Research context: Incident Reporting Systems

One way of monitoring organisational performance is through information that is offered voluntarily by those working on the frontline of healthcare. Incident reporting systems allow individuals to submit information about individual errors, systemic problems or near misses that they, or relevant others, have experienced. Local incident reporting systems exist within every hospital and

healthcare professionals receive training to support them in using them optimally.

Incident reporting data can be collated, analysed and fed back to promote wider learning. The possibility exists to harness the power of such large datasets to learn from experience across many individual units, to analyse what may be relatively infrequent events, to establish commonly agreed national standards and to tune guidance for safer, better quality care (Leape, 2002). The National Reporting and Learning System (NRLS) is the UK’s centralised incident reporting system set up in 2003 shortly after the publication of the pivotal report, “An Organisation with a Memory” by the Department of Health (Department of Health, 2000). All trusts are required to upload their locally reported incidents monthly. The goal of centralised incident reporting systems is to share learning from one site to another. By extracting the key messages and learning across a broader dataset it is possible to encourage wider scale learning from individual incidents (rather than confining the learning to the area in which the original incident took place) (Williams & Osborn, 2006).

However, despite its vast potential, feedback from current incident reporting systems is not optimal and requires improvement (Barach & Small, 2000; Leape, 2002). In the UK, policy initiatives focused upon incident reporting have raised questions around how best to feed back and use incident reporting data to support both professional and organisational learning. One of the only systematic reviews to address this issue specifically was conducted by Benn and colleagues by looking at case studies of feedback (Benn et al., 2009). The authors identified five modes and 15 requirements for effective feedback based on a systematic scoping review and accompanying guidance from an expert panel. The review emphasised the wide variation in practice in terms of the mechanisms by which reporting systems link to local action to improve clinical work systems. It demonstrated that there is little evidence of capacity for rapid action in current high level systems and little evaluation of the impact of feedback upon operational quality and safety. In terms of characteristics of effective feedback, the review article emphasised the importance of leadership, credibility and channels for dissemination. However, despite this work, there remains a need to better understand the use of information and action from incident reporting at the organisational level to improve quality and safety through individual level learning.

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There are also potential unintended consequences of feeding back organisational level information from incident reporting systems. For example, when individuals become aware of an area of focus for management, they may consciously or unconsciously neglect other aspects of care in attempt to meet and exceed expectations of improvement (Asch, 2004; Rosenbaum, 2015). It is vital that research explores such issues, in their complexity, and that a stronger understanding of these potential barriers is incorporated into the development of new incident reporting systems and procedures.

Understanding how to increase the effectiveness of feedback from incident reporting is an ongoing challenge for healthcare systems globally. Multiple studies have identified ineffective feedback as a barrier to future reporting and general engagement with information systems at the individual level (Anderson, Kodate, Walters, & Dodds, 2013; Barach & Small, 2000; Braithwaite, Westbrook,

Travaglia, & Hughes, 2010; Evans et al., 2006; Firth-Cozens, Redfern, & Moss, 2004; Gandhi, Graydon-Baker, Huber, Whittemore, & Gustafson, 2005; Gong, Song, Wu, & Hua, 2015; Holmström et al., 2012; Kaplan & Fastman, 2003; Kingston, Evans, Smith, & Berry, 2004; Macrae, 2015; Pfeiffer, Manser, & Wehner, 2010; Stavropoulou, Doherty, & Tosey, 2015; Thoms, Ellis, Afolabi, & Graham, 2012).

Incident reporting, more generally, has received significant attention in the recent literature. A qualitative study based on the views of international patient safety experts presented five key challenges as an explanation as to why incident reporting has not reached its potential to date (Mitchell, Schuster, Smith, Pronovost, & Wu, 2015). These included inadequate processing of

incident reports in terms of analysis and prioritisation and insufficient visible action for frontline staff as a result of their reporting efforts. This is further emphasised by Sujan (Sujan, 2015) who explores the difficulties of breaking down the barriers between the high level processes of incident reporting and the experiences of front line staff. This author goes as far as to suggest that incident reporting should become less centralised and focus more on generating action through local processes on the front line of healthcare. A recent systematic review found that incident reporting has been

unsuccessful at enabling double loop learning and therefore its existing impact on safety culture is limited (Stavropoulou et al., 2015).

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3.4 Work stream aims

The primary research aim for this PhD is to describe and investigate the characteristics and

mechanisms by which feedback influences professional behaviour in healthcare. The specific aim of this work stream is to investigate the perceptions and experiences of healthcare professionals using organisational level feedback from incident reporting systems. In doing this, the objective is to understand and enhance the effectiveness of organisational level feedback from incident reporting systems and extract the characteristics and mechanisms by which it influences professional

behaviour.

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