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The No Reports™ Campaign Rationale

Posted by Richard Irvin Cook on Thursday November 7th, 2013

The No Reports™ campaign is an effort to stop new incident reports from being made to the office or authority that collects such reports in the facility, company, or organization. The campaign is currently focused on healthcare but this rationale applies to many other domains as well.

In early 2000, President Clinton announced a program to reduce medical error in medicine by 50% in 5 years.[1] One significant element of the program was incident reporting.[2] Over the next few years virtually every hospital and major medical facility in the U.S. formally adopted some sort of incident reporting system.

Other countries quickly hopped on the bandwagon. Patient safety became an international phenomenon with incident reporting as its centerpiece. Incident reporting, incident reports, and the organizational response to incident reports are the most visible face of patient safety. For many organizations, the making and handling of incident reports consumes a large proportion of the resources available for work on patient safety. For many clinicians, incident reports and their handling are their most direct contact with the safety apparatus of their organization.

Incident reporting has produced virtually no meaningful change in medical care. Despite tens of thousands of reports submitted, in the vast majority of medical facilities incident reporting is a futile exercise that consumes energy but produces nothing of value. Clinicians are pressured to submit reports but nothing about the workplace really changes. The reports do not prompt deep investigations into the nature of work or strong, effective actions to correct deep-seated problems.

Paradoxically, incident reporting has become a barrier to progress on safety. Incident reports and the methods for categorizing and classifying them provide the organization with a comfortable sense that it is doing something to advance safety. The reduction of reports to numbers allows management to believe that progress is being made. But this progress is an illusion. Many incident reporting systems have received thousands of reports without making any significant changes in the system that gave rise to them. Incident reporting systems are little more than a fig leaf, a cover story for inaction.

This cover story comes at great cost. The time and resources lavished on reporting are not available for more productive work on safety. The lack of meaningful action in response to reports breeds cynicism about management’s real purpose. The volumes of data collected are used internally and externally to pretend safety competence. The blunt end of the system is flogging the sharp end to produce reports but entirely failing in its duty to use these reports to make meaningful change.

Incident reports are inherently qualitative data. Despite this, they continue to be quantitative data. Medical managers actually measure their incident reporting system’s success by the number of events collected. In one Stockholm facility this has led to management requiring each employee to submit at least one incident report each year! More importantly, simply managing the flow of reports overwhelms the risk management staff of many hospitals. People are so busy counting, categorizing, and collating the reports that there is no time left for inquiring, investigating, or studying the events being reported.  

The goal of the No Reports™ campaign is not to eliminate incident reporting systems. The goal is just to stop new reports from flowing into these ineffective, wasteful databases. By stopping new reports we will provide time for the staffs to concentrate on making sense of and using the already existing reports to formulate effective change and make that change happen. If that cannot be done with the thousands of reports already in the hoppers then the whole incident reporting system is truly worthless and should be scrapped.

small “no reports™” logo buttons are AVAILABLE AT cost

[1] The White House web site, February 22, 2000, “Clinton-Gore administration announces new actions to improve patient safety and assure health care quality”. (http://clinton4.nara.gov/WH/New/html/20000222_1.html, accessed 25 June 2013).

[2] Pear, Robert. “Clinton to order steps to reduce medical mistakes. New York Times. February 22, 2000. (http://www.nytimes.com/2000/02/22/us/clinton-to-order-steps-to-reduce-medical-mistakes.html, accessed 25 June 2013).

Add your comment

November 29th, 2013 by Gary Wong

Richard, what probably started off as a good idea (collecting data at the frontline) apparently has turned into a “big data” nightmare. Furthermore, the analysis has become a “categorization” exercise; that is, we (management?) have predetermined the types and causes so let’s now collect the data to confirm what we have already pre-written in our safety reports. Blunt end flogging the sharp end. I also would be really concerned if the people doing the Big Data Analytics carry the paradigm that the Past is a good predictor of the Future.

As you noted in your last paragraph, let’s concentrate on making sense. I suggest that we do more:
1. Apply complexity principles (distributed cognition, disintermediation, finely granulated objects) since healthcare is a complex adaptive system.
2. Replace incident reporting with the collection of stories (finely granulated objects). Stories are ideal for capturing complex situations. As per Safety-II, let’s also collect narratives about work-as-done that went right.
3. Turn stories into data points and map them to create 3D landscapes.
4. Focus on the peaks, valleys, and outliers as starting points for change.
5. We know incidents will occur since the real world is a Pareto not a Gaussian world. So build Resiliency by placing attention on Fast Recovery and ways to trigger Early Detection of failure (margin of manoeuvre concept).

Whether the No Reports campaign works or not, what you are doing is shaking up the system. In Cynefin Framework terms, it’s a safe-to-fail experiment in a complex adaptive system. I liken this to dropping a pebble into a pond and watching the ripples. Monitor how the agents behave in the system and observe what new patterns emerge. The phenomena of wearing Logo buttons going viral would be a terrific indicator. Good hunting!

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Dr. Richard Cook is the Professor of Healthcare System Safety and the chief of the patient safety division in the Skolan för teknik och hälsa [School of Technology and Health] at KTH, the Kungliga Tekniska Hogskölan [Royal Institute of Technology ] in Stockholm, Sweden.

Dr. Cook graduated with honors from Lawrence University where he was a Scholar of the University. He worked in the computer industry in supercomputer system design and engineering applications. He received the MD degree from the University of Cincinnati in 1986 where he was a General Surgery intern. Between 1987 and 1991 he was researcher on expert human performance in Anesthesiology and Industrial and Systems Engineering at The Ohio State University. He completed an Anesthesiology residency at The Ohio StateUniversity in 1994. From November 1994 until March 2012 he was a practicing anesthesiologist, teacher, and researcher in the Department of Anesthesia and Intensive Care at the University of Chicago.

Dr. Cook is an internationally recognized expert on medical accidents, complex system failures, and human performance at the sharp end of these systems. He has investigated a variety of problems in such diverse areas as urban mass transportation, semiconductor manufacturing, and military software systems. He is often a consultant for not-for-profit organizations, government agencies, and academic groups. His most often cited publications are "Gaps in the continuity of patient care and progress in patient safety", "Operating at the Sharp End: The complexity of human error", "Adapting to New Technology in the Operating Room", and the report "A Tale of Two Stories: Contrasting Views of Patient Safety", and “Going Solid: A Model of System Dynamics and Consequences for Patient Safety”.

Dr. Cook lives in Stockholm.

Website: http://www.ctlab.org

 

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