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Creating and Maintaining a Reporting Culture

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					                          CREATING AND MAINTAINING A REPORTING CULTURE

                                                Michelle L. Harper
                                                Robert L. Helmreich
                                            University of Texas at Austin


This paper presents the theoretical foundation of the concept of reporting culture. The first section of this paper presents
theoretical argument defining reporting culture as a critical component of an organization’s ability to create and maintain a
proactive approach to safety. Second, a brief description of event reporting in two high risk industries is presented. And, third
this paper outlines the parameters of a study to identify the main factors that define an organization’s reporting culture,
including proposed methodology for the development of a reporting climate survey and analysis strategies for longitudinal
assessment of reporting culture.


                   Introduction
                                                                    Aviation Safety Reporting System (ASRS 1985), and
The use of event reporting systems in the safety oriented           more recently has been further encouraged by the
professions has steadily increased in the past 10 years.            Aviation Safety Action Program (ASAP). Other
Prompted by a shift to develop proactive approaches to              voluntary reporting programs that require informed
safety, there has been a huge increase in the number of             consent but not manual input of from pilots have also
event reporting programs that have sprung in                        become prominent contributors to this proactive safety
organizations that must manage human error. As a result             approach. These programs include Flight Operational
employees or operators in these industries have found               Quality Assurance (FOQA) and the University of Texas
themselves being prompted to participate by submitting              at Austin Line Observation Safety Audits (LOSA).
reports of their own errors. (Note the term operator will
be used throughout this paper to refer to an employee or            One of the more ambitious yet increasingly popular
an individual in either the medical or aviation                     proactive safety programs is ASAP. This program is
industries). In an attempt to further clarify what enables          based on the direct voluntary reporting of events by
an organization to maintain a reliable and stable event             pilots and the airline’s endorsement of non-jeopardy
reporting program the theoretical argument and research             principles that govern the review of these reports. This
methods for assessing attitudes, beliefs and behaviors              program is unique in that it is based on a joint
surrounding the use of event reporting systems are                  memorandum agreed on by representative members of
discussed. An overview of the current state of event                the FAA, the Airline Pilots Association (ALPA) and the
reporting in both the medical and aviation industries as            participating airline. The ASAP requirement that a joint
well as a brief description of where the concept of                 agreement be met by all three representatives serves as
reporting culture lies within larger more commonly                  an incentive to pilots to submit reports because once
referred to cultures is presented.                                  accepted into the program individual disciplinary action
                                                                    by the FAA or the participating carrier is prohibited. As
                                                                    of February 2003, 25 airlines have submitted proposals
Review of Event Reporting in Aviation                               to the FAA to start an ASAP. On average, those airlines
                                                                    that have established programs receive between 3 to 12
There has been a cultural change in the last 15 years in            reports per day. Although this program is fairly new to
aviation safety programs that has resulted in an increase           the industry (American Airlines began an ASAP pilot
in the availability of previously unknown information.              program in 1996), the increase in carriers starting ASAP
The focus of this shift has been to collect and act on              suggests the number of reports collected annually may
voluntary, protected safety information before it leads to          match or exceed the 30,000+ reports received annually
a consequential or adverse events. This proactive                   by ASRS.
approach has strengthened by the development and
endorsement of non-jeopardy reporting programs. A
reporting system is considered non-jeopardy if it                   Review of Event Reporting in Medicine
provides reporters protection from disciplinary action or
any negative repercussion that would normally occur.                Spurred by a controversial report of the prominence of
This protection is often provided through offering                  medical error (IOM, 1999) the medical industry has seen
reporters anonymity or through the de-identification of             a similar increase in the number of event reporting
reports. This shift started with the development of the             systems both at the national and institutional level. As of
April 2000, 15 states registered as having mandatory          Mallon 1999, Van der Schaff 1991). These findings
systems for reporting adverse events, with 6 more states      support the assumption that reporting systems can
awaiting legislation to start mandatory systems (National     provide the means for identifying potential hazards
Academy for State Health Policy, 2000). With similar          before they become consequential. With the knowledge
goals in mind of reducing human error at the institutional    that information to proactively address safety is available
level, the Joint Commission on Accreditation of               the next problem to solve is how to ensure this
Healthcare Organizations (JCAHO) introduced the               information is reported.
requirement that each accredited organization establish
“a way for care providers to report adverse events as
well as near misses” (O’Leary, 2000). And more                Components of Successful Reporting System
recently the American College of Physicians called for
congressional support of a uniform, voluntary, and non-       Mandatory vs. Voluntary Systems
punitive reporting program (Roscoe & Krizek, 2002).           Regardless of the industry the success of a reporting
Following the release of the Institute of Medicine’s          system is based on the voluntary reporting of operators.
report on the prominence of human error in the medical        Even mandatory reporting programs, like Captains
industry (IOM, 1999), the National Academy of                 Irregularity Report Program required by most
Sciences who authored the report suggested that health        commercial airlines or the nurse reporting requirements
care institutions must “create a culture of safety” and       depicted in the State of Texas’s Nurse Practice Act, are
that it is critical that this culture support the             still based on the operator’s willingness to report.
identification and prevention of error. Yet this report       Findings from a study conducted in both the US and with
also suggested that the creation of a safety culture should   the British National Health System (NHS) suggests that
not be based on attaching blame to those involved but         under reporting of adverse events may be as high as 96%
rather focus on the identification of root causes (IOM,       (Stanhope 1999, Barach & Small, 2000). These findings
1999).                                                        suggest that despite the fact that hospitals in both the US
                                                              and NHS mandate the reporting of adverse events, the
                                                              use of reporting systems remains a choice of the
Objectives of Event Reporting Systems                         operator.

