This century has been the era of CEO commitment. At times, the list of initiatives that couldn't be accomplished without the full and constant support of the CEO was long enough to flow out the door — and into the C-suite. Everyone with a particular "mission" in health care called for and demanded the CEO's attention and focus.

Of course, they are right. An initiative will likely fail if the CEO doesn't commit to it or does so half-heartedly. The latter may be more damaging to a CEO's future agenda. When he or she is genuinely passionate about a cause, many will smile and act enthusiastic, but they will be thinking about what happened "that other time."

Over time, CEOs prioritized all of these must-do items, and many of them made the commitment to quality and patient safety. They now talk about patient safety with the passion that effective leaders use to energize organizations.

In the early stages, much of the attention focused on the roles of the CEO, the C-suite and the board. But now the successful model for quality and patient safety initiatives has been stood on its head. This year's winner of the AHA-McKesson Quest for Quality Prize and the finalists credit employees as the drivers of the movement.

Kenneth Sands, M.D., senior vice president of health care quality for Beth Israel Deaconess Medical Center, Boston, this year's winner, cites as proof of that bottom-up organizational focus on quality the center's annual quality and patient safety symposium, which highlights noteworthy quality improvement efforts across the hospital, and they generally come from the units, not from management.

"There's no committee that organizes that work," Sands says. "We've really gotten to a place where [quality improvement] is a held value at the local level."

Similarly, leaders at St. Mary's Hospital, Centralia, Ill., a Citation of Merit winner, credit their shared governance model, which gives front-line employees a voice in running the facility, as one of the key drivers behind the hospital's culture of safety and quality.

"We don't make decisions at the top of the organization unless they need to be made there," says Bruce Merrell, hospital president.

This is a noteworthy change in the traditional top-down dialogue about quality and patient safety practices in hospitals. I'm not saying that employee ownership just happened overnight. A lot of hard and thoughtful work brought these hospitals to that point. But it also brings to mind a buzzword that has lost some of its buzz over time: employee engagement.

You don't have to be a human resources genius to conclude that a happy employee who feels respected and involved performs better. Some research shows dramatic differences in attitudes about patient safety between engaged and disengaged employees. Engaged employees are two to three times more likely to speak up if they see something that may negatively affect a patient and report a medical error.

A study by Gallup linked higher nurse engagement to reduced patient mortality.

The first steps to that other long journey we are on now — patient and family engagement — may begin with employee engagement.

— You can reach me at mgrayson@healthforum.com.