“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
1
Enhancing Safety Culture
Through Improved Incident
Reporting: A Case Study
In Translational Research
ABSTRACT
The Imperial College Healthcare National Health Service Trust, a large health care
provider in London, together with an academic research unit, used a learning health
systems cycle of interventions. The goals were to improve patient safety incident
reporting and learning and shape a more just organizational safety culture. Following
a phase of feedback gathering from front-line staff, seven evidence-based
interventions were implemented and evaluated from October 2016 to August 2018.
Indicators of safety culture, incident reporting rates, and reported rates of harm to
patients and “never events” (events that should not happen in medical practice) were
continuously monitored. In this article we report on this initiative, including its early
results. We observed improvement on some measures of safety culture and incident
reporting rates. Staff members’ perceptions of six of the seven interventions were
positive. The intervention exercise demonstrated the importance of health care
policies in supporting local ownership of safety culture and encouraging the
application of rigorous research standards.
A mature safety culture has been found to be a common characteristic of
high-performing health care organizations.1 Safety culture is defined as “the product
of individual and group values, attitudes, perceptions, competencies, and patterns of
behaviour that determine the commitment to, and the style and proficiency of, an
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
2
organization's health and safety management.”2 Beyond that definition, there is
increasing acknowledgment that a strong safety culture is one that adopts the
principles of a “just culture that abandons blame as a tool and promotes the belief
that incidents cannot simply be linked to the actions of the individual healthcare staff
involved but rather the system.”3
Given the complexity of organizational culture and the subjectivity of its
components, measuring it in a way that yields actionable data can be difficult.4
However, aspects of culture can be detected via staff engagement surveys, as the
relationship between staff engagement and the delivery of high-quality services has
been extensively corroborated.5,6 Furthermore, safe systems are typically
characterized by high rates of reporting of patient safety incidents and near misses.7
Evidence from health systems around the world focuses on three barriers to incident
reporting: time-consuming and cumbersome reporting systems, insufficient feedback
provided to reporters, and fear that reporting will result in blame8,9 (see the online
appendix).10 These barriers create a web of psychological considerations that
compound the ability and likelihood of staff members to report incidents.7 The
barriers result in a reporting deficit and an opaque culture that lacks meaningful
mechanisms with which to applaud “good catches” or learn from mistakes.11
Furthermore, evidence suggests that learning is also restricted at national levels. For
instance, the UK’s repository of all voluntary incident reports captures “a large
volume of high frequency, low intensity incidents” but provides a limited degree of
insight about the root causes of harm.12 This problem has been shown to inhibit
learning from incidents at local, national, and international levels.13,14
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
3
Imperial College Healthcare National Health Service (NHS) Trust, the
organization referred to throughout this study, in collaboration with the National
Institute for Health Research’s Imperial Patient Safety Translational Research
Centre, initiated the intervention described here to shape its organizational safety
culture. The Trust is an NHS acute teaching hospital organization and major trauma
center in Northwest London with over 11,000 staff members across five hospital
sites. In comparison to the other thirty acute teaching hospitals in the English NHS,
the Trust is much larger: The median number of sites for similar organizations is four,
and the average total staff count is just 4,953.15 The organization serves a diverse
patient population, with approximately 125 million patient contacts per year—
including nearly 300,000 emergencies.
While revising local incident reporting policy appears to be a straightforward
organizational decision, evidence suggests that operationalizing cultural change is
not.16 Hence, this intervention employed evidence-based rigor to guide interventions,
adapting them with local codesign. Seven of the teams within the organization, four
of which include lay representation, explored incident reporting and learning as an
enabler of improving safety culture (exhibit 1).
