25/09/2013
A4: Open Disclosure Best Practice:
A “How to” Guide from International
Success Stories
Part 1 – Implementing Open
Disclosure – Lessons from national
and state implementation
Adjunct Professor John Wakefield
Chair Australian National Open Disclosure Pilot
Committee
Faculty and Program Lead Queensland Health Open
Disclosure
Open Disclosure Best Practice IHI APAC Forum – Auckland NZ
September 26th 2013
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Acknowledgements
Australian Commission for Safety and Quality in
Healthcare (and the former Council)
Jurisdictional Program Leads
Professor Rick Iedema and colleagues at UTS –
Evaluation of National Pilot
Patients/families who participated in research
Dr Mark O’Brien and the Cognitive Institute
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Overview
Part 1:
History of OD in Australia
Part 2:
Key lessons for organisations
implementing Open Disclosure
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The Safety Problem
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Open Disclosure
....is the open discussion of incidents
that result in harm to a patient while
receiving health care.
Elements include:
–
–
–
–
expression of regret;
a factual explanation of what happened;
the potential consequences;
steps being taken to manage the event
and prevent recurrence.
ACSQH National Open Disclosure Standard 2003
NOW CHANGED SEE LATER IN PRESENTATION!
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History of OD in Australia
Drivers for disclosure:
– Medical indemnity crisis 2002
– High profile failures eg. Bristol, KEM etc.
– National Safety Reform: The Safety and Quality
Council.
AHMAC Legal Process Reform Group Report 2002
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History of OD in Australia (cont.)
Led to publication of Open
Disclosure Standard in
2003.
Endorsed by Ministers
through AHMC in 2003.
Educational and support
materials produced by the
Council
Pilot delayed until mid
2006 (insurers/Council)
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OD National Pilot Goal:
Find the best strategies to…
THEORY
PRACTICE
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Governance
Australian Health
Ministers Conference
(AHMC)
Australian
Commission on
Safety and Quality
National Project
Manager
Australian Health
Ministers Advisory
Committee
(AHMAC)
Interjurisdictional
Committee
National OD Pilot
Steering
Committee
Jurisdictional Pilot
Project Officers
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National Pilot Sites
42 sites participating nationally
–
–
–
–
–
–
–
Queensland – 7 public and 1 private
NSW – 11 public and 1 private
Vic – 6 national pilot sites + 6 state pilot sites
WA – 5 pilot sites
SA – 3 pilot sites
ACT –1 pilot site
Tasmania – 1 pilot site
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Models used for pilot
Varied state governance and funding arrangements –
centralised vs. decentralised; funded implementation versus
funded training only; some statewide plan – others left to
individual services.
Training programs ranged from 1hr to 2 day programs;
Queensland - clinician communication consult model (Liebman &
Hyman 2005);
Centrally funded program; part of incident management system;
faculty trained to high level;
Pre-screened senior clinicians to become organisational
communication consultants for OD; Initial
Hi-fidelity simulation training using professional actors and
based in Sim lab to enable video and debrief.
Open Disclosure Best Practice IHI APAC Forum – Auckland NZ
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Evaluation of the National Open
Disclosure Pilot
“What it is about Open Disclosure that
works, for whom does it work, in what
circumstances does it work, in what
respects does it work, and why does it
work?”
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Outline of Evaluation Study
41 HREC Applications; 21 progressed
154 interviews: 23 patients
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Current Status of Open Disclosure
2012
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Differences between the Standard and
Framework
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Overview
Part 1:
History of OD in Australia
Part 2:
Key lessons for organisations
implementing Open Disclosure
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Pitfall 1 –Seeing OD as medicolegal risk
management rather than part of good clinical
care
Health Service
Interests
Patient & Family
Interests
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Pitfall 2
Failing to be clear about what you mean by OD in
your organisation; what it should look like; and how
you will know if it is happening as intended.
1.
2.
3.
4.
5.
When is it left to front line clinicians?
When do you require institutional involvement?
How do you ensure that key elements are included - everytime?
How do you plan for it?
How do you incorporate involvement in and feedback from incident
analysis?
6. How do you ensure commitments are followed through?
7. How do you provide financial support?
8. How do you assess the outcomes – for patients, staff and
organisation?
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Pitfall 3
Thinking that a reliable experience for patients
and families after an adverse event can be
achieved by running some training courses.
1. Needs organisational leadership to require it and resource it (and
mostly to believe in it!)
2. Agreed triggers, processes, administration
3. Integral to incident management system – not an added extra
4. Competent professionals available where and when it is required
5. Follow up and delivery on commitments for patients and staff
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Pitfall 4
Expecting that OD will always ‘go well’; will ‘fix’
things for affected patients and families; and
equating this with success or failure of your OD
efforts.
