Most health systems can launch an improvement initiative. Far fewer can keep one alive. Dr. Prerna Singh Kahlon has spent more than 25 years building quality, process improvement, and patient safety programs from the ground up — first across Boston-area adult and pediatric hospitals, and now at Grady Health System, a safety net hospital where resources are tight and the margin for error is thin. Her verdict on the part everyone underestimates is blunt: “It is the hardest part, and it comes with accountability.”
How Grady Health System Sustains High Reliability
The chaos. Safety net hospitals absorb the highest-acuity, highest-complexity patients with the least financial slack. On top of that, Grady committed in 2022 to becoming a high reliability organization — a science borrowed from nuclear power, aviation, and naval aviation, industries that operate under extreme risk yet produce remarkably few errors. Translating that into a hospital means changing how thousands of people behave on their busiest day, not their calmest one. And the default posture in most health systems works against it: a firefighting mentality that reaches for the band-aid. As Dr. Singh Kahlon puts it, “that band-aid will rip soon after, and the problem’s going to happen again.”
The leadership. Grady started with a current state assessment, then built governance before building enthusiasm — a steering committee, an implementation committee, and dedicated resources. Staff and leaders each attended design sessions and chose their own tools from a menu: error prevention behaviors for the front line (more than 150 staff participated), separate leadership skills for the blunt end of the system. Leaders were trained first, so they could speak the language before staff learned it. Then came the structures that make it daily rather than aspirational: a cause analysis program with dedicated resources, leadership rounding, tiered huddles, safety stories to open every meeting, an error prevention tool of the month and a leader skill of the week.
The success. Grady is now layering Lean Six Sigma white and yellow belt training on top of the safety foundation, teaching staff to improve the systems they’ve learned to see. Dr. Singh Kahlon’s standard for sustainment is uncomfortable and useful: “the real test of improvement is not whether it works when everyone is focused on it… It is when it still works if it is the hardest day, when people are stressed.” On AI, she is equally clear — it can surface themes and patterns, but “Data can only tell you what’s happening. It can’t tell you why it’s happening.”
Why listen. If you are trying to make quality inseparable from operations rather than a department off to the side, this conversation is a field guide from someone who has done it under real constraint.
Listen to the full conversation.
Episode Chapter Guide
00:33 Introduction to Dr. Prerna Singh Kahlon and her journey
02:11 From dentistry in India to healthcare quality in the US
07:39 Understanding high reliability organizations
09:05 Partnering for safety at Grady Hospital
12:57 Training leaders and staff in error prevention tools
15:15 Sustaining improvement through accountability and measures
19:26 The role of AI in healthcare quality and safety
22:50 The importance of human relationships in quality improvement
24:18 Leadership qualities for complex healthcare environments
28:30 The most important skill for future success
Full Transcript
AI-generated transcript. Accuracy may vary; please excuse any transcription errors.
Dr. Prerna Singh Kahlon: So the sustainability is not easy. And if anybody tells you it is, they they don’t know what they’re talking about. It is the hardest part and it comes with accountability. It comes with leaders having a presence, right? If we are saying something is important, then we have to make an effort to ensure that every day that message is coming across. And the minute we deviate from that, right? Th there needs to be leadership accountability to bring us back to that mission.
Episode
Kandice Garcia: And welcome to Success in Chaos, a healthcare podcast where we dive into how the people who are leading create success amid the chaos of our system. I’m Kandice Garcia, the CEO of Tungsten QI Partners and Quality Director for the ACR Learning Network. And I am running solo today. Angela Adams, the CEO of Inflo Health, will be joining us next time. So I am here, I’m going to introduce our guest.
This is a really special guest for me because quality is what I do, it’s what I love. And our guest today started her career as a dental surgeon in India. She took a leap of faith to Boston, discovered quality and patient safety through a single internship, and never looked back. She spent over twenty-five years building quality programs from the ground up across some of the most demanding environments in America’s healthcare.
And right now she’s spearheading Grady Health System’s quality, process improvement and patient safety efforts, a safety net hospital where resources are tight and the work is anything but simple. Dr. Prerna Singh Kah, welcome to Success in Chaos.
Dr. Prerna Singh Kahlon: Kandice. Nice to meet you.
Kandice: Thank you so much for being here. Now, you started your career as a dental surgeon in India, and somewhere along the way, you ended up as one of the most credentialed quality leaders in American healthcare. Now, walk us through that journey. What was the through line that kept pulling you deeper into quality and patient safety?
