Building a High Reliability Network from the Ground Up
How bold leadership and a purpose-built platform helped a rural Critical Access Hospital network transform quality improvement, performance data, and safety culture - across every facility.
Automated CMS dashboards, MBQIP reporting, and board-ready benchmarking
Structured improvement projects, AI coaching, and cross-hospital learning
Staff NPS tracking, engagement surveys, and safety culture measurement
+20pp
MedRec accuracy gain at BHI
45% → 65% in first redesign cycle
+39pt
NPS improvement at DMH
From −9 (2023) to +30 (2025)
+18pp
Staff engagement at DMH
Across 24-month period
78.9%
Rate workplace as excellent
Up from 50.3% at baseline
Rural Critical Access Hospitals operate at the edge of healthcare's resource frontier - carrying the full weight of quality expectations with a fraction of the staff, technology, and infrastructure of large health systems.
For Alliant Management Services, the challenge wasn't any single hospital's performance. It was the absence of a network. Each facility had its own approach to quality improvement - its own tools, spreadsheets, and reporting rhythms. Administrative burden consumed the hours that should have gone to improvement. And underneath every quality metric, a more fundamental question had never been systematically answered: did staff feel safe enough to speak up?
In January 2024, AMS launched a network-wide transformation through three integrated Beterra platforms - turning a collection of individually managed hospitals into a learning system capable of shared improvement, consistent measurement, and compounding gains.
AMS Program Charter · January 2024
"Enhance quality and safety improvement efforts through digitization, best practice, and collaboration - while reducing administrative burden."
The Challenge
Quality Improvement Driven by Individual Effort - Not Institutional Capability
AMS's quality leadership identified four compounding barriers - each significant alone, devastating together.
Methodological Fragmentation
QI practices varied by facility. Lean, PDSA, or no formal model - the approach depended on who was hired, not what worked best in the CAH setting.
Administrative Overload
Quality Directors spent the majority of their time maintaining Excel-based reports for CMS, boards, and regulators - leaving little bandwidth for proactive improvement.
No Shared Learning
Breakthrough projects at one facility stayed local. There was no repository, no template library, and no mechanism for cross-hospital replication.
Hidden Culture Risk
Staff disengagement and cultural fragmentation are invisible on a balance sheet - until they surface as turnover, near-misses, or poor patient experience scores.
The Solution
Three Pillars. One Platform. Designed for the CAH Setting.
In January 2024, AMS engaged Beterra to build a purpose-configured platform addressing the three foundational dimensions of High Reliability - quality metrics visibility, structured process improvement, and measurable safety culture.
Quality View
Replaces manual Excel reporting with automated, always-current performance visibility - from CMS KPIs to board-ready benchmarking.
- CMS Quality KPI dashboards with automated benchmarking against rural, state, and national comparators
- Historical trend analysis by month, quarter, year - MBQIP compliance built in
- One-click board and regulatory reports replacing hours of manual preparation
- Network-wide visibility for AMS executives across all partner facilities
PI Repository
Transforms individual QI projects into institutional assets - with structured tracking, AI coaching, and cross-hospital best practice sharing.
- Full project lifecycle tracking from problem identification through PDCA completion
- Best practice templates - decision trees, checklists, audit frameworks - stored and searchable
- AI-powered coaching guides leaders on evidence-based action plans at each stage
- Cross-hospital sharing: a completed project at one facility becomes a template at all others
Culture of Safety & Engagement
Makes the invisible visible - using validated surveys, NPS tracking, and unit-level action cycles to turn culture data into measurable improvement.
- Validated staff engagement survey with annual and pulse-check cadence
- Net Promoter Score tracking as a leading indicator of culture health and staff loyalty
- Trend analysis: organizational direction, supervisor trust, psychological safety
- Leadership action integration: survey data feeds directly into huddles, rounding, and improvement planning
Stakeholder Value Across All Three Pillars
| Stakeholder | What They Put In | What They Get Back |
|---|---|---|
| Executive Team & Board | Regular metric review; support for QI and culture improvement initiatives | Automated board reports; network-wide quality and culture dashboards; early warning on safety culture gaps; PSSM compliance tracking |
| Quality Director | Safety/quality metrics; structured improvement projects; survey administration | Automated regulatory and board reporting; PI templates and examples; culture data with benchmarks; time redirected from admin to improvement |
| Front-line Leader | Collaborate on QI projects; participate in engagement surveys; lead unit huddles | Proven best practice processes; unit-level engagement feedback; structured Safety Huddle and rounding cadence; leadership development support |
Clinical Proof Points
Real Results. Real Hospitals. Documented in the Repository.
Two facilities demonstrate the platform's impact across the PI and Culture pillars - with every project tracked, documented, and made available as a network-wide template.
Medication Reconciliation: 45% → 65%
An April 2025 pharmacy audit found only 45% of medication histories were accurate on admission - traced to fragmented workflows, role confusion, and EHR auto-population errors. A multidisciplinary PDCA redesign followed.