The data collected by event reporting systems in both the     Reporter Protection
aviation and medical industry varies, but the goals of        One of the largest differences found between the aviation
event reporting remains the same. These goals can be          and medical reporting systems is the level of protection
divided into two objectives;                                  that each industry offers to operators who submit reports
  1) Collect safety information that would not                of potentially incriminating events. One type of
  have been known through conventional                        protection commonly characterizing reporting systems is
  means and provide protection to the reporter.               anonymity. The fields of aviation and medicine have
  2) Use this information to develop corrective               dealt with anonymity issues differently. Aviation
  actions to reduce the potential for                         reporting systems, in particular ASAP, is currently
  reoccurrence of accidents, incidents or safety-             experiencing the benefits from the many years of
  related problems.                                           growing pains experienced by the long established
                                                              ASRS program. One of the greatest benefits stemming
One of the reasons these industries have chosen to invest     from ASRS is the influence that it has had on pilot’s
resources into the development of event reporting is the      level of trust with reporting personal error and
commonly held assumption that the operator is privy to a      vulnerabilities.
large amount of information that is not discoverable by
conventional safety programs. Initial findings from           On the other hand the medical industry has not benefited
ASAP reports collected through several airlines suggests      from such shifts, in fact the safety culture of this industry
that between 85 to 90% of reports submitted by pilots         is commonly referred to as heavily punitive and blame
would not have been discoverable by any other means.          oriented (Leape & Berrick 2000, Cohen 2000). A recent
This statistic suggests that even in a heavily studied,       study of physicians in the state of Colorado found that
safety conscious industry, the operator is solely aware of    although most agreed that there is a huge need to
a tremendous amount of untapped safety relevant               develop a reliable means for reporting medical error, a
information. Further evidence of the unique perspective       large percentage stated reluctance to do so without legal
that these programs may add to a safety database is the       protection (Robinson et al. 2002).
finding that close calls or near misses are 3 to 300 times
more likely to occur before an adverse event (Battles,        From studies of event reporting in both medicine and
Kaplan, Van der Schaff & Shea 1998, Gambino &                 aviation it can be assumed that the success of reporting
systems is dependent on the continued, voluntary              critical component of a strong safety culture. Further
participation of operators and the commitment to protect      evidence of the existence of reporting culture adversely
the identity of those willing to report or submit             affecting the use of reporting systems has been discussed
information on potentially incriminating events.              by the British National Health System (Vass, 2002) and
                                                              a series of studies completed in obstetric units in the
Reporting culture: Under the umbrella of safety culture       United Kingdom (Vincent et al 1999, Stanope et al.
                                                              1998).
Although clarity surrounding the definition of
organizational culture is an ongoing source of debate         With this information in mind the following definition of
(Glendon & Stanton, 2000 for a review), it is readily         reporting culture is suggested. Reporting culture is a
maintained throughout management and safety research          component of safety culture that is characterized by the
that the concept of safety culture exists under the           beliefs and attitudes that operators hold towards the
umbrella of an organization’s defining values, beliefs,       reporting of their own errors and the behaviors that
attitudes and behaviors or it’s organizational culture. The   characterize the use of reporting systems designed to
definition of safety culture is also a source of debate.      submit this information to management. Therefore one
This debate centers around the premise that traditionally     basic assumption of this study is that reporting culture
an organization’s culture has been considered a stable        not only lies under the umbrella of safety culture but is
concept and relatively impermeable to change. Yet, the        characterized by beliefs, attitudes and behaviors held
commonly held definition of safety culture suggests that      towards reporting systems and their use. With this
it is a much more dynamic concept and therefore more          assumption in mind the following study was developed
likely to be susceptible to change.                           to identify the specific attitudes and beliefs that operators
                                                              hold towards the use of reporting systems.
Adding support to a dynamic definition of safety culture
is research completed on high reliability organizations or
organizations that have been shown to maintain high                                Methods
levels of safety in complex and technically advanced
environments. Case studies and direct comparisons of          The proposed study suggests that the following methods
these organizations do not report a static or stable          will identify an organization’s reporting culture and
approach to addressing operator error but instead have        assess whether or not the implementation of a reporting
been recorded as having a flexible and proactive              system will have an impact on traditionally held attitudes
approach to safety (Rochlin 1999, La Porte 1996). The         towards event reporting. Although survey research is
idea of safety culture as a dynamic concept is                commonly assumed to assess climate of an organization
exemplified in these organizations in that the culture is     this study will look at a range of parameters to define
often seen as being driven by striving towards specific       reporting culture and not simply the results of a single
but changeable safety goals. The values held by these         survey at a single point in time. The methodology used
organizations present evidence for a possible shift in the    will encompass the measurement of basic assumptions or
traditional views of culture in that they present a strong    norms held towards event reporting as well as specific
culture that is susceptible to change.                        attitudes towards the establishment of a new reporting
                                                              system and the behaviors surrounding the systems use.

