A4: Open Disclosure Best Practice: A “How to” Guide from International
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 1 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 2 1 25/09/2013 Overview Part 1: History of OD in Australia Part 2: Key lessons for organisations implementing Open Disclosure Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 3 The Safety Problem Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 4 2 25/09/2013 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! Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 5 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 6 3 25/09/2013 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) Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 7 OD National Pilot Goal: Find the best strategies to… THEORY PRACTICE Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 8 4 25/09/2013 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 9 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 10 5 25/09/2013 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 September 26th 2013 11 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?” Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 12 6 25/09/2013 Outline of Evaluation Study 41 HREC Applications; 21 progressed 154 interviews: 23 patients Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 13 Current Status of Open Disclosure 2012 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ 2013 September 26th 2013 14 7 25/09/2013 Differences between the Standard and Framework Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 15 Overview Part 1: History of OD in Australia Part 2: Key lessons for organisations implementing Open Disclosure Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 16 8 25/09/2013 Pitfall 1 –Seeing OD as medicolegal risk management rather than part of good clinical care Health Service Interests Patient & Family Interests Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 17 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? Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 18 9 25/09/2013 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 19 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. Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 20 10 25/09/2013 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. Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 21 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. Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 22 11 25/09/2013 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 Open Disclosure Best Practice IHI APAC Forum – Auckland NZ September 26th 2013 23 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] 12 25/09/2013 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 13 25/09/2013 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 14 25/09/2013 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” 15 25/09/2013 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 16 25/09/2013 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 17 25/09/2013 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 18 25/09/2013 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” 19 25/09/2013 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 20 25/09/2013 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” 21 25/09/2013 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? 22 25/09/2013 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 23 25/09/2013 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 24 25/09/2013 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 25 25/09/2013 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 26 25/09/2013 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 27 25/09/2013 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 28 25/09/2013 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 29 25/09/2013 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 30 25/09/2013 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 31 25/09/2013 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 32 25/09/2013 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 33 25/09/2013 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 34 25/09/2013 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 35 25/09/2013 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 36 25/09/2013 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 37 25/09/2013 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 38 25/09/2013 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 39 25/09/2013 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 40 25/09/2013 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 41 25/09/2013 [email protected] 42
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