Case-Study Context
At the outset of the intervention, a series of indicators across the organization
revealed a problem with safety culture. In 2016 the organization was rated 163 out of
203 in a UK-wide Learning from Mistakes League Table and classified as having
"significant concerns.”17 The league table was a simple ranking of all acute
organizations in the NHS and was developed based on key questions from the
National NHS Staff Survey relating to how staff perceived the fairness and
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
4
effectiveness of incident reporting, their confidence in the reporting systems, and the
proportion of staff reporting that they had been bullied at work.17 This ranking was
used to suggest to organizations’ leadership whether they needed to improve their
ability to learn from mistakes. In addition to this ranking, the organization also
demonstrated poor patient safety culture metrics on the 2016 organizationwide Local
Staff Engagement Survey (exhibit 2).
In both 2016 and 2017 the organization also reported four never events,
defined as incidents that should never occur in medical practice—for example,
operating on the wrong body part or leaving surgical instruments inside a patient
after an operation. The list of never events is not fixed but is responsive to what are
deemed to be the most dangerous eventualities in health care, which can change
over time.18 While never events cannot be compared across organizations without
full context, only eighteen other organizations reported a figure as high or higher
during the same period.18
The combination of these indicators provoked action from the organization’s
executive board and underpinned a suite of interventions to improve safety culture.
The planning for this work took place in mid-2016, and the work itself began with
feedback gathering in October 2016. Interventions were launched in June 2017 and
evaluated iteratively over the course of the intervention cycle, ending in August 2018.
The aim of this work was to improve the incident reporting process at Imperial
College Healthcare NHS Trust and develop the foundations for a more just safety
culture. The intention was to use a translational, learning health system approach to
improving incident reporting and, over time, yield improved culture.
Study Data And Methods
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
5
Translational Approach
The intervention used a translational approach. Translational refers to the
process of adapting evidence-based interventions to the practical needs of a health
care provider environment, with the support of embedded research expertise.
The technique has its root in a theory known as engaged scholarship, which
asserts the role of academic research principles in the practical context of
organizational social research and discourages the often removed position that
academics hold in solving practical problems.19,20
Interventions were introduced in an iterative way, meaning that feedback from
each helped inform subsequent interventions.21 They included codesign with a
seventy-person multidisciplinary group of patients, staff members, researchers, and
senior managers to solicit their feedback.3,22,23 The iterative nature of these
interventions reflects the improvement cycle model put forward in literature about
learning health systems that places a problem—in this case, how to foster a safety
culture—at the center and addresses it by collecting data, continuously analyzing
them, and making relevant changes.24,25 After initial feedback gathering and the
construction of a research aim, a cycle of evidence-based interventions was
implemented in a way that met the provider’s needs and retained the ability to apply
robust academic evaluation.
Measurement And Evaluation
Five indicators were continuously monitored throughout the duration of the
intervention cycle, from October 2016 to August 2018, including National NHS Staff
Survey results, Local Staff Engagement Survey results, incident reporting rates
measured against the organization’s patient activity data (i.e. how many patients are
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
6
seen by the organization each month), reported levels of incident harm, and rates of
never events. Anecdotal feedback regarding staff perspectives on changes to
incident reporting and management was also collected.18
Analysis
This intervention included the continual collection and analysis of relevant
safety culture data, the results of which are reported below. The main findings relate
to improved staff engagement, increased incident reporting rates, and reduced rates
of never events. The results presented below, some of which have been published
previously,25 are based on survey data and data collected on various types of
events. We report results of tests of significance that compared pre-intervention and
post-intervention measurements, with additional details provided below.
