Incident Management and Supervision:
A Necessary Alliance

(C), 2001, Antone Aboud Associates, Inc.

written by,

Antone Aboud, Ph.D.
Antone Aboud Associates, Inc.
Clearwater Beach, Florida
http://www.aboud.com antone@aboud.com

The regulatory environment, exceptionally effective advocacy and good moral sense have combined to create a groundswell of concern for improved incident management policies and practices throughout the caregiving industries. At the same time such polices and practices must be developed within a context of existing organizational structure and culture. The best laid incident management plans cannot survive an inhospitable environment any more certainly than good surgical procedures can survive a contaminated operating room. One such area of concern is the quality of supervision. The manner in which we manage people must nurture the values which promote excellent incident management practices.

Incident management is the collection, classification and use of incident data to better protect people from harm. When speaking of the importance of incident management in caregiving organizations, we believe that protecting people from harm is critical in aspiring to the common mission among all such organizations: to provide appropriate services in a caring and hospitable environment.

Excellent incident management requires that organizations create structures that do not simply isolate that function in a "quality improvement" office. Too often we hear managers say something to the effect: "That's not my area; Joe handles incident management." In the very best systems, no one would suggest that incident management is the job of any single person or office. The very structure of such a system should involve all offices and, if displayed in appropriate detail, would illustrate how all individuals in the organization constantly approach their work as if they were personally responsible for the development of that caring and hospitable environment to which we previously referred.

But perhaps the most critical element of an effective incident management system is also the most difficult to observe. If we are to best protect people from harm, all parts of the incident management system must celebrate open and honest communication. I use the word "celebrate" because such systems will not be sufficiently successful if we only "tolerate" open and honest communication. Telling the truth about one's observations of the caregiving environment will only take place over an extended period of time when an organization's culture honors such candor. Put differently, an organization which fears the truth will often provide external trappings of honor, but eventually punish the truth teller. Such cultures make it difficult for individuals and groups to step forward. They will likely believe that "no good deed goes unpunished." It is precisely that culture which justifies the existence of whistle blower statutes. In the caregiving industry we also see laws and regulations which make it improper to fail to report incidents. In some cases such failures are crimes. In other cases such failures can result in the loss of a professional license. In all cases such failures make it difficult to protect people from harm.

And why should someone tell the truth? The answer seems so morally obvious that it appears silly to ask the question. Yet, the moral imperative is not the entire case for truth telling. An equally compelling reason flows from what we all believe is important as a decision making strategy. All decisions require information. We collect information and use that information to decide how to proceed. If we collect less than the available relevant information, we will make a decision based on fewer, rather than more facts. We all believe that the quality of our decisions is directly related to the percentage of the relevant information we collect. Concealing or lying about facts reduces the quantity of relevant information on which we will decide a matter. If, for example, we want to understand the cause of a series of bruises to the arms and legs and we have failed to report the circumstances under which the person was struck by another, we leave decision makers will a less complete database with which to understand the matter. They might deduce that the bruises were caused by another person. Or they might draw another conclusion. Regardless, if the objective is to protect people from harm, drawing incorrect conclusions of fact can only make it more difficult to create a caring and hospitable environment.

Although virtually no one would argue with the implications of the previous paragraph, even in the context of incident management – at least as it is imperfectly understood – organizations often tolerate cooked data. In fact, an organization, or parts of it, often conceive of incident management as a public relations problem. Someone might ask, "Just how much about ourselves can we disclose without harming our image?" For those of us who fly, it is not the question we would want mechanics to ask prior to deciding which errors in maintenance to report. However, it is not an uncommon way staff approach the care of the ill and disabled.

Let me add one additional comment. Organizations do not approach incident management in this fashion with the objective of creating harm. Such behavior generally exists in environments where staff at all levels are bedeviled by harm that does occur. More commonly, organizations do not understand the connection between treating incident data as a public relations issue and the overall effectiveness of the incident management process itself. This is an issue that forces us to see connections between incident management and the other systems with which that process coexists.

