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Most hospitals run patient safety rounds. Far fewer have a reliable system for what happens after the rounds. Issues get documented inconsistently, ownership is unclear, prioritization is informal, and frontline teams quickly learn that raising the same concern twice doesn't actually change anything. The unspoken lesson — speaking up isn't worth the effort — is exactly the lesson a safety culture cannot afford to teach.
This session is about how one hospital fixed that. Lindsey Booty, Dr. Christopher Thomas, and LeaAnn Teague from Our Lady of the Lake Regional Medical Center walk through how they redesigned their patient safety rounds process using the SAFER Matrix and KaiNexus, what changed for frontline staff, and what the data looks like now — including a culture of safety score in the 91st percentile in the United States.
The honest framing they bring is what makes the session useful. Accountability didn't break down because people didn't care. It broke down because the system made follow-through unreliable.
Our Lady of the Lake Regional Medical Center is a Level 1 trauma center and academic medical center in Baton Rouge, part of the Franciscan Missionaries of Our Lady Health System. The patient safety rounds team visits 83 locations across the market, once a week, supported by one registered nurse plus rotating leaders from administration, quality, nursing, security, IT, environmental services, and food and nutrition.
The pre-redesign process looked like most hospital safety rounds programs. Go to the gemba. Talk to frontline teams openly. Capture what you hear. Map it manually to the Joint Commission's SAFER Matrix. Send a closing summary email. Return to the unit roughly three months later.
The signal that something was broken came from the units themselves. When the team would return and ask "what are your current safety concerns," they would hear the same concerns they had captured the previous visit. And the visit before that. Lindsey's framing: the rounds were listening intently, but they didn't have full loop closure. Frontline teams were raising priority safety issues that weren't getting resolved.
There was also a structural problem. The hospital had no real-time view of what the SAFER Matrix looked like. The team was building it manually in Excel for quarterly meetings. There was no way to roll up data across units, much less across the multi-hospital health system.
The first move was inside KaiNexus. The team built a custom Opportunity for Improvement (OI) template with a category specifically for patient safety rounds, plus secondary categorization (medication safety, supply chain, communication, and so on) so the same item could be tagged on multiple dimensions.
What made the design work was branching logic and provisioning controls. When a user inside the patient safety department's location in the KaiNexus organizational hierarchy tags an item as "patient safety rounds," the form opens additional fields tied to the SAFER Matrix — likelihood of harm to a patient, staff member, or visitor, and scope of the issue. The fields use Joint Commission language directly, so what gets captured in KaiNexus maps cleanly to the matrix used in regulatory reporting.
The provisioning piece matters. Other users entering OIs don't see the SAFER Matrix branching questions and aren't slowed down by them. The intake stays simple for everyone except the patient safety nurses who actually need to assess against the matrix. That kind of selective surfacing is the difference between a feature that gets used and a feature that gets resented.
The dashboard the team built off this intake is what turned the data into a working tool rather than a reporting artifact.
The whole dashboard runs off a created-date filter, so the team can pull the SAFER Matrix view for the past week, the past month, since launch in October 2023, or any window in between. In meetings, they can toggle the date range live to match whatever audience is in the room — operating committee, executive committee, nursing leadership, or a single unit conversation.
A stacked bar chart shows category trends month over month. The expectation built into the design is that if medication safety becomes a real issue across multiple units, it grows visibly in the chart. Then, if the system is working, the bar shrinks back down as issues get resolved and stop being raised on subsequent rounds.
A Kanban view shows status across all rounds-derived items. A quick-create button lets the safety nurse open a new OI directly from the dashboard with the right category pre-selected and the SAFER Matrix branching ready.
The visual centerpiece is the matrix itself rendered as nine tiles. The format mirrors the standard SAFER Matrix layout that anyone familiar with Joint Commission reporting will recognize. Across the top, the team layered an additional lookup the organization had developed previously: if an item lands in this cell, this level of leader needs to be assigned to drive the change. High and widespread items route to senior leaders automatically, with the urgency surfaced in the assignment rather than buried in a status email.
Same gemba walks. Same listening. Same multidisciplinary teams. What changed is what happened after.
KaiNexus handles assignment notifications, deadline approaches, and overdue alerts directly to the responsible leaders. The accountability layer that used to depend on someone remembering to follow up on a quarterly summary email now runs automatically. Leaders aren't surprised by their assignments and they aren't getting them buried under other email traffic.
The result, measured against the team's own definition of success: when rounds returned to the same units, frontline staff stopped raising the same concerns. That's the signal Lindsey emphasizes — not the metric on a slide, but the absence of the same complaint from people who had every right to keep raising it.
Two specific examples surfaced during the session. Supply ordering processes for frontline clinicians were streamlined so units get supplies in time. Specimen labeling accuracy in the emergency department and operating rooms — two of the highest-risk environments for specimen labeling errors — improved measurably.