Codesigned Interventions
Initial feedback gathering was conducted via Listening Events. These were
forums where front-line and managerial staff could articulate their ideas for improving
safety culture, facilitated by a trained researcher or member of the safety culture
team (details are available in the appendix).10 Seven evidence-based codesigned
interventions were then implemented (exhibit 3), followed by the assembly and
analysis of relevant data.25
The seven interventions were the introduction of the Incident Reporting
Reference Group; new reporting forms; local trigger lists for commonly occurring
incidents; new incident management processes; simpler approaches to incident
quality checking; anonymous reporting options; and the Learning from Excellence
program. The interventions were rolled out from October 2016 to August 2018. Their
specifications and the evidence supporting them are in the appendix.10
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
7
Limitations
The main limitation of this work related to its translational approach, which
meant that elements of more robust research methods, such as randomizing and
blinding, could not be applied, given the constraints of working within a real health
care environment. Future work to simulate these interventions in randomized
controlled trials would bolster the academic evaluation. Alternatively, quasi-
experimental designs, such as nonequivalent groups and pre-post test designs,
would also provide a useful method with which to evaluate the interventions’ impact.
Study Results
Continuous Measurement
National NHS Staff Survey:
There were nonsignificant reductions (data not shown) in the number of staff
members who reported being bullied by other staff members and a significant (p <
0.05) increase in the percentage of staff members who witnessed potentially harmful
errors, near misses, or incidents in the past month (the increase in witnessing errors
is published as a problematic outcome; however, the increase could indicate a
positive shift toward increased reporting and openness about error).26
Local Staff Engagement Survey:
Local survey results demonstrated improvements on patient safety culture
metrics. From 2016 to 2017 and from 2017 to 2018, there were significant increases
in the percentage of staff members who reported that they felt safe and comfortable
about speaking up (exhibit 2). There were also significant increases from 2016 to
2017 in the percentages who believed that the organization encourages speaking up
and thought that care of patients was the organization’s top priority (exhibit 2). A new
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
8
survey question was added in 2018 about whether staff members understood
incident reporting policies. Ninety-two percent of the staff reported that they did;
however, there were no points of comparison to other years to interpret the
significance of this finding.
Rates Of Incident Reporting, Harm, And Never Events:
There was also a significant increase in incident reporting rates over the
duration of the intervention cycle. An independent samples t-test that compared the
mean value for monthly incident reporting rates in 2016 (mean: 44.38; standard
deviation: 3.21) and 2017 (mean: 49.52; SD: 2.96) demonstrated a significant
increase in incident reporting rates (t = 4.40, d.f. = 22, p < 0.01) (exhibit 4).
Between 2016 and 2018 there were no significant differences in levels of
reported harm (see the appendix).10
Finally, the rate of reported never events fell from four per year in 2015 and
2016 to one in 2018 (data not shown), placing the organization in the normal range
for this rate for similarly sized organizations.
Intervention-Specific Findings
The measurements above were used to evaluate the suite of interventions
and feed into a cycle of continuous improvement. In addition, specific findings were
recorded about how staff members perceived the acceptability of each intervention
(see the appendix).10
The Listening Event feedback sessions involved 250 staff members who
discussed eight events and derived specific improvements necessary to enhance
incident reporting, which helped formulate the subsequent interventions.
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
9
Of the seven interventions, six received positive feedback. The only
intervention not to be viewed positively was the new incident reporting management
process, as staff members did not find the new centralized process for signing off on
incidents useful to their services’ learning and development.
Furthermore, the Incident Reporting Reference Group met twelve times from
October 2016 to August 2018 to develop new incident reporting forms and oversee
the cycle of interventions. The group surveyed the staff about the new, streamlined
incident reporting forms. Seventy-six percent of respondents were satisfied with the
new forms. The process of developing the forms engaged staff and highlighted areas
where the forms did not reflect clinically relevant information or asked for
unnecessary information. In terms of the trigger list intervention, staff members felt
that such lists were helpful in engaging staff and raising awareness about common
incidents.
Despite some resistance to change before the interventions, both anonymous
reporting and the Learning from Excellence program were well received by the staff.
Eighty-two anonymous reports were made since the option was introduced in March
2018 to July 2018, which corresponds to 0.82 percent of all reports made across the
organization in that period. From April to August 2018, 126 positive reports were
made across the clinical areas that tested the Learning from Excellence program. In
the same clinical areas over the same time period, 163 negative incident reports
were submitted, which means that the positive reporting rate was 77 percent that of
the negative reporting rate.