Defining Reporting Culture                                    Populations to be assessed
                                                              The reporting climate survey and the behavioral
If safety culture is developed through the operators          assessments proposed by this study will be completed at
attitudes towards and interaction with a safety program       two participating medical institutions in the University
than it should follow that a set of specific attitudes,       of Texas Medical Branch and at two participating
beliefs and behaviors should exist surrounding various        airlines who maintain both domestic and international
types of safety programs. The existence of a sub-culture      operations. These four participating organizations are in
that both supports and shapes an organization’s safety        the process of implementing event reporting systems and
culture has been consistently suggested by investigators      will be surveyed pre and post implementation of the
assessing the success and failure of reporting systems in     systems. Behavioral assessments recording the use and
high risk industries. Reason (1999) supports the              type of errors reported will be completed 3 to 5 months
existence of a sub-culture of safety culture pertaining       following the implementation of the reporting system.
directly to attitudes held towards the reporting of
personal error. He further suggests that the larger
umbrella cultures are dependent on sub-cultures and
goes as far as suggesting “a reporting culture” to be a
Assessing reporting culture                                   commitment to safety as the strongest factor found in an
                                                              employee safety survey. It is therefore hypothesized that
The survey was designed to assess reporting climate pre       degree and level at which action is taken by
and post the development and implementation of a              management, be it Quality Assurance, Risk Management
reporting system. The survey items were developed             or Unit Managers within the medical field or Flight
through a series of structured interviews with managers       Operations, the Safety Department or Fleet Managers in
and operators in both industries. Through the use of          aviation, will increase positive perceptions of an
confirmatory factor analysis it is hypothesized that the      operators ability to make changes and impact reporting
following factors will be identified through the              rates.
administration of the Reporting Culture Survey:
                                                              Ease of use.
Ability to create change                                      The next factor predicted is one that is composed of
One primary assumption of this study is that at the           questions regarding the ease with which operators can
driving point of a reporting culture are the opinions that    understand and use a reporting system. There has been a
people hold towards their ability to make changes. It is      large amount of research devoted to deriving stable
therefore hypothesized that one factor of reporting           definitions of error in both the aviation and medical
culture is based the beliefs that an individual maintains     industries. For example, there is currently a debate
on their ability to create change. The questions predicted    ensuing with the participating members of the rule
to load on this factor include assessments of attitudes       making committee in charge of overseeing ASAP policy.
towards usefulness of the systems and individual’s            At the center of this debate is the lack of agreement over
experience with making changes in the past. At the            the definition of “intentional disregard for safety”. The
longitudinal level, it is hypothesized that the degree to     medical industry is also struggling with issues of
which a person sees a reporting system as a viable place      definitions, although these arguments have centered on
to create change will be a strong determinant of the          definitions of the level of severity of an error. Due to the
organization’s reporting rate.                                lower levels of standardization of this industry in
                                                              comparison to aviation, definitions and opinions of what
Anonymity issues: Fear of litigation and disciplinary         constitutes a close call tend to vary according to
action                                                        institution, unit, and at times profession of the care
Two basic conclusions drawn from the study of high            provider being asked. These clarity of these definitions
reliability organizations is that these organizations tend    are critical to the development of a reporting system
to reward the reporting of error and that root causes of      because they determine what types of events will be
error tend to lie with the organization and not the           accepted into a reporting program and what operators
individual (Weick, 1987). It is hypothesized that this        will be told is appropriate to report and what information
factor will include questions assessing opinions of trust     they will expect to be protected.
and issues of disciplinary action, finger pointing and
discoverability. The prediction of this factor is based on    Personal responsibility to address problems.
the assumption that prior to using a reporting system an      The final factor predicted is one that loads on questions
operator will make an assessment of a risk/benefit ratio.     of personal responsibility. These questions address
If he/she believes their identity can not or will not be      issues regarding both the opinions towards moral and
protected or that their report of a safety problem will       professional responsibility surrounding the reporting of
affect their relationships with other co-workers then even    errors. If is further hypothesized that operators with
large levels of motivation stemming from possible             stronger opinions of personal responsibility will be more
benefits of creating a change are at risk of being negated.   likely to use a reporting system.
Therefore it is also predicted that those reporting systems
that offer higher levels of protection will benefit from      Behavioral assessments
higher reporting rates.
                                                              This study hypothesizes that degree and level at which
Attitudes held towards current reporting systems              action is taken by management, be it Quality Assurance,
The third factor that is predicted includes questions         Risk Management or Unit Managers with in the medical
regarding attitudes and beliefs held towards management       field or Flight Operations, the Safety Department or
that currently run safety programs as well as attitudes       Fleet Managers, will increase positive perceptions of an
held towards those individuals that will manage the new       operators ability to make changes and impact safe
systems being developed. These questions address              operations. One hypothesis is that manager’s verbal
operator’s opinions of how errors were historically           endorsement of a reporting system must be followed by
handled both formally and informally. O’Toole (2002)          actions and without tangible evident of this action the
found that employee perceptions of management’s               operator will loose motivation to submit reports. By
establishing this connection between the verbalization of    an organization to tap into the unique information that
values and the behavioral endorsement, the current study     exist between the operator and the environment, and if
hopes to predict that changes in reporting culture can be    designed with a reporting culture in mind a reporting
driven through behavioral endorsement and this change        system may be the most direct outlet through which an
can be measured through a longitudinal assessment of         employee can play a critical role in establishing a strong
reporting climate.                                           safety culture.


