Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Incident Reporting and Complaints Procedure
4.32 The Human Resources Manager commented that he was not aware of any
feedback from staff that they were unhappy with the current incident reporting
policy. This lack of reported feedback may be more reflective of a lack of an
appropriate forum in which to discuss these issues with the Human Resources
Manager.
4.33 Based on their experience of using the system, staff were very forthcoming
during interviews with the investigation team in identifying deficiencies and
suggesting improvements to the system.
Effect of incident reporting on the culture of the organisation
4.34 The response individuals receive to an incident they have reported may
influence whether they use the system in the future. A blaming culture
promotes cover-up because of fear of retribution. If a staff member chooses
not to use the incident reporting system the opportunity for the organisation to
learn from an incident or “near miss” is lost.
4.35 The Human Resources Manager talked of incidents being valued in Tairawhiti
Healthcare and used as a mechanism for feedback. This is not reflective of the
experiences of a significant number of staff. It appeared from interviews that
staff felt the incident reporting process has become personalised and a
criticism of individuals rather than an opportunity to increase safety and
patient focus. Several staff experienced disapproval of incident reporting and
spoke of a culture of fear.
4.36 THL stated:
“No matter how well the system is structured, some staff will always feel
they have been blamed or victimised when an incident is investigated,
and improvements suggested (or, alternatively, no action taken because
analysis showed no need for further action). A cultural change is needed
across all agencies investigating complaints or incidents before this
perception will change.”
4.37 The Chief Executive stated:
“If staff are not happy with the way in which an incident is resolved they
can take it to their Group Manager. The Group Manager and the
Clinical Director both report to [the Chief Executive]. Staff who are
dissatisfied with the response from their Group Manager or Clinical
Director can take it up the line themselves or they can get someone to
advocate on their behalf such as the Human Resources Manager or the
Quality Co-ordinator or their union.”
4.38 It appeared to the investigation team that many non-medical staff did not feel
able to follow this advice. Staff perceived a climate of fear and retribution,
and experienced their immediate manager not taking action on their concerns.
In the situations involving Dr Lucas, staff also felt unable to work with
medical colleagues to address the issues. As one staff member explained:
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