Discussion
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
10
Evidence about incident reporting suggests that while reporting systems are
plentiful and often rich in data, they are not always equipped to support learning and
can contribute to a blame culture.13,27,28 However, when implemented appropriately,
they can be a key feature of a learning health system.13,22
This case study explored a holistic approach to implementation, addressing a
range of concerns that restrict the ability of incident reporting to fuel a learning
culture.29 The experience of conducting the feedback gathering stage and keeping it
open to all staff resonated with theories of appreciative enquiry: that respecting staff
authority as commensurate to that of other stakeholders can solicit honest and
helpful views.30,31
Furthermore, results from the interventions demonstrated a general
enthusiasm, indicative of a cultural readiness for learning and improvement.32 This
was reflected in specific metrics about staff culture in the Local Staff Engagement
Survey results (exhibit 2) and in qualitative accounts from staff members, a key
source of information from which to advance the cyclical trajectory of improvement.24
Not all interventions were successful. Following the introduction of a new
incident management process, staff members articulated that they required more
details about events to generate learning. As evidenced extensively in the
organizational change literature, the psychological barriers to change in practice also
inhibited the effectiveness, rate, or both of the uptake of this intervention.33
In terms of the anonymous reporting intervention, evidence from other
organizations suggests that this intervention provides an option that helps staff
members feel safe to report, a feeling that is accepted to be a first step toward a just
culture.34 Results from this case study demonstrate that the intervention was
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
11
welcomed by staff but not used often, which suggests that in the majority of cases,
the intervention did not obstruct root cause analysis.
This case study supports existing findings that academic research principles
can be adapted to support real-life hospital improvement cycles.12 While this work
benefited from organizational readiness, staff willingness, and executive
championship, the role of national policies was apparent in the sense that the
redesign of incident reporting forms was underpinned by the needs of mandatory
reporting to the national system.12,35
Impact On Policy
Impact on lpolicy at the local provider level has already been seen.
Incremental changes throughout the cycle of improvement included the
establishment of new policies that were successful at the pilot stage, such as the
new incident reporting forms, the removal of the senior manager quality checking
step in incident reviews, and the expanded rollout of the Learning from Excellence
program (see the appendix).10 Furthermore, a “no brief, no start” policy, which
ensures that surgical teams do not start work without a briefing about the operation,
was introduced based on feedback from the Listening Events. Finally, the
importance of having a positive staff culture is now articulated within the training
curriculum for staff preparing for their first management role. More specifically,
changes from the Listening Events were also integrated, so that there is now an
improved intranet and an organizationwide strategy for safety communications,
which includes how the CEO communicates safety-related information.
The role of local provider–level policies and practice should not be
overlooked. This work provides a precedent for using a cycle of staff- and patient-
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
12
driven interventions to improve incident reporting and bolster reporting rates and
feelings of having a safer culture. The rigorous documentation associated with this
case study and considerable flexibility for local rather than academic ownership yield
substantial potential for knowledge transfer. While it is impossible to rerun full
intervention cycles in new settings, given the variation in teams, resources, and
operational structures, the method and results of this study provide the opportunity to
reflect on one learning health system’s cycle of improvements and derive a model for
implementation elsewhere. Vehicles such as the Academic Health Science Centres
in the UK and other academic, health care, and government partnerships across
systems internationally can support the diffusion of this work and its dissemination to
other organizations and policy makers.
The organization in this case study has identified emerging priorities related to
how to better learn from mistakes, and this work has already attracted interest
regionally in scaling up across other organizations in Northwest London. Work is
under way to take a safety culture baseline across three more organizations. The
next step is not only to continuously monitor, evaluate, and disseminate information
but also to invite critical inquiry from other interested organizations at the local or
national level to assess its value across geographies.
