By Coleen Smith, MBA, MSN, RN, Director of High Reliability Initiatives
Joint Commission Center for Transforming Healthcare
Preventing safety lapses before they occur is a two-way street between staff and leadership.
Staff needs to take individual responsibility for their actions, but they also need to know that administration will listen and act when they raise a safety issue.
The Joint Commission’s newest Sentinel Event Alert 60: Developing a Reporting Culture: Learning from Close Calls and Hazardous Conditions addresses this issue at the heart of high reliability culture.
Leaders help create the personal responsibility by establishing clear performance expectations among employees within a psychologically safe environment in which there is no fear of negative consequences for reporting mistakes.
While this sounds like it’s straight out of any management playbook, it doesn’t always happen as seamlessly in reality as it looks on paper. Every year, The Joint Commission receives reports from health care staff of unsafe conditions in their organizations. The majority of these reports indicate that leadership had not been responsive to early warnings, even though their reaction may have prevented harm events from occurring.
Complacency toward risk is unacceptable. This kind of culture seeps down to the front lines where a “no harm, no foul” attitude may leave a near miss or at-risk behavior unreported, fostering conditions that may eventually result in harm. Another way to think about this issue is the “tolerance of risk”. Organizations need to ask themselves what risks continue to be “tolerated” in that no action has been taken.
A solid governance structure goes a long way toward communicating leadership commitment and ultimately building truest. Starting at the board level, down through the CEO and senior leadership team, consistent messaging and transparent support for reporting are crucial to establishing this trust culture.
This one’s easier said than done. Staff not only needs to know that leadership wants to hear from them, but also needs guidance on exactly what can and should be reported. Unfortunately, it’s quite common for staff to consider something an annoyance when it’s actually a close call or unsafe condition foreshadowing a poor patient outcome.
The good news is that technology should make all of this easier. Build your incident reporting system to feature:
- wide accessibility
- ease of use
- timely data analysis
- a feedback loop to let employees know action is being taken
Recently, “Good Catch” programs rewarding employees for reporting errors are springing up at organizations across the nation. This positive reinforcement seems to be working. At Memorial Hermann Health System (Texas), there are approximately 1,000 “good catches” reported a month, as clinicians identify possible lapses and intervene before harm occurs. The Medical University of South Carolina Health (MUSC) recognizes a “safety star” in a monthly system wide email, congratulating the employee for reporting a near miss.
It’s important to note that these successful programs also offer the option of sharing the report’s conclusion with the individual who filed the report, i.e. the feedback loop. If staff feel that reports go into a black hole, they will stop reporting. Establishing a robust mechanism to inform reporters and others who need to know of the actions taken is crucial.
Eliminate Fear of Punishment
Employees won’t make a report if they think they’ll be punished so it’s important to reinforce the notion that reporting allows the organization to learn from mistakes and make improvements. Often, investigations uncover the reality that system error is to blame, rather than a person, which we talked about in our Six Steps for Evaluating Broken Processes blog post.
Don’t expect the fear of punishment to disappear from employee culture overnight. Fostering psychological safety is still very much a work in progress in most health care settings. According to the U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Surveys 2018 database report, 47 percent of respondents reported feeling like unsafe event reports are held against them.
While it’s hard to enforce an across-the-board discipline policy about the near misses or close calls reported by staff, there are a few general guidelines.
- All staff must see that those making human errors will be consoled.
- Those responsible for at-risk behaviors will be coached.
- Those committing reckless acts will be disciplined fairly and equitably, regardless of outcome.
What’s really important is that employees at all levels are held to the same standard. Senior management and physicians will be held to the same standard as nurses and other staff members. Leaders can perpetuate this equality by making an effort to be among the first to raise their own hands and say "I made a mistake.”
Examine Errors, Close Calls and Unsafe Conditions
All reports should be investigated and it’s invaluable to incorporate data into these studies. The numbers tell the real story in:
- identifying the frequency of error-prone situations
- aggregating the severity of the error
- distinguishing successes of the staff and situation
There are so many ways to harvest the data and employ it to prevent future errors. Use data to:
- identify times of day, days of the week or even units were certain types of incidents are more likely
- validate the factors that lead to a situation
- strengthen protective processes within the system
The use of objective accountability evaluation/ assessment tools can help determine what happened as well as whether actions taken were blameless or blameworthy. Two just culture decision trees – one developed by James Reason and the second by David Marx – serve as a primary basis for distinguishing between errors that occur because we are imperfect humans who make mistakes and actions considered to be at-risk or reckless. To make these decision trees work best within their particular settings, many health care organizations have modified them and built upon them by developing additional tools.
Does your organization use decision trees? If you’ve found any other tools to be helpful in inspiring reporting, we encourage you to share shamelessly!
Coleen Smith, MBA, RN, is director of high reliability initiatives for the Joint Commission Center for Transforming Healthcare. In this role, she is responsible for the development, coordination and implementation of activities supporting the adoption of high reliability practices in health care. Smith joined The Joint Commission in 2004 and the Center in 2011. Prior to her current role, she held the role of Project Lead and Robust Process Improvement Black Belt in the Center. Smith has also held positions in the areas of quality improvement, leadership and clinical pediatric specialty care at Rush University Medical Center in Chicago, Rady Children’s Hospital in San Diego and Lurie Children’s Hospital of Chicago.