(A) SEIPS V.2.0 person, task and tools and technology factors influencing clinician engagement in hospital-wide IRS and whether the specialty-specific IRS addresses these factors. (B) SEIPS V.2.0 organisation and environmental factors influencing clinician engagement in hospital-wide IRS and whether the specialty-specific IRS addresses these factors
| Barriers | Ways the specialty-specific IRS addresses these factors | |
| (A) | ||
| Person factors | ||
| P1: clinician knowing how to access the hospital-wide system P2: the clinician perceiving this is a matter worth reporting versus one resolved in an alternate manner | ‘It may be because they just have no idea where the(hospital-wide IRS)report links are.’ interview 5, anaesthesiologist ‘…if something’s missing during the case and it was a close call, we don’t do anything except grumble…‘Come on, I do this case every week. Can we please just have the equipment I need?’…but probably we should say at the end, ‘You know, I needed that Johnson retractor, and let’s make sure it’s available every time we have this case.’ That doesn’t happen. It ends up being a polite, snide comment about something, rather than a formal safe report.’ interview 9, surgeon | P1 and P2: having the specialty-specific reporting system embedded in the EHR facilitates access and encourages reporting events occurring recently. ‘…having it [in the EHR] when you close the record is probably going to be your best [bet] because that’s when it’s still fresh. And I think a lot of times there’s also a recency bias in terms of, ‘Oh yeah, it just happened. I remember this, I did this,’ and it’s easy to do when it’s in the moment.’ interview 16, anaesthesiologist |
| Task factors | ||
| Ta1: no protected time to report incidents Ta2: if the event that occurred was a stressful one; having to report on it immediately does not allow time for reflection Ta3: create opportunity to describe positive events | ‘I know they try to make it easier and have a link on the main page before, but it still takes some time to fill out.’ interview 16, anaesthesiologist ‘that system you’re describing where you’re forcing a clinical person to address a situation like that when they’re in the midst of acute clinical care, …that is something that’s adding, not really giving them the appropriate time to deal with what should be an important thing to think about. And for most people, especially if there was a bad event or a stressful event… the time where just at the final part of the clinical experience with that, that is probably the worst time to ask them to try to sort through it and intelligently report it.’ interview 14, surgeon | Ta1: not addressed by specialty-specific IRS. Ta2: not addressed by specialty-specific IRS. Ta3: the specialty-specific IRS allows for submitting ‘kudos’ reports or positive reports on others. ‘….the positive side of all of it, why can’t we be doing clinical shout outs too?…If you have an exceptional encounter with a provider or a nurse, why can’t we prop them up?…And then make sure that those things are sent to our bosses.’ interview 7, anaesthesiologist |
| Tools and technology factors | ||
| T1: poor accessibility requiring separate log-in on computer T2: burdensome reporting experience | ‘…before [having a direct EHR link in new system), it seemed like too many steps to put these things in. Maybe I would shoot off an email to someone in the department if it was something particularly concerning.’ interview 4, anaesthesiologist ‘The(hospital-wide system)is not intuitive for a clinician who is a physician to use. It’s not structured in a way that it will take the types of reports that we would submit frequently, easily.’ interview 3, QI project team ‘Sometimes…when you go to put in a location, it won’t accept the location…The software isn’t functioning properly…’ interview 22, anaesthesiologist | T1: the user accesses the specialty-specific system through the EHR. T2: there are limited fields for the reported to fill out. ‘That piece about being required to complete before you close out the record, that it’s super easy, that you don’t have to enter usernames and passwords and remember to do it or access a separate system. It’s right there for you at the end of the case. You’re easily able to see, to record any issues that occurred. I think ease of use or ease of reporting, mandatory reporting, those would probably be the two key elements.’ interview 19, anaesthesiologist |
| ‘Almost everybody has to type in their username and password three or four times before they’re able to actually get into(Hospital-wide IRS)if they’re logging in from even a hospital computer, unless the previous user of the desktop happened to already have(Hospital-wide IRS)open and they just immediately logged out. It’s these kinds of mental hassles and just finger typing hassles that I think add to the collective burden of just digital burnout and having to just navigate through these various circumferential routes in order to ultimately circumvent one’s way towards whatever one’s trying to find in(Hospital-wide IRS)or on anything else on the hospital instrument. That’s been my frustration.’ interview 5, anaesthesiologist | ||
| (B) | ||
| Organisation factors | ||
| O1: prior experience with professional retaliation discourages future reporting O2: rare feedback on impact of reports O3: suboptimal processes to detect and address recurrent trends in reports O4: no systematic way to address safety issues at the department (rather than institution) level O5: lack of training during onboarding O6: used as to highlight resource needs for leadership O7: necessary to have all staff act on reports in a manner consistent with maintaining psychological safety O8: norms regarding roles encourages completion of hospital-wide reports to nursing staff | ‘If I thought that submitting the report could improve any aspect of care…then I would gladly take part in it. But it seems like if you submit a (Hospital-wide IRS) report, the person who is on the receiving end of it gets punished. And that’s not what I want, but that’s unfortunately what happens.’ interview 9, surgeon ‘It just goes into the void and we’re like, ‘Why are we doing this’ Because nothing is going to change. It’s a big system. Nobody cares about this little problem, although this little problem happens a lot.’ interview 7, anaesthesiologist ‘Most of these [reports), I think, result from human error. So I think there should be a way for us to more easily detect patterns instead of just looking at it and be like, ‘Okay,’ and then forget about it… You have to be able to group the complaints into different bins otherwise I think it’s just kind of useless.’ interview 11, anaesthesiologist ‘Yeah, at its core, the department has no visibility of the safety and quality issues that we have, at least in a systematic way. So you might hear about a safety issue, you might experience it yourself, you might hear a rumor that one happened, you might talk to another provider and they’ll tell you that something happened…but there’s no systematic way the department has historically captured this information, collated it, prioritized it, and acted upon it. So it might have been that the same safety events happened a hundred times over the last several years, and every time people talked about it in the back rooms or kept it secret or mentioned it to someone, and nothing ever changed because we never actually had a method for addressing the issues.’ interview 2, QI project team | O1: the specialty-specific system is only for quality/safety reports and not for professionalism reports. O2: feedback on types of reports and QI projects created based on the reports is included in the anaesthesiology monthly meetings and is sent out in a newsletter. ‘And so I brought up the concern…as a resident…the person followed up with me that they were instituting now a red flag that would come up with certain drugs that are tagged the same way that there’s a cross allergic reaction with other medications in the EHR system so that it would trigger the nurse to be like, ‘Hey, there’s an epidural in place, don’t give this drug.’ So that was rewarding to see.’ interview 10, anaesthesiologist O3 and O4: the reports from the new system are reviewed every month and allow for quick turnaround in reacting to problem—that is, the workflow for peripheral intravenous bag and tubing set-up was adjusted and the reporting system was able to document an increase in the rate of intravenous bag and tubing failure associated with this new workflow. ‘And the clinical director told us, ‘Whenever that happens, file a [report).’ Because if you don’t, then the leadership doesn’t know, there isn’t a way to bubble up this piece of information in a meaningful way because other than the director saying, ‘Hey, here are a bunch of days that we didn’t have an anesthesia tech,’ that can be more easily dismissed [by leadership). Whereas if you have 20 [reports] that say, ‘Oh, we didn’t have an anesthesia tech,’…It did get the message across that we need an anesthesia tech all the time.’ interview 15, anaesthesiologist ‘There was collective buy-in to those reporting systems that led to everybody wanting to contribute to the reporting process. And there I guess is a collective hunger and I suppose divisional humility to want to share errors and mistakes and improve from each other’s events. I’m not sure that that same culture still has been fully embraced enough within the [name of division] for everybody to actually appreciate what the QI reporting system does aside from just another thing that needs to be checked off in order to close the record.’ interview 5, anaesthesiologist O5 and O8: physicians are required to note whether or not a QI incident occurred for any anaesthetic record in the EHR. |
| ‘During my fellowship orientation when people are teaching us how to use the system, this wasn’t brought up at all. So I just assumed it’s not important for part of the learning logistics that a fellow should be aware of…it’s not a built-in system. I don’t even know how to log in…’ interview 11, anaesthesiologist ‘…it’s also a very fragile situation because at the [outside institution] that I’m referring to, there was an event that occurred where a physician filed a report and then one of their clinical supervisors became upset about the report being filed. And so that completely destroyed the psychological safety that people had in the system. And from that point forward for several years actually, the number of physician filed safety reports dramatically dipped.’ interview 15, anaesthesiologist ‘…usually it’s nursing that on the behalf of the event. So I haven’t felt the need to do one on top of that, nor do I have enough time usually.’ interview 8, surgeon | ‘There was collective buy-in to those reporting systems that led to everybody wanting to contribute to the reporting process. And there I guess is a collective hunger and I suppose divisional humility to want to share errors and mistakes and improve from each other’s events. I’m not sure that that same culture still has been fully embraced enough within the[name of division] for everybody to actually appreciate what the QI reporting system does aside from just another thing that needs to be checked off in order to close the record.’interview 5, anaesthesiologist ‘…now [with the new system), I have a lower threshold [to report something). When there’s equipment issues, when there’s logistical issues that might harm patients, I’m more comfortable putting those in.’ interview 4, anaesthesiologist O6 and O7: not addressed by specialty-specific IRS. | |
| Environment factors (internal and external) | ||
| E1: work activities vary by profession; lack of streamlined computer access is particularly burdensome to surgeons E2: fear of litigation may be the only driver for reporting; as oppose to reporting for the purpose of preventing future incidents E3: in settings with limited staff, such as ORs, reports can lead to identification of the reporter and possible retaliation | ‘Yeah, I think there’s a default for it to probably be submitted more by people who are around a computer in the hospital all the time. I think as a surgeon, it’s hard to submit a(hospital-wide report)because you have to log in through the intranet, which may not be readily available on your phone. It’s rare that I’m sitting down in front of a computer for a prolonged period of time.’ interview 18, surgeon ‘But also I think from the reporting aspect, it’s not something that you report because you want feedback on, it’s something that you report because you’re afraid you’re going to get sued and if you get caught not reporting it or asking for help or trying to hide something that it’ll be worse.’ interview 10, anaesthesiologist | E1: not addressed by specialty-specific IRS. E2: not addressed by specialty-specific IRS. E3: not addressed by specialty-specific IRS. |
EHR, electronic health record; IRS, incident reporting systems ; QI, quality improvement; SEIPS, Systems Engineering Initiative for Patient Safety.