How can we fix things if we don’t know what is broken?
The truth is that we can’t. Working at the North Central Nursing Clinics (NCNC) in Indiana as a quality improvement analyst, I quickly realized that the incident reporting system was in itself broken, and hindering the clinics from improving quality and safety. Incident reporting provides a foundation for discovering specific problems and developing a culture of continuous improvement. Thus, my team decided to improve this system iteratively, focusing on three key changes in the process of reporting incidents: procedural changes for initial reports, procedural changes for response to reports, and overarching cultural transformations at NCNC.
In addressing initial reporting procedures, we have defined incident more broadly than in the past. Our redefinition of “incident” included actual and potential errors that have physical, mental, emotional, or financial effects. By including near-misses and events that result in non-physical harm, we can address more of the so-called “holes in the Swiss cheese” — latent errors that contribute to harm in James Reason’s Swiss Cheese Model of systemic failures. Through multiple Plan-Do-Study-Act (PDSA) cycles, NCNC has iteratively redesigned the incident report form to capture more information about systemic failures in our clinics.
Responding to adverse event reports
As a next step, we are beginning to run PDSA cycles to improve response to reports received. Currently, many crucial response steps are being performed inconsistently or not at all. These missed steps include investigating outcomes and systemic failures, mitigating negative outcomes, and improving quality and safety at NCNC based on reported incidents. In trying to improve the reliability of this process, we are not reinventing the wheel, but rather researching incident reporting at other health care organizations and human factors literature regarding accident investigation to inform the improvements at NCNC. Then, we apply the PDSA cycles to test and tailor the changes so that they are most valuable for NCNC. Furthermore, this project will inform improving our collection of and response to patient and family grievances.
To ensure the success of these procedural and policy improvements, the culture must evolve. Our cultural transformation is guided by the concepts of Just Culture
to address the prevalent fear that incident reports are strictly punitive. To improve reporting, we are educating NCNC staff about the systems perspective to health care error and serving as models of adopting this perspective. Similarly, the words and actions of NCNC leadership should reinforce that quality improvement is best not only for the patient, but also for the health care professionals and organization as a whole.
We are measuring our improvements in two main ways: the number of incidents reported in the short term and evolving staff perceptions in the short and long term. Though increasing incident reports seems contrary to improving health care, we know that incidents are severely underreported. The increased feedback in the short term will be immensely valuable for long-term development. This project is difficult but essential, because it provides a broad foundation for continued quality improvement. As NCNC expands, these policy and procedural changes in combination with overarching cultural changes will be crucial to the health care we deliver.
IHI CEO Maureen Bisognano, patient safety advocate Helen Haskell, and Amanda Hobbs attended the 7th Annual South Carolina Transforming Health Symposium in April 2014.
About the Calkins Scholarship: Every year, IHI offers this scholarship in memory of David Calkins, MD, MPP, a physician, teacher, IHI Fellow, and health care improvement champion who was a member of IHI’s 100,000 Lives Campaign team. A panel of judges, including Dr. Calkins’s family, choose a winning essay that they believe encompasses what Dr. Calkins was passionate about — health care improvement.