A few specific data points from the session, with the context that matters.
71% resolution rate across all issues captured in patient safety rounds. The team is direct that they don't know what the baseline was before this redesign because they didn't have a way to track it.
55-day average cycle time from frontline rounds to resolution. Dr. Thomas's framing on this is important. The cycle time is 55 days because the easy issues now get fixed in real time during the 8:15 and 9:00 a.m. daily huddles, before they ever get boarded as a SAFER Matrix item. What ends up on the matrix is the harder material — the items frontline teams aren't sure leadership can fix. That selection effect is what makes 55 days look like a working number rather than a slow one.
91st percentile in the United States on culture of safety scores. The October 2024 engagement survey came roughly a year after the redesign launched. The team scored 4.08 out of 5 on safety culture, ranking in the top 10% nationally. The connection between the system change and the culture score is the trust loop — frontline staff learned that raising concerns actually produced action, which made them more willing to raise harder concerns, which made the culture stronger.
Dr. Thomas spent time on a point that sits beneath the metrics and is worth surfacing on its own.
Without a digital feedback mechanism, the importance of an issue can quietly get lost. A frontline nurse raises a concern. Nothing visible happens. They check back in a week, hear nothing, and conclude that it wasn't really taken seriously. That's the futility loop, and it's how safety cultures degrade even when leaders mean well.
The system change made it possible to elevate concerns based on what the team is actually feeling, not just on the matrix scoring. If a nurse raises something that seems modest on harm probability but is clearly causing the team significant stress, the team can move it to the top of the red category and ask senior leaders to address it quickly. The justification is that the team's experience is data — and ignoring it is a faster path to safety culture decay than mis-categorizing an item.
This is the kind of nuance that doesn't survive a paper-based system. The matrix becomes a checklist, the urgency stays in someone's head, and the elevation never happens. Built into a digital tool, the elevation becomes a routine action with audit trail.
Top-line items on the SAFER Matrix don't just sit. They feed into the hospital's performance improvement funnel through the Lake Lean Management Office. The harder communication and patient flow issues become full PI projects with dedicated teams, and the frontline staff who originally raised the issue often participate in the solution work.
That participation is part of what's driving the cultural shift. The frontline team that flagged a problem isn't watching from a distance while leaders solve it. They're in the room when the countermeasure gets designed. That changes the dynamic for the next round.
Daily near-miss reporting feeds the same loop. The hospital captures more than 200 safety events per week, with 25%+ classified as near misses. The volume isn't a sign of a problem — it's a sign of the trust the system has built. People are willing to report.
A theme that came up multiple times during the session is what leaders need to do differently when they show up at safety rounds.
The instinct for many leaders is to defend or justify when frontline teams raise concerns. That instinct kills the round. The hospital had to coach some of its leaders specifically — your job here is to listen, ask clarifying questions if you need to, and resist the urge to explain why something is the way it is. Curiosity beats defensiveness.
Quick wins on early rounds matter. Lindsey describes intentionally identifying one thing per unit that the team can feel and touch resolved within 24 to 48 hours. The trust gets built through small, fast follow-throughs more than through any large project.
Two phrases come up as critical: "I don't know" and "thank you." Saying "I don't know" honestly when a frontline concern is genuinely difficult — recognizing that some problems are national, not local — is more credible than producing a fast answer that doesn't hold up. Saying "thank you" recognizes that the person reporting is often carrying an emotional weight underneath the operational issue. The event they're describing is sometimes the surface of an experience they're still living with.
A practical detail worth surfacing: rounds aren't just nursing leaders. The OLOL team brings security, IT, food and nutrition, environmental services, plus patient safety, quality, and administration. Sometimes seven or eight leaders from across functions show up to a single unit visit.
The composition is the point. When a frontline nurse mentions a barcode scanner that isn't working or two computers that have been giving problems for two weeks, the IT director is standing right there. They text a technician on the spot. The nurse often sees the technician arrive before the rounds team has finished the unit visit.
Those quick wins build the trust that lets bigger conversations happen. The harder communication and process issues only surface when staff have evidence that the small things actually get fixed.
A question came up during the Q&A about how a hospital uses KaiNexus in a HIPAA-controlled environment. The team's answer is precise.
KaiNexus isn't where patient-specific events are reported. The hospital has a separate patient safety event reporting system for those, which lives within patient safety work product protections. KaiNexus captures the process — the system-level issues that surfaced through a conversation, not the patient identifiers from the conversation.
A practical example: instead of "patient X had a near miss in the OR last Tuesday," the OI in KaiNexus reads as "the handoff tool isn't being used uniformly on the night shift, and the same pattern shows up on weekends." The process is the focus. Training the people entering the data on that distinction is the controllable variable, and it's why provisioning is tight.
