How to improve the culture for incident reporting

You need a safe reporting culture and a proactive improvement culture if you want to adopt a structural approach to improving safety and quality within your organization. It is a culture in which everyone is alert to potential risks and in which, in an atmosphere of openness, people are actively engaged in safely reporting incidents. It is an environment in which unsafe situations in processes are easily addressed and improved.

Based on the points listed below we will explain how you can work towards a safe reporting culture and a proactive improvement culture.

1. Conditions for improving the reporting culture
2. Further explanation of a Just Culture
3. Create awareness with the safety culture ladder
4. Support for improvement actions
5. Safety II as a new approach to improvement

Conditions for improving the reporting culture

In order to learn from incidents, it is important that all incidents and near incidents are reported. Unfortunately, reporting an incident is still often considered an administrative burden that is difficult and redundant. So how do you still ensure a good reporting culture? Below we provide some framework conditions:

• Ensure a safe and open reporting culture: Just Culture. See below for further explanation of the importance of a Just Culture in your organization;
• Make it clear why incidents need to be reported. After all, each incident is a learning opportunity and an opportunity to improve safety in the work place;
• Make reporting quick and easy with an online form that is always accessible via both desktop and mobile devices. Ensure that only those questions are asked that are required for the initial registration and analysis;
• Show what happens after a report has been made, what the follow-up actions are, who is involved and what is expected of the notifying person;
• Ensure feedback of the results to the notifying person and the rest of the department. When people see that a report is actually addressed, the willingness to report will increase. Also show when an improvement action is scheduled based on the incident;
• Involve employees by requesting further information and having them contribute ideas for improvement actions and the assessment thereof.

Further explanation of a Just Culture

From a black-and-white perspective, we can distinguish two cultures that address ‘human errors’ within an organization: On the one hand the retributive culture, based on rules and on the other hand the restorative culture, a Just Culture. A corporate culture centered on trust, learning capacity and accountability.

A retributive culture is based on rules, violation of those rules and penalties. There is a (basic) moral debt that needs to be settled. To the company, the victims, the community. And that payment is a balanced, fair and proportional penalty, that places responsibility with the offender and serves as an example.

In a restorative culture, also called a Just Culture, the emphasis is placed on open and honest sharing of errors made. The focus is not on ‘the offender’ but on ‘the victim’ and how this person can be best assisted. Subsequently, it is important to look at the factors that led to the error. The basic principle here is that human errors occur regularly within a complex organization and therefore there needs to be an open investigation and discussion as to where the error or errors were made, in order to bring about change.

It is important that an organization has a transparent and respectful procedure to assess the role of someone involved in an incident as objectively as possible. Based on the ‘Swiss cheese model’ of psychologist James Reason who extensively investigated and described ‘human errors’, the British National Patient Safety Agency formulated a so-called ‘decision tree’ that can be broken down into four questions:

1. Did the person deliberately cause the damage?
2. Was their judgement capacity limited? (think of depression or drugs)
3. Were there sufficient, effective measures in place to prevent the damage?
4. Would someone with the same background in the same situation have done the same?

Asking and answering four relatively easy questions contributes to care providers being addressed justly, which increases trust in the safety of the organization.

People need to be sure that reporting errors is treated justly, that there are no disproportionate consequences. The dilemma is of course that in certain cases you need to call people to account, with the risk that others will remain silent in the future. This is where Just Culture becomes important: to balance accountability with learning.