Orchestrating Reliability
How one of the nation's largest faith-based nonprofit health systems built a unified, trust-driven learning system for safety — guided by promise principles, fueled by psychological safety, orchestrated through systemic anticipation, and sustained by digital infrastructure.
THR invests in safety training and event reporting — the foundation is set
20% reduction in second victim experiences · 10% improvement in support
83.6% near-miss reporting growth · 99% action plan engagement
+83.6%
Near-miss reporting growth
Over 5 years system-wide
99%
Action plan follow-up engagement
In 24 months post-feedback
1,500
System-wide improvement projects
Documented in ACT Platform
Top ¼
National reporting culture
Quartile performance ranking
By the mid-2010s, Texas Health Resources had invested in safety training and event reporting — but progress had leveled off.
Safety training programs had been rolled out. Leaders spoke of just culture and zero harm. Many meaningful improvement efforts were underway. But the opportunity lay in bringing them together in a more unified, connected approach. Local units launched their own projects with limited visibility beyond a single department, and successes often depended on individual champions rather than a systemic approach.
What followed was a system-wide orchestration that reset focus, expectations, and the daily demonstration of safety principles. Reliability had to become who THR is — not what THR does.
+83.6%
over 5 years
Near-miss reporting growth system-wide
Near-miss identification was embedded into high-reliability development. Instead of being overlooked, near misses were celebrated — publicly acknowledged as evidence of proactive safety. Staff trusted the system to focus on learning, not blame.
The Challenge
Before the Shift: The Plateau
With 30,000 employees across 29 hospitals, THR's scale made fragmentation the default. Three compounding barriers stood between where the system was and where it needed to go.
Siloed Improvement
Local units launched their own projects but had limited visibility beyond a single department. Successes depended on individual champions rather than systemic approaches — breakthroughs stayed local.
One-Directional Reporting
Event reporting felt one-directional. Limited feedback made it difficult for teams to see how investigations supported learning — creating hesitation among leaders and staff and an opportunity to strengthen transparency.
Safety as Compliance
HRO training risked being perceived as a compliance activity rather than a driver of safer, more collaborative care. Safety language was abundant but felt hollow without consistent reinforcement and visible leadership action.
The Shift
Four Design Principles That Reshaped How THR Embeds High Reliability
Every leader completed a training program. Expectations were embedded in safety behaviors. Performance metrics tied success not just to clinical outcomes, but to the daily demonstration of high-reliability principles. Four key design principles emerged from this commitment.
Psychological Safety, Reframed
The question was no longer simply whether people would speak up, but whether they felt safe to do so. Leaders used safety language daily, reports were acknowledged and addressed, and the cumulative effect built trust. The result: a 20% reduction in second victim experiences and a 10% improvement in second victim support between 2023 and 2025.
Near Misses as Gifts
Near-miss identification was embedded into high-reliability development. Leaders were tasked with finding and fixing a near miss during onboarding, and departments were held accountable for analyzing their top near misses through structured PDSAs. Instead of being ignored, near misses were celebrated — publicly acknowledged as evidence of proactive safety.
Accountable Learning System
Investigations into safety events underwent a philosophical transformation. Rather than stopping at individual blame, leaders were trained to dig deeper, exhausting every "why." The guiding principle became: "Did the system fail the employee, or the employee fail the process?" This reframing built a culture of shared accountability and continuous learning.
Broadened Definition of Harm
Beyond physical outcomes, THR classified safety events with an emotional harm level. The patient's experience of care and deviations in practice standards came to represent harm. By broadening the definition, THR underscored that safety was about dignity, trust, and the whole patient experience — reinforcing their Promise Principles of Reliability and Safety.
"When you get a near miss, that is your gift. You fixed something before it reached the patient."
Kristin Duncan Sr. Director of Safety and High Reliability — Texas Health Resources
The Digital Infrastructure
If Culture Provided the Vision, Infrastructure Made It Scalable
With 30,000 employees spread across a vast geography, no cultural commitment survives without the systems to sustain it. The Beterra ACT Platform became the central system supporting THR's high-reliability programming.
One Unified View of Safety Culture
ACT measures organizational culture across all 29 hospitals — connecting safety culture scores, psychological safety data, and second victim metrics into a single, coherent structure. No disconnected systems. No data silos.
- System-wide culture dashboards across 29 hospitals
- Psychological safety and second victim tracking
- Perception gap analysis: leadership vs. frontline
1,500 Projects. All Documented. All Accountable.