Prerna: Yes, absolutely. So I like you mentioned, I started my career as a dentist in India. And at that level, you know, as you see patients every day, you’re problem solving, you’re trying to understand what’s the best course of action for each individual patient. Of course, I found that whole process very rewarding. However, very early in my career, I decided to learn a little bit more about healthcare business.
I felt I could do more. And so I came to Boston to be able to study healthcare business. And while I was in my master’s program, I did an internship where I got exposed to quality, patient safety, process improvement. And what I really liked about that was the healthcare challenges that I was seeing, how to approach them from a systems thinking perspective.
And I felt immediately connected to that approach. And so that experience made me realize that, you know, while I was practicing as a dentist, I was looking at each problem and each patient individually, but through the quality and process improvement lens, I was able to see how beyond an individual event, how do you ask broader questions? To understand why this happened, connected beyond this just the individual to the system that contributed to it, why did the process break down and what infrastructure was missing? And how could we make it all better? Right.
So, this experience led me to realize that I actually really enjoy complex problem solving. And it’s very interesting to me that good problem solving quality is really driven by a strong infrastructure. And in order to drive good outcomes, you need need to have good processes, good structure, good information flow. And that’s something I’ve really enjoyed building it throughout my career.
So I completed my internship. I started to progressively grow into different leadership roles in quality, patient safety, process improvement in the various Boston area hospitals, and that ultimately led me to Grady. And so the organizations and challenges may have been different, but the through line has remained the same. So understanding how systems work, identifying why they fail sometimes, right? And building infrastructures and processes to and the capabilities within people to help them enable to achieve better outcomes. That’s been exciting to me.
So what may keeps me bringing back to this work is ultimately the human impact, right? Building strong quality and patient safety programs, improving quality, it ultimately impacts that patient. And that’s what’s most rewarding. And all these organizations have brought different challenges and opportunities with this. And it’s really helped me get to know better about myself that I can actually be challenged in different environments as well and still be able to succeed.
So along the way in my career, I invested a lot of time and energy to get certified in quality, patient safety, high reliability, Lean Six Sigma. I’m a black belt by training. And again, this helped me not only increase my knowledge, but then take on problems where I could help with the skill set. I’ve also enjoyed educating folks in the national, international level in quality and patient safety. And the reason I enjoy that very much is it’s like building an army of problem solvers, right? Folks don’t need to rely only on the experts. They need to be able to do it themselves, really own those changes and improvements. And that’s how they sustain. So that in a nutshell has been my journey. I’ve really enjoyed my journey so far and I continue to learn something new every day.
Kandice: Yeah, you know, you touched on something that I think organizations sometimes don’t grasp is that improvement isn’t about having a good problem solver or a leader who can solve problems. It’s about building improvement capabilities within your organization. You’ve mentioned systems many times, and you know, the role of the quality leader of quality and safety at your organization is about building the systems in which problem solving can occur.
Now, Grady’s on a high reliability journey. You mentioned they’ve been there since, you know, started in the twenty twenty two. Now they have real constraints, lots of complexity. Can you tell us a little bit about what high reliability is and how did you begin at Grady?
Prerna: Yeah, absolutely. So high reliability is actually a science, and we actually learn from organizations that do really well in it. So like the nuclear power industry, the aviation industry, the naval aviation industry, right? These organizations have one thing in common. They all operate under very high risk conditions, yet they manage to have their fewer than fair sh fair share of accidents or errors.
So healthcare has really been, I would say for the last 15 to 20 years, healthcare has been on a journey as an industry to learn from these organizations and understand how we can make our organizations safe because we deal with lives, right? We are a very high risk business. So Grady went on this journey back in 2022. We decided that, you know, just providing high quality outcomes was not enough. We need to take it to the next level.
We need to really focus on learning from what’s happening with human error, what’s happening in the organization with safety events. And let’s let us do everything it we can do to keep that patient safe and really provide exceptional care. Right. So we partnered with — we actually did an assessment of all the consulting partners out there, and we landed up partnering with an organization that I had previously worked in Boston with, as well as my CMO at that time had.
And so we embarked upon the journey by conducting first a current state assessment of the organization to understand what were some of the issues in terms of structure that were would be would impact the success of this journey. We also interviewed a ton of people, looked a ton of data policies to see, okay, were we set up correctly, right? What are some of the opportunities for improvement?
Simultaneously, we actually first built a executive structure to ensure that we have the right level of governance before we kicked off on this very complex and long term journey, right? So we set up a steering committee, we had an implementation committee, we dedicated resources, myself and a project manager, to really ensure that we had the right information flow happening in the organization.
