LAUNCH: 12 November 2013
What is Open Disclosure?
An open, consistent approach to
communicating with patients when things go
wrong in healthcare. This includes
expressing regret for what has happened,
keeping the patient informed, providing
feedback on investigations and the steps
taken to prevent a recurrence of the adverse
event.”
(Australian Commission on Safety and Quality in Health Care)
What is an Adverse Event?
An undesired patient outcome that may or
may not be the result of an error.
(World Health Organisation: The conceptual Framework for the
International Classification for Patient Safety: Version 1,1 2009)
Principles
1. Acknowledgement
2. Truthfulness, timeliness and clarity of communication
3. Apology
4. Recognising patient and carer expectations
5. Professional Support
6. Risk management and systems improvement
7. Multidisciplinary responsibility
8. Clinical governance
9. Confidentiality
10. Continuity of care
Open Disclosure: Why?
1. The patient/service user’s perspective
2. The staff’s perspective
3. The organisation’s perspective: Changing Culture,
Patient Safety, Quality Improvement and Financial
Considerations.
4. Policy, Regulatory, professional and ethical
requirements
5. Learning from national and international
reviews/investigations.
1.
The Patient/Service User’s
Perspective
Do patients
want to know?
At least 98%
want to be
told the truth
Hobgood et al 2005, Mazor et al
2004
The Importance of Open
Disclosure for Patients
•
The process can assist with providing closure for the patient/family
and quicker emotional recovery.
•
It can help to rebuild trust and confidence within healthcare.
•
OD facilitates patient involvement in decisions relating to their
ongoing care.
•
OD prevents patient misconceptions in relation to the cause of the
adverse event.
•
Patients are more willing to continue an effective relationship with
the Health Care Provider.
•
Feelings of desertion after an adverse event are a major contributor
to litigious intent.
Why Patients Sued
•
•
•
•
Patients felt rushed
No explanations given
Felt less time spent
Felt ignored
(Hickson et al 1994)
•
•
•
•
91% wanted to prevent a recurrence.
90% wanted an explanation.
68% wanted the doctor to know how they felt.
45% due to attitude of hospital staff following the
error.
(Vincent et al 1994)
HIQA and CIS
Exploratory Study 2010
• Study involved patients or their families who had
been involved in an adverse event, on whose
behalf claims were settled by the State Claims
Agency.
• To determine an insight into Irish patients’
experiences of adverse events and the outcomes
desired by patients and their families following an
adverse event.
• To establish what prompted patients or their
families to take legal action following an adverse
event
Reasons for taking legal action:
Respondents’ comments
• “ I consulted legal representatives to represent
me and my family at the inquest into my husband’s
death. As the hospital never acknowledged the two
serious incidents that led to my husband’s death I
felt I needed a solicitor to help me communicate
with them”.
•
“I felt that they thought that offering me
compensation without acknowledging the wrong in
not giving me any explanation would make it ok”
Reasons for taking legal action:
Respondents’ comments
“I felt forced to take legal action because it was the
only action open to me. I took the matter to a
solicitor because I felt I had an obligation to others
as well as to myself to do so”
“Staff were secretly telling me that a mistake had
been made! It was very obvious to the maternity
hospital that a mistake had been made but they
focused on closing ranks and protecting the
organisation and healthcare professionals
involved. I was told my daughter would be dead
within 12 months…”
Quote from a
Patient Advocate
Open disclosure is not about blame.
It is not about accepting the blame.
It is not about apportioning blame.
It is about integrity and being truly professional
And the reason:
You hold our lives in your hands and we, as
patients, want to hold you in high regard.”
2.
The Staff Perspective
Why disclosure
is difficult
• Culture: Historic Medical Culture of Non disclosure
• Institutional Barriers: “Blame and Shame” approach – no
institutional support or mechanisms to facilitate disclosure
• Fear of litigation
• Fear concerning professional advancement
• Fear with regard to reputation
• Fear of being reported to professional body
Why disclosure is difficult (continued)
• Fear of the Media
• Fear of the patient’s/family’s response
• Financial concerns
• Uncertainty with regard to extent of information to be
disclosed
• Lack of training and guidance for healthcare professionals
The Importance of Open
Disclosure for Staff
• Improved staff recovery.
