Case Study:
After a considerable investment of both money and time, executives at Leman Healthcare were delighted that the new incident-reporting system at Leman was now fully operational. The incident reporting system had been deployed across the health care system; frontline and management staff as well as physicians in both inpatient and ambulatory settings had been trained and were able to use the incident-reporting system to access patient information, document adverse events, and report as required to senior management, risk management, and the QI department. However, even with full system deployment, QI activities across the health system had not changed. The QI department had full access to the data warehouse that housed data collected through the incident-reporting system as well as data from the electronic health record (EHR) and other information systems, yet QI staff members were apparently not using these data. Instead, QI projects continued to follow historical patterns involving laborious efforts to develop queries and reports rather than use the new system’s immediate reporting capabilities to supply information for managers and to drive process improvement projects both locally and across the hospital system. Similarly, the potential for clinicians to use the newly accessible data was not being realized. Physicians were reluctantly compliant with requirements to use the incident-reporting system for documentation and reporting events, but the general consensus seemed to be that the system was just a way to point fi ngers at the medical staff. Despite efforts from the senior management team to work individually with clinicians to educate and explain the importance of error and near-miss reporting that would provide information to reduce errors, these physicians continued to view the incident-reporting system as a punitive tool, not as an opportunity for them to explore ways to improve their work.
questions
1. In a narrative format, discuss the key facts and critical issues presented in the case.
2.
Given this situation, what are the apparent barriers to using incident reporting systems for QI? How can these barriers be overcome?
As a leader in health care, how would you handle the problem and implement changes?
Expert Solution Preview
Introduction:
The case study presented depicts the challenges faced by Leman Healthcare in implementing their incident-reporting system successfully. As a medical professor, I will answer the following questions about the case.
1. In a narrative format, discuss the key facts and critical issues presented in the case.
The case study highlights that Leman Healthcare had implemented an incident-reporting system across their entire health care system. However, even with the system’s full deployment, the Quality Improvement (QI) department had not changed its activities. Despite having access to data collected through the system and other information systems, they continued to follow their historical patterns of developing queries and reports. The system’s potential was also not being realized by the physicians using the system for documentation and reporting events, viewing it as a punitive tool. The key facts in the case are that the incident-reporting system was fully deployed, but QI staff and physicians were not using it effectively to drive process improvement projects, reducing errors and improving work methods.
2. Given this situation, what are the apparent barriers to using incident reporting systems for QI? How can these barriers be overcome?
The apparent barriers for using incident reporting systems for QI are lack of awareness, training, and fear of retribution. QI staff may not understand the system’s capabilities and how to use its data for QI activities. Physicians may fear that the system may be used against them and view it as a tool to punish them for reporting errors or near-misses. These barriers can be overcome by proper education and training programs for QI staff and physicians. They should be made aware of the system’s capabilities, how to use it for QI activities, and the benefits of a system geared towards process improvement. They should be reassured that the system is not a punitive tool but a tool to support and encourage learning and better practices.
3. What steps would you propose to engage both clinicians and QI staff in enhanced QI activities?
To engage both clinicians and QI staff in enhanced QI activities, I would propose the following steps:
– Create an awareness campaign that highlights the benefits of using the system for QI activities and dispels the misconception of the system as a punitive tool.
– Provide continued training and education programs for QI staff and physicians on how to use the system effectively to drive process improvement projects and local hospital system changes.
– Encourage QI staff and physicians to work collaboratively on QI projects, with QI staff providing the technical support and data analysis, and physicians providing their clinical expertise.
– Recognize and reward staff and physicians who use the system effectively to drive QI activities and improvements.
4. As a leader in health care, how would you handle the problem and implement changes?
As a leader in healthcare, I would address the problem by implementing the proposed steps to engage both clinicians and QI staff. I would create an awareness campaign that highlights the benefits of using the system for QI activities and dispels the misconception of the system as a punitive tool. We would provide continued training and education programs for QI staff and physicians on how to use the system effectively to drive process improvement projects, recognizing and rewarding staff and physicians who use the system effectively to drive QI activities and improvements. Additionally, I would encourage collaborative work between QI staff and physicians to ensure QI projects’ success.
