How to Promote Self-Reporting

If you’ve been following this column, you know that the majority of hospitals suffer from a culture of blame that poisons efforts to improve quality and safety. The dysfunctional Quality Assurance (QA) Model for Clinical Peer Review is a major part of the problem. It perpetuates the negative cycle of blame and fear by focusing on competence and punishment rather than on performance improvement. We can’t “Learn from Defects” if fear of discovery inhibits reporting and open dialogue. T his poses a challenge: if learning from defects is critical to the process of advancing patient safety and if self-reporting of adverse events, near misses and hazardous conditions is needed to make learning possible, how do we get there – particularly if we’re stuck in a culture of blame?

At Mount Sinai in New York, Katz and Lagasse found that “Anesthesiologists will comply with a system of self-reporting if they understand the process, if there is institutional and departmental encouragement and support for the process, and if the process is non-punitive and can result in real improvements in patient care.” (1) Other work tells us that the reporting process must be simple and quick. I believe this prescription can be generalized to all physicians, nurses and allied healthcare providers.

Of the key ingredients understanding, encouragement, and ease of reporting are not hard to obtain. Encouragement comes from a simple act of leadership. Leadership, or its lack, is reflected in the qualities of how we speak and interact with colleagues. Anyone can choose to act like a leader. Event reporting need not be complicated. Where the hospital has a cumbersome electronic or paper system, a confidential, recorded hot-line can be used as a by-pass. Clear communication of the process and the program sparks understanding.

The other two ingredients, no blame and visible improvement, take a bit more work, but come naturally out of the Quality Improvement (QI) Model for clinical peer review and event analysis, which we’ll explore in future columns. Other actions can also help. To eliminate fear of repercussions from self-reporting, the hospital can adopt policies that unequivocally protect the reporter. For the medical staff, I suggest language such as: “No medical staff member shall be subject to disciplinary action in relation to cases that are self-referred for peer review, in the absence of reckless disregard for patient safety.” With small changes, this can also be used for nursing staff. While a policy alone might be useful to promote self-reporting, the open question will be whether physicians and nurses will trust management to abide by it.

Here, then, is an opportunity to gain more value from your PSO relationship. The Patient Safety Act protects reporters. Be it for peer review or general event reporting, the commitment to PSO reporting reinforces the intent of the program, testifies to the integrity of leadership, and provides additional collateral to build trust even among skeptics.

To pull this all together, your Patient Safety Evaluation System (PSES) should define the process. I believe it makes sense to maintain most case review activity as Patient Safety Work Product (PSWP). Recall that PSWP may not be used for disciplinary action. In states with strong protections against legal discovery such as California, some would argue to pull peer review cases out of the PSES. Their rationale is to avoid encumbering any potential disciplinary action. But what kind of message does that send? Disciplinary action is the exception not the rule. Only minimal additional effort is needed to re-review cases outside of the PSES for use in such proceedings. By packaging peer review within the PSES, you gain the opportunity to promote self-reporting and learning from defects in a way that builds credibility and trust.

For more information about self-reporting, contact me for a free reprint of my latest article from the Physician Executive Journal: Engaging Physicians in Patient Safety through Self-Reporting of Adverse Events. Before we move on to look more deeply into the QI Model and how to promote it, we’ll pause to learn how the QA Model came to dominate practice for the past 30 years.

Coming Next: A Short History of the QA Model

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Marc T. Edwards, MD, MBA

President & CEO

QA to QI

An AHRQ Listed Patient Safety Organization


  1. Katz RI, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program. Anesth Analg. 2000;90:344–350.