June 22, 2022
Co-authors: Michael Boggs MD, and Madeline Holmes
When I was training as a psychiatrist at Massachusetts General Hospital (MGH), I was introduced to the storied practice called the Incident Report. MGH, like other top hospitals, had instituted a policy where it actively encouraged clinicians and staff members to report ‘Incidents’, where something was missed, care could have been better, or processes could have improved. Everyone, including clinicians and support staff, were actively encouraged to file incident reports. Very importantly, there was no blame or finger-pointing: the culture of filing reports was all about improving collectively. These reports were reviewed by a committee, and corrective action plans were put in motion to improve care. This is how the best healthcare systems continued to get better.
This process is a great way to foster continuous clinical improvement. So we brought it to Cerebral.
In addition to encouraging all staff to report incidents, we allow people to report anonymously so that everyone feels comfortable to speak up. Additionally, we adopted the blameless culture. The only purpose here is to ensure that we get better at taking care of our patients.
Cerebral staff file Incident reports on a wide breadth of topics, ranging from suggestions for tech improvements, to situations where clinicians could be more responsive, to ideas on how clinical notes can be made more efficient. Once filed, reports are tracked, categorized, and delivered to the right stakeholders. For example, clinical concerns are reviewed by Cerebral’s Clinical Safety Team, which is led by a dedicated psychiatrist. Weekly discussions are documented, and corrective action plans are formulated and executed.
Our current incident reporting process consists of the following:
Structured processes for reporting, tracking, and improving the safety and quality of client care are ubiquitous in top hospitals and mental health clinics nationwide. Having had over 1,800,000 clinical visits to date, large clinics like Cerebral benefit significantly from a system that encourages open communication and continual improvement. Cerebral is proud to have instituted this industry standard in order to follow best practices relating to patient safety.
David Mou, MD
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