Leadership Perspectives: Robust Incident Reporting - Critical to Success

There are several traits which most leaders of successful organizations possess; among these are executive presence, and the ability to innovate, strategize, and communicate. Leaders are responsible for creating the culture of an organization i.e., the way things are naturally done. That does not happen by accident. Leaders create the culture by guiding and coaching the team to achieve the desired environment. To achieve this they need accurate, unfiltered information.

Leaders are key to achieving an optimal organizational culture; reflect for a moment as to the reason why most companies have supervisors, managers, directors, and other “bosses”.

Humans, in any role: student, athlete, hobbyist, craftsman, or employee, all fall under a “normal” distribution, with 80% in the middle, 10% at the top and 10% at the bottom. 

Top 10% are natural superstars and leaders, it appears to come easy to them, they have the aptitude and the attitude to succeed despite the challenges – these are the people that just need to be told the goal once

 Middle 80% are the majority who do the right thing most of the time, if it’s not too hard, and the influence from the top 10% is stronger than the bottom 10% - they often require more frequent reminders of the goal along with support and regular affirmation

 Bottom 10% are not capable of achieving what is expected and are frustrated by this, or they are inherently contrarian or selfish, opposed to following most any rules – either case results in gossip being the favored communication tool and proliferation of the tendency of misery to love company

Of course, we all have different roles in our personal and professional lives, and where we fall under the curve will depend on which role we are performing. Understanding this norm of human behavior illustrates why having rules or policies is insufficient, there is a need for supervision and leadership at various levels to double check and make sure the middle 80% don’t just do it their way.

Unless someone is leading a very small operation, it is imperative that there be a robust incident reporting system. Sure, in a Mom & Pop shop, they (Mom & Pop) will be aware of every time someone doesn’t follow policy, doesn’t treat a customer the way they should, when supplies are running short, when a mistake was made, as well as when a mistake was almost made.

For organizations of any significant size, there needs to be an incident reporting system.

Incident reporting in healthcare needs to be viewed in a much broader sense than just the realm of quality, safety, and regulatory requirements – it needs to be seen for what it truly can be – the key to high reliability and a leader’s secret weapon in creating the desired organizational culture.

When most people think about incident reporting images of policy or procedural violations come to mind; fundamentally that is correct. As a leader are you confident that you will know if these key components of your system are being followed before a disaster occurs? More importantly what is your definition of a disaster: a flagrant disregard for policy, a major knowledge gap, loss to the competition, a near miss patient safety event, a patient injury, or a patient death – no doubt these all qualify. I posit that in healthcare there is a mini disaster every time someone fails the mother test, i.e., a patient does not get the care one expects for their most precious loved ones.  

Reflect on organizations that you have been a part of; have things happened that fly in the face of the company’s mission? Would these things have happened if a senior leader was present? Since senior leaders cannot be present 24/7, they need incident reporting systems that are robust in every aspect. 

If one were to do an analysis comparing two organizations to determine which one is more reliable, would you choose the one with fewer incident reports or the one with the larger number?  Before answering consider what was presented regarding the normal distribution of human behavior, and the need for supervision and leadership.  

The more reliable organization will be the one that has more reports, reflecting a culture of transparency and continuous improvement. 

Passing the mother test requires creating a culture in healthcare that gives the kind of care you would insist on for your own mother to everyone. This requires a system of incident reporting that is mature:               

• It cannot be looked at as punitive, i.e. “writing someone up”

• Unexpected outcomes should be reported

• Near misses need to be reported and rewarded as great catches

• Policy and procedure violations must be reported

  • This should include all unprofessional actions including communication shortcomings:

    • how staff speak to each other

    • how staff speak to customers/patients/families/visitors 

If you want your organizational culture to have the norm of high-quality care delivered by a highly engaged team with a very low complication rate, take a close look at your incident reporting system. The checklist that follows is a good starting point to be sure you are getting the most from your incident reporting system or might suggest that it’s time for an upgrade. 

Remember, you can’t personally be there 24/7, 365 days a year but you can still enjoy the reputation, public image, and star rating you desire with a robust incident reporting system.

Characteristics of an Ideal Healthcare Incident Reporting System 

Brand Inspiring

• Non-punitive name/customizable

• Promotes the organization vision

  • E.g. Quality Check, Safety Report, Our Care, etc.

Easy to Access

• Get to incident reporting system from most common workstations or mobile devices

• Do not allow paper as an option (except downtime protocols)

Easy to Use

• Complete report in one or two screens

• Minimize info required by reporter:

  • Personnel or patient name MRN

  • Date and Location

  • Brief description of event

Allows partial or complete anonymity

• Reporter may identify themselves because they want feedback

• Reporter may wish to be identified by their generic role in the organization

• Reporter may wish complete anonymity

Ability to designate reviewers as well as FYI notifications

• One or more primary reviewers

• Multiple secondary reviewers

• FYI for leaders’ situational awareness, pending review by others

Auto-notification

• Reviewers know when they have an assigned task and expected completion

• Reviewers know when all primary and secondary reviews have been completed

• Reminders if assigned deadlines are missed

• Notification by email or SMSo  

Organization Specific Priorities

Reviewed reports that have been      substantiated need to be categorized by event type

• Required categories: hospital acquired infections, security & safety concerns, patient identification, falls, etc.

• Custom categories: current priorities as well as highly specific issues such as radiology delays on third shift, unnecessary patient transfers, inappropriate physician responses, etc.

Advanced Reporting Capabilities

• Overall reporting

• Reporting by broad categories

• Reporting by sub-categories

• Filter reports

  • By unit

  • Day/time

  • Care Giver

  • Diagnosis

  • Ability to capture any discrete field desired