Reporting Systems

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Reporting Systems

• Allan Frankel MD
• Director of Patient Safety
• Partners HealthCare
• Boston, Massachusetts

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Why do we have reporting systems?
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Information is critical

• We work in complex systems
• We are interested in the collection of
  information
• Our interest stems from a variety of factors
• Systems improvement
• Accountability and apportionment of Blame
• Politics

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The act of Reporting

• Visualize, for a moment
• One individual
• A Reporting System

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The Individual

• Hopes (that an action will occur)
• Ponders morality (Its the right thing to do)
• Is frustrated/irritated (Im sick of this not
  working. Im going to tell someone about it.)
• Fearful (of retribution or blame or punishment)

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The Organization

• Obtains Information
• Fulfills requirements
• For further reporting to
• For disciplinary action
• And then identifies excellence and deficiencies
• Direct improvement efforts
• Monitors activity

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The Oversight Agency

• Obtains Information
• Uses data to maintain high quality and safety
• Via public reporting
• Via blame and punishment/sanctions
• By establishing goals and standards
• Monitoring compliance

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Reporting The flow of information

• Patient/Employee/Provider
• to Institution (incident reporting)
• to Oversight agency (reportable incidents)
• to Improvement agency (ASRS)
• to Media
• Institution
• to Patients/Employees/Providers
• to Oversight agency (DPH, JCAHO, BRM)
• to Improvement agency (ASRS, MedMarx, UHC)
• Oversight Agency
• to Public ( through Freedom of Information Act)

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• Aviation safety reporting system

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ASRS

• Started in 1974
• Dr. Charles Billings
• Linda Connell RN
• Funded by the FAA, run by NASA
• Confidential to anonymous reporting
• Experts, on rotating basis, evaluate narrated
  reports
• 30,000 reports/year, over ½ million today

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The sciences that influence Reporting

• Library science
• Cataloguing
• Grounded theory hypothesis
• Graphic Arts
• Visual presentation

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The sciences that influence Reporting

• Philosophy Morality and Ethics
• Locke/Hobbes
• The nature of human behavior
• Accountability
• Philosophy Politics
• Machiavelli
• Engineering
• Human Factors
• High Reliability

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Framework for Reporting
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Mechanisms for eliciting information

• Spontaneous
• Stimulated

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• Face to face
• Computer/paper/telephone

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Charles Vincent

• Incident analysis framework
• Teamwork
• Communication
• Task
• Environment
• Patient Factors
• Hardware

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Types Level of Protection

• Open
• Confidential
• Confidential to Anonymous
• Anonymous

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Types Severity

• Near-Miss
• Adverse Event

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Types Specifc

• Specialty Specific
• Neonatologists
• Transfusion
• Medication Specific
• Medmarx
• ISMP

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Types Patient/Provider

• Satisfaction

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Objectives Met

• The flow of information
• The ASRS
• The Sciences underlying reporting systems
• The framework for reporting systems

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Next Objective

• To make and support the argument that, in
  general, we misunderstand the value and purpose
  of reporting systems.

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We love accountability and blame

• In recent years we have been told that reporting
  systems should be non-punitive.
• We are confused about the purpose of reporting
  systems -
• Basically because there is little in life more
  satisfying than the opportunity to blame.

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Spontaneous Reporting versus Audits/Surveillance
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Reporting versus Audits/Surveillance

• What is the purpose of a reporting system?
• To learn
• What is the purpose of a surveillance system?
• To monitor

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• Counting incidents is a waste of time. Why?
  Because incident reporting is inherently
  voluntary. Because the population from which the
  sample is drawn is unknown and therefore can not
  be characterized, and because you lose too much
  information and gain too little in the process of
  condensing and indexing these reports unless you
  do what we were fortunate enough to do blindly,
  and that is keep all the narratives.

C.Billings re ASRS
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Analysis of Reports
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• Incident reports are unique sets of data. Each
  incident is unique and not easily classified or
  pigeonholed.
• Generalizations may be possible , given enough
  detailed data .. But this means understanding
  details of the task, the context, the
  environment, and its constraints.
• Simply constructing taxonomies is grossly
  insufficient and it permits only counting of
  incidents that fall under phrase a, b or c of the
  taxonomy.

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• For any useful degree of understanding of the
  reports, incident reporting requires expertise at
  the South end equal to that which was on the
  North end,
• that is, there must be expertise used in
  evaluating the reports as they are obtained.

C.Billings re ASRS
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Mandatory/Voluntary
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Limitations

• Anonymous limits further understanding
• Confidential impossible in small institutions
• Confidential to Anonymous resource intensive
• Open requires robust non-punitive policies

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Aleksandr Solzhenitsyns Gulag Archipelago

• Gradually it was disclosed to me that the line
  separating good and evil passes not through
  states, not between classes, nor between
  political parties eitherbut right through every
  human heart and through all human hearts.
• This line shifts. Inside us it oscillates with
  the years.

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Aleksandr Solzhenitsyns Gulag Archipelago

• And even within hearts overwhelmed by evil, one
  small bridgehead of good is retained.
• And even in the best of hearts there remains an
  uprooted small corner of evil.
• It is impossible to expel evil from the world in
  its entirety, but it is possible to constrict it
  within each person.

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Fallacy

• A report supplies information
• Information leads to accountability.
• The possibility of accountability maintains good
  behavior.
• Therefore, reporting systems can be a tool for
  the constriction of evil in each of us.

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Catch-22

• Reporting increases with positive reinforcement
• Reporting decreases with negative reinforcement
• Reporting as a deterrent stifles the act of
  reporting

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• Reporting systems are learning devices
• About flaws in our systems
• Trying to use them to monitor for bad individuals
  limits their primary purpose.

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Reporting requirements across agenciesin
Massachusetts
Here it is Its awkward to print Karen
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Reporting requirements across agenciesin
Massachusetts
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Disclosure and Confidentiality
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Plan for the future

• Understand clearly the purpose for your reporting
  system
• Are you seeking accountability?
• Then monitor and survey
• Are you seeking to learn about your system?
• Then set up a spontaneous reporting system and
  clearly delineate accountability

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Healthcare Institutions

• Develop appropriate accountability policies
• Have OPEN reporting systems
• Use them for LEARNING
• Have Surveillance and Auditing systems
• Use them for MONITORING
• Develop Categories based on
• Human Factors and Systems theory
• Act on information learned
• Develop FEEDBACK mechanisms
• That relate reported information to actions

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Integrated Delivery Systems/States/Federal

• Broadcast information widely
• Alerts
• Bulletins
• Newsletters
• Standardize categories

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Questions?