Improve incident reporting culture – be curious, add value, and remove waste
By Justin King, Associate Director of Quality – Patient Safety & Risk at University Hospitals Coventry & Warwickshire NHS Trust, interviewed by Cat Harrison, Sign up to Safety
At the start of our journey at University Hospitals Coventry & Warwickshire we had relatively low incident reporting rates and staff were telling us that they didn’t hear about the outcome of incident reports. We knew we had to do something about it if we were to deliver our aims of putting patients first and delivering safer care.
We knew we wanted more staff to report and be proactive when something had gone wrong, but how should we go about it? We are one of a handful of trusts lucky enough to be partnered with the Virginia Mason Institute who challenged our approach. The old way might have been to ‘promote’ incident reporting or simply mandate it. But our thinking had been challenged by our mentors – we needed to understand the gap between work as we managers might imagine it to be, and how it really looks on the shop floor.
We realised that we needed to be curious, to properly listen to staff, to see what was happening in our places of work, to observe the process from a staff member’s point of view. I realise now that if we hadn’t done this, we would have missed out on so much knowledge. We might have thought we were tackling low incident reporting, but we would have wasted time, because we wouldn’t have truly understood why we had the problem in the first place.
Our first step was to get clinicians and patients in a room for a week to gain an understanding of what is valuable for them, and what’s wasteful. We asked ourselves, from the patient and staff point of view, what adds value? When it comes to an incident, clinical staff don’t want to fill in a long and cumbersome form. Patients and carers don’t want to sit around waiting for people to apologise and explain – the longer that elapses the less trust they have in our care.
We started to look at our existing processes in terms of waste and value – for example, we take two months to do a serious incident review, but why? The value is in the learning right now, and engaging with patients right away. The SI framework says report within 60 days, so that’s how long we tended to take before implementing change and didn’t challenge that. But we often know on the day of the incident a lot of what went wrong and why, and what we can do straight away. We also knew from our conversations with staff that they needed more support – not just emotionally but to take steps to make it right and to feel empowered by the process. Some didn’t even hear back for the whole two months after filing a report which can be extremely stressful, isolating and dis-empowering.
Inadvertently we had given staff the impression that all they had to do was ‘report and it will get fixed’, which we know from experience doesn’t work. We weren’t saying ‘talk to your team about your ideas of how this can be fixed, as well as do the incident form’ – it is a small change in message, but it makes a difference. Daily and weekly safety huddles now give an opportunity for people to talk about their ideas, what went well, what didn’t, what can be done differently – within hours of an event. The old way was for the manager to log in to Datix, sometimes weeks later – less real, too late and possibly meaningless by that point.
Now we tell staff they can make change happen today. Our ethos is that anyone should have the mindset to support people in doing what needs to happen and help them to navigate the system and remove, not create, barriers.
Another step we took was to form a Patient Safety Response team. This is a team who respond straight away to a serious incident. We help the team apologise for any harm and distress and provide help and support to the patient, family and our staff. We collect information on what happened and get started on a thorough investigation. Put simply we start putting things right and making improvements from day one.
We are all on the rota, including the Chief Medical and Nursing officers, plus Patient Safety team members. This is a significant commitment of many senior members of the trust. Certainly you invest a lot of yourself in trying to support others and dealing with difficult situations- but it has been worth it. It is the right thing to do for patients and staff.
For us, two years in, it’s absolutely a work in progress and we are learning with each day how better to support people. Trying to get the balance right between getting key information and not putting undue pressure on staff, trying to make it clear to patients that senior staff in the trust are taking it seriously, without unnecessarily worrying them. One of the simplest but most effective changes was to wear a badged uniform to be more approachable and look more like a member of the team. We’ve made the process better by being open minded and willing to listen.
As with every project of this type, measurement has been key and we’ve changed our approach to this too. Some of the measures we’ve chosen to track our progress were uncomfortable at first, like having to acknowledge the number of investigations that we had as ‘work in progress’ but very little happening day to day. Our mentors challenged us – ‘why are you waiting to learn?’ We now also look at the time between the incident being recognised and the changes being made – this again felt scary at first as it is a longer timescale but it recognises that it is not the report, it is the change to practice that adds value for patient safety.
We have implemented Learning Teams where we gather staff who do the work to re-design their processes to make them safer. Historically our root cause analysis action plans would be written by investigation leads and managers. They would produce, on average, only one system change to the process of care per report – the changes generally regarded to be more effective. The rest of the recommendations were behaviour based, eg to remind and re-educate staff. As a result of Learning Teams we now have on average five system changes per report. We are testing the impact these are having, but the changes are well received by those doing the work as they have been designed by them.
We aren’t just claiming to listen, we are getting people in the room to participate in the work. For us, it is not just rhetoric, and we are getting great results. Our incident reporting is up, and our staff survey shows staff feel incidents are managed fairly and effectively.
After just one or two incidents working in this new way, my eyes were open. It gives a much greater value and meaning to what I’m doing. I couldn’t turn back now.
My tips for changing the approach to incident management
Try to understand the systems from other points of view:
- Use any opportunity with front line staff to give them space to tell you how the system really works
- Use whatever forums exist already, like training updates or management meetings, and ask staff or patients to spare a little time to share ideas of what works now and what doesn’t, so you can redesign it together
Change the way you talk about incidents:
- Build a group of people around you who are supportive of describing things from the patient and staff point of view
- Get the executive or top team on board and be willing to put a patient or a member of staff in front of senior people
- Let them tell the real story of their own experiences and it’s hard to ignore. It’s about opening people’s eyes
Keep it quick and simple:
- Start small and be empowering; e.g. trial a Patient Safety Response team. Pick one type of incident, mobilise a team once and discuss how it went, which doesn’t require any extra resource – just be ready to measure the effect it had and be willing to learn
- It needn’t take long. When we redesigned our ‘Sorry’ brochure for patients, we sat down with patients and staff members and wrote it together in one hour – one person described it as like being on the apprentice!
Spread the things that work well:
- With safety huddles, we got something that worked well in critical care, then expanded that to five more areas
- We told people to go and see how it was done
- Be flexible in how you spread – our only two rules are that it is a multi-disciplinary team and they ask the same four questions (What happened yesterday? What went well? What didn’t go well? What are we going to do differently today?). Each area has picked a place and time that suited them. We provide support with a dashboard, reminders and resources and now this is done all over the trust.