Practical Applications of Assessing Reporting Culture:                              References
Why is it important to identify an organization’s
reporting culture?                                                    Barach, P. & Small, S. D. (2000). Reporting
                                                             and preventing medical mishaps: lessons from non-
One possible practical application of assessing reporting    medical near miss reporting systems. British Medical
culture may be found in the power that it lends to an        Journal, 320, 759-763.
organizations ability to address safety issues. What has
been shown by research conducted in this area is that a               Battles JB., Kaplan HS., Kaplan HS., Van der
successful safety reporting system can provide a medium      Schaaf TW., & Shea CE. (1998). The attributes of
through which to identify potentially hazardous              medical event-reporting systems: experience with a
situations. It then becomes the responsibility of the        prototype medical event-reporting system for transfusion
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process. Each organization is going to complete the          systems should be voluntary. British Medical Journal,
stages of a safety change process differently based on       320, 728-729.
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This study hypothesizes that the development of a
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suggested that the strength in reporting systems stems
from using the operator as the expert in the organization             Institute of Medicine. To Err is Human. 19991.
and that the operator is not only a powerful determinant
in compliance with safety practices but privy to                      O'Leary M & Chappell, S. (1996). Confidential
information of how to best manage regularly occurring        incident reporting systems create vital awareness of
safety issues. As suggested by the review of the current     safety problems. ICAO, 51.
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development of a non-punitive reporting system not only                O'Toole, M. (2003). The relationship between
aids in the identification of the sources and locations of   employees' perceptions of safety and organizational
potential accidents but can also act as a tool to directly   culture. Journal of Safety Research, 33.
involve the operator in the making improvements to
safety.                                                              Quality Interagency Coordination Task Force
                                                             (QuIC) (2000). Doing What Counts for Patient Safety:
As this study hypothesizes, it is believed that a strong     Federal Actions to Reduce Medical Errors and Their
safety culture can only be developed by continued            Impact.
support of the employee at the front line. Rochlin (1999)
suggests that one of the critical components of a strong
                                                                    Reason, J. (2000). Human error: models and
safety culture is free information flow and promotion of     management. British Medical Journal, 320, 768-770.
personal responsibility of all employees. This study
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         Robinson, A., Hohmann, K., Rifkin, J., Topp,
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