The unintended benefit of this approach: it teaches teams to think in process terms rather than person terms, which is itself a foundation of high-reliability culture. Reporting that focuses on individuals tends to drift toward blame. Reporting that focuses on process drifts toward learning.
A few specific things the platform does that connect to what OLOL described.
KaiNexus captures concerns at the gemba in a structured, repeatable way that maps directly to the SAFER Matrix. It handles assignment, escalation, and notification automatically, so accountability isn't dependent on someone remembering to follow up. It produces real-time dashboards that work in any meeting context, from a single unit conversation to a health-system executive review. It supports the multi-site rollup that lets sister hospitals see the same patterns across the system. And it spreads improvements — when one hospital builds a working safety rounds dashboard, the other hospitals in the system can adopt the same structure quickly.
If your hospital is running safety rounds today but losing the back half of the loop — the documentation drift, the inconsistent escalation, the same concerns surfacing visit after visit — that's the gap KaiNexus is built to close.
Lindsey Booty, RN, BS, CNOR is the Supervisor of Performance Improvement at Our Lady of the Lake Regional Medical Center. She drives improvement work through data-driven strategies, multidisciplinary collaboration, and a focus on safety, process improvement, and quality education to enhance patient outcomes and operational efficiency.
Christopher Thomas, MD is an Assistant Professor of Clinical Medicine at LSUHSC and Chief Quality Officer for Franciscan Missionaries of Our Lady Health System. He specializes in reducing clinical variability, accelerating evidence-based care, and implementing quality initiatives. His research focuses on sepsis diagnostics, hospital mobility, and unit-based safety scores, and he has more than 40 peer-reviewed publications.
LeaAnn Teague, MBA, MT(ASCP), SBB, PMP is Senior Director of Performance Improvement at Our Lady of the Lake. Her work spans healthcare management, patient outcomes, operational efficiency, compliance, and revenue. She is known for connecting improvement work to organizational priorities across complex healthcare systems.
Why do hospital patient safety rounds often fail to produce follow-through?
Most safety rounds programs are strong on listening and weak on closing the loop. Issues get documented inconsistently, ownership isn't always clear, escalation depends on individual leader follow-up, and there's rarely a system-level view of which concerns are actually getting resolved. When frontline teams raise the same concerns visit after visit with no visible action, the implicit message is that speaking up doesn't matter — and that erodes safety culture faster than any single unresolved issue.
What is the Joint Commission SAFER Matrix?
The SAFER Matrix is a Joint Commission framework for prioritizing patient safety risks based on two dimensions: likelihood of harm to a patient, staff member, or visitor, and scope of the issue. The framework groups items into nine cells from low/limited to high/widespread, which helps leaders make consistent decisions about urgency and escalation. OLOL embedded the matrix directly into their KaiNexus intake using branching questions tied to the framework's standard language.
How did Our Lady of the Lake change their patient safety rounds process?
They rebuilt the intake in KaiNexus with a custom OI template tied to the SAFER Matrix, using branching questions and provisioning controls so only the patient safety team sees the matrix-specific fields. They built a dashboard with a real-time view of the SAFER Matrix, category trends over time, a Kanban status view, and quick-create capability. They added automatic notifications for assignment, deadline, and overdue items so accountability runs systemically rather than through individual follow-up.
What results has Our Lady of the Lake seen?
A 71% resolution rate across all issues captured in patient safety rounds, an average cycle time of 55 days from frontline conversation to resolution, and a culture of safety score in the 91st percentile in the United States on their October 2024 engagement survey. Frontline teams stopped raising the same concerns visit after visit, which the team treats as the most important measure that the loop is genuinely closing.
Why is the cycle time 55 days rather than something faster?
Because the easy issues are getting resolved in real time during 8:15 and 9:00 a.m. daily huddles, before they ever land on the SAFER Matrix dashboard. What gets boarded is the harder material — the issues frontline teams aren't sure leadership can fix. The 55-day cycle time reflects the difficulty of the items being tracked, not the speed of the system.
How does this approach handle HIPAA?
KaiNexus is used to track process-level issues, not patient-specific events. Patient-identifiable safety events are reported separately through the hospital's patient safety event reporting system, which lives within patient safety work product protections. The OIs in KaiNexus describe the process gap — for example, inconsistent use of a handoff tool on the night shift — rather than the individuals or patients involved. Tight user provisioning and training reinforce the discipline.
What leadership behaviors make safety rounds actually work?
Listening before defending. Coaching leaders out of the instinct to justify or explain when frontline teams raise concerns. Identifying a quick win on each rounds visit that can be felt and touched within 24 to 48 hours. Saying "I don't know" honestly when an issue is genuinely difficult, and saying "thank you" to recognize the emotional weight that often sits underneath an operational concern. Bringing a multidisciplinary team — security, IT, environmental services, food and nutrition — so cross-functional issues can be addressed on the spot.
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