How To Engender A Reporting CulturePosted: August 30, 2012
In my last post, I mentioned the intervention we designed at the University of Illinois Medical Center to increase incident reporting by resident anesthesiology physicians. In the two-year retrospective analyses we used as our baseline measure, we found that residents reported 0 adverse events (AE) per quarter. At the end of the intervention period (7 quarters after study completion), we found that number had increased to 30 reports per quarter.
What changed in the residents, other than the fact that we required they submit an AE into the incident reporting system? And equally, what changed in us and our system through this study? To begin with, the students were exposed to an educational program that:
- Defined AEs, medical error, serious error, minor error and near miss.
- Discussed ACGME core competencies in relation to reporting of harm events.
- Discussed and clearly communicated the mechanics of filing a report.
- Provided 24 hour access to a consult service.
- Discussed how their report would be followed-up, and consistently adhered to this committment.
- Provided an educational manual/reference tool.
- Included regular conferences every 3-4 weeks for: a) Review of educational material; b) An opportunity for discussion around the AEs that were reported in an aggregated, de-identified manner; and c) Process improvements that came from their reports and feedback.
- Included support of the Department of Safety & Risk Management which provided “near-immediate feedback to residents upon receipt of their reports”. When possible, the residents were included in the root cause analysis of the event, or the quality improvement the team put together to address the near miss or unsafe condition.
The increase in resident reporting was very encouraging. But what truly tested our just culture was that the reports in one of the three-month periods shed light upon the fact that more than 50% of procedure related incidents reported that quarter were associated with lack of attending physician supervision. No one knew who the reporting residents were in these cases (except our safety department team) and no one knew who the attending physicians were that the residents felt had not supervised them adequately enough. This was because the data was always shared in an aggregated, de-identified manner. The purpose was to learn and improve, not finger-point or blame. Instead of arguing the data, our department rallied around it, and improved our own system of being there at the times residents reported feeling we had not been. Not only were the residents exposed to the educational messaging of the intervention, but maybe just as important, they also experienced firsthand the just culture that engenders a reporting culture after the study is complete and the researchers are no longer measuring.
Without a culture in place to reward, support and model incident reporting that effectively addresses the incidents and devises solutions to problems in real-time, results like those found in this study will not last. It would be interesting to give the survey now, to the same group of residents–some who have moved on to other institutions–and see what their attitudes and beliefs around reporting are today.
These same messages are shared with our students in Telluride, during the Student Summer Camps, and they have embraced the idea that the reporting of unsafe conditions, near misses and harm is a good thing. See numerous posts on the Transparent Health blog that give evidence to a fresh culture emerging:
It is up to us, as role models and educators, to ensure this is the culture that takes hold in medicine moving forward.