Healthcare entities can prevent staff errors and improve response to problems if they focus on developing an effective reporting culture.

One place to start is the new Sentinel Event Alert from The Joint Commission about improving a healthcare organization’s reporting culture. The initiative includes a one-page flier, titled, “The 4 E’s of a Reporting Culture.” It provides four basic steps that healthcare organizations can take, starting with establishing trust.

“Ambulatory surgery centers, being generally smaller than inpatient acute care settings, have an advantage,” says Coleen Smith, MBA, MSN, RN, director of High Reliability Initiatives at The Joint Commission Center for Transforming Healthcare. “One of the best ways to understand barriers is to talk with small groups of staff. This can be done more effectively in smaller organizations because more viewpoints can be accessed.”

The Sentinel Event Alert asks leaders to establish clear performance expectations among employees within a safe environment, meaning people do not need to fear negative consequences when they report mistakes. The goal is to eliminate the “no harm, no foul” mentality, which leaves near-miss incidents unreported.

Technology makes it easier to report problems and errors, The Joint Commission notes. Organizations can build these features into their incident reporting system: wide accessibility, ease of use, timely data analysis, and a feedback loop to let employees know someone is acting. ASC directors should remember that staff might be more forthcoming about issues with people who are not in their reporting structure, Smith offers.

“For instance, the manager of sterile processing could meet with the OR nurses, and the business manager might meet with support staff,” she says. “Appreciative inquiry, which is a model that involves stakeholders in positive change, can guide such focus group discussions.”

ASCs could learn more about barriers and solutions through these discussions. “Having a formal performance improvement project to address the barriers and take these suggested solutions forward is equally important,” Smith says. “This is the starting point as the 4 E’s are a journey, not a spring.”

Once trust is formed, ASCs could encourage reporting with a feedback loop that lets staff know that action is taken to address safety problems, and they could eliminate fear of punishment. Fear is one of the primary reasons why it is difficult to build a robust reporting culture, Smith notes.

“The aviation industry eliminated this issue by having their reports go to NASA, not the FAA,” she says. “Healthcare, unlike the high reliability industries such as nuclear power or commercial aviation, is not in the habit of being preoccupied with failure.”

One way to eliminate fear as a barrier to a reporting culture is to develop a “good catch” program in which employees are rewarded for reporting errors. Some organizations might give employees a safety star for reporting a near miss, according to The Joint Commission. Organizations with exceedingly safe operations, despite operating in hazardous conditions, never rest and are always looking for the next bad thing to happen and trying to prevent it.

“In healthcare, we generally expect bad things to happen because that is the norm,” Smith says. “For instance, medications arrive late, equipment is missing or hard to locate, and disruptions are common. All of these are unsafe conditions, though not reported as such because they are accepted.”

A final step toward improving an organization’s reporting culture is to examine errors, close calls, and hazardous conditions. Healthcare has not created the robust process improvement capacity that exists in other industries, Smith says. “This impacts the ability of healthcare organizations to improve on the issues that are reported,” she explains. “If follow-up is not occurring, reporting dries up.”

Reporting Culture Building Blocks

The Joint Commission has created “The Four E’s of a Reporting Culture” to help employees learn from mistakes and to maintain an overall safer working environment. The key ideas are:

  • Leaders build a sense of trust;
  • The organization encourages reporting;
  • Policies eliminate fear of punishment for those reporting;
  • Examine error-prone situations and hazardous conditions.

Learn more about the four E’s at: Further information from The Joint Commission about creating a better reporting culture is available at: