Patient Safety Requires a Reporting Culture

“Let’s see, Curmudge, there’s a Lean Culture, a Safety Culture, a Just Culture, a Learning Culture, and even a culture we don’t want, a Punitive Culture. We’ve got more cultures than a microbiology lab.”

“Think of the Learning Culture as supporting the other cultures, Jaded Julie. All of the other ‘good’ cultures require us to learn continually how to make our activities safer and more effective and efficient. We must ‘routinely capture data on processes to discover how work really happens.’ This practice forms the basis of a ‘learning infrastructure that makes continual learning part of business as usual.’ (1) Without a Reporting Culture, the Learning Culture can’t function, and the other cultures are in jeopardy.”

“And in a hospital we need blame-free reporting so we can find and correct systemic problems—if that’s what they are—before they turn into something more serious.”

“Good point, Julie, and it’s well known in industry. Heinrich’s Law on Safety says that for every 330 industrial accidents, one may be serious. (2) Heinrich said that to avoid that one serious event, the minor and no-damage accidents should be reduced. Mark Graban teaches the same lesson using the Alcoa safety pyramid, in which there are 30,000 unsafe behaviors per 3,000 first-aid accidents or near misses for each fatality. (3) One cannot obtain these data or conduct an effective safety program without the organization’s having a reporting culture.”

“Golly, Curmudge, is this another instance—like Lean—where health care is lagging industry in finding better ways to do what needs to be done?”

“Regrettably true, Julie, but I think we are finally getting our act together. The University of Nebraska Medical Center has collected a lot of information, all on the same website, about engineering a reporting culture, a just culture, a flexible culture, and a learning culture. (4) Their PowerPoint presentation on Reporting Systems as the Foundation of Patient Safety Programs is especially informative. In it they quote Dr. Lucian Leape’s list of characteristics of successful reporting systems:
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive”

“Those headings look valuable. I’ll bet there’s good information behind them.”

“There is, Julie, but you’ll have to go to the web to read it. Remember that this is a blog and not a textbook.”

“Curmudge, I don’t want to wreck your day by bailing out now, so I’d better ask if there is any more info about a reporting culture that we need to mention.”

“One very import thing, and it’s from our friends at IHI. It’s an example of a non-punitive reporting policy from Wentworth-Douglass Hospital in Dover, New Hampshire (5) The document looks like an excellent model that captures much of what we have discussed about a just culture.”

“I can’t wait to read it. See you soon.”

Affinity’s Kaizen Curmudgeon

(1)http://www.ncbi.nlm.nih.gov/pubmed/18681298

(2) Imai, M. Gemba Kaizen. p. 274, McGraw-Hill 1997.

(3) Graban, M. Lean Hospitals. p. 133, CRC Press 2008.

(4)http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm

(5)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Non-Punitive+Reporting+Policy+Wentworth+Douglass.htm