Conclusion
Improving safety culture in health care is a long-term process that demands
conviction for improvement and timely interventions that are aligned with the needs
of staff members and the preferences of patients. The continuous measurement
principles of learning health systems are congruent with the needs of practical
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
13
improvement: Academic approaches have an important role to play in designing and
evaluating initiatives, although such approaches require flexibility and adaptation.
The results of the interventions from this case study are encouraging and
worthy of follow-up. The most impressive result, however, is that diverse teams and
hundreds of staff members have been engaged in the transformation process. This
input should be harnessed to support evaluation at this organization and reflected
upon to provide a blueprint for future cultural improvement cycles elsewhere.
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
14
Notes
<eref>1. Health Foundation. Safety culture: what is it and how do we monitor and
measure it? A summary of learning from a Health Foundation roundtable [Internet].
London: Health Foundation; 2013 Mar [cited 2018 Oct 15]. Available from:
http://www.health.org.uk/sites/health/files/SafetyCultureWhatIsItAndHowDoWeMeas
ureIt.pdf</eref>
<bok>2. Advisory Committee on the Safety of Nuclear Installations. ACSNI Study
Group on Human Factors: third report—organising for safety. London: HM Stationery
Office; 1993. p. [please provide]. </bok>
<eref>3. National Health Service England. Serious incident framework: supporting
learning to prevent recurrence [Internet]. London: NHS England; 2015 Mar 27 [cited
2018 Oct 15]. Available from: https://www.england.nhs.uk/wp-
content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf</eref>
<eref>4. Yu A, Flott K, Chainani N, Fontana G, Darzi A. Patient Safety 2030
[Internet]. London: NIHR Imperial Patient Safety Translational Research Centre;
2016 [cited 2018 Oct 15]. Available from: http://www.imperial.ac.uk/media/imperial-
college/institute-of-global-health-innovation/centre-for-health-policy/Patient-Safety-
2030-Report-VFinal.pdf</eref>
<jrn>5. Raleigh VS, Hussey D, Seccombe I, Qi R. Do associations between staff and
inpatient feedback have the potential for improving patient experience? An analysis
of surveys in NHS acute trusts in England. Qual Saf Health Care. 2009;18(5):347–54
PubMed.</jrn>
<eref>6. Wolf JA. State of patient experience in 2015: a global perspective on the
patient experience movement [Internet]. Dallas (TX): Beryl Institute; c 2015 [cited
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
15
2018 Oct 15]. Available from:
http://c.ymcdn.com/sites/www.theberylinstitute.org/resource/resmgr/Benchmarking_
Study/2015-Benchmarking-Study.pdf</eref>
<jrn>7. Howell AM, Burns EM, Bouras G, Donaldson LJ, Athanasiou T, Darzi A. Can
patient safety incident reports be used to compare hospital safety? Results from a
quantitative analysis of the English National Reporting and Learning System data.
PLoS One. 2015;10(12):e0144107 PubMed.</jrn>
<jrn>8. Macrae C. The problem with incident reporting. BMJ Qual Saf.
2016;25(2):71–5 PubMed.</jrn>
<jrn>9. Evans SM, Berry JG, Smith BJ, Esterman A, Selim P, O’Shaughnessy J, et
al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual
Saf Health Care. 2006;15(1):39–43 PubMed.</jrn>
<unknown>10. To access the appendix, click on the Details tab of the article
online.</unknown>
<jrn>11. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting
adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1):13–21
PubMed.</jrn>
<eref>12. Mayer E, Flott K, Callahan R, Darzi A. National Reporting and Learning
System research and development [Internet]. London: NIHR Patient Safety
Translational Research Centre at Imperial College London; [cited 2018 Oct 15].