So once that current state assessment was completed, the findings were then delivered to our C-suite. And based on those findings, we actually conducted two different design sessions in the organization. One was for all staff. And the staff were engaged to look at these findings and pick a set of tools that would address those findings from an error prevention perspective. So really engaging the staff in that process was really important. We had about over 150 staff join this design session. It was all day. It was real fun. Our consulting partner offered us a menu of tools, and then we picked the ones that we thought would work here at Grady.
And these error prevention tools were really targeted on employing certain safety behaviors that help catch errors before they actually happen. So, like attention to detail, example being the stop, think, act, and review tool, right? Something like that. So simultaneously, we actually had leaders look at the findings and have a leader design session. And leaders looked at the findings and picked leadership tools to help them lead differently in an HRO. Because in high reliability organizations, you have to lead differently. And oftentimes we talk about the blunt end sharp end model in high reliability organizations. If you’re not familiar with it, I can quickly orient you to it.
Kandice: Mm-hmm.
Prerna: So the sharp end is where the work happens, where the outcomes are, right? Where the frontline workers work. Their behaviors are influenced by the environment, the technology, the structure, the culture, essentially, the policies and procedures. And that’s where leaders play a key role in providing those aspects in the healthcare organization or any organization to help the frontline do their job effectively and prevent harm from happening.
So that’s where we have the intersection of our leader skills in an HRO and our error prevention skills for our front line. We want to make sure folks are catching errors before they happen. So once we designed these tools, we actually got our leaders trained on both of these different types of toolkits because we wanted them to be first speaking the language before we started training staff, because they had to support staff in that.
So now all that is good, but what structures did we need in the organization to further this message and codify it into daily operations? So we set up a lot of — we did a lot of work around cause analysis, making sure being an HRO, trying to strive to be an HRO, we would want to learn from our mistakes and something called commitment to resilience in an HRO. You learn from your mistakes and you make your organization better, more resilient, right?
So we set up a cause analysis program with dedicated resources focused on conducting root cause analysis to learn from those, put action items in place, and make sure the organization becomes safer. We also set up leadership rounding, tiered huddle structure so that every day we were using high reliability language in how we were operating. Till today, we start our meetings with a safety story. We center everyone to safety.
And we ensure that we are constantly revisiting our error prevention tool of the month, our leader skill of the week, making sure that we are rewarding folks who are utilizing these tools and safety behaviors. And so till today, the messaging exists and we are still on that journey. But it really does take that combination of good structure, good process, and ensuring there’s accountability, learning from mistakes and and all of that. So that’s in that’s been our journey. And it continues.
Kandice: Yeah. I mean, it is a huge journey. This is a huge undertaking really to transform an entire organization. And like you were saying, it’s about the role of the leader and how they interact with the staff. It’s the staff being able to participate in a meaningful way every single day. And the technology integration that not only supports the process, but supports the environment around the process and the way that you manage. It just sounds — it sounds so complex, these complex systems. But, you know, at the end of the day, it really does sound like, you know, the technology is not replacing the people. Am I getting this right? It’s just supporting the people.
Prerna: Yes.
Kandice: And you’ve been on this journey for a long time. How do you keep the energy and intensity for improvement high when, you know, there’s so much going on and we’re still taking care of patients? What are some of the things that you do to keep your staff engaged in the sustainability of improvement?
Prerna: Yeah, so the sustainability is not easy. And if anybody tells you it is, they they don’t know what they’re talking about. It is the hardest part.
Kandice: Yeah. It’s the hardest. It’s literally the hardest part. Yeah.
Prerna: And it comes with accountability. It comes with leaders having a presence, right? If we are saying something is important, then we have to make an effort to ensure that every day that message is coming across. And the minute we deviate from that, right? Th there needs to be leadership accountability to bring us back to that mission.
So having good level of feedback, measures, hardwiring it into the day-to-day operations is really, really important from a sustainability perspective. One of the ways we’ve kept staff excited is yes, we went on the high reliability journey and we’re still on it. However, now we’re taking it to the next level. So what we have done since is my team and I, we have designed our Lean Six Sigma course from starting from white to yellow belt. And we are currently in the yellow belt phase.
And what we’re doing is we’re telling staff, okay, now that you know you have this safety lens on, right? You’re looking at your systems. How do you improve them? So we are equipping them by teaching them how to continuously improve their systems and processes on a day-to-day basis.