1. Our assessment of outcome is not always consistent with the
experience of the patient or family
2. Do not assume that if it goes ‘well’, that you have made things better;
3. Conversely, do not assume that if it goes ‘badly’ that it was not a
critically important intervention for the patient or family.
4. Sorry fatigue – this is emotionally and intellectually very demanding.
Spread the burden.
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Pitfall 5
Believing that funders, insurers, management or
clinicians believe in the concept of Open Disclosure
1. Evidence is that many still harbour fears about personal risk,
professional reputational damage and impact on litigation – this is in
spite of much evidence to the contrary.
2. Whilst indemnity insurers publicly support OD, anecdotal evidence
that individual advice can be at odds with this.
3. Doctors often are ignorant of the statute in respect of protected
apologies (which is not surprising given each state is different)
4. Need to ensure that you are working in full consultation with all
stakeholders to ensure staff see rhetoric matches reality.
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Pitfall 6
Failing to call cases where liability is not in
question
1. Most cases do not have clear fault and proceed as part of traditional
disclosure practice with or without financial support.
2. When it is clear that the organisation is at fault from the ‘getgo’, you
need to involve insurers immediately and call it with the
patient/family (do not do without first consulting your legal counsel!)
3. Best practice approach is to apology of admission and commence
course to defining quantum for settlement.
4. Failure to accept responsibility early in these cases is interpreted
badly by most patients.
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Closing Messages
Start with the end in mind….
The goal is not to train a bunch of
clinicians in how to do OD…. It is to
establish the system that will deliver a
reliable experience of open disclosure
for patients and families after an
adverse event.
At the heart of this however, are
clinicians who have mastery of the art
of empathic communication
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Implementing Supported
Open Communication
(Open Disclosure)
Capital and Coast
District Health Board
Kate MacIntyre
Patient Safety Officer
Capital and Coast District Health Board
[email protected]
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Drivers
As well as the Australian Standard……. Some other
drivers for us in New Zealand:
• Disclosure of Harm “Good Medical Practice”,
NZ Medical Council, Dec 2004 www.mcnz.org.nz
• Being Open: Communicating Patient Safety Incidents
with Patients and their Carers,
NHS National Patient Safety Agency, 2009
www.npsa.nhs.uk
• Guidance on Open Disclosure Policies,
NZ Health and Disability Commissioner, Dec 2009
www.hdc.org.nz
• National Policy Reportable Events Feb 2012 HQSC
Other Drivers
• 2007
– Open exposure via media
• 2009
– New Chief Executive Officer and Chief
Operating Officer from Australia
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But we already did it?
• Did we?
• Reportable events policy stated “patient
to be informed”
• Commissioner asked for our policy but...
• Did we do it? How would we know?
• And if we did…..how well did we do it?
– Scary for clinicians
– I am an artist, who is the organisation to tell
me
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Hollywood Style?
Ref: Ghost Town
Keeping in mind
The process if
done well, is
therapeutic for all
participants but,
it can go poorly:
“It felt like the
professional
apologists had
come to call”
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Making “Just Do It” a reality
• Policy and guideline
• Specified open communication
• Included specified commitment to:
– Experts
– Presenters and education
• Policy held until budget confirmed
• Cognitive Institute engaged
www.cognitiveinstitute.com
• CEO and COO direction to staff
Experts
“Clinical Incident Support Leaders”
• Selection – will anyone apply?
• Commitment
• Expert training and
development
• What to call the expert?
• What will the expert do/not do?
• Will anybody use them?
• Buddying and evaluation
• Ongoing professional
development and learning
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Here’s one I prepared earlier....
Introducing.... A real live expert:
Dr Derek Snelling
Executive Clinical Director Anaesthesia,
Operating Theatre and Intensive Care
AND
Clinical Incident Support Leader
Presenters and Education
•
•
•
•
•
•
Selection – will anyone apply?
Commitment
Presenter training and development
Administration support
Buddying and evaluation
Ongoing professional development and
learning
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Skills Workshop for Staff
• Ethos-what is the purpose?
• Theory and research-what is the
evidence?
• Framework–components of effective
conversation-how to do it
• Impact on clinicians-how to cope
• Key skills-what to bear in mind
• Practical exercises-make em work!