Systematic prompts ensure leaders close the loop on reports and follow through on PDSAs. Micro-learnings refresh perishable skills without overwhelming staff. Learning repositories capture both successes and process failures — allowing lessons to spread system-wide.
- Structured PDSA tracking with automated follow-up reminders
- Learning repositories for system-wide template sharing
- Micro-learnings to refresh perishable HRO skills
The Right Action Easy. The Wrong Action Hard.
Through human factors design, reliability became intuitive. The platform reduces administrative burden on frontline leaders, giving them real-time visibility without the overhead of managing multiple disconnected systems.
- Real-time visibility without administrative overhead
- Timely reminders that close the loop on reports
- Designed to reduce cognitive burden on frontline leaders
What the Data Shows
Reporting volumes climbed steadily, indicating a positive reporting culture. Serious Safety Events continued to decline. Staff engagement and psychological safety scores trended upward — reflecting trust in both leadership and the reliability journey.
- 99% action plan follow-up in 24 months post-feedback
- 95% of plans completed · 90% rated as successful with meaningful improvement
- 1,000+ leaders engaged · +12% above national benchmark on near-miss perception
"To prevent harm, we must design systems that make it easy to do the right thing and difficult to do the wrong thing."
Kristin Duncan Sr. Director of Safety and High Reliability — Texas Health Resources
Outcomes in Motion
Ten Years In — A Living, Breathing Learning Organization
THR describes itself as a "living, breathing learning organization." The transformation has created a more aligned, efficient, and purpose-driven environment. Leaders begin every safety briefing with safety language, and harm is viewed as a collective opportunity for mitigation rather than a reflection of individual fault.
+83.6%
Near-miss reporting growth
Over 5 years system-wide
+12%
Above national benchmark
Near-miss reporting perception
99%
Action plan follow-up
In 24 months post-feedback
95%
Plans completed
System-wide completion rate
1,500
Improvement projects
Approx., system-wide
1,000+
Leaders engaged
Safety culture & harm reduction
90%
Plan success rate
With meaningful improvement
−20%
Second victim experiences
2023–2025 reduction
Key Takeaways
THR's high-reliability journey offers a replicable roadmap for any health system committed to moving from safety as a stated value to safety as an organizational reflex.
Reliability Must Become Who You Are, Not What You Do
When high reliability is treated as a program, it fades when attention moves on. THR embedded it into daily leadership behavior, performance expectations, and the digital systems that support frontline teams — making it organizational identity, not a compliance activity.
Near-Miss Reporting Is the Leading Indicator That Matters Most
An 83.6% increase in near-miss reporting over five years is not a problem — it's evidence that staff trust the system. Organizations that see reporting volume as a liability are measuring the wrong thing.
Digital Infrastructure Makes Culture Scalable
With 30,000 employees across a vast geography, no cultural commitment survives without the systems to sustain it. The ACT Platform unified culture data, improvement plans, and follow-up actions — reducing administrative burden and giving leaders real-time visibility without disconnected tools.
Psychological Safety Is Built Through Consistent Action, Not Statements
The shift from "speak up for safety" as a slogan to genuine psychological safety required consistent reinforcement — leaders acknowledging reports, following through on PDSAs, and demonstrating over time that speaking up had consequences beyond acknowledgment.
"Reliability is achieved through proactive anticipation and responsive adaptation."
Kristin Duncan Sr. Director of Safety and High Reliability — Texas Health ResourcesClient Profile
Texas Health Resources
Faith-Based Nonprofit Health System · North Texas
One of the nation's largest faith-based nonprofit systems
30,000
Employees
System-wide workforce
29
Hospitals
Across North Texas
10+ Yrs
HRO Journey
Continuous since mid-2010s
Top ¼
Reporting Culture
National quartile ranking
+83.6% Near-Miss Reporting Growth
Over 5 years — top-quartile culture
99% Action Plan Engagement
Post-feedback follow-up completion
20% Reduction in Second Victims
2023–2025, with 10% support improvement
Beterra Solutions Used
ACT Platform
Unified culture measurement, improvement tracking, micro-learnings, and learning repositories across all 29 hospitals.
SafeCulture Survey
Validated safety culture and psychological safety measurement across the THR network.
Care for Caregivers
Second victim identification and caregiver support, driving a 20% reduction in second victim experiences.
Case Study
Orchestrating Reliability — Beterra × Texas Health Resources
Ready to build your high-reliability system?
See how Beterra's ACT Platform can unify safety culture measurement, improvement tracking, and caregiver support across your health system.
Talk to our team