Thoughtfully implemented technology is a valuable tool in enhancing the delivery of high quality medical care. Electronic health records (EHR) systems provide crucial checks and balances for safety, allow for structured documentation and ordering practices, and improve the communication of patient information along the continuum of care.
The Computer Told Me So
Healthcare technology users place a high level of trust in the data they receive. This trust makes it critical to avoid errors when designing and configuring a medical record system. When a clinician makes a mistake in care through his or her own judgement, it is a single, non-recurring event. However, when an electronic system guides a clinician through a work process leading to an error, it becomes a repeatable error; one that may recur hundreds of times if left unchecked. Because of the complexity of the modern electronic health record, the number of handoffs in care, the dynamically changing healthcare and technology businesses, and the reality that humans are involved in the process; system errors that affect patient care or the business aspects of healthcare will occur. It is how errors are managed that is crucial.
The culture of the information technology (IT) department and its end users plays a large role into the reporting, resolution, and recurrence of errors. A disciplined IT approach that exercises comprehensive testing, tight change control, and accurate documentation is key to minimizing potential system errors. Creating a culture that facilitates and encourages error reporting is a necessity in identifying and correcting system faults.
Harmful Cultural Norms in Error Reporting and Resolution
A punitive or fear-driven culture discourages both issue reporting and fosters ineffective communication. When a staff member is afraid of possible disciplinary actions, criticism, or loss of his or her job over a mistake, he or she will be less likely to report the error. Worse, the person may try to cover up or disguise the error. Even when an issue is resolved silently without reporting, the organization has lost the opportunity to learn from that error to prevent recurrence or may be blinded to historical issues resulting in patient harm or decisions that might have been based on that error.
Similar to, or even part of, the culture of fear is one where finding a scapegoat is the first reaction to a reported defect or error. When an organization emphasizes and focuses on assigning blame, delays in resolution occur and collaboration is eliminated. Issues can bounce from person to person with no energy spent on a resolution. Placing blame does not resolve the issue, nor does it rectify the potential impact to patient safety or the organizational business.
Creating a Learning Culture
Through creating and adopting an environment of trust and combining it with a learning culture, IT is able to honestly acknowledge human fallibility and hold accountable each person to accept his or her own responsibility to learn and grow from errors or mistakes. Providing a circle of safety for employees is a key responsibility of a leader. When employees feel safe, they can open the lines of communication, innovation, and productivity. Encouraging and rewarding the reporting of errors provides cultural safety where staff will openly report their own or their peer’s errors. Errors become teaching and learning opportunities. Within a learning culture, errors are resolved quickly and decrease in frequency.
In a learning environment, the first step when an issue is discovered is the communication. Regardless of a known cause or planned solution, immediate communication of what has been reported is the first step. This communication both mitigates the effect of the issue and provides a point in time for retrospective fixes to be applied.
Following the initial communication, mobilizing resources to determine the cause and the solution come into play. After resolution, conduct and document a formal root cause analysis including proactive steps to mitigate recurrence in the future. This mitigation may occur through technical changes, process changes, or modification of communication pathways. Sharing the results of the root cause analysis is a key in sustaining a learning environment.
The concept of a healthy, learning culture does not imply that there should be no repercussions for employee errors. What it does is effectively demonstrates the importance of doing the right thing for patients and users; it shows integrity, a value in any healthy culture. Employees must show transparency, humility, and a desire to learn from their errors. Repeated errors and the lack of improvement remains a cause for employee discipline.
Driving Cultural Change
Cultural change is difficult but can be achieved. Leaders must be both the catalysts and the examples of change. The culture will be defined through the reactions of leaders in times of crisis. If leaders react in ways that provide encouragement for transparency and learning from errors, the staff will follow. Sharing stories of past experiences that emphasize the desired behaviors also help cement changes in culture.
In healthcare, patients are the primary focus with the goals of safety, high quality care, and improvement of outcomes. Progressive leaders recognize that healthcare IT is a key member of the patient care team. All employees affect the ability to care for or interact with patients. Recognizing the linkages between all staff and the patient and supporting them in a patient-centric, learning culture allow them to value the importance of their role in patient care. Through recognition of every individual’s role in patient care, a sense of responsibility it generated to improve transparent communication and improve care at all levels.
For more information on Culture Shaping in Healthcare please see Impact Advisors Culture Shaping Service.