Pilot
•
•
•
•
3 months
Evaluation
Refined processes
Now business as usual
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Feedback from the Experts
“We need to have regular refresher training sessions to make
sure we don’t forget, and build on what we learned”
“We need CEO endorsement of our roles and DHB
expectations that communication will be open”
“We need to buddy each other to support and learn as we go”
“It is key to pre plan, confirm arrangements (and then not
assume people will turn up!), and allow time to debrief and
clarify what was agreed afterwards”
Feedback from the Presenters
“The best train the trainer I have experienced”
“The feedback is honest and has allowed me to change
what I do effectively”
“It’s fun and a privilege”
“It is a good workshop and we need to get more people
at the front line to come to it – particularly senior nurses
and RMOs”
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Evaluation
• Policy and guideline
– reviewed 2011 and will be reviewed later this
year
• Ongoing peer and outcome review
– Clinical Incident Support Leaders in action
– Expanding CISL team planned
– Professional development for both groups
– Presenters
• Workshops
– Attendance and participant feedback ongoing
Participant Feedback on
Workshop
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Participant Feedback on
Presenters
Participant Feedback Verbatim
“Great presentation good skills to practice”
“Impressed that Doctors were presenting”
“Good use of personal and real examples”
“I now have a framework to utilise as and when needed”
“Like the interactive and inclusive approach to the session”
“All presenters had excellent examples and angles on subject”
“Overall very good and relevant to the current environment. Need to
provide and encourage full attendance across the organisation”
“Good to mix with wide variety of other disciplines Doctors, Nurses, Allied
Health, Hospital & Community viewpoints experiences rather than focused
solely on your particular service area”
“Informative interesting held my interest throughout the session”
“Excellent work book and good explanation during presentation”
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Also Thought Provoking
“How does the DHB sort out these things beyond "sorry"?”
“Why not use a real CCDHB scenario?”
“When is it OK to say "This is my fault and I apologise"?”
“How does our event review process support or threaten
the Open Communication process?”
Impact on Complaints?
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Complaints where Expert Role
Utilised
• When done at right time, with expert
• No new complaint to DHB or Health and
Disability Commissioner
• Final report provided to patient/family
• None have taken report to media
• Patients/whanau have indicated the
process was useful
Other Things We Grappled
With
• Breaking bad news, managing care v open
communication
•
•
•
•
Is it ethical to tell them?
Not a clinical conversation
I have to leave
I will not apologise
• Laparoscopy case
• Sudden death whanau case
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Other impacts
• Grand rounds
• Complaints policy:
– Letters and process adopted framework
• Open communication by letter
• Open communication by phone
• Open communication by media
What next?
• Updates of policy and guideline
• Continued development of experts and
presenters (retention, further recruitment)
• Workshops are business as usual
• Research
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Dr Don Cave
Medical Consultant
Clinical Safety and Quality Unit
Mater Health Services
The Open Disclosure Process
at Mater Health Services
1. How did we do it
2. Key Operators / Connections
3. Evaluation
4. Conclusions / Learnings
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Current Structure
Administrative
Officers
Management Team
Clinical Safety Officers
Senior Clinical Risk
Management Consultant
Quality Improvement
Co-ordinator
Carepath Coordinators
CNC – Venous
Thromboembolism (VTE)
Prevention
Medico Legal Lawyer
Clinical Safety
& Quality Unit
Clinical Risk & Claims
Manager
Emergency Response
Coordinator
Clinical Governance
Improvement
Co-ordinator
Clinical Governance
Officer
Patient Representative
Patient Safety Officers
(Projects)
Infection Control
Practitioners
CIMS
Cognitive Institute in consultation with Mater developed an
education package focused on sentinel event identification
and consultation including patient consultation
Cognitive Institute trained small groups of senior clinicians
(medical and nursing) in adverse outcome management
The senior clinicians trained in Adverse Outcome
Management were available to assist on request. Relevant
policies were developed to support this
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CIMS in line with the Standard
The approach to CIMS is synonymous with the
Australian Commission on Safety and Quality in Health Care
Open Disclosure Standard. Open Disclosure as defined
in the Standard includes discussion/ explanation
incorporating
(i) an expression of regret
(ii) explanation of what happened
(iii) understand and address consequences of the
event
(iv) steps being taken to manage the event and
prevent re-occurrence
Mnemonic
A cknowledge
S orry
S tory
I nquiry
S olutions
T ravel
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Open Disclosure Policy applies to
all patients
As soon as practicable following a clinical event and after
thorough investigation, patients will be informed
(i)
what occurred regarding the event (to the extent that Mater
at that point can reasonably be expected to provide this
information, given the circumstances)
(ii)
significant factors relevant to the event, and
(iii)
what risk management activities are being done to prevent
like circumstances happening again
Open Disclosure - Policy
When the adverse or sentinel event concerns treatment which
has been provided by clinician/s who are not employees of Mater
Health Services, then the Open Disclosure must only occur
following Mater’s direct consultation with those clinician/s and
CSQU, ie. Open Disclosure is not avoided if primary care
clinician is not an employee
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Open Disclosure Policy approach –
incorporating CIMS
• Parties authorised to attend to the Open Disclosure would ordinarily
be a CIM Colleague and or the relevant treating Consultant and / or
a member of the Mater Health Services Executive
• Ordinarily this would only occur after seeking advice from Mater
Health Services Legal Counsel.