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Incident Management's Relationship to Other Management Systems

If the objective of incident management is to protect people from harm, we must immediately acknowledge that such an objective cannot be achieved independent of other systems within that same organization. For example, an effective incident management process might result in a decision to hire additional staff. It will be the human resource management system that will then be responsible for hiring those staff. If the HR system fails to hire staff in a timely fashion, or hires staff who are unmotivated, or hires staff who are incompetent, the good intentions emerging from the incident management process will be thwarted.

We can easily imagine other ways in which incident management interacts with other systems within an organization.

• The processing of incident data will require the use of computers. Without an adequate Information Management System in place, it will be more difficult to understand and classify incident data.
• The incident management process will often ask the organization to purchase different types of merchandise that will help improve the environments in which people live, learn and work. If the purchasing system is not capable of responding to such needs in a timely fashion, that inadequacy can subject individuals to the continued potential for harm.
• Caring and hospitable environments require a stable workforce which exhibits high morale. A labor relations function that spawns rather than resolves conflict will punish not only an organization's employees, but also those the employees serve.

In other words, we cannot create incident management systems in a vacuum any more than we can create human resource management systems, information management systems, purchasing systems and labor relations systems in a vacuum. Each system may be discrete, but they are intertwined with the practices and culture of the others. And although we can imagine countless ways in which incident management interacts with other organizational systems to either enhance or diminish an organization's ability to protect people from harm, perhaps the most important relationship is the one which asks incident management to co-exist with the way in which the organization supervises its staff.

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Reflections on Supervision

I use the word "supervision" with some trepidation. The word exudes connotations of a bygone era when supervisors roamed factory floors as the overseers of the manufacturing process. In that world employees most often viewed supervisors as the "cop on the beat." The supervisor was the most visible embodiment of managerial authority. The supervisor gave orders. It was the employee's job to obey. The system's culture considered it morally objectionable for an employee to complain by "going over the supervisor's head" to a common supervisor. It took great courage, particularly in non-unionized settings, for employees to complain, either individually or in concert with others.

Certainly organizations operating in such a traditional mode might resent the way in which I have characterization supervision. They would likely argue that given the operational necessities of their time, there was need for clear lines of authority. The supervisor was held responsible for his or her unit's performance and must, therefore possess authority commensurate with that responsibility. Such organizations would also point out that the bureaucratic system is designed not only to send orders from top to bottom – through each level of supervision – but also to collect and transmit relevant data from bottom to top – through each level of supervision. This more balanced view of the traditional world suggests that open and honest communication has always been the ideal of the most traditional approaches to the management of people.

And in truth, few organizations today would even suggest that they do not value open and honest communication. In fact, most would even reject the traditional view of supervision as characteristic of their own circumstances. They are more likely to affiliate with more contemporary conceptions of a supervisor that seek to cast the supervisor's role as one which helps staff to achieve good performance, not merely as one which seeks to identify and punish bad performance. In this conception the supervisor must balance the authority that role inherently possesses in any bureaucratic structure with a more dominant vision: to help individual staff and groups of staff to develop their abilities and understanding of their jobs in a manner that will produce the very best performance possible. Consistent with this conception, organizations have asked supervisors to become more attentive to the social and emotional needs of staff. Frequently organizations have restructured their decision making systems to allow greater staff participation. The early development of such concepts as quality circles and eventually total quality management concepts are specific examples of such initiatives.

However, even if organizations presume to follow this more contemporary path, they are not likely to institutionalize those supervisory practices that would more certainly create cultures that would nourish not only excellent incident management practices, but improve performance in all other areas of human endeavor. Organizations make a variety of common errors when addressing supervisory interventions, such as:

• Training is haphazard. It often occurs as a product of duress rather than as a consequence of thoughtful planning. In other words, an organization is more likely to require supervisors to attend supervisory training because of a critical audit than because the organization had developed a commitment and implementation plan, part of which was to improve supervisory practices.
• What is taught is often contradictory to existing institutional policies. We worked with one organization that required supervisors to take a course on counseling and discipline; however, that same organization enforced a policy on written counseling memos that contradicted portions of the training program it had endorsed.
• Supervision is often thought to be the province of first line supervisors and middle managers, with training efforts often exempting executive staff from participating, even though they provide the most visible role models within an organization. [They certainly are not always the best role models.]
• We often teach good supervisory practice but at the same time in practice tolerate individual deviations from behavior on the premise that, "everyone has his own style."
• Good practice is often taught in a classroom, it is most often not measured in practice. In other words, there are precious few examples of how an organization provides valid and reliable feedback to those who supervise about how they supervise.