And the importance of having good measures in place, right? If you implement something, that’s wonderful. You did all this work. But if you don’t have a way to know whether it’s working through measurement, you’re not going to be able to understand if it was the change was effective or not. So setting up good measures, making sure those measures are not too complicated, ensuring those measures are being looked at, leaders are asking for those measures, reviewing them continuously. And if things are starting to go in a different direction, taking action in a timely fashion so that we are able to continue to keep our systems safe.
So I would say the real test of improvement is not whether it works when everyone is focused on it, right? It is when it still works if it is the hardest day, when people are stressed. And if people are stressed, but these these improvements have been hardwired, it will become the way they work anyways. So things will not go back to the old way and errors will start happening. So it’s not an easy thing to achieve sustainment, but you can put practices in place in order to strive for it.
Kandice: Yeah. So what I’m hearing you say is structure is very important, expectations and accountability. We set expectations and we hold each other accountable. Measuring things — if you don’t measure it, you can’t improve it. And if you don’t measure it, you can’t monitor it. But also I’m hearing you say it’s a lot about education and the language that we use and everybody understanding how to participate in improvement from where they stand. And that this is integrated into the operations.
So often I feel like quality is a side note, an afterthought, a department that it’s like, yeah, go do your thing over there, but like just don’t touch the operations. And what I’m hearing you say is that actually it is 100% intertwined and operations are quality. Quality are operations. Like it is, it’s all together. Did I get that right?
Prerna: Yes. Yeah.
Kandice: You know, as we implement AI technology, I know, you know, we’re all thinking about it, we’re all trying to come at it from different perspectives. I think we’re pretty clear that it’s not going to replace us as caregivers, but what is the role of AI in quality and patient safety that you think is a big opportunity? Where can it help? And where does human judgment still matter the most?
Prerna: Yeah, so you know, we are already using AI to help us with some of the groundwork in quality and patient safety. So there is a lot of, you know, when you organize trainings, you want to seek feedback, you want to understand what’s the feedback telling us. AI does a fantastic job in helping us create materials, right? That we would have taken hours developing. It can take all the feedback you’ve received, give you the theme. Right? It can do all these wonderful things. It can point to certain patterns that may exist.
However, what it can’t do is tell you why that’s happening. Right? You still need the human mind and the critical thinking to dig deep, go into the medical record, look at what exactly happened. Context is everything, right? Data can only tell you what’s happening. It can’t tell you why it’s happening. So that’s where, you know, humans are going to continue to need to critically think and apply themselves to understand why systems are performing the way they are. And so that’s what I think AI can really help us with, is just the big data piece, the pattern recognition, theme analysis. But us, you know, humans understanding why it’s happening is ultimately going to be our responsibility.
Kandice: I could not agree more. And especially in quality, I feel like a lot of the work is about gathering large swaths of information that come in from multiple modalities. And yeah, I do see the role of AI about organiz — organizing that information. Help me figure out what is written here and what are the themes.
But I actually think that’s also the gift of quality is how people interact and how we understand one another. And an AI can’t create a shared mental model or help us shift our thoughts and beliefs about how we interact with one another, but it can lay things out in a way that we can all discuss and organize and come to consensus on so that we can all move together in the same direction. I actually think that quality is a huge opportunity and measures around measures, around data, large collections of information and data and say, what do we see here? Where before I think we’re doing so many things manually. So of all the places, I actually think quality is a huge opportunity for AI.
Prerna: And I really do think that AI can help our people be more capable, but it cannot make them less thoughtful. Because the day we start blindly relying on AI, I don’t think we are going to be in a good good spot, right? You AI cannot go to Gemba, like we say in in Lean, right? You go to the place where the work happens. You have to go see what’s actually happening. It can tell you why your throughput measures look the way they do. But it can’t tell you — I mean it can tell you what it’s signaling, but ultimately you’ve got to go see where are the bottlenecks and understand what’s happening in reality.
Kandice: Yeah. And it can’t connect people. I really do think that, you know, the gift of what we do is about when we care for others. It’s a gift for us as caregivers and it’s a gift as them for patients. And actually as coworkers as well, when we’re working on a project together and we’re, you know, trying to solve something important, that is what creates the culture of improvement. That is what brings joy back to people’s work, is solving these problems as a team and creating something that wasn’t there before, solving a problem that seemed unsolvable. And that gift of change and improvement that we get as people, we can never replace with technology. It’s the experience.
Prerna: Exactly. And like you said very well that quality is based on relationships, right? You have to understand what’s happening in the process from the front lines perspective. You’ve got to engage them. You’ve got to create that trust. And so no AI tool can do that for you. So humans still need to be human and build relationships. Yes.