MedRec Accuracy - Improvement Arc
Redesigned process: dual-source ED verification, standardized MedRec Cerner reports at each handoff, admitting MD reconciliation, pharmacy final verification. BHI's decision tree, checklists, and audit framework are now shared as AMS best practice templates.
I-PASS Handoff · Wave Rollout
Wave I - Acute Care & Respiratory
Observer Champions deployed at launch
Wave II - Surgery & ED
Full hospital adoption goal: Q2 2026
+39-Point NPS Climb in Under Two Years
When CEO Lauren Faison-Clark arrived at DMH, she found cultural fragmentation, staff disengagement, and no strategic path staff could articulate. Her first act was a declaration: "Pardon Our Dust - We're Building a Culture of Excellence." Beterra's engagement platform made that change measurable.
NPS Trajectory - 2023 to 2025
78.9%
Staff rating DMH excellent - up from 50.3%
+18pp
Overall engagement across 24-month period
Trust in Supervisor
+12.4pp
72.4% → 84.8%
Right Direction
+14.9pp
76.4% → 91.3%
Key interventions: CEO walking rounds and daily huddles, ED redesign replacing third-party providers with in-house clinicians, real-time frontline communication loops. Beterra surfaced the signals - DMH leadership acted on them consistently through hurricanes, economic shocks, and operational pressure.
"There was no strategic path staff could articulate. We needed a unifying principle - something to believe in. From the moment those signs went up, change became visible. Beterra's engagement data made it measurable."
Lauren Faison-Clark, CEO · Doctors' Memorial Hospital · Perry, Florida
"We stood beside our teams during every crisis - from hurricanes to economic shocks. Being present matters. It's how people know you mean it."
Lauren Faison-Clark, CEO · Doctors' Memorial Hospital · on leadership visibility and trust
Framework Alignment
Mapping to the CMS Patient Safety Structural Measure
The AMS program directly addresses five domains of the CMS PSSM - the publicly reported framework benchmarking hospital safety maturity. Shaded domains (1, 3, 4) are most directly addressed by the Beterra platform.
1
Leadership
Board accountability, safety metrics in executive compensation, rapid event notification
2
Strategy & Policy
Safety as a core strategic value embedded in organizational policy and planning
3
Culture of Safety & Engagement
Annual validated survey, safety dashboard, learning network, structured event analysis
4
Accountability & Transparency
Public outcomes reporting, safety events tracked and shared with board and staff
5
Patient & Family Engagement
Patients as co-producers of safety, engaged in care redesign
PSSM scores are publicly reported on CMS Hospital Compare. AMS facilities are targeting full PSSM compliance through the Beterra platform rollout.
Path Forward · 2026
Scaling All Three Pillars Across the AMS Network
The BHI and DMH proof points mark the beginning of a system-wide rollout. Three coordinated initiatives will bring the full Beterra platform to every AMS partner facility in 2026.
01
Quality View Network Alignment
AMS Quality Directors standardize metrics, dashboards, and benchmarks - replacing fragmented facility-level reporting with a unified network view and automated CMS comparison.
02
PI Repository Activation
Formal project tracking launches across all partner hospitals. BHI's MedRec and I-PASS work serve as the inaugural templates in the shared best practice library, available for immediate replication.
03
Culture Survey Standardization
A standardized staff engagement measurement approach is deployed network-wide - enabling system-level benchmarking and surfacing culture risk before it becomes a retention or patient safety issue.
Key Takeaways
The AMS experience reveals lessons that apply to any healthcare management company building quality infrastructure across a multi-facility network:
Network Standards Must Precede Network Scale
Before a management company can drive improvement across facilities, it needs shared methodology, shared data, and shared language. Fragmented approaches cannot compound.
Culture Is a Leading Indicator - Not a Lagging One
The facilities that improved fastest were those where staff trusted leadership enough to report honestly. NPS and engagement scores predicted quality trajectory before metrics moved.
Administrative Burden Is a Quality Problem
Every hour a quality director spends on spreadsheet maintenance is an hour not spent on improvement. Reducing administrative load is an evidence-based quality intervention.
Shared Learning Is a Competitive Advantage
When BHI solved medication reconciliation at scale, that solution became available to every AMS facility. A managed network has an inherent advantage - if it builds the infrastructure to use it.
"The NPS didn't surprise me. The leadership behavior came first."
Lauren Faison-Clark Chief Executive Officer - Doctors' Memorial HospitalClient Profile
Alliant Management Services
Healthcare Management Company · Rural Kentucky
Critical Access Hospital Network
CAH
Hospital Type
Critical Access Hospitals
6
Facilities
AMS network partner hospitals
Rural KY
Geography
Underserved rural communities
Jan 2024
Engagement Start
Network-wide transformation
CMS PSSM Aligned
All 5 domains addressed
MBQIP Dashboards Live
Quality View deployed network-wide
PI Repository Active
BHI MedRec project complete
Beterra Solutions Used
Case Study
Building a High Reliability Network from the Ground Up
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