Available from: http://www.imperial.ac.uk/media/imperial-college/institute-of-global-
health-innovation/IMPJ4219-NRLS-report_010316-INTS-WEB.pdf</eref>
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
16
<jrn>13. Braithwaite J, Westbrook MT, Travaglia JF, Hughes C. Cultural and
associated enablers of, and barriers to, adverse incident reporting. Qual Saf Health
Care. 2010;19(3):229–33 PubMed.</jrn>
<jrn>14. Travaglia JF, Westbrook MT, Braithwaite J. Implementation of a patient
safety incident management system as viewed by doctors, nurses and allied health
professionals. Health (London). 2009;13(3):277–96 PubMed.</jrn>
<eref>15. Care Quality Commission. Intelligent Monitoring: NHS acute hospitals:
indicators and methodology guidance to support the July 2014 Intelligent Monitoring
update [Internet]. London: CQC; [cited 2018 Oct 15]. Available from:
https://www.cqc.org.uk/sites/default/files/Intelligent%20Monitoring%20Indicators%20
and%20Methodology%20JULY.pdf</eref>
<jrn>16. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C.
Strategies for improving patient safety culture in hospitals: a systematic review. BMJ
Qual Saf. 2013;22(1):11–8 PubMed.</jrn>
<eref>17. National Health Service Trust Development Authority. Learning from
Mistakes League [Internet]. London: The Authority; 2016 Mar 9 [cited 2018 Oct 15].
Available from: https://www.gov.uk/government/publications/learning-from-mistakes-
league</eref>
<eref>18. National Health Service Improvement. Never events list 2018 [Internet].
London: NHS Improvement; 2018 Jan [cited 2018 Oct 15]. Available from:
https://improvement.nhs.uk/documents/2266/Never_Events_list_2018_FINAL_v5.pdf
</eref>
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
17
<jrn>19. Marshall M, Pagel C, French C, Utley M, Allwood D, Fulop N, et al. Moving
improvement research closer to practice: the researcher-in-residence model. BMJ
Qual Saf. 2014;23(10):801–5 PubMed.</jrn>
<bok>20. Van de Ven AH. Engaged scholarship: a guide for organizational and
social research. Oxford: Oxford University Press; 2007. p. 343.</bok>
<jrn>21. Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act
cycles in practice, not just in name. BMJ Qual Saf. 2017;26(7):572–7 PubMed.</jrn>
<eref>22. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: a white
paper [Internet]. 2015 [cited 2018 Oct 15]. Available from:
http://aihi.mq.edu.au/sites/default/files/aihi/resources/From_Safety_I_to_Safety_II_A
_White_Paper.pdf</eref>
<jrn>23. Bate P, Robert G. Experience-based design: from redesigning the system
around the patient to co-designing services with the patient. Qual Saf Health Care.
2006;15(5):307–10 PubMed.</jrn>
<edb>24. Institute of Medicine. Best care at lower cost: the path to continuously
learning health care in America [Internet]. . Washington (DC): National Academies
Press; 2013. Chapter 5: a continuously learning health care system; [cited 2018 Oct
15]. p. 133–45. Available from: https://www.nap.edu/read/13444/chapter/10</edb>
<eref>25. Learning Healthcare Project. Background: learning healthcare system
[Internet]. Newcastle upon Tyne: Newcastle University, Institute of Health and
Society; c 2108 [cited 2018 Oct 15]. Available from:
http://www.learninghealthcareproject.org/section/background/learning-healthcare-
system</eref>
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
18
<eref>26. Imperial College Healthcare NHS Trust. 2017 national NHS staff survey:
results from Imperial College Healthcare NHS Trust [Internet]. London: The Trust;
[cited 2018 Oct 15]. Available from:
http://www.nhsstaffsurveys.com/Caches/Files/NHS_staff_survey_2017_RYJ_full.pdf
</eref>
<eref>27. Reporting and Learning Subgroup of the European Commission
PSCQWG. Key findings and recommendations on reporting and learning systems for
patient safety incidents across Europe [Internet]. Brussels: European Commission;
2014 May [cited 2018 Oct 15]. Available from:
http://buonepratiche.agenas.it/documents/More/8.pdf </eref>
<eref>28. West M, Collins B, Eckert R, Chowla R. Caring to change: how
compassionate leadership can stimulate innovation in health care [Internet]. London:
King’s Fund; 2017 May [cited 2018 Oct 15]. Available from:
https://www.kingsfund.org.uk/publications/caring-change</eref>
<jrn>29. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al.
