Question

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.

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?

3. What steps would you propose to engage both clinicians and QI staff in enhanced QI activities?

4. As a leader in health care, how would you handle the problem and implement changes?

Answer 1