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Supervision and Incident Management

Because creating a caring and hospitable environment is central to the mission of caregiving organizations, it is critical that organizations construct and then institutionalize supervisory systems that will support incident management.

Perhaps we can understand this need by analyzing one aspect of the incident management process. We noted at an earlier point that incident management requires the celebration of open and honest communication. In addition, incident management cannot survive if other organizational systems do not similarly celebrate open and honest communication. It is particularly sensitive to the culture of supervision. Every participant in the incident management process has a supervisor. If on the one hand we ask [even require] employees to be open and honest in the incident management process, but on the other hand ask them to perform their duties in a supervisory culture that does not similarly laud honest – in fact may punish honesty – we would be foolhardy to believe that we are likely to adequately protect people from harm.

One of the most compelling reasons to institutionalize a contemporary understanding of appropriate supervisory practice is the unintended effects of the more traditional view of supervision. In the traditional view, employees are viewed as inherently unreliable producers who will, whenever possible, do less rather than more. A supervisor becomes the organization's first and sometimes last line of defense in seeking to control that factor of production. The result of that role is that direct reports tend to view the supervisor and his or her activities with suspicion. It will be as difficult for the [take a look at the term] direct reports to always be candid with a person fulfilling an authoritarian role – the supervisor – as it would be for the supervisor to be entirely candid with individuals he or she believes do not fully embody the organization's mission. No matter how noble the incident management policies, the actual practice of supervision in this type of environment will never permit the open and honest communication critical to likelihood that we will protect people from harm.

We should add that much of what staff perform in the caregiving environment occurs outside the direct involvement of supervisors. Aides who work on the most richly staffed hospital ward conduct most of their activities with patients in private surroundings without supervisory observation. Staff who work at night in a group home, for example, are often working at a location that is several miles from the nearest supervisor. Doctors who perform surgery are usually the most senior staff in the operating room. In such contexts it is even more imperative that we develop trusting relationships that epitomize open and honest communication inasmuch as it is that relationship that will generate such a large proportion of the relevant facts organizations need to make clinical decisions. When a treatment team reviews a clients chart, for example, that team need to have confidence that a staff member actually made the observation which reads: "Observed client sleeping at 1:00 a.m. Client was breathing normally."

The contemporary view of supervision assumes the ability of two individuals, no matter their level of formal authority, to develop sufficient trust to allow honest communications. This view, however, also assumes that such trust will not exist merely because someone has achieved the position of "supervisor." Trust is ordinarily not a product of formal authority, but more likely the result of the informal processes which exist within an organization. In other words, we develop that perception of individuals based on their behaviors, not just their position. Therefore, in developing leadership skills among supervisors, we must always focus on the identification and institutionalization of behaviors which are likely to encourage trust, and consequently, open and honest communications.

Let me add one additional thought: excellent supervision does not insure excellent incident management. We need both systems to exist simultaneously for incident management to be effective.

Creating a Supervisory System that Supports Incident Management

Creating a supervisor system that supports incident management is at one level a traditional exercise in organizational development. It is also a time consuming process which never completely ends. We never become perfect. We become increasingly effective in our approach to supervision, developing information systems about our successes and failures to allow what Gareth Morgan describes as "double loop learning."

Step 1

Developing Executive and Board Leadership

It is almost trite to write that an organization must develop executive and board support for major initiatives of this sort. Without such support an effort requiring a large amount of time and money will almost certainly fail.

Developing support, however, is more than merely keeping those entities informed about progress, or receiving private assurances that the efforts are viewed with favor. Beyond these superficial illustrations of support, the organization needs to actually involve board and executive staff in the planning process, including the identification of core supervisory skills that the organization will claim to value. In addition, executive staff must participate in training programs as participants. There cannot be a sense among other staff that executive staff are exempt from the expectations associated with the core skills, or that no matter what others are taught, executives are free to behave however they choose. [We certainly would not make such distinctions between executive staff and others when developing expectations with respect to ethical standards or appropriate rules for documenting travel expenses.] And executive staff must "walk the talk" by not only performing as expected, but consistently rewarding subordinate staff who also perform as expected.

