World Patient Safety Day puts a specific spotlight on health workers this year, calling on the industry to help them strengthen patient safety culture and practices. In recognition of the day, Sentact is launching the “Patient Safety Expert Spotlight,” a new series of conversations with the people building safer care, one unit at a time.
Our first guest is Dr. Allison Luu, Patient Safety Officer and Assistant Chief Quality Officer at one of the nation’s largest and busiest public safety-net teaching hospitals, and a practicing emergency physician who also teaches residents on shift. It’s an environment that’s often short on time, staff, and funding, which means every safety initiative she runs must hold up.
Ask Dr. Luu how she’s managed to build a strong patient safety culture under those constraints, and the answer keeps coming back to one idea: Nothing changes for the people doing the work without the people doing the work.
“Nothing About Me Without Me”
Dr. Luu traces this philosophy back to her residency, when she sat in on her hospital’s emergency department lean team. Patients were waiting upward of 20 hours just to see a physician, with some taking days off work just to be seen. The team that took on the problem wasn’t just doctors and nurses; it included unit clerks and environmental services staff, the people who saw where the bottlenecks were. Over her final two years of residency, the ideas that team generated, many of them from residents themselves, were implemented, and length of stay dropped substantially.
“As soon as you see something everybody said couldn’t change actually get better, it’s a little addicting,” she says.
That project became the model for how Dr. Luu leads today. Her team’s guiding principle: “Nothing about me without me” – a phrase she picked up from her mentors during her QI fellowship training. No change gets rolled out in a unit without first asking the people who work there what they think.
“Our frontline staff just don’t get included in these conversations enough,” she says. “Oftentimes our staff know the issues. They know how to make the improvement. And their ideas are often amazing, and we end up going with them.”
Building the Skill, Not Just the Buy-In
Asking for input is one thing. Giving people the tools to act on it is another, and that’s the gap the organization’s Quality Academy was designed to close. The hospital’s philosophy is straightforward: Quality shouldn’t only happen in the C-suite; it should happen on the front line.
Getting there starts with change management basics, including finding early wins to engage people and making sure their ideas are implemented.
Then it goes further. Instead of handing frontline teams a mandate, the Quality Academy trains them. Take a clinic team looking to improve appointment cycle time. Rather than an administrator dictating a fix, the Quality Academy pulls together a multi-disciplinary team such as a physician, a nurse, and a clerk from that department and trains all three in the same performance improvement tools, data analysis, and coaching that leadership uses, then lets them drive the change in their own space.
Going to the Gemba: Rounding as a Practice
Rounding is where this philosophy becomes visible day-to-day, and Dr. Luu treats it as a real habit. Her organization runs weekly executive leader walk-arounds, simple conversations about what’s working and what people need. Medical-surgical units hold regular safety huddles, where she’s learned that staff pain points are rarely dramatic — a missing supply, being out of a specific type of syringe — and rarely expensive to fix, but make an impactful difference.
Her own habit of walking into a unit and speaking directly with a patient is one she doesn’t think twice about. But she’s also seen firsthand what happens when leadership skips that step.
Her first assignment as Patient Safety Officer was reducing central line infections, a problem well outside her emergency medicine background. She spent nearly a year in committee meetings hearing the same answer: the dressings were clean; nobody knew why infections were still happening. Eventually, she went to see for herself.
“I said, I’m going to go look at a dressing myself,” she recalls. “I walked into the ICU, and I found the problem.”
The gap wasn’t in the nursing care; it was in the standard. What people auditing charts from an office considered “clean” wasn’t the same as what nurses on the floor understood the requirement to be. “It shouldn’t even be peeling, even a little, on a corner,” she says of the education that followed, a standard nobody had actually spelled out until someone went and looked.
Her instinct to go see for herself is why Dr. Luu has worked to get more clinical leaders into patient spaces, not just frontline staff. A group of hospitalists was named unit medical directors and paired with nurse leaders and administrative leaders on medical-surgical units, with rounding built into the role: checking on patient experience, but also on the specific safety priorities the hospital was tracking, like central lines and catheters. Leaders who’d never felt fully at ease walking into a patient’s room started getting comfortable doing exactly that.
“The clinical leader’s job is really to be in that space, not in an office behind a computer,” Dr. Luu says.
Vulnerability From the Top
Rounding builds trust between leaders and staff. But Dr. Luu says the deeper cultural shift, the one that gets people to report the things that go wrong, started somewhere less obvious: peer support.
Her team’s approach began with training every nurse leader in how to respond when a staff member came to them following an incident. The instruction was simple: lead with “How are you doing? How can I support you?” instead of judgment or a punitive response.
From there, Dr. Luu took it a step further, starting a webinar series, “Changing Culture, Case by Case,” and invited the hospital’s C-suite leaders to share real mistakes they’d made. The CEO talked through a program he’d built without looping in the right people early on. The COO, a nurse by background, described a serious clinical error. The hospital’s CNO drew the largest audience of anyone when she shared her own clinical mistake — “the room was filled,” Dr. Luu remembers.
During each conversation, Dr. Luu modeled peer support live, on camera, before walking through the event using just culture principles. It’s a small, deliberate detail with an outsized effect: when a hospital’s own C-suite is willing to describe a medication error or a clinical misstep in front of staff, it tells every clinician watching that their own mistake is safe to talk about, too.
Extending the Circle: Learning Beyond One Hospital
That same instinct, treat mistakes as something to learn from, is part of why Dr. Luu’s hospital participates in the Sentact PSO. Adverse events get logged into the hospital’s safety intelligence system and, through the patient safety organization, shared and protected in a way that allows for broader learning across organizations.
Dr. Luu is candid about how rare that kind of sharing still is. “There’s a lot of learning, education, and sharing that should be done across the nation,” she says, “but there’s so much concern about patient protection and privacy that we don’t share enough about the events happening everywhere.”
For her, participating in the Sentact PSO is one more way of applying the same principle that drives everything else in this piece — that safety gets stronger when people are honest about where it broke down, whether that honesty happens in a single unit or across a national network of hospitals.
Where This Meets the Patient
Not everyone on a care team walks in the door excited about quality improvement, and Dr. Luu doesn’t pretend otherwise. Her go-to move for engaging people who aren’t naturally drawn to the work is simple: bring it back to a patient.
“Our patients have a story to tell, and they all deserve top-notch care,” she says. It’s a line she returns to often, because most people on her staff are already aligned with that goal — they just need the work connected to it directly.
Empowering Health Workers to Build a Patient Safety Culture
Inclusion, skill-building, visible rounding, leadership vulnerability, cross-organizational learning, and a constant return to the patient — none of these are separate initiatives for Dr. Luu. They’re the same idea, applied at every level of the hospital.
She sums up the spirit behind all of it simply: giving back to the people coming up behind you has a bigger impact than most leaders realize. “You may be mentoring someone and not even know it,” she says.
That, in a sentence, is what it looks like to support health workers in strengthening patient safety culture — and why Sentact is proud to make Dr. Allison Luu the first feature in the Patient Safety Expert Spotlight. Watch the full video interview here, and if you know a safety leader who should be featured next, let us know.
