Application of the Incident
Decision Tree as Standard
Work in Safety Event Review
It’s Just Culture
Cat Mazzawy, RN, MSN, CPPS
Patient Safety Officer
November 05, 2014
About us
Group Health is a consumer-governed, nonprofit health system
in Washington state and North Idaho that brings together care,
coverage, research, education, and philanthropy to serve its
members and create healthier communities
• Membership: approximately 600,000
• Primary care clinics: 25 locations in 17 cities
• 24/7 Urgent Care Centers: 3
• Outpatient surgery centers: 3
• Physician group: Group Health Physicians with 380 primary care
physicians and pediatricians, and 720 specialty physicians in more
than 60 specialties and subspecialties; 98 percent board certified
• Other services: eye care; mental health; hearing centers; speech,
language, and learning centers; and occupational health
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Unusual Occurrence Reporting
Culture in 2011
• 8742 Unusual Occurrences reported
• 6% reported by a practitioner
“Our practitioners, in
particular, still think reporting
Unusual Occurrences is
punitive.”
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Unusual Occurrence Review
Process in 2011
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What we did
• Ceased sending Unusual Occurrence Reports to human resources
from the Patient Safety Office
• Moved from error classification to patient impact classification
• Embedded the Incident Decision Tree into Unusual Occurrence
reviews
• Filtered the credentialing view to only include cases in which there
was individual culpability
• Aligned manager and practitioner review processes
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Unusual Occurrence Reporting
Culture Today
Patient Safety Culture Composites
Average % Positive Response
1. Teamwork within Units
80%
2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety
71%
3. Organizational Learning--Continuous Improvement
61%
4. Management Support for Patient Safety
68%
5. Overall Perceptions of Patient Safety
61%
6. Feedback & Communication About Error
61%
7. Communication Openness
63%
8. Frequency of Events Reported
59%
9. Teamwork Across Units
61%
10. Staffing
49%
11. Handoffs & Transitions
50%
12. Nonpunitive Response to Error
42%
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Next Steps
• Open up the event categorization fields in cases with individual
culpability
• Develop a report to improve visibility of culpability cases to senior
leaders
• Reconsider our modifications to the James Reason/NHS Incident
Decision Tree
• Train leaders how to use the Incident Decision Tree
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Is this innovation or
merely variation in
practice?
© 2013 Group Health Cooperative and Group Health Options, Inc.