Incident analysis in healthcare: an intergroup perspective

Abstract

Incident analysis is a structured method of investigation to determine the underlying cause of adverse events in healthcare so that recommendations for safety enhancements can be implemented to improve patient safety. Despite significant investment in incident analysis for over 18 years, Australian hospital reports suggest that the rate of adverse events is not decreasing. In Queensland (QLD) public hospitals, the human error and patient safety (HEAPS) method is the most widely used form of incident analysis. HEAPS teams consist of members from different health professions and status levels and include those who have been involved in the adverse event.Since healthcare is an intergroup context, this makes incident analysis an intergroup environment. The first aim of this thesis was to identify the challenges to incident analysis from the perspective of the healthcare executives, policy makers, and clinicians involved in the process. The second aim was to use intergroup theories to understand how professional identity and status level of those involved impacts the analysis effectiveness.MethodsFour qualitative studies were undertaken. Data were analysed using a thematic content analysis approach. A data-driven approach was used to understand participants’ perspectives of challenges to analysis effectiveness. A theory-driven approach invoking social identity theory (SIT) and communication accommodation theory (CAT) was used to investigate how intergroup factors impact. In Study 1, 11 senior healthcare executives were interviewed to provide an organisational and regulatory context and in Study 2, three Patient Safety Officers, who conduct analysis meetings, were interviewed. In Study 3, three HEAPS analysis meetings in a Queensland hospital were observed and communication categorised according to CAT. Finally, to triangulate the findings, in Study 4 six participants from the observed meetings were interviewed.ResultsStudy One: Power, status and professional identity were categorised as barriers to analysis effectiveness: impacting open disclosure; feedback to stakeholders; and dissemination of learnings. Organisational capacity to remedy error was perceived to conflict with organisational requirements to meet key performance indicators around financial performance and capital expenditure. The current model of accreditation and a decentralised model of error management were perceived to adversely impact the quality of the analysis process, service improvements and the sharing of learnings. The capacity of clinical governance committees to enact change was perceived to be hampered by status, organisational agendas and cost concerns. Stakeholders’ limited understanding of human-factors principles resulted in a persons’-approach to incident analysis.Study Two: PSOs were found to view analysis as an intergroup process. They used communication strategies to reduce intergroup differences and build a superordinate team identity. From a CAT perspective, interpersonal control, interpretability, emotional expression and discourse management were employed to reduce intergroup differences.Study Three: Intergroup differences adversely impacted team processes in analysis meetings. Members’ and the PSO’s use of accommodative communication strategies reduced intergroup differences, heightened team identity and facilitated member engagement. Non-accommodative communication strategies heightened intergroup divides and resulted in unequal participation and deviation from analysis methodology. There was no integration of a human factors methodology nor systematic method for generating error cause or recommendations to reduce error.Study Four A: Professional identity and status were salient for members: historic intergroup tension and professional and hierarchical boundaries impacted members’ engagement, receptiveness to the input of others, and cross disciplinary knowledge sharing. Profession informed members’ motivations in the process. Fear of blame was a concern for nurses but not allied health professionals.Study Four B: Participation in analysis was perceived to facilitate interdisciplinary collaboration, knowledge sharing, reduce intergroup divides, promote reflection on practice and increased awareness of safety factors. Management was perceived to not value the analysis process.ConclusionsThis research extends the applicability of CAT and SIT into a systematic description of how group identities manifest in the intergroup analysis environment and demonstrates the utility of an intergroup approach in informing communication tools to facilitate the analysis process, reduce intergroup differences and improve the rigour of the process and its capacity to generate patient safety improvements.Human factors training and intergroup communication skills could facilitate a more effective analysis process. This research demonstrates the need for transparency of analysis reports, the importance of developing an infrastructure to ensure timely feedback to relevant users and objectivity around translating learnings to practice. Accreditation of healthcare error management processes should be extended to include requirements to ensure the robustness of the process and change management. The appointment of independent expert investigators has the capacity to reduce the impact of intergroup factors on analysis effectiveness. The development of a centralised knowledge repository database has the capacity to disseminate learnings, provide ongoing feedback on the effectiveness of recommendations across the healthcare industry and build a critical body of understanding on error patterns for users.Future ResearchFuture research could focus on integrating a CAT framework to develop communication tools to reduce intergroup differences in incident analysis teams.