Open disclosure: The road to success
Being open with patients and their families following an adverse event is not only the right thing to do, it can also help mitigate complaints and claims. Dr Chui Tak-Yi charts the journey towards successful implementation at the Hong Kong Hospital Authority
In the past two decades, in the healthcare arena worldwide, there has been increasing recognition of the importance of open disclosure of medical incidents. Disclosure of harm and/or error (error can include problems in practice, products, procedures and systems) has evolved from an individual’s ‘act of goodwill’ in respecting patients’ right to know and decide on their treatment, to a system of meeting public expectation for transparency and accountability.
The global approach
Various governments, healthcare providers and professional bodies have developed their own policy and guidelines related to open disclosure as part of a risk management system and clinical governance. In the US, in 2001, the US Joint Commission on Accreditation of Healthcare Organisations announced a policy that demands disclosure of a critical event by the provider or the institution. In some states, it is a statutory requirement for organisations to notify patients in case of an adverse event.
In the UK, from 1 April 2013 the new standard NHS contract requires all NHS and non-NHS providers of services to NHS patients to comply with a “duty of candour” in reporting patient safety incidents.
In 2007, New South Wales Health in Australia defined open disclosure as the process of providing an open, consistent approach to communicating with the patient and their support person following a patient-related incident. This includes expressing regret for what has happened, keeping the patient informed, and providing feedback on investigations, including the steps taken to prevent a similar incident occurring in the future. It is also about providing any information arising from the incident or its investigation relevant to changing systems of care in order to improve patient safety.
How does Hong Kong measure up?
The Hospital Authority (HA) Hong Kong is the statutory body established to manage all public hospitals and general outpatient clinics since 1990. A set of quality standards was established in 1995 and is periodically reviewed. It served as part of the Hospital Annual Planning process for quality improvement and accountability reporting. It gave an overall view of the desired service standards in hospitals and provides quality parameters in essential service areas so that hospital managers can use the parameters as tools for improving the service of their hospitals.
In October 2007, with reference to international practices, the HA established the Sentinel Event Policy, which requires mandatory reporting of nine categories of incidents, and a standard process in reporting, investigation, documentation, identification of root causes, and implementation of recommendations. In 2010, the HA further improved the reporting mechanism by mandating the reporting of two more categories of Serious Untoward Events, namely, medication error and misidentification that could have led to death or permanent harm.
In 2009, the Hong Kong government launched pilots in hospital accreditation systems to enhance healthcare quality in Hong Kong. Hospitals under the HA have taken part in the accreditation exercise since then. In one accreditation standard, the organisation is expected to show how the principles of open disclosure is evident in its system of incident management and how it educates and trains staff in the principles and practices of open disclosure. Through the current accreditation exercise, hospitals in Hong Kong evaluate their current systems in facilitating open disclosure for continuous improvements.
The organisation is expected to show how the principles of open disclosure is evident in its system of incident management
Support system grows for openness
Open disclosure of incidents is strongly encouraged in the HA. The Code of Conduct of the HA, published in 2009, stipulated that professional behaviours that align with Vision (Healthy People, Happy Staff; Trusted by Community), Mission (Helping People Stay Healthy) and Values (Peoplecentred Care, Professional Service, Committed Staff, Teamwork) of the HA includes open disclosure of adverse events and being honest and open in our interactions with our patients.
In order to equip healthcare professionals with better communication skills in conflict resolution, a scheme to sponsor staff to attend formal training in mediation skills has been introduced. Most of the participants found the principles and skills they have acquired relevant and useful in challenging situations, including the dialogues related to a medical incident.
Dr H Bill Chan, Chief of Service, Paediatric & Adolescent Medicine, United Christian Hospital, Hong Kong Accredited Mediator (Hong Kong International Arbitration Centre) said:
Mediation skills like active listening with empathy, reframing, taking win-win approaches, options generation and appropriate assertiveness are skills I find useful in the disclosure conversation to achieve optimal outcomes
“Open disclosure in the event of medical incidents is the prerequisite of regaining trust of our patients and their carers. Barriers to open disclosure include concerns about personal, professional and legal consequences, as well as adequacy of communication skills.
