Paving the way to better communication in health care!
Kremena Payova grew up in Bulgaria in a family with roots in the health care system. Her mother Pepa is a midwife. Kremena chose to work with autistic adults in the UK, where she quickly discovered there was a gap in the inherent reporting systems that were often failing patients and reflecting badly on the NHS.
From these experiences emerged The Safety Shield™, a method for building error-free clinical environments. It allows hospitals to expand their capacity and serve more people by making the most of every staff member’s talent. By providing a clear framework of support, it ensures that no clinician is ever left to carry the weight of systemic pressure alone.
THE SAFETY SHIELD™ is not a document or a piece of software; it is a multi-layered system of systems designed to protect a healthcare institution from “unpriced” clinical and legal risks.
It is a dual-facing architecture. It protects the clinician from burnout and systemic failure at the bedside, while simultaneously protecting the Board from unmanaged liability and institutional risk. You cannot have one without the other.”
YOUR FAMILY WERE INVOLVED IN THE HEALTHCARE SYSTEM IN BULGARIA, HOW DID THAT AFFECT YOUR CHOICE OF CAREER?
I grew up in Bulgaria in a home where healthcare was an everyday conversation. My mother is a midwife, and stories of life, birth and risk were part of the air we breathed, it seemed!
Interestingly though, my early academic choices were not clinical. Instead, I studied Journalism, then Social Pedagogy which helped me imagine a path through words and social systems rather than through hospitals.
At that time, I thought I would interpret systems from the outside, not work inside them.
YOU MOVED TO THE UK TO WORK WITH A VULNERABLE GROUP IN SOCIETY, TELL US MORE ABOUT IT?
When I moved to England, I began working with autistic individuals. It was a wonderful experience where I encountered one of the purest forms of human connection: relationships built with almost no words, no conventional feedback, yet marked by a deep and unmistakable bond with people whom society frequently overlooks.
It was that experience which permanently changed how I understand vulnerability, dignity and care. It taught me that the absence of language does not mean the absence of truth – and that systems often fail precisely the people who cannot advocate for themselves.
Then I stepped into the healthcare system itself.
YOUR NEXT ROLE MEANT TRANSFERRING TO THE NHS, HOW DID CHANGE YOUR VIEWS?
I entered the NHS at the lowest Band 2. From that vantage point, one question would not leave me: why do so many brilliant nurses, with 10 to 15 years of experience, remain stuck in the same place?
How can our healthcare system depend so heavily on its nurses, yet provide so little structured room for them to grow?
I made a promise to myself: if I stayed, I would move only forward.
I progressed through emergency care, qualified as a registered nurse, went on to Independent Prescribing, and completed an Advanced Clinical Practice pathway including Level 7 Diagnostic Reasoning, Level 7 Leadership Strategies and the Edgar Jenner Leadership Academy.
This was not a straight career ladder. It was a series of decisions that kept me breaking through glass ceilings to learn more about the profession I was working for and with each day.
YOU SAY THERE WERE PATTERNS EMERGING THAT LED TO YOUR DEVELOPMENT OF THE SAFETY SHIELD, WHAT WERE THEY?
It seemed a pattern emerged of recurring failures that were rarely about individual competence. They were about how the system permitted decisions to be made. Clinical demand was scaling faster than clinical governance. Decision rights were blurred: who could decide, on what, and within which constraints. Escalation depended more on personal courage and informal workarounds than on designed pathways. Boards could see incidents and metrics, but had little direct visibility of how decisions actually moved day to day.
I began calling this decision latency: the delay between risk emerging and a system’s ability to recognise it, act on it and learn from it.
HOW DID THE PANDEMIC CRYSTALISE YOUR THOUGHTS?
COVID-19 Made Decision Latency Impossible to Ignore
The clearest lesson did not come in a classroom. It came in the emergency department, in the middle of the pandemic.
COVID-19 was not simply about more patients, it was about the uncertainty layered into every single decision.
Every oxygen saturation, every comorbidity, every admission or discharge felt like a fork in the road with no clear sign pointing the way forward. Protocols and risk scores surrounded us. Yet in the noise and pace, one pattern became impossible to ignore: decisions were queuing just as much as patients were.
Escalation depended on who happened to be on shift, how confident they felt, and how safe they believed themselves to be in acting. Senior input was a scarce resource pulled in every direction. There were nights when decision latency was not an abstract concept.
It was the fiercely demanding physical reality of caring for people in corridors that had become extensions of a ward.
I remember cannulating patients on a bent knee in the hallway, manoeuvring through rows of trolleys, wrapped in PPE that made me feel more like an astronaut than a nurse!
Our breaks disappeared and I remember holding hands through gloves in patients’ final hours, knowing they could not feel human skin – only pressure. They could not see my whole face, but they could see the tears in my eyes. Such a distressing time!
