How Cerebral Uses Incident Reports to Improve Clinical Safety

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. 

The Cerebral Incident Reporting System

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:

  1. Reporting form: Individuals use this to report anything related to client safety or quality
  2. Categorization of reports: Categories include Compliance, Clinical, Crisis Response, Med Management + Pharmacy, Client Support, and Clinical Support
  3. Review by security level lead: Security leads reviews all reports within their category
  4. Documentation of review and/or next steps: Security leads mark each report as ‘done’ when they have completed their review. Flags are added to reports that need to be reviewed by other teams as well. Alternatively, reports can be reassigned to other security levels if applicable. 
  5. Completion and documentation of action plan: If action plan is needed, security leads will formulate the action plan, delegate next steps to the appropriate operations teams, and provide documentation of completion. Relevant parties will be notified. 
  6. Weekly Clinical Incident Reporting Meeting: The clinical safety and quality teams meet regularly to discuss incident reports that require further review or discussion.

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. 

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