The Safety Attitudes Questionnaire: psychometric properties, benchmarking data,
and emerging research. BMC Health Serv Res. 2006;6:44 PubMed.</jrn>
<jrn>30. Trajkovski S, Schmied V, Vickers M, Jackson D. Using appreciative inquiry
to transform health care. Contemp Nurse. 2013;45(1):95–100 PubMed.</jrn>
<jrn>31. Richer M-C, Ritchie J, Marchionni C. Appreciative inquiry in health care. Br
J Healthc Manag. 2010;16(4):164–72.</jrn>
<jrn>32. Sheard L, Marsh C, O’Hara J, Armitage G, Wright J, Lawton R. The Patient
Feedback Response Framework—understanding why UK hospital staff find it difficult
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
19
to make improvements based on patient feedback: a qualitative study. Soc Sci Med.
2017;178:19–27 PubMed.</jrn>
<jrn>33. Martin AJ, Jones ES, Callan VJ. The role of psychological climate in
facilitating employee adjustment during organizational change. Eur J Work Organ
Psychol. 2005;14(3):263–89.</jrn>
<jrn>34. Nakajima K, Kurata Y, Takeda H. A web-based incident reporting system
and multidisciplinary collaborative projects for patient safety in a Japanese hospital.
Qual Saf Health Care. 2005;14(2):123–9 PubMed.</jrn>
<jrn>35. Howell AM, Burns EM, Hull L, Mayer E, Sevdalis N, Darzi A. International
recommendations for national patient safety incident reporting systems: an expert
Delphi consensus-building process. BMJ Qual Saf. 2017;26(2):150–63
PubMed.</jrn>
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
20
EXHIBIT LIST
Exhibit 1: (Table) Exhibit 2: (Figure) Caption: Percentages of staff members at the Imperial College Healthcare National Health Service (NHS) Trust who agreed to the statements about safety culture shown from the Local Staff Engagement Survey in 2016–18 Source/Notes: SOURCE Authors’ analysis of responses to the Imperial College Healthcare NHS Trust’s Local Staff Engagement Survey. NOTES Significance refers to the difference from the previous year. The numbers of respondents to each question for 2016, 2017, and 2018 are shown below. a3,216, 2,766, and 3,131. b3,115. The item was introduced in 2018; see the text for more details. c3,201, 2,765, and 3116. d3,019, 2,568, and 2,950. e3,214, 2,755, and 3,133. **p < 0.05 Exhibit 3: (Table) Exhibit 4: (Figure) Caption: Patient safety incident reporting rates at the Imperial College Healthcare National Health Service Trust, 2016–18 Source/Notes: SOURCE Authors’ analysis of a statistical process control chart of organizational incident reporting rates. NOTES The upper and lower control limits are comparable to the standard deviation around the mean and can be interpreted in a similar way. The baseline mean in 2016 is 44.38, the calculated mean for 2017 was 49.52, and the difference is significant (α = 0.01).
