Clinic Intranet encourages doctors to report concerns

When officials with the Everett (WA) Clinic wanted to change the organization's culture to emphasize patient safety, they realized that a key strategy was getting physicians and employees to report their concerns freely and without fear of backlash. Simple encouragement wasn't enough, so they turned to a more sophisticated solution that not only encourages more candid reporting but also consolidates what used to be a hodgepodge of data-collection methods.

Everett Clinic implemented an Intranet system that allows physicians and employees to report any issues that may threaten patient safety, and the results have been excellent, says Richard J. Rafoth, MD, associate medical director for quality and care management.

The clinic's board became interested in emphasizing patient safety about four years ago, Rafoth says, so he and his colleagues studied how they might encourage a more open exchange among the clinic's 210 doctors at 10 locations in Washington state.

The clinic already employed the typical ways of collecting information on patient safety, such as patient complaints, employee safety procedures, and other reporting methods. But while each of those methods yielded some information about patient safety, there was no central way to collect data.

"With four or five different ways to report your concerns, employees never knew which one to use, so they just said, 'I'll do it tomorrow,' and then it never got done," he says. "We decided to come up with a one-stop approach where they could just give us two sentences about their concerns and we'll take it from there."

Simple web page allows quick report

Voice mail was the first option considered, but then the Everett team realized that the clinic system already had an Intranet that was used to communicate between the different clinics. Nearly everyone had easy access to a computer, they realized, so the Intranet seemed like the solution.

"We set up a fairly simple web page that asks who they are but also explains they can remain anonymous if they want to," Rafoth says. "Then it asks them for a little bit about what happened, the patient name and history number if appropriate, and that's about all. It's simple."

The page also asks the user to indicate whether he or she wants to be informed of what happens in response to the submission. While users can remain anonymous or ask not to be updated, the Everett team thought it important to provide that option because trust is built when people can see that the administration listens to their concerns and takes action.

Then the user simply hits the "submit" button, and the message goes to Rafoth.

Some resistance at first from employees

Initially, Everett employees and physicians resisted the idea because they saw it as an invitation to rat on their friends and co-workers. When the clinic announced the program and asked for suggestions for a name, one of the first was "Rat on a Rat." So Rafoth and other Everett managers had to go back to the work force and emphasize that the Intranet messages were not primarily meant to be a way to report co-workers' misdeeds. Rather, the system is intended to give employees an avenue to report concerns.

"The Intranet does not substitute for the usual procedures of speaking to your supervisor about personnel concerns and things of that nature," Rafoth explains. "If something like that comes to us through the Intranet, we're just going to turn it right back around and send it to the manager anyway."

The clinic settled on the name "Culture of Excellence" for the patient safety program that includes the Intranet reporting option. The basic rule for the Intranet system is this: Use it to report anything that would annoy or upset you if you were the patient or the family member.

"If the paint is chipped on the wall, if there is no toilet paper in the bathroom, whatever it is, just tell us," Rafoth says. "That was the first phase, to build some trust and make it easy. We'll take anything, any sort of concern, just to get people comfortable with using the system and trusting us that we'll do something with their reports."

Policy promises no punishment for reporting

The other key strategy was to get the Everett Clinic's board to pass a policy that guarantees the reporting system is nonpunitive for the person reporting the problem. Rafoth and others convinced the board to offer that guarantee by showing how well it works in the commercial airline system. Rafoth explains that for professional pilots, the Federal Aviation Administration guarantees no punishment when a pilot reports a problem, even his own mistake. But if someone else reports that pilot's mistake, all bets are off.

"We guarantee that if you report something you were involved in, and it's not criminal or done under the effects of alcohol or drugs, your report will not be used against you," he says. "Our human resources department was probably our biggest barrier to this part of the plan." The human resources department resisted because such a guarantee would run counter to many of the disciplinary procedures already in place, but the clinic CEO eventually overruled them.

"With that guarantee and a lot of education among employees, we won people over to the idea that this can be an effective way for them to air their concerns and improve patient safety," Rafoth says. "We also make a point of personally thanking people who report problems, if they don't want to be anonymous, so we can tell them we really appreciate bringing it to our attention."

In the first quarter in which the system was in place, there were 20 reports. In the most recent quarter, about three years later, there were 120 reports. The quality of the reports has also increased dramatically, Rafoth says.

The first reports included a lot of picayune complaints about the dress code or concerns about housekeeping — things that users were encouraged to feel free to report early on as a way to get them comfortable with the system. But fairly quickly, Rafoth says, the employees and physicians started reporting more serious concerns about clinical errors or procedures that could compromise patient safety.

The administration at Everett emphasized to physicians and employees that they wanted to hear about all patient safety concerns, large and small. The reporting system is not just for alerting officials to big, catastrophic errors. The Everett leaders used the aviation system and the nuclear power industry as examples of how reporting small concerns can contribute to an overall improvement in safety.

"Continual feedback really makes a difference," he says. "They need to know that what they're reporting matters, that you're not just waiting for something big and scary."

Late radiology reports show system problem

The benefits of the Intranet reporting system can be seen in one incident that Rafoth recently investigated. Complaints about X-ray misreads or late radiology reports, which come in once in a while under normal circumstances, suddenly jumped to five messages in a week that said radiology reports were eight days late. Rafoth realized this flurry of messages represented a significant problem, because if he got five complaints, there were probably 50 more that weren't reported.

When Rafoth investigated, he found that the clinic had recently switched to a sensor system for electronic tracking of radiology reports. No one realized that the system was so efficient at moving radiology films through the system that the radiologists couldn't keep up.

"We were five days behind in reading films," he explains. "So I spoke to our people and said they had to put some pressure on the radiology group to staff up and take care of that backlog. This was ridiculous, because an eight-day lag is just a risk-management issue waiting to happen."

The radiology group responded with a more concerted effort to clear the backlog and prevent future delays.

"All of this happened because of five different people sending me reports saying they wanted an explanation for this eight-day lag," Rafoth says. "Without this system to let me know something was wrong, that situation would have continued a lot longer."

Rafoth says the Intranet reporting system is part of a larger effort at Everett to implement a culture of safety. Nearly all incident reports and risk management data are now consolidated into a central system that allows him to search for related information from a number of sources.

Small changes eventually add up

The Intranet system allows Rafoth to keep a log of everything done in response to a report, and he can cut and paste e-mails into the log. Then the whole thing can be filed as a record of the report and resulting action. Plus, he can send the file or parts of it to the person submitting the report to show what action was taken.

Rafoth estimates that he gets a couple reports a day from the Intranet system, and most of them contain at least a small issue that could threaten patient safety if not corrected.

"To me, improving patient safety is more about making hundreds of these small changes instead of implementing some big, massive initiative," he says. "I like this approach because it's sort of a small, rapid process improvement applied to patient safety. At the end of the year, I figure I've made 300 smaller things better, and over time, that adds up to a bigger change."