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Closing the Loop with Ambulatory Staff on Safety Reports
Joint Commission Journal on Quality and Patient Safety
|November 20, 2019
Summary
Healthcare staff often don't report safety events due to lack of feedback. Implementing a closed-loop system significantly improved feedback delivery, enhancing communication and safety reporting in ambulatory care.
Area of Science:
- Healthcare quality improvement
- Patient safety systems
- Health informatics
Background:
- Lack of management feedback on safety reports is a barrier for healthcare professionals.
- Improving safety reporting systems requires a closed-loop feedback mechanism.
Purpose of the Study:
- To assess barriers to reporting safety events in ambulatory care.
- To implement and evaluate a system for providing feedback to staff who report safety events.
Main Methods:
- Surveyed ambulatory staff on reporting barriers.
- Implemented system changes to the electronic safety reporting system.
- Established a 'Feedback to Reporter' program using Plan-Do-Study-Act cycles.
Main Results:
- Baseline feedback provision was below 50% for staff requesting it.
- Feedback to reporter rates consistently exceeded 90% by fiscal year 2018.
- The percentage of reports requesting feedback ranged from 35.0% to 49.7%.
Conclusions:
- A multidimensional approach enhanced closed-loop communication regarding ambulatory safety reports.
- Improvements in feedback delivery were sustained for over one year.
- Closed-loop feedback systems can improve healthcare safety reporting and communication.
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