• It encourages a culture of honesty and openness.
• Staff are more willing to learn from adverse events.
• It enhances management and clinician
relationship.
• It leads to better relations with patients and their
families.
• Maintains personal and professional integrity
• Lightens the burden of guilt
• Allows for reflective learning
3.
The Organisation’s Perspective:
Culture, Patient Safety and
Financial Considerations
Levels of Transparency required to
change culture – Lucian Leape 2014
•
Transparency between clinicians and patients/service users
demonstrated by open disclosure following adverse events
•
Transparency between clinicians demonstrated by peer review and
other mechanisms to share learning
•
Transparency between healthcare organisations demonstrated by
shared learning and collaborative working.
•
Transparency between both clinicians and organisations and the
public demonstrated by public reporting of patient safety data
Additional layers of transparency
identified in Evaluation of OD in ROI
Transparency between:
 Clinicians and hospital management, through staff support and
a protective environment to disclose
 Health and social care organisations, patients and their families,
and representative patients’ organisations, in development of
open disclosure policies, training and practice.
Transparency results in : Improved patient outcomes, fewer errors,
happier patients, lower costs, increased
public confidence
Transparency helps to:
•
Build the will to improve care
•
Shape the culture into one of openness, with attention to eliminating defects.
•
Raise improvement capability through access to real time data.
•
Engage partners and empower teams across boundaries
•
Provide patients and community members with opportunities to participate
in improvement and to motivate change .
(IHI White Paper)
University of Michigan
Health System
2002, Adopted full disclosure policyMoved from, “Deny and defend” to
“Apologise and learn when we’re wrong, explain and vigorously
defend when we’re right and view court as a last resort”
August 2001-August 2007
• Ratio of litigated cases : total reduced from 65-27%.
• Average claims processing time reduced from 20.3 months to 8
months.
• Insurance reserves reduced by > two thirds.
• Average litigation costs more than halved.
• Savings invested into patient safety initiatives.
4.
Policy, Regulatory, Professional and
Ethical requirements
Agencies Endorsing
Open Disclosure
•
Statutory:
•
Government: DOH
•
Indemnifying: SCA/CIS
Medical Protection Society (MPS)
•
Professional: The Nursing and Midwifery Board of Ireland (Previous ABA)
•
Regulatory:
•
WHO
HSE including non statutory organisations funded by the HSE
The Medical Council of Ireland
HIQA
CORU
PHECC
Mental Health Commission
Recommendations by the
Patient Safety Commission
• National Standards to be developed and
implemented
• Legislation to provide legal protection
• Open communication training for all healthcare
professionals
• Support and counselling programmes
• Research in to the impact on patients and families.
HSE
“A Patient can expect open and appropriate communication
throughout your care especially when plans change or if
something goes wrong.”
(You and Your Health Service, 2010 - Revised 2012.)
“Safety Incident Management occurs within the framework of
the principles of open disclosure, integrated risk
management, just culture and fair procedures. This policy
must be read within the context of the HSE/SCA Open
Disclosure National Guidelines 2013.”
(HSE Safety Incident Management Policy 2014)
State Claims Agency
“At the heart of open disclosure lies the
concept of open, honest and timely
communication. Patients and relatives must
receive a meaningful explanation when
something goes wrong”.
(Ciarán Breen, Director of the SCA 2015)
Medical Protection Society
National Standards for Safer
Better Healthcare 2012
Standard: 3.5:
“Service providers fully and openly inform
and support service users as soon as
possible after an adverse event affecting
them has occurred, or becomes known and
continue to provide information and
support as needed.”
CORU:
“If a service user suffers harm, speak openly and
honestly to them as soon as possible about what
happened, their condition and their ongoing care
plan”
(The Codes for Dietitians 2014, Speech and Language Therapists 2014 and
Occupational Therapists 2014)
PHECC (April 2015)
•
PHECC wholly endorses the HSE principles of open disclosure.