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
21
EXHIBITS
Exhibit 1: Teams involved in the Imperial College Healthcare National Health Service Trust (ICHNT) case study Teams Responsibility Number of people on
the team who supported this work
ICHNT Safety and Effectiveness Team
Assurance of and compliance with national standards and external reporting requirements; includes lay representation
6
ICHNT Safety and Quality Subgroup
Subgroup of Executive Quality Committee (chaired by the medical director); reviews risk and receives assurance from divisions and corporate directorates on matters relating to quality and safety in the Trust; includes lay representation
25 (committee)
ICHNT Safety Culture Steering Group
Steering group for the Trust safety culture program (chaired by the medical director), which aims to continuously improve the safety culture in the Trust; Includes lay representation
20 (committee)
ICHNT Quality Improvement Team Corporate team sitting in the Medical Director’s Office with the aim of creating a culture of continuous improvement in the Trust through the use of quality improvement methodology, supporting core program aims, and service-‐led and strategic projects
6
ICHNT Datix Team Part of the Safety and Effectiveness Team with responsibility for management of the electronic incident reporting management system
2
Medical Director's Office Corporate executive directorate with responsibility that includes quality, medical education, and research
6
Patient Safety Translational Research Centre
Generate scientific evidence base for safety and support implementation of evidence-‐based interventions for safety; includes lay representation
5
SOURCE Institutional organization charts.
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
22
Exhibit 3: Summary of interventions to improve incident reporting in the Imperial College Healthcare National Health Service Trust Intervention Summary
Feedback gathering: Listening Events
An opportunity for front-‐line and managerial staff to express their priorities for cultural improvement across the organization
Incident Reporting Reference Group and Feedback Survey
A multidisciplinary group set up to make incident reporting forms more user-‐friendly and strengthen staff investment in learning from incidents
Revised incident reporting forms Shortened incident reporting forms designed to increase incident reporting rates and align reporting to the needs of subsequent investigations
Local trigger lists for incidents A list of common incidents produced by clinical teams to increase reporting consistency and provoke a conversation about the frequency of such incidents
New incident management process
A policy that centralizes the incident review process, enables reporters to receive timely feedback, and reduces the burden on clinical staff to review incidents
New incident validation and quality checking
A process designed to reduce the number of incident investigations awaiting senior manager sign-‐off and to redirect resources from administration to learning
Anonymous reporting options An option for staff to report anonymously to remove the possibility for blame after reporting
Learning from Excellence program
A mechanism for reporting positive occurrences and learning from best practices
SOURCE Authors’ summary of interventions.
“flott_RFCE_clean.docx”; 9/25; dl 10/10; lw to jf 10/12; names checked 10/12, jf to az 10/16; az to lw 10/16; lw to au 10/16;
23
Acknowledgment
The research was supported by the Imperial Patient Safety Translational Research
Centre of the UK National Institute for Health Research (NIHR) and the NIHR
Biomedical Research Centre. The views expressed are those of the authors and not
necessarily those of the National Health Service, the NIHR, or the Department of
Health. An earlier version of the manuscript was presented at a working paper
review session in Washington, D.C., April 10, 2018, organized by Health Affairs and
supported by the Gordon and Betty Moore Foundation.
Bios for 2018-0706_Flott
Bio 1: Kelsey Flott ([email protected]) is a manager of the Patient Safety Translational Research Centre, Department of Surgery and Cancer, Imperial College London and St. Mary’s Hospital, in London, United Kingdom. Bio 2: Darren Nelson is head of quality compliance and assurance, Imperial College Healthcare National Health Service (NHS) Trust and St. Mary’s Hospital. Bio 3: Tammy Moorcroft is a program manager in the Safety and Effectiveness [please provide], Imperial College Healthcare NHS Trust and St. Mary’s Hospital. Bio 4: Erik K. Mayer is a [please provide], Surgery and Cancer, Imperial College London and St. Mary’s Hospital. Bio 5: William Gage is manager of the Safety Improvement Program, Imperial College Healthcare NHS Trust and St. Mary’s Hospital. Bio 6: Julian Redhead is CEO of the Imperial College Healthcare NHS Trust and St. Mary’s Hospital. Bio 7: Ara W. Darzi is executive chair of the World Innovation Summit for Health, Qatar Foundation, and director of the Institute of Global Health Innovation, Imperial College London.