Executives and Board members must exhibit visible enthusiasm for such an endeavor. They need to take the kind of ownership that leaves no doubt that they are leading, not just tolerating the effort.

Step 2

Identifying Core Supervisory Skills

Supervisors engage in countless discrete tasks each day requiring a wide variety of skills. At one time a supervisor might be giving feedback to a direct report, or receiving feedback, or facilitating a meeting, or managing a project. To begin to address the development of supervisory skills that represent appropriate behaviors consistent with the care and well being of those an organization serves, the organization should spend time discussing those skills it most values.

The specific skills will be a product first of broad policy guidelines, and then, the need to endorse behaviors which implement such policy. For example, if the organization sees a clear connection between open and honest communications and policies which are most likely to produce a caring and hospitable environment – one free from harm – within which it provides services, it would want to identify skills which would nurture that form of communication: e.g., communicating orally; listening actively; giving feedback; receiving feedback; facilitating a meeting. The organization would then create a competency statement – a detailed listing of elements comprising the correct way to perform each skill. For example, one organization created the following description of the competency, Facilitating a Meeting.

	Element
1	Did I greet individuals as they entered the meeting area?
2	Did I use each person's name as I greeted him or her?
3	Did I introduce myself to those individuals with whom I was not previously familiar?
4	Did I begin the meeting on time?
5	Did I review the reason for the meeting with the group before beginning discussion of the agenda?
6	Did I ask participants to identify the individual who would keep minutes of the meeting?
7	Did I ask participants to address issues in the order contained on the agenda?
8	Did I allow sufficient time to consider each issue raised?
9	Did I allow opportunity for all those with an interest in speaking an opportunity to speak?
10	Did I avoid letting one person dominate the discussion?
11	If someone interrupted another, did I redirect the floor to the individual who was originally speaking?
12	Did I conclude each agenda item with a clear record of what, if anything, had been decided?
13	For each agenda item for which there was a decision, did I assist the group in assigning responsibility for any subsequent work that decision might require consistent with the standards identified in the competency, "Delegating Work"?
14	Did we conclude the meeting on time?
15	Did I thank the group for their participation?
16	When speaking, did I communicate consistent with the standards identified in the competencies, "Communicating Orally" and "Listening Actively."

The creation of the competencies, however, is not the end of the organization's quest to interject appropriate values and clarity into its supervisory function. The resulting competencies staff to engage in future discussions about the appropriateness of each element, or perhaps missing elements. Much of that discussion will be generated by individual and group experience in the training and feedback steps of this process.

Step 3

Creating Training Modules that Teach Core Supervisory Skills

Most of the elements in the sample competency, Facilitating Meetings, hardly constitute vexing intellectual dilemmas. For example, element 15 asks: Did I thank the group for their participation? Most of us would not find it hard to utter the words,"Thank you for helping us today." Nor would many of us believe it would be an inappropriate gesture. At the same time, performing our duties on the job consistent with that expectation is more difficult. We sometimes forget, or sometimes we dismiss its importance, or sometimes we allow our emotions to overwhelm our reason because we leave a meeting upset with participants' behavior. In other words, we can never take for granted that any person will perform an element in a competency as written even when that same person acknowledges it is the correct way to behave.

As a consequence, organizations must not only publish clear performance expectations for supervisors, they must give supervisors an opportunity to learn and practice applying those expectations. The development of competencies allows organizations the opportunity to train staff in an efficient manner by asking small groups of staff to assess role plays or video productions using the competency as an evaluation tool. Staff, then, practice using the set of expectations that the organization has determined should guide their behavior.

Also, training supervisors to properly manage staff is only part of the equation. Too often supervisors attend a training program and either learn the material imperfectly, or selectively, or simply misrepresent the content to their own direct reports. One way to guard against such slippage in learning is to conduct training in vertical rather than horizontal groupings. In other words, most often organizations put a group of similarly placed supervisors in a classroom to learn a skill. These same individuals return to their own units, often the only person in the unit who has received instruction. A more effective way to avoid slippage is to put whole units in the same classroom – including both supervisors and direct reports.