• In circumstances where legal advice is not available, Open
Disclosure should only occur after first consulting with the relevant
Mater Health Services Executive
Key Connections
• “On board” medical malpractice Insurer
• Patient Representative
• Clinical Safety Officers
• Senior Clinical Risk Management Consultant (Clinical Safety &
Quality Unit Team member) with coal face connection
• In-house medico-legal lawyers identifiable and accessible (round the
clock) for advice – also regularly providing education at the coal face
• CIM partners
• Senior Clinicians/ Executives
• Vigorous / committed CSQU
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Key Operations relevant to ongoing uptake
and implementation
• A “just culture” policy
• Twice weekly Sentinel Event meetings
• CISA – Clinical Incident System Analysis regularly occurring, per
Clinical Safety Officers
• RCA legislation process which supports
• Speaking Up For Safety – is consistent with principles on which
Open Disclosure is based
• In house medico-legal
• WE ARE PLACED TO MAKE OPEN DISCLOSURE HAPPEN,
with minimal delay
Evaluation of Success
• Testimonials from patients and families
• Testimonials from CIMS colleagues
• Positive feedback from outside agencies about MHS Clinical
Risk Management strategies, eg. State Coroner, ACHS, HQCC,
ACSQHC and our Insurer
• Positive feedback from clinicians actively involved in the
process
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Open Disclosure in the Mater Hospital Group
Direct quote from ACSQHC Annual Report 2011/ 2012
There are many open disclosure success stories in Australia. Mater Health Services Brisbane is among them.
Mater recognises that openly discussing adverse events and near misses with patients and their families is an
integral component of Mater’s Mission and Values, and is openly committed to the principles of open
disclosure and the promotion of a safety culture that values transparency, honesty and respect
Mater implemented a service wide Open Disclosure Policy in 2003, complemented by:
•
introducing in-house medico-legal and claims management services
•
engaging an external contractor to advise on a communications and training package to educate and
engage all clinicians in the roll out of open disclosure practice, and clinical incident management
For the majority of reported clinical incidents at Mater, open disclosure now takes place as a matter of course,
initiated by the clinicians involved in patient care
Mater recognises that in sharing early, honest and comprehensive disclosure with the patient in relation to an
event, fosters a good rapport with the patient and their family and that this will ultimately have a positive
influence on patient clinical care and the rapid resolution of the patient’s concerns
Mater has also received a considerable amount of positive feedback from patients and families on its approach
to open disclosure
Making OD Work – Key Conclusions
1. Clinicians at the coal face must have an understanding of
those clinical adverse events which need to be reported, ie. in
the context of their warranting follow up including Open
Disclosure
2. In clinical environments there must be a general awareness
among clinicians / understanding of approach required in
terms of discussion with patients about what occurred,
significant factors relevant to the clinical event, risk
management and incorporating an apology
3. Clinicians must feel safe to report and at same time have a
willingness / desire to seek advice and be advised re 2. above
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Key Conclusions, in essence …
In its simplest form Open Disclosure is all about embracing risk
management:
•
Identifying problems including the “bad things” which we are
responsible for
•
Putting out the fires – risk management, anticipating what
could happen
•
Connecting the problems with a cause and being open and
honest and in doing so incorporating an apology
Key Conclusions - Fact
Unless doctors recognise there is a problem which might benefit
from explaining clinical events and saying sorry, then nothing
happens, including Open Disclosure
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Key Conclusions - Fact
Informing/ advising clinicians they need to say sorry without their
recognising that there is a problem (event warranting review and
discussion with patient/ family) is a waste of time
Information ≠ understanding
Key Conclusions - Fact
If clinicians feel:
i.
ii.
