Project Outline: Proactive Safety Work to Improve Culture of Safety Across the Medical Group

As Director of Quality and Safety for the Multi‑Specialty Group, I led a proactive, systemwide initiative to strengthen the Culture of Safety across Medical Group clinics, targeting locations that scored below 4.0 (out of 5.0) on the annual Safety Culture Survey. This work aligned with organizational priorities to build a high‑reliability environment and support frontline Mission Partners in delivering safe, error‑free care.

Approach & Methodology

Using the Safety Culture Survey results, clinics scoring below 4.0 were identified as priority sites. The Quality & Safety team will conduct Safety Walks in all clinics that scored below 4 on Safety Culture.

I led the expansion of the All In for Safety Safety Walk program over the course of a year, across the Medical Group. Safety Walks were designed to:

• Discuss safety with frontline Mission Partners

• Identify opportunities for improvement

• Promote change and meaningful communication

• Reinforce event‑reporting expectations

• Celebrate successes "We do the walking, you do the talking!” and outlines the purpose: “Build a culture of safety… transparency & learning.”

Project Goals

• Improve Culture of Safety scores across targeted clinics.

• Increase psychological safety and frontline engagement.

• Strengthen transparency, communication, and event‑reporting awareness.

• Build relationships between Quality & Safety, leaders, and frontline Mission Partners.

• Identify and remove barriers to safe, reliable care.

1. Data‑Driven Targeting

2. Safety Walk Implementation

3. Cross‑Functional Engagement

The initiative involved collaboration with:

• Clinic leadership

• Risk Management

• Quality & Safety teams

• Frontline Mission Partners

• Operational leaders across shifts and roles

This ensured that improvement strategies were tailored to each clinic’s unique needs

4. Action Planning Using Innovation Strategy

Each targeted clinic developed an action plan addressing:

• Unit‑level scores

• Role‑ or shift‑specific concerns

• Individual question trends

• Areas with significant declines from the previous year

Outcomes & Impact

1. Significant Improvement in Culture of Safety Scores

• The following year 44% of clinics increased their Culture of Safety results above 4.0.

• 18% improved but did not yet reach 4.0.

• Only 15% decreased from the previous year.

2. Statistically Significant Positive Change

• The mean Culture of Safety score increased by 0.2029.

• A T-test was conducted & the P value = 0.0002, indicating a statistically significant improvement.

3. Strengthened Relationships & Psychological Safety

Safety Walks created space for Mission Partners to openly discuss:

• What keeps them safe

• What makes their work harder

• Good catches

• What keeps them up at night

4. Enhanced Transparency & Learning Culture

The initiative increased awareness of event reporting, improved communication between frontline staff and leadership, and reinforced the organization’s commitment to zero harm.

Summary

I led a proactive, data‑driven safety initiative across the Medical Group, targeting clinics scoring below 4.0 on the Culture of Safety Survey. Through expanded Safety Walks, cross‑functional collaboration, and structured action planning, we achieved statistically significant improvements in safety culture, with nearly half of clinics surpassing the 4.0 benchmark and strong evidence of correlation between Safety Walk engagement and improved outcomes.