CUSTOMER STORY:
Northern Arizona Healthcare Built a Patient Safety Culture Where Every Voice Leads to Action
Background
Northern Arizona Healthcare built an award-winning patient safety culture by creating an environment where employees trust that speaking up leads to action. Learn how the health system combined leadership engagement, Just Culture principles, and Inovalon’s VigiLanz Safety Managementâ„¢ to strengthen reporting and drive measurable improvements across its hospitals.
In this customer story, you’ll learn how Northern Arizona Healthcare:
- Built a stronger patient safety culture by creating trust
- Turned frontline feedback into measurable improvements
- Strengthened collaboration and accountability
- Increased employee engagement while earning national recognition for patient safety
Building a Safety Culture People Trust
Every healthcare organization wants a strong culture of safety. Building one, however, takes much more than encouraging employees to report incidents. It requires creating an environment where people trust that speaking up will lead to action and leadership remains visibly engaged so every lesson learned becomes an opportunity to improve patient care and safety.
That’s exactly what Northern Arizona Healthcare set out to accomplish. Serving more than 700,000 people across northern Arizona, the health system includes Flagstaff Medical Center, a Level I Trauma Center, Verde Valley Medical Center, and a freestanding emergency department in Sedona. At the region’s largest nonprofit health system, patient safety is a strategic initiative and shared responsibility across every department.
The health system’s commitment to patient safety earned national recognition in 2025 when ECRI presented Northern Arizona Healthcare with its Safety Excellence Award. The honor recognized the organization’s comprehensive, systemwide approach to advancing a culture of safety, accountability, and transparency.
The award validated years of intentionally building a stronger patient safety culture, supported by sustainable processes and technology, said Susan Goldberg, MPA, BSN, RN, Director of Accreditation and Patient Safety.
2025 ECRI Safety Excellence Award 
Every Voice Matters
Creating a culture of safety begins long before an event is ever reported. Healthcare organizations continue to struggle with capturing the information needed to improve patient care. A recent report from the HHS Office of Inspector General found that hospitals failed to capture nearly half of patient harm events, limiting their ability to understand risks and identify patterns that can prevent future harm.
Northern Arizona Healthcare believed every safety event, near miss, and frontline observation represented an opportunity to make care safer. Realizing that vision depended on employees feeling comfortable speaking up.
That philosophy became the foundation of the team’s patient safety program, where encouraging employees to report concerns was only the first step in building trust. Employees had to feel safe raising concerns, knowing those concerns would receive thoughtful follow-through. The team refreshed its Just Culture program, integrating key principles with Extreme Ownership leadership concepts to reinforce accountability, transparency, and trust. Every leader completed immersive training using real-world scenarios. Education has since expanded to charge nurses, new leaders, and recurring quarterly refresh sessions built around actual safety events.
Leadership visibility is equally important. Monthly safety lunches invite employees from every department to meet directly with the CEO and patient safety leaders to discuss concerns and share ideas for improvement. Each concern is addressed through a documented action plan that’s shared across the organization, reinforcing the critical message that speaking up leads to lasting improvements. To date, those conversations have generated more than 177 documented improvement actions.
177+
documented improvement actions
“We depend on staff to relay information so we can improve the issues they identify,” said Goldberg. “We nurture that trust, which is the foundation on which everything else is built.”
Patient safety is reinforced throughout the organization, from a new employee’s first day through daily operations. Managers regularly discuss safety events during huddles and department meetings, while frontline caregivers play an active role in investigations and improvement initiatives. Daily safety briefings bring clinical and operational leaders together to identify barriers before they affect patient care, and lifesaver awards recognize employees whose actions help prevent harm. Together, these efforts reinforce that frontline employees are the eyes and ears of Northern Arizona Healthcare, and every voice has the power to make care safer.
Turning Information Into Action
Before modernizing its patient safety operations, Northern Arizona Healthcare managed many parts of the safety process separately. Reports, investigations, supporting documentation, and action plans often lived in different places, making it difficult to follow an event from initial report through resolution. Identifying trends required significant manual effort, and opportunities for broader organizational learning were harder to uncover.
”We depend on staff to relay information so we can improve the issues they identify. We nurture that trust, which is the foundation on which everything else is built."
