beginning to see your organization more clearly as your teams embrace a culture that prioritizes safety. As psychological safety improves and people feel more comfortable raising concerns and reporting near misses, event numbers often go up. In moments like these, leaders need to be simultaneously curious and courageous.
The organizations that succeed are the ones that can hold steady through that initial turbulence, because they understand that the goal is to build a learning culture, and a learning culture generates visible data. Anticipating this early increase also allows teams to prepare for it, respond thoughtfully, and avoid mistaking greater visibility for worsening performance.
Another barrier that tends to alienate those from the high reliability journey is when it becomes too much of an academic exercise. People hear the term “high reliability” and assume it’s something an expert somewhere understands, not something they can lead. That’s a shame, because anyone can lead this work. What they need is clarity, support, and the right tools.
What Healthcare Has Been Missing: The Scaffolding
I use the word “scaffolding” deliberately. Think about what scaffolding does: it doesn’t replace the building. It holds the building up while it’s being constructed. It provides structure and support so that the work that’s happening inside can be sustained.
That’s exactly what technology needs to do for high reliability programs in healthcare. The hospitals will do the cultural change. What technology provides are the tools to make that culture change durable. Not to replace it. Not to automate it. But to institutionalize it, so it keeps going when the champion moves on, when a new initiative is prioritized, when the environment shifts.
Take the rounding example we already discussed. A robust rounding platform doesn’t just track whether rounding happened; it guides the person rounding and adds a higher level of purpose to the activity. It creates accountability for those who rounded, what they observed, and what actions were triggered as a result. When an environmental issue is identified during a round, it doesn’t go into a notebook and get forgotten. It generates a task, it gets routed, it gets resolved, and it gets closed in the system. That loop — observe, report, act, close — is what turns rounding from a feel-good activity into a genuine improvement mechanism.
“Just because you buy a rounding product doesn’t mean you’re going to round. But if you have a robust rounding program that you take pride in, and you connect it to technology that monitors outcomes after you leave — it is very likely that program will continue.”
Then there’s the safety huddle. You can have the best huddle practice in the country. But if the information from that huddle lives on a whiteboard or in someone’s head, you’ve lost it by noon. A strong technology platform allows you to enter information into a dashboard, cascade it to the different huddles happening throughout the hospital, and build consistency into the structure of the meeting itself. Every day looks the same. Every leader gets the same information. That consistency is what makes it reliable.
And take event reporting. If staff is going to report events, they need to trust that doing so is safe — that their candor won’t be turned against them. That’s why the combination of accessible, easy-to-use event reporting software with the protections of a Patient Safety Organization (PSO) is so powerful. The PSO creates a legal cloak around those reviews. It means that when someone reports a near miss, that report stays protected within the system. That is exactly what you need to build a culture of psychological safety — not just talking about it but structurally guaranteeing it.
If you look across all these tools, there’s a single thread: they’re all different mechanisms for getting to the same place, which is reliably safe practice. Not sometimes safe. Not safe when the right leader is in the room. Reliably, systematically, durably safe.
Why Now – And The Financial Reality
The financial pressure within healthcare constantly challenges hospitals to balance their capital needs, care for anyone who presents to the Emergency Department, and maintain the capital not just to grow, but to keep operating effectively.
Healthcare systems will always face financial constraints, and every purchase will beg the question, “What is the return on investment for this purchase?” Justifying a new million-dollar robot that brings in more surgical volume can sometimes be easier than investing thousands of dollars in safety tools that may never directly attract more patient volume. That said, I think we often overlook the cultural and financial impact a leader can have by building their vision around safety.
“I’ve never seen a board criticize a CEO for investing in safety. I’ve never seen a hospital do worse because it tried to become safer. If you’re looking for one platform that can uniformly galvanize support across the whole hospital, it’s this: how do we make our hospital safer?”
Safety is not a departmental initiative. It’s not a budget line that competes with one constituency against another. It is the one mission that every person in the building — from the board to the bedside — will rally behind. And the case for investing in it is not complicated: every CEO I have worked with who has made safety the foundation of their leadership has been successful.
We’re also in a moment where the tools have genuinely caught up with the ambition. The technology that exists today — integrated rounding platforms, real-time safety huddle dashboards, analytics that can tell you your serious safety event rate in a meaningful, actionable way — is far more capable than what existed even five years ago. The infrastructure’s here. The question is whether organizations will build on it.
Why I Am Here
I spent a long time as a health system leader. I was proud of that work, and I learned something valuable in every hospital I visited and every conversation I had with a patient, a nurse, a physician. I have been privileged to see what it takes to build a safety culture from the inside.
But I also saw the limitations of working within a single system. You can move 29 hospitals. You can change a region. But the same problems are happening simultaneously in thousands of hospitals across the country, and the cultural change is moving faster than the infrastructure supporting it.
That’s why I made the transition to Sentact — because I believed that having the opportunity to now support not one healthcare system, but the entire healthcare industry, was too important to pass up.
The vision I had been working toward for years had reached the critical mass to deliver on its promise: a single partner that could provide hospitals with the technology, the analytics, and the human expertise (consulting, peer review, medical staff support) to genuinely become a High Reliability Organization.
Because here’s what I know to be true: hospitals aren’t going to stop caring about safety. Leaders aren’t going to stop trying. The commitment is there. What has been missing is the scaffolding that holds those programs up across leadership transitions, across budget cycles, across the inevitable entropy of a complex system.
High reliability isn’t a destination you arrive at and then move on from. It’s something you build, continuously, through the right combination of culture and systems working together. Healthcare has done extraordinary work on the culture side. The next chapter is building the scaffolding around it.
About The Author
Nicholas Testa, MD, is Chief Clinical Officer at Sentact, where he leads the clinical strategy across the company’s integrated suite of safety, quality, experience, and compliance solutions. He previously served as Chief Medical Officer for the California region of CommonSpirit Health, overseeing 29 hospitals. Dr. Testa is a board-certified emergency physician and has led high reliability implementations across multiple large health systems.
