Healthy Incident Reporting System

I have been deeply troubled and saddened by the trajectory of healthcare in recent years.  I am overjoyed that many formerly secret thoughts are now being shared and openly discussed. 

In this blog, I have paraphrased a few relevant conversations I have been participating in on social media, to highlight the need for reform in Leadership, and specifically on the topic of Patient Safety.  I have interacted with and ascribe to the beliefs of the authors I have quoted below.  I thank them for their courage to stand up with me in these sensitive dialogues, and chose to withhold their identity for privacy reasons. 

"Studies have shown that when all members of a clinical care team feel comfortable speaking up, team performance improves. However, to have an impact on patient safety, patients and families must feel comfortable voicing their concerns to the medical team.

After the terrorist attacks on September 11, 2001, the Department of Homeland Security developed the campaign "If you see something, say something" to raise public awareness of indicators of terrorism or terrorism-related crime and to report suspicious activity. This campaign is now used in law enforcement, child, elderly, and animal protection agencies, and human trafficking organizations to report suspicions of cruelty and crimes."

Despite all of this, healthcare workers at all levels, and even administrators are being censored, disciplined and even terminated for voicing quality and patient safety concerns.

WHAT?!?!? Is this for real?

OH YES!

This has happened to many professionals of all specialties, including very astute, well-published, thought leading physicians, especially surrounding the COVID debate.

Clinical licenses are at risk.

Careers are at risk.

LIVES are at risk! 

"Sham peer reviews are in the toolkit of poorly performing healthcare organizations with toxic leadership," to either silence or crucify the whistle-blowers.

"Many CEOs use favoritism and bullying techniques to deliberately 'Divide and Conquer.' If the healthcare staff is arguing and aggravating each other… then they can’t unify against C-Level manipulation. It’s the oldest dominating strategy in the book!" 

“I’ve never met a group of people who thought they were immune to criticism like administrators. Every healthcare system should be a free speech zone where professionals can do their job and speak their minds without fear of repercussions. If every board adopted a no-tolerance policy to prevent administrators from firing employees who speak out, healthcare would become a safer industry.”

“I write from experience as a hospital administrator who was often punished for speaking up. I hear this daily from clinicians. It’s everywhere!”

"Punishing or Silencing voices of advocacy for patient safety is a crime against humanity!"

Do patients know their care teams often work in fear of career loss if they advocate for safer care?

Dr. Kuper’s Response:
As CMO, I also tried bringing staff concerns forward to improve work-flow, patient safety and quality of care. My efforts to serve as the liaison between the medical staff and administration were met with resistance much of the time. The medical team was extremely supportive of me but individuals were so afraid of “the target on their back” that no one would join forces with me. “I need this job! I just need to keep my eyes down and my mouth shut” was the mantra. I did my best to represent the medical group, and they watched me get demoted for speaking up. This was pre-COVID. 

I just kept thinking - where is the Board in all of this?  Don't they see the massive turn over and understand what is happening here?  Then I was reminded that the Board is for governance only, not operations!  Besides that, few of them had a healthcare background, were donating their time to serve on this Board, and meetings barely met a quorum most of the time.  They were completely at the mercy of what they were being told by the CEO and CFO - who is keeping them accountable?  

This was the motivation I needed to start speaking out, to share not only what I had personally learned about burnout, but all the other leadership competencies that if ignored, leave the medical establishment in shambles.  Once I got out of my own head, I quickly learned how ubiquitous these problems were - thus "Stand Up, Stand Out DOCs" was born. 

The trouble is, healthcare workers are trained to be so altruistic that we place the needs of everyone else before our own.  Though we may be suffering, we have learned to keep those thoughts and feelings private, sometimes to the detriment of ourselves AND even our patients' safety at times! 

