Risk management in healthcare is dependent on information. What happened? Who did it happen to? Where did it occur?
A lot of that information comes from incident reports voluntarily submitted by staff members. But as the Director of Clinical Risk and Patient Safety at McLaren Health, Kevin Smart is focused on something else: the incidents that don’t get reported and why.
Since stepping in to the role in early 2018, Kevin has been performing weekly rounds. Through his discussions with staff on the floor, he discovered that fear of punitive actions was one of the single biggest actors discouraging staff from event reporting.
“I think we made the mistake early on of just going out an telling people what we wanted them to report and not really backing it with why it’s important to report,” says Kevin.
Kevin has been working hard to change the culture around reporting, working closely with department managers. “My goal is for everyone to understand that I’m not just there when things are bad, I’m a support system they can reach out to at any time.
A core focus of these conversations has been to stress the importance of reporting near misses – even when the errors are caught well in advance of an error reaching a patient. Right now, Kevin has been spending a lot of time working with the nursing department, but soon he hopes to include managers from the ER, OR and other units that, according to McLaren’s data, only report when an adverse event occurs.
Making RL Work with McLaren Staff Workflows’
As Kevin was visiting departments and having conversations with staff, another barrier to reporting quickly became clear. There was a lot of confusion around what information should be reported and staff were put off by the extra work it added to their day.
In response to this feedback, Kevin’s team made some changes in their RL risk management software to make the process of reporting easier on staff. They started by reducing the number of mandatory form fields so that only essential information was required. The result? It now only takes an average of four minutes to file a report.
To help staff remember what information to include and when they should file a report, Kevin’s team distributed tip sheets and placed laminated copies at nursing stations. And while they may seem simple, each of these small adjustments have helped shift the culture around reporting and increase the number of reports filed each month. From 2015, when McLaren went live with RL, to 2017 reporting increased by 20 percent. So far this year it has already increased by over 11 percent.
“I think it’s really just having those conversations with people and getting their feedback, making them part of the process, making them excited and passionate about it,” says Kevin.
Kevin will drop by departments and deliver small treats with thank-you notes for staff that consistently report. His team also administers monthly “great catch” awards, and the corporation is currently working towards implementing a new program called The Safety Champion. Kevin says this will likely include a ceremony where one of the “great catch” winners will be selected as a Safety Champion and rewarded for their hard work.
“Everyone is risk management and everyone is a patient safety officer,” says Kevin. “We all have to be advocates.”