Kelly.Manning@ncf.ca
Date: Mon, 8 May 2017 12:02:38 -0400 (EDT)
http://ihealth.islandhealth.ca/2016/11/the-cochrane-report/ http://ihealth.islandhealth.ca/wp-content/uploads/2016/11/Summary-of-Recommendations.pdf http://ihealth.islandhealth.ca/wp-content/uploads/2016/11/ihealth-review-2017.pdf http://vancouverisland.ctvnews.ca/video?clipId=1115112
"Issue reporting and resolution
At roll out, when users were highly supportive and enthusiastic, they
actively engaged in reporting issues of performance, usability and
safety. At the time, reporting was accepted through multiple sources
including the Patient Safety Learning System (PSLS), health
informaticists, the Help Desk, emails, red dot reports and meetings. Peer
mentors and informaticists were actively engaged in addressing issues as
they arose.
Unfortunately, follow up with users that had reported a concern was
inconsistent. Many users reported an absence of feedback. The reasons for
the lack of feedback are not clear but may relate to the volume of issues
being reported and Island Health's capacity to address them. As a result,
from the users' perspective, many issues remained unexplained and
unresolved, undermining confidence in the safety of the system and the
effectiveness of the reporting systems. Users stopped reporting because of
fatigue and the lack of feedback.
Some individuals who provided reports perceived that those responding to
issues were transferring responsibility to the users. Explanations for
issues included user error, bad habits, and users failing to remember.
Island Health's reactions were described by interviewees as punitive and
involved public shaming and bullying (see emotional responses below). It
was claimed that there were no gaps in education or training, but rather
gaps in remembering and a lack of engagement of staff for voluntary
learning.
In a previous job a "Creating Satisfied Customers" course taught that a lack of problem reports indicates a failed system for users to report concerns, get status updates and see that concerns are addressed and resolved in a timely fashion.
Many customers will choose another service provider or product if one is available, and they keep encountering issues.
A minority of users will try to follow the problem reporting process. Most will give up if they find it too much bother to complete and they keep encountering issues.
Most will not bother to continue to report issues if they get no resolution to the initial issue reports.
Very few will persist in requesting follow up status reports, particularly if there is no regular feed back or perceived resolution. They just give up.