The National Patient Safety Foundation designed this year’s Patient Safety Awareness Week theme— “Be Aware for Safe Care” — to encourage everyone in the healthcare continuum to get involved and be aware. Whether it’s a nurse being aware of a fall-risk, a surgeon being aware during the timeout or even a family member being aware to ask questions and take notes, it’s critical that everyone in the delivery of care is involved and aware.

This is especially important for healthcare leaders, as awareness applies both to personal behavior and to a global awareness of the organization’s strengths, weaknesses, opportunities and threats.

A recent report from the Department of Health and Human Services Office of the Inspector General identified a weakness for many hospitals — an underutilization of medical event reporting systems or MERS.

In the report, OIG recommended that the Agency for Healthcare Research & Quality and the Center for Medicare & Medicaid Services “provide guidance and incentives to hospitals to use incident reporting systems more fully.”

The study on which the report is based, however, only analyzes what causes hospital staff not to report events, leaving the bigger question — the opportunity — unaddressed: What environment or factors foster the successful use of medical event reporting systems?

A December article in Patient Safety & Quality Healthcare by Patricia Daughenbaugh and Kathy Martin poses that the answer lies in the link between medical event reporting and a culture of transparency.

In early 2010, 13 private, acute-care hospitals in Rhode Island teamed up in an effort to improve the reporting of adverse event and near miss data. All of the hospitals used the same medical event reporting system and joined a patient safety organization to have a forum to share insights and best practices without the fear of legal liability.

Their results were remarkable. Sandra Coletta, president and CEO of Kent Hospital in Warwick, Rhode Island, revealed that in the first year of the project, their reporting rate grew 167 percent per quarter and has been sustained for more than a year.

David Mayer, MD, associate professor of anesthesiology for the University of Illinois at Chicago and co-executive director for UIC’s Institute for Patient Safety Excellence, noted in the article that solving the underreporting dilemma still must start with an electronic reporting system. “Electronic reporting systems make it much easier to communicate about unsafe conditions and problems,” Mayer told PSQH. “If it takes 20 minutes to fill out paperwork on a near-miss event, chances are, many people won’t do it.”

So what are Coletta’s and Mayer’s hospitals doing that produce such strong reporting results? Both experts say cultural transparency in combination with MERS has helped them combat two of the biggest obstacles that prevent hospital staff from reporting: “Fear of retribution and apathy from lack of feedback.”

Both Coletta and Mayer tout the “Just Culture Model” as an effective method to overcome a staff’s fear of retribution. The “Just Culture” concept is a contemporary risk-management model in which hazardous human behavior is discussed openly with the intent of improving processes and systems instead of assigning individual blame or punishment. Central to the model is a very specific decision tree used to address an issue: Was the event the result of human error, at-risk behavior, reckless behavior or malicious behavior? A key distinction is that a “Just” culture, unlike some, treats human error AND at-risk behavior in a non-punitive way.

In October of last year, Kent Hospital went all-in with the Just Culture Model — literally. The hospital threw out its entire disciplinary process and now uses the Just Culture concept for the whole organization, not just patient safety. “We want to create a consistent culture in which everyone who works at Kent Hospital can be transparent with themselves,” Coletta told PSQH. “I have to be able to see my weaknesses and accept the fact that I have them. Only then can I be transparent with my co-workers.”

Some hospitals have even formalized the process of analyzing an issue. At the AAHQ winter conference, Shelly van’t Riet, performance improvement coordinator of VCU Health System in Richmond, Virginia, shared several examples of how VCU uses their custom-designed, Just Culture decision tree to address events.

For battling employee apathy from lack of feedback, Mayer suggested that managers be diligent about providing feedback that concretely shows how reporting a given event helped the organization improve. “Leaders need to find ways to thank the reporter, to share how the report helped the organization improve, and if warranted, use each report as a teaching moment to help the reporter learn how to prevent similar events from occurring in the future,” Mayer told PSQH.

And Mayer should know. Like Coletta, his results back him up. “In the last three years, through the combination of our electronic reporting system and our educational efforts, we’ve increased from 1,500 reports a year to more than 7,000 reports a year at the University of Illinois Medical Center,” Mayer said in the PSQH interview. “Resident reports account for nearly 1,000 of that total — up from zero reports when we started the program.”

Colletta’s and Mayer’s comments underscore how crucial it is for healthcare leaders to “be aware;” aware of how our organization’s culture affects our goals and, more importantly, aware that any attempted shift in culture like transparency starts at the top. “You can’t expect employees to be courageous if their leaders aren’t,” Coletta said.

At American Data Network PSO, we’d love to hear how your organization is planning to “Be Aware for Safe Care” this year. Tell us comment stream below what your organization is doing for PSAW 2012.

To learn more about American Data Network’s Medical Event Reporting Application, click here.

For more information about the Patient Safety Awareness Week toolkit, click here.