Such an experience helps direct reports understand what to expect from a supervisor, thus reducing the likelihood of conflict based on a misunderstanding of expectations. It also helps direct reports prepare to compete for supervisory positions. Finally, it reduces the likelihood that "slippage" in supervisory learning will occur.

Step 4

Measuring the Quality of Supervisory Performance

Supervision is not an output variable. There is no direct measure of its contribution to the organization's mission. We estimate the value of any supervisory system based on based on contemporary behavioral science research and our own experience. That research and experience is reflected in our competency statements. When we actually measure the quality of supervision, we must focus on the degree to which supervisors behave consistent with the competencies.

The measurement of individual and group performance of input variables – including supervisory skills – is the most difficult portion of the five steps necessary to create appropriate supervision. In its most sinister form, it is a type of audit that places individuals in a state of fear. In its most benign form, it provides data with which legitimate feedback to individuals and groups can occur. And we should distinguish measurement from mere judgement. If we ask an organization to simply "judge" performance, we are asking the organization to engage in a task which is associated with a variety of common "errors": e.g., the error of first impression; the halo effect. It would be the equivalent of asking a group of judges to follow a golfer around a course and instead of adding the number of strokes as his or her score, decide whether the golfer performed in an "excellent," "good," or "poor" manner.

The development of any reliable and valid set of measurement devices will require a substantial investment of time and energy. For each core skill there would be an independent determination concerning the most appropriate measurement methodology. The organization would then need to train managers, supervisors and others in the use of that methodology. In fact, in many cases we have worked with entities that allowed staff to participate in the measurement process itself, an activity that made the receipt of feedback [see Step 5, below] much less stressful.

Step 5

Creating Feedback Mechanisms Related to Performance of the Core Supervisory Skills

A set of competency statements related to core supervisory skills is the a critical component when providing supervisory feedback. The statements represent the definition of what the organization would consider appropriate supervisory performance. Once defined, performance can then be measured. Once measured, the organization must then find effective ways to communicate and use that data to improve supervision.

As in any quality management program, the manner in which feedback occurs will determine whether those who receive the feedback will view it as part of a constructive dialogue which results in improved performance, or as an assault upon their dignity. In the latter case, recipients may "listen" and perform, however, their commitment to useful change will be tempered by their anger. It is always better to create mechanisms which encourage individuals to be willing to listen than mechanisms which require their attention.

We also tend to think of feedback as an individual experience: a supervisor sits down with a direct report [in this case a supervisor] and communicates the results of the measurement process. In the best learning organizations, feedback occurs at all levels, beginning with the executive staff. Whatever the measurement device – and as we noted in Step 4, an organization ought to measure, not just judge – the macro results can serve as a focus of discussion with the organization in trying to determine its overall strengths and weaknesses in performing consistent with the core supervisory skills. For example, one organization with which we worked received feedback using a multi-rater instrument. Although the overall feedback generally was quite good, supervisors received low scores with respect to two core skills: giving feedback and receiving feedback. The organization would do well to consider what portions of the competencies were most difficult for supervisors to achieve and then continue develop interventions to assist individuals in improving their performance.

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Concluding Comments

Perhaps the intersection of incident management and supervision was no more poignantly illustrated that the situation involving a staff member who gave the wrong medication to a person in her care. Immediately after placing the pill in the disabled person's mouth, the staff member realized her error, was able to retrieve the pill before it was swallowed, properly disposed of the pill, gave the person the correct medication and recorded her error on an incident report form. When one of the managers within that organization reviewed the incident report, he decided she should be fired. He claimed that the organization could have been placed in legal jeopardy had the staff member not caught her own error.

Had the staff member been fired, the real casualty would have been open and honest communication. The organization would have taught its members that acts of honesty would routinely be punished. The very people on whom we rely to care for those we serve would have learned that it would have been personally safer to have lied about the loss of the pill than have told the truth. And if we negatively reinforce open and honest communication, there is little reason to believe that we can create caring and hospitable environments any more than the airlines can keep us safe if mechanics lie about their maintenance of jet engines.

Supervision is not the only system within organizations that affects incident management; however, its involvement is constant and its consequences are substantial. We cannot adequately protect people from harm if we do not properly consider the policies and practices that define how we will manage our human resources.