In other words, each of our IRs probably generates an average of 80 minutes of work: 20 minutes of reporting and 60 minutes of reading/analysis. For our 20,000 IRs per year, that’s 26,667 hours of work. (Of course, we could shave this number by doing nothing with the submitted IRs – a recent study found that this is precisely what happens in about one-in-four U.S. hospitals, which don’t even bother to distribute IRs to hospital leaders or managers. Sounds like something out of Catch-22 or The Office).
If we value the time of our people doing the work of reporting, reading, analyzing, and acting on IRs (an amalgam of nurses, quality and risk managers, and a few physicians) at an average of $60/hour (salary and benefits), we’re talking about a yearly investment of $1.6 million in my one hospital. Nationally, for 30 million reports, the cost (of 40 million hours of work) would be $2.4 billion! Now we’re talking about real money.
Even that expenditure (which is 50 times more than AHRQ spends on patient safety research yearly) wouldn’t be so horrible if this work was yielding useful insights, but, for the most part, it’s not. My colleague Kaveh Shojania recently wrote a terrific piece entitled “The Frustrating Case of Incident-Reporting Systems,” in which he argued that, while all events should be reported...:
Many incidents, even if important (e.g., common adverse drug events, patient falls, decubiti) do not warrant investigation as isolated incidents. In such cases, the IR system should simply capture the incident and the extent of injury to the patient, not barrage users were a series of root cause analysis-style questions about the factors contributing to these events.
This is a great idea but I’d go one step further, to a system I’ll call, “If It’s February, It Must Be Falls.” Here’s how it would work:
I’d limit complete, year-round IR reporting to only those errors that cause temporary (33% of all IRs in one large study) or serious (1.5%) harm, along with a small number of reporting categories, such as the disruptive provider, that require complete data. For the remainder of the categories, I’d switch to a monthly schedule: all medication errors get reported in January, all falls in February, all serious decubitus ulcers in March, and so on…
I’d estimate that this change would cut the number, and cost, of IRs by at least 50%, while having virtually no detrimental impact on the value derived from the systems. Risk managers would still hear about the worst errors, sentinel events would come to light to generate root cause analyses, and a month of complete data for each of the error categories would easily provide sufficient information to explicate more subtle problems. More importantly, caregivers, freed from the "report everything" mantra, would be more enthusiastic about reporting, and hospital leaders and administrators would have the time to analyze the reports and develop meaningful action plans (as well as to focus on other methods of error detection such as Executive Walk Rounds and trigger tools). As Kaveh wrote,
…organizations must recognize that the generation of periodic reports from IR systems does not constitute an end in itself. IR systems must stimulate improvement. Achieving this crucial goal requires collection of data in such a way that important signals are not lost amidst the noise of more mundane occurrences and so that hospital administrators do not experience information overload. If submitting incident reports produces no apparent response from hospital administrators, front-line personnel will predictably lose interest in doing so. In addition to undermining effort to monitor for safety problems, lack of meaningful change will negatively impact the culture of the organization in general.
I couldn’t agree more. Our unquestioning support for "report everything" incident reporting systems has created a bureaucratic, data-churning, enthusiasm-sucking, money-eating monster. It is past time we slayed it. Is anybody with me on this?
This blog orignally appeared at The Health Care Blog. More recent posts from The Health Care Blog:
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