Susan Goldberg, MPS, BSN, RNDirector of Accreditation and Patient Safety, Northern Arizona Healthcare
“The information that we had was not very usable in a comprehensive way,” Goldberg explained. “There was not an analytical component with our other systems.”
To support its growing patient safety program, Northern Arizona Healthcare implemented Inovalon’s VigiLanz Safety Management solution, bringing every stage of the patient safety process together.
Each reported event is reviewed daily by a multidisciplinary team that includes patient safety, physician leadership, medication safety, accreditation, and quality leaders. From there, reports move through investigation, Root Cause Analyses (RCA), Failure Mode and Effects Analyses (FMEA), action planning, and follow-up within a single workflow. Unifying steps of the process gives teams the continuity and visibility needed to identify trends and improve care.
“Safety Management helps us make sure we never leave a report unresolved,” said Goldberg.
Closing the loop remains an ongoing focus. Managers share outcomes through department meetings, safety newsletters, and other communications so frontline staff can see how their observations contribute to positive change. When employees can see the impact of speaking up, trust continues to grow.
Making Safety Everyone's Responsibility
Creating a connected process with Inovalon software made it easier to investigate safety events. It also created more opportunities for the people closest to patient care to help solve them.
One of the clearest examples of Northern Arizona Healthcare’s culture is the way frontline employees participate in solving problems. Over the past year alone, the safety team completed nearly 40 Root Cause Analyses and Failure Mode and Effects Analyses, far exceeding regulatory expectations.
Rather than limiting those conversations to leadership, frontline caregivers actively help identify contributing factors, recommend improvements, and design sustainable solutions. As Goldberg put it, “When they come up with the solutions, they’re much more likely to be sustainable because it comes from the people doing the work.”
That collaborative approach has led to safer practices across departments. Employee-led recommendations have strengthened pediatric medication dosing, emergency department equipment, standardized nuclear medicine handling, medication safety initiatives, patient rounding, and countless other care processes.
Nearly 40
Root Cause Analyses (RCA) and Failure Mode and Effects Analyses (FMEA) completed in 2025
Building on that foundation, Northern Arizona Healthcare is now expanding its approach through an emerging Safety II model. Rather than responding only after something goes wrong, leadership is using trends, near misses, and lessons learned to identify opportunities to improve care before harm occurs.
A Culture That Earned Recognition
The impact of Northern Arizona Healthcare’s patient safety efforts extended far beyond individual departments or isolated initiatives. In fiscal year 2025, the patient safety team received more than 5,276 safety event reports, a 19% increase over the previous year. Approximately 11% were Good Catch or Near Miss reports, reflecting stronger frontline engagement and growing confidence in the reporting process.
That cultural shift was reflected in employee feedback as well. The health system’s Safety Culture Prevention and Reporting percentile ranking increased from the 61st to the 70th percentile. Staff perceptions that Northern Arizona Healthcare actively improves patient safety rose from the 53rd to the 71st percentile, while more employees reported feeling comfortable raising concerns without fear of punishment.
Those outcomes reinforced what leaders had already begun to see across the health system. Employees were speaking up, investigations were leading to action, and patient safety had become part of the culture. The ECRI Safety Excellence Award recognized that progress, validating years of intentional work to build a systemwide approach to patient safety.
5276+
safety event reports
19%
YoY increase
11%
Good Catch/Near Miss reports
For Goldberg, the recognition confirmed what she’d witnessed firsthand. “It really is a statement about the organization. About leadership’s investment in patient safety.”
The recognition continued in 2026, when Inovalon named Goldberg its Healthcare Hero, an Impact Award honoring professionals who whose use of technology is improving how care is delivered and experienced.
The Work Continues
For Northern Arizona Healthcare, the work isn’t finished. The health system continues building on the progress it has made, strengthening communication with frontline staff and helping employees see how their voices continue to shape safer care.
For Goldberg, that work is far from over. “We no longer have a problem getting reports or working through them to create change. Inovalon makes it simpler to get the information back to all of our thousands of end users.”
Turn Every Voice Into a Stronger Safety Culture
Learn how VigiLanz Safety Management helps healthcare organizations create a more connected patient safety process, so every safety event becomes an opportunity to improve care.