safe in a reporting environment and
understand the need for Open Disclosure, and
iii. have appropriate resources to tap into by way of support (in
particular timely support),
this will provide an essential key to open communication
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AUSTRALIAN COMMISSION
ON SAFETY AND QUALITY IN HEALTH CARE
Australian Open Disclosure Framework
Supporting materials and resources
Open disclosure organisational readiness
assessment tool
Case Study
• Mrs KM, 36 year old multi gravida
• Uneventful pregnancy, planned CS
• Semi emergency CS for spontaneous labour before planned
procedure
• Apparently uncomplicated procedure. Bladder densely adherent
to uterus
• Uncomfortable post natal first night. Slightly blood stained urine
• Mild pyrexia, abdominal distension and increased analgesic
requirements 20 hours after surgery
• Medical Officer contacted and patient reviewed
• Provisional diagnosis – paralytic ileus - given antibiotics
• Numerous attempts by Nursing staff to MO to review over the
next 24 hours
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Case Study – cont’d
• Abdo x-ray reveals free fluid and distended bowel. Laparotomy
performed and severe peritonitis
• Nursed in Intensive Care Unit for 36 hours. Very unwell
• Protracted recovery and hospital stay
• Complaint received by Patient Advocate
• Subsequent contact with HQCC
Lessons learned from
Open Disclosure Success Stories
Matthew O’Brien, Managing Director
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Today’s presentation
• Overview of the Clinical Incident support model
• 20 things successful organisations do
• An Open Disclosure training map
Our organisation
• Leading provider of communication skills and
risk management training in south east Asia
• Education designed by clinicians, for clinicians
and delivered by clinicians
• Founded in 2000
• Each year 12,000 clinicians across 10 countries
attend 1000 Cognitive Institute designed courses
• Part of Medical Protection Society
– not for profit, world-leading mutual medical defence
organisation
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Our open disclosure experience
• More than 10,000 clinicians in 9 countries
• Integrated into ministry programmes
• Singapore, Irish State Claims Agency, Australian States,
Capital and Coast DHB
• TTT model
• Led the introduction of the peer support model through
Clinical Incident Management (CIM) Programme
Clinical Incident Management
• Organisational response to high level open disclosure
• Addresses the issues of:
–
–
–
–
Psychological needs of the parties
Safety and quality agenda
Compensation/restitution
Legal and regulatory requirements
• Provides expert support to treating clinicians
• Places importance on preparation
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An effective response –
Who is involved
•
•
•
•
•
The treating doctor/nurse
The hospital/organisation’s risk manager
Quality and safety professional
The hospital’s legal advisers
Claims manager
PLUS
CIM Senior Consultant
The importance of hi-fidelity training
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The advantages of this model
•
•
•
•
•
•
Recognises support and expertise needed
Concentrates the experience for serious events
Introduces increased objectivity to the conversation/s
Reduces stress for the treating clinician
Keeps the conversation/s “on track”
Acts as a backup if a clinician can’t undertake the
conversation/s effectively
20 things successful organisations do
•
Know a policy is only a start, and do not expect this to translate into culture change,
capability and compliance
•
Know they can only expect clinician support if they practice an open and just culture
•
Identify what they are trying to achieve from disclosure and commit to the
processes and resources to reliably achieve it
•
Want confidence all patients and families will experience the same intended
standard of care and support when serious harm occurs, irrespective of the treating
clinician
•
Consider disclosure an organisational responsibility, not just an individual clinician
task
•
Recognise that different severity of event warrants different approaches, resources
and clinician skill
•
Are motivated by an ethical, professional and patient-centred response, not
litigation or complaint mitigation
•
Engage with senior leaders to ensure understanding and commitment
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20 things successful organisations do
•
Provide training that aims to overcome the significant historical and cultural
barriers, as well as provide skills
•
Treats disclosure as a multidisciplary response
• Clinical, legal, quality and safety, managerial
•
Have a documented process that prepares, implements, follows through and
reviews
•
Understands the importance of considering early financial assistance
•
Recognises the impact on the treating clinician
• Ability to meet patient needs
• Further distress
•
Accepts not every treating clinician is capable of undertaking this challenging task –
even with training
•
For serious events, provides expert trained senior managers/colleagues to support
or represent the treating clinician in talking to the patient and family
•
Appreciates these experts need high level training and ongoing to support
20 things successful organisations do
•
Understand the natural response clinicians may have to an organisational response
•
Plan a communications strategy to
•
•
•
show high level executive commitment
position the programme as support for clinicians
report back on “success”
•
Are equally committed to supporting all disappointed patients and family, even
when there is no harm
•
Have open disclosure totally integrated with incident reporting and safety reviews
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Summary
Successful open disclosure:
• A systemised, graded response programme to produce
reliable, effective support for patients and family
• Recognises disclosure for serious events as a professional
skill and the need to provide clinicians with support
• Do not underestimate the cultural and personal barriers, and
address through comprehensive training strategy
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[email protected]
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