Secondly, physicians have lost so much influence to the business-minded administrative teams and boards that we don't seem to have much of a voice anymore!  But we can’t fix problems if we don’t openly discuss them.  And if we get punished for bringing concerns forward, everyone suffers!  It seems that the rhetoric has become incredibly mean and nasty in some organizations.  It is unbelievably sad to learn how poorly so many healthcare professionals are being treated these days! 

“The moment the leader becomes the primary reality that people worry about, rather than the reality itself, you have a recipe for mediocrity or worse. Purposeful misdirection/manipulation has ethical and psychological implications that must be addressed as soon as possible.”– Jim Collins

AGAIN - is it any wonder the burnout rates are astronomically high?  We know that the healthcare worker shortage is only going to get worse!  THEN WHAT?!?!?  Who is going to take care of you and your loved ones when you need it?  Don't expect timely or even safe care!  Systems are way over stressed, with no end in sight - the SOS has been sounding for some time now, with too few administrators awake at the wheel to hear or do anything about it!  The culture has got to change, and soon! 

We need to remember that even with the huge amount of training and expertise that healthcare workers have, we are all still human! We have feelings, just like everyone else, and we expect to be treated with kindness and respect; despite our tough, very resilient exteriors. And yes, despite our best intentions, the more stress you add to the job, we as fallible humans are more likely to make an occasional mistake.

Obviously, we all want to avoid errors and mistakes; therefore everyone is equally responsible for this critical role. Within our quest to take excellent care of the patient, our collective job is to identify errors and safeguard our systems to minimize them.  

System factors are the cause of most errors (80+% of cases), not individual performance errors (only 20% of cases). We must understand that a weak system, that does not have protective barriers set in place, can set up a situation for an error to occur. When leaders begin to change their attitudes towards mistakes; asking “what happened” instead of the blame game of “who made the error”, the culture will begin to change.

The Leadership team needs to establish patient safety as a strategic priority and build a culture of high quality, safety, transparency, and collective accountability. And a part of that is a healthy Incident Reporting System.  These are all critical elements in developing a Highly Reliable Organization.

It's not realistic to believe that errors won't occur.  The KEY is to redesign the system so that errors don’t reach the patient!  Policies such as the Swiss Cheese Model are effective means to set up protective barriers and other defenses to catch and minimize errors BEFORE anyone suffers.

One way to decrease errors is by decreasing variations in care = STANDARDIZATION. Sometimes, we as autonomous physicians don't like this approach. Working synergistically as a team to determine what best practice looks like within your specific circumstance is where the hard, but rewarding work occurs.  You may not be able to deliver care the same way your competitor does down the street!  And that's a good thing - be your creative, innovative and ingenious self - and get these problems handled ASAP!  

BUT, error prevention systems are only effective IF we maintain a high degree of psychological safety. ALL staff must trust one another, remain kind, and professionally accountable to one another. "If you see something, say something" means that anyone on the team is empowered to stop an unsafe procedure or work-flow until it is corrected. The procedure should not resume until everyone is comfortable proceeding.

This is not a punitive intervention, and it is not about a single person being “in charge,” with a disruptive, over-inflated ego. It is about TEAMWORK and patient safety. We need to focus on getting it right, not being right. That’s where the “Time-Out,” and “STOP the Line” protocols came from. In case you are under the illusion that these policies are elementary, realize that major errors including wrong site surgeries are STILL happening today!

Once the procedure has been safely executed, then an Incident Report still needs to be filed to trigger the system to perform a Root Cause Analysis so that policies can be corrected ASAP. Interventions for correcting and preventing errors depend on the Type of Error (Knowledge-Based, Rule-Based, or Skill-Based). Each type of error requires a unique way to Redesign the System to assure better and more consistent performance in the future.  The end goal is that very very few errors make it to the patient!  

Leadership must promote a healthy Incident Reporting mechanism along with “A Just Culture" methodology for resolving all problematic issues, from the mechanics to the human behaviors associated with an error. These are learning tools to improve the system, and should never be used for retribution against individuals who bring the issues to light.