Kandice: Yes. You know, you’ve had such a long career from adult to pediatric to safety net hospitals. And, you know, the themes that I’m hearing from you is that you’re drawing on complex, mission-driven environments and you’re building infrastructure and you’re championing change. You know, what does that kind of work require from a leader? And what has that taught you about yourself?
Prerna: Yeah, so I think a leader really needs to be thoughtful, right? And thoughtful leadership will lead to meaningful improvement. Oftentimes in organizations you’ll notice that there’s often a firefighting mentality that, gosh, we gotta fix this, we gotta fix this. But sometimes you’ve got to take a s step back and look at the system from a system perspective and say instead of taking that band-aid approach, why don’t we look at what is the root cause of these issues happening? And is the system really designed to support what we are trying to achieve? Because you could fake do a band-aid approach today, and then that band-aid will rip soon after, and the problem’s going to happen again. So you have to be very, very thoughtful as you lead in these environments.
This requires more than that technical capability, right? People can go get certifications and everything, right? But — and they can be very knowledgeable. But you’ve got to, as a leader, create clarity when things are complex, when things are ambiguous, right? You’ve got to take that step to build those — that trust and relation — those relationships. Really drive some practical structures and changes instead of trying to just constantly have this band-aid approach.
You’ve got to be able to balance a sense of urgency with empathy. And because this sustainable transformation only happens because of people, right? People are the ones who — healthcare is a team sport, it’s a people business. And you’ve got to make sure, yes, you’re pushing people to be better, but at the same time, you’ve got to be realistic and empathetic that what can they manage?
So this — the all these experiences have led me to understand about myself, I really do enjoy building. I do love the complex problems, I love that infrastructure, taking it back to that structure to help drive processes to be successful and giving us successful outcomes.
I’ve also learned the importance of humility, right? The leader may help set the direction, however, it’s the people doing the work who are going to make sure that those direction is actually followed and the changes that you’re trying to see actually happen. So you’re always, you know, as a leader, your job is to communicate, remove barriers, support those who do the work. That is your job as a leader. And if you’re not doing that, you’re really not supporting the people and truly not driving improvement, then it becomes a mandate, right? Which nobody likes.
So ultimately, this work can be only reinforced if folks tie it to the mission, they’re engaged in the process, and they understand the impact of it, which is our patients ultimately. So for me, that’s what I’ve learned about myself. It’s really important to engage the folks who do the work.
Kandice: You know, the part I love about what you’re saying, and it’s what I think is a little bit different, a shift than what we’ve heard from others, is that leadership is not necessarily about who you are, but the environment you create for others to become who they are. And I think that’s really the essence of good quality and of an organization who will become better every single day. It’s the environment, not just the person.
No, that’s fantastic. You know, we’re getting to the end of our session here. So before we go, I just want to say — or I just want to ask you one more question about what you can help anybody learn about how do we deal with this environment. So if you’re, you know, imagine you’re coaching your best friend’s son or daughter, and they ask you, what’s the most important skill that I can work on to be successful in the next decade? What would you tell them?
Prerna: Would tell them the most important skill is to be a thoughtful problem solver. I think that is one thing with all the technology, rapid changes happening right in the field, AI and all of that. You know, the world does not need any more people who telling us, okay, what’s wrong, they’re identifying the problem. We need people who can actually fix it, right? AI can help us identify the problem, like people can today too, but it cannot help us solve the problem.
So that’s where I would say is keeping those critical thinking skills, you know, alive, making sure even young professionals today — if you know, I feel like even for my own children, I’ve been teaching them process improvement tools. They are Gen Z and they are the future workforce, right? And so how are they going to use these tools to problem solve? And I think that piece is really transferable not only to your career but to your personal life every day. You can utilize these tools to improve your day to day as well. So yeah, thoughtful problem solving.
Kandice: That we’ve come full circle where quality is an afterthought, it’s a nice to have, and really it’s the foundational skill. Become a professional problem solver, and there’s nothing that you won’t be able to accomplish. Well, thank you so much for joining us today. This was such a lovely discussion. And we look forward to speaking with you again.
Prerna: Thank you so much, Kandice. I really enjoyed today’s conversation. I appreciate it. Thank you.
Kandice: You’re welcome. And thank you, audience, for joining us on Success in Chaos. Be sure to like, follow, and share today’s episode on Spotify, Apple Podcasts, YouTube, or wherever you get your podcasts. And a special thank you to the Inflo Health team for their production support.
