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Reliability at the Sharp End of Care

Posted By Administration, Tuesday, April 12, 2016

Breakout session at the NPSF Patient Safety Congress to focus on engaging frontline staff and physicians
in high reliability principles and safety culture.

by Patricia McTiernan, MS

Kate Kovich
For the past year, Kate Kovich's team
at Advocate Health has focused on
engaging frontline staff in principles of
high reliability and safety culture.


For Kate Kovich, MS, OT, CPPS, vice president for patient safety and a 26-year veteran employee of Chicago-based Advocate Health Care, the pursuit of high reliability began with a medical error that resulted in the death of an infant.


“We were always very committed to safety,” says Ms. Kovich, “but after that event, we realized that we needed to fundamentally change our approach.”


And so the organization embarked on a strategic, multiphase plan to improve safety culture and reliability. In the three years since starting the program, Advocate has seen improvements in the AHRQ Safety Culture Survey scores at all of its 12 hospitals, a greater than 25% increase in reports of safety events and near-misses, and a 38% decline of serious safety events in its hospitals across the system.


The program put into place three years ago began with leadership training developed with the help of a consulting group and implemented throughout the system. “If you don’t start with your leaders, you’re never going to get to high reliability at the front line,” says Ms. Kovich.


At the same time, the organization began positioning safety as foundational to the care it provides. This involved a giant step in transparency: posting a calendar of “days since last serious safety event.” When an event occurs, and the calendar needs to change, Ms. Kovich’s office sends a brief e-mail to leaders, physicians, and staff to alert them to the risk without identifying the site, department, or patient.


Were they ever concerned about being so transparent? Yes, says Kovich, but “The presidents of the hospitals stressed the importance of getting this information to the front line. The president of the system responded and made the decision that it was a risk worth taking.”


For the past year, the program has focused on engaging those on the front line of care through training in high reliability principles and tools, and recruiting and training “safety coaches” for each unit or clinical department.


What surprised Ms. Kovich during this work? “I didn’t realize how vastly different the cultures of the organizations were from one to another; they move at different paces, so it is challenging to get an entire organization of this size to move together.” Still, she says, the response from leaders and the frontline health professionals has been positive.


Personally, Ms. Kovich says that one of the most important things she has learned over the past few years is the importance of influencing people in her organization—to connect them to the “why” of what they are doing—through story telling. “Telling stories is such an effective way to get people’s attention,” she says. “We never use the patient’s name. But we try to personalize it so it is not just an event we’re talking about, it’s somebody’s life we are holding in our hands.”

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Kate Kovich will be discussing Advocate Health Care’s experience at the NPSF Patient Safety Congress. Get the details of Breakout Session 101: Implementing a Strategic Approach to High Reliability at the Sharp End and the rest of the Congress program at


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Tags:  2016 NPSF Congress  HRO 

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