COVID-19 did not create decision latency. It stripped away the illusion that we could afford it. It made one truth impossible to ignore: when a system does not deliberately design how decisions move – who can act, when, and with what authority – the weight falls entirely on individual clinicians’ knees, backs, hands and hearts.
From that point on, working well inside the system was no longer sufficient. I had to work on the architecture that determines whether working well is ever enough.
YOU TALK ABOUT DECISION ENGINEERING, WHAT DID THAT ENTAIL?
The same pattern I witnessed during the pandemic now appears with particular intensity inside rapidly expanding health systems: those undergoing aggressive licensing reform, accelerated capital deployment and ambitious workforce growth all at once.
Nowhere I believe is this more visible than across the Gulf, where the scale and speed of healthcare transformation represent some of the most ambitious nation-building endeavours in the world today.
In these environments, clinical infrastructure scales with impressive speed. New facilities open, headcount grows, and digital platforms multiply the volume of data available to decision-makers. Yet even the most well-governed systems reach a point where growth generates complexity faster than existing frameworks were designed to absorb. When decision architecture does not evolve in parallel, the result is expansion at the front end, and quiet pressure building at precisely the point of care.
What THE SAFETY SHIELD™ stress-tested across real clinical environments like these consistently reveals is that decision latency is rarely visible from the inside. Even in well-governed, well-resourced systems, the gap between how decisions are designed to move and how they actually move in practice is almost never where leadership expects to find it. The most exposed points in a system are not the obvious ones. They are the ones that look on paper, entirely under control.
THE SAFETY SHIELD™ is designed for exactly this moment – not to find fault, but to give boards, executives and clinical leaders a structured way to stay ahead of that pressure before it reaches patients, staff or the institution’s risk profile.
This is where what I describe as the 40% physician capacity leak becomes consequential. The most expensive clinical assets in any system are routinely anchored to low-complexity, high-volume encounters that do not require their level of decision authority. High volume is mistaken for efficiency. In structural terms, it is a quiet but persistent constraint on both clinical performance and financial sustainability.
The second structural risk is what I call the Liability Vacuum. Delegation does not fail because people are incompetent. It fails because escalation clarity is absent – the precise threshold at which responsibility must transfer is undefined. Without an engineered audit trail, lower-tier clinical layers operate inside a governance gap. Autonomy without structure becomes unmanaged liability.
Data platforms and AI can now surface risk in real time. But data does not make decisions. When a red signal is raised, multiple stakeholders may see the same alert; few have clearly defined authority to act. The question is no longer whether we know. It is who owns this decision, at this moment, in this team.
Scaling safely requires moving from narrative trust to decision engineering.
SO THIS IS HOW YOU DESIGNED THE SAFETY SHIELD™, HOW DOES IT WORK?
THE SAFETY SHIELD™ is the clinical governance architecture I developed in response to this lived complexity.
From kitchen table conversations in Bulgaria about birth and risk, through pandemic corridors, to boardrooms in some of the world’s most rapidly scaling health systems.
It is structured around three elements.
Decision authority – a precise articulation of who is authorised to decide what, at which level of complexity, within a clearly engineered scope rather than a vague expectation.
Escalation clarity – defined thresholds governing when and how decisions move up or across the system, so that no role operates inside a liability vacuum.
Accountability structures – mechanisms that keep decisions visible, auditable and aligned with institutional risk appetite as the system scales.
In practice, THE SAFETY SHIELD™ enables the safe redistribution of low acuity demand away from physicians while maintaining clinical safety, stabilising flow and surfacing emerging risk earlier. It treats clinical decision-making as a structured, auditable capability – not an informal by-product of good people doing their best.
Through Alora Health Premier, I work with boards, investors and system leaders navigating the pressures of rapid growth. The work includes mapping how decisions are made today, redesigning decision rights and supervision structures, strengthening board assurance and supporting safe scaling in environments undergoing simultaneous workforce expansion and digital transformation.
YOU BELIEVE THIS CAN BRING DECISIONS BACK INTO VIEW, HOW DO YOU SEE THAT?
Leadership, as I understand it, is no longer about personally holding every answer. It is about designing conditions in which the right people can make the right decisions, at the right time, for the patients in front of them – and ensuring that emerging risk never has to live off screen.
When decisions slow down, risk does not slow with them. It simply disappears from view.
Our responsibility as clinical and governance leaders is to bring those decisions back into the light – so that patients experience safety, clinicians experience dignity, and boards can honestly say that growth has not outpaced governance.
Kremena Payova is Principal Architect of THE SAFETY SHIELD™ and Founder of Alora Health Premier, a London-based clinical governance practice working with boards and executive leadership teams across international health systems. www.alorahealthpremier.com