•
The Pre-Hospital Emergency Care Council (PHECC) in its commitment to
protecting the public recognises that despite the best intentions of the
highly qualified and committed responders and practitioners occasionally
things may go wrong.
•
PHECC is committed to the process of open disclosure as included in the
Education and Training Standards since 2007. We believe that the open
disclosure process encourages the reporting of adverse events which leads
to a manifestation of the patients’ autonomy and ultimately leads to
opportunities for systems improvement and delivery of the highest
standards of care delivery.
•
In addition PHECC is committed to information being available following the
incident review as being an essential component of an open disclosure
policy.
Mental Health Commission 2015
“The
Mental Health Commission fully endorses Open Disclosure
and communicating with service users and their families
following adverse events in healthcare. As Open Disclosure
is now national policy, the Commission will be making it a
requirement in its revised Code of Practice on the
Notification of Deaths and Incident Reporting “.
Statement from the Mental Health Commission May 2015
Medical Council of Ireland
“Patients and their families are entitled to
honest, open and prompt communication
with them about adverse events that may
have caused them harm.”
(Medical Council’s Guide to The Professional Conduct and Ethics for Registered
Medical Practitioners 2009)
The Nursing and Midwifery
Board of Ireland
“Safe quality practice is promoted by nurses
and midwives actively participating in
incident reporting, adverse event reviews
and open disclosure”
(Code of Professional Conduct and Ethics for Registered Nurses and
Registered Midwives December 2014 )
WHO
“The inclusion of open disclosure processes in many
hospitals today reflects the increasing importance
of professionalism and honesty with patients and
their carers. This in turn is increasing
opportunities for partnerships with patients”.
http://(www.who.int/patientsafety/education/curriculum/who_mc_topic-8.pd
5:
Action on Learning from
national and international
reviews/investigations
National Open Disclosure
Policy 2013
Requirements
National Policy Requirements
1. Incidents are identified, managed, disclosed and reported and that
learning is derived from them. The service user must be informed in
a timely manner of the facts relating to the incident and an apology
provided, where appropriate.
2: Suspected Adverse Event: The service user should also be informed
if an adverse event is suspected but not yet confirmed.
3: No Harm Events: “No harm events” should generally be disclosed.
4: Near Miss Events: Near miss events should be assessed on a case
by case basis, depending on the potential impact it could have had
on the service user. If, after consideration of the near miss event, it
is determined that there is a risk of/potential for future harm from
the event then this should be discussed with the service user.
National Policy Requirements
5. The HSE will provide an environment in which staff feel supported in
the identification and reporting of adverse events and also during
the open disclosure and review process following an adverse event.
6: The HSE and SCA will provide and facilitate training in open
disclosure for health and social care staff.
7: When a clinician makes a decision, based on his/her clinical
judgement, not to disclose to the service user that an adverse event
has occurred, the rationale for this decision must be clearly
documented in the service user’s healthcare record and this
decision may need to be reviewed by the clinician at a later date,
depending on the circumstances involved.
National Policy Requirements
8: The salient points discussed with service users during open
disclosure meetings, including the details of any apology provided,
should be documented in the service user’s healthcare record in
accordance with the National Guidelines on Open Disclosure 2013.
9: All health and social care services must have the required
governance processes in place to ensure that open disclosure
occurs and to address situations where there is a difference of
opinion as to whether open disclosure should occur or not.
10: All health and social care staff have an obligation under the
National Standards for Safer Better Healthcare 2012 to “fully and
openly inform and support service users as soon as possible after
an adverse event affecting them has occurred, or becomes known
and continue to provide information and support as needed.
Resources
Fact: Things go wrong and will
continue to go wrong ……..
• Adverse events happen to the best
people in the best places – none of
us are immune.
• We must be honest with our
patients, our colleagues and
with ourselves.
• Learning is difficult
where transparency is absent.
• Transparency must involve
an empathetic approach to the
patients, families and staff involved
In adverse events.
In Summary:
“To err is human, to cover up is unforgivable
and to fail to learn is inexcusable”
(Sir Liam Donaldson (CMO UK)
Contact Details:
Thank you for your time
and
attention….any questions
?