“Mediation focuses on interest-based solutions to meet the immediate needs of the affected patient and their family. It seeks timely sharing of information to promote discovery of systemic problems and to prevent recurrence. Mediation skills like active listening with empathy, reframing, taking win-win approaches, options generation and appropriate assertiveness are skills I find useful in the disclosure conversation to achieve optimal outcomes. Successful mediation brings about reduced anger and punishment behaviour.”
Dr KM Li, Chief of Service, Accident & Emergency Department, United Christian Hospital, Hong Kong, said:
“To disclose an incident to patients and/or their family is one of the most difficult tasks for doctors, especially when it is associated with severe adverse outcomes or the death of patients. Not much has been taught in medical school.
“Doctors have to learn and equip themselves in dealing with such situations. I strongly recommend mediation training for doctors in tackling this challenge. The skills taught in mediation training – like how to demonstrate empathy, active listening, create harmony, summarising and reframing, and getting somebody to ‘step into the other’s shoes’ – are all valuable techniques, helping us in the disclosure of medical incidents.”
Putting policy into practice
Establish formal procedures
From the organisational perspective, there should be a clearly stated policy and procedure about open disclosure, which should be consistent with the existing clinical governance framework, quality and safety policies and procedures, supported by senior health professionals using the process, and consistent with corporate direction and government regimes, insurer requirements and employment obligations.
Health services should ensure the procedure that triggers the open disclosure process is in place whenever an adverse event occurs. The disclosure process should incorporate the “no blame” (or “fair blame”) approach and health professionals and managers need to be consistent in their understanding of it. Engagement and culture building in the organisation about open disclosure should be multidimensional and multidirectional. Identifying and establishing local champions would be a useful start.
Health services should ensure the procedure that triggers the open disclosure process is in place whenever an adverse event occurs
Healthcare professionals may fear that by being honest they will expose themselves to litigation and disciplinary action and damage to their reputation; they may feel anxious about admitting mistakes or feel incompetent to undertake an open disclosure process. They may also feel that there is a lack of managerial and institutional support if they are involved in open disclosure procedures.
Some professionals may not understand what the real purpose of open disclosure and what the real needs of the clients are; they may also be very uncertain about the do’s and don’ts and what they ought and ought not to say to patients and their families during open disclosure.
Provide emotional support and coaching
A disclosure support system has been advocated as an institution support to overcome barriers to error disclosure. The system aims to provide disclosure education, ensure disclosure coaching is available at all times and provide emotional support to the patients and family, the healthcare workers (the “second victim” in an incident), and administration. Sufficient resources should be allocated to sustain the support system. Medical staff are required to engage in disclosure activities, which are to be integrated with other patient safety and risk management activities.
Plan your response
Open disclosure is communication in a challenging setting where one might find denial, distancing, defence, guilt, blame, mistrust, high emotion, anger, confrontation, demand for compensation and a threat of a lawsuit. In the actual occurrence of an incident with the need for open disclosure, before the disclosure meeting, the care providers and relevant parties who are taking part in the disclosure should role play, practise and plan the disclosure dialogue (including crafting an apology appropriately, identifying a key spokesperson, etc), review the known current facts of the event, prepare to use plain language and consider legal presentation if appropriate.
The inevitability of error
In conclusion, despite much effort, errors in healthcare are still inevitable. The obligation to disclose harm is the physician’s responsibility to act in patients’ best interests. The disclosure of harm not only helps to respect patients’ autonomy, it also ensures that the patient can access timely and appropriate interventions for the harm suffered.
Dr Chui Tak-Yi is Hospital Chief Executive, Haven of Hope Hospital, Hong Kong
- The Hong Kong government is considering plans to introduce legislation enabling public agencies to apologise without fear of legal liability.