APHA 33rd National Congress

Open Disclosure Workshop with Case Studies

Presented by

Dr Chris Beck, Prof Rick Iedema, Dr John Wakefield, and Shane Evans

25 March 2014

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A. Overview and Framework

B. Patient Perspective

C. Case Studies

D. Key Messages

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A. Overview and Framework

Mid Staffordshire Trust Public Inquiry

• A key “theme” was a lack of effective communication (open and transparent) across the healthcare system

• A core recommendation was openness, transparency and candour throughout the system. Complaints should be able to be submitted freely, fearlessly and with openness. All Trusts should be under an obligation to tell the truth. Open disclosure is vitally important

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Open Disclosure Framework Key Changes

• Use the phrases “I am sorry” or “We are sorry”

• Avoid speculative statements

• Executive/management take a key role

• Focus on early response

• Can be triggered by a variety of mechanisms eg complaint

• Emphasis on evaluation and improvement in OD processes

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Open Disclosure Framework Fundamentals will be emphasised

• Apology or Expression of regret

• Facts about what happened

• Opportunity for Patient/Family/Carer to relate their experience

• Discussion of potential consequences arising from the adverse event

• Explanation of the steps to manage the adverse event and prevent recurrence

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Why engage in Open disclosure ?

• It’s the right thing to do

• Respect for patients and their families

• A patient and consumer right

• An expectation to meet individual professional obligations and clinical governance obligations for the organisation

• Good practice and part of care continuum

• Reduce alternative complaint paths or litigation

• Part of your assessed accreditation

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Barriers to Open disclosure

• Legal issues

• Perception generates legal claims through disclosure and admissions

• Documentation produced can be relied upon adversely to your or staff interests

• Perception apologies construed as an admission of liability

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Barriers to Open disclosure (cont.)

• Practical issues

• A difficult conversation admitting you got it wrong or harmed somebody

• Personal consequences to clinician or impact upon the organisation may affect decisions and communication

• Blame or finger pointing

• Mixed messages about what happened

• Failure to have an ongoing dialogue

• Failure to support if injury and expenses

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Why patients pursue alternative action ?

• Silence

• Perceived cover-up

• Lack of, or poor, communication

• Seek answers

• Prevent happening to somebody else

• Delays in communication or taking promised actions

• Insincerity and to get your attention

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Root cause analysis and system reviews

• Patients and families can find the process and terminology confusing

• They generally believe it is an investigation, so they can be perplexed when the outcomes are explained

• Needs to form part of the discussions about what we are doing to reduce the chance of this happening again

• Important information can be obtained to feed into your system review and quality processes ie consultation

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B. Patient Perspective

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C. Case Study 1

• 51 year old morbidly obese female

• Laparoscopic sleeve gastrectomy

• Not insured and full fee paying

• Signs consent form including ‘risk of leak at staple site which can have a large impact on your recovery’

• Surgery performed and patient deteriorates during the admission

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Case Study 1 (cont.)

• Develops peritonitis from leak

• ICU admission for 1 week at private hospital

• Due to non-insured status transferred to public hospital ICU

• In ICU for 2 months, touch and go

• Teacher and unable to return to work for 1 year

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Case Study 1 (cont.)

• First contact for the hospital is an angry call to accounts saying she will not pay the $20K bill due to “your negligence”

• Patient says that she would never have agreed to the surgery if she knew this would occur

• Further communication back and forth with accounts, patient angrier, now saying “you have prevented me from working”

• Escalated to the EDMS ME_105826223

Prior to your involvement …

• A letter has been sent “Thank you for bringing your concerns to our attention. Unfortunately there are complications that may occur despite our best efforts and provision of appropriate care. We are sorry that your care expectations were not met in this instance. We thank you for your feedback”.

• The letter has been returned by the patient and handwritten over it in black ink “HOW DARE YOU. THIS IS AN INSULT. YOU WILL PAY !”

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VMO engagement

• Refusal to participate as “I have done nothing wrong”, “I warned her”, “She is crazy and I am not talking to her again”

• What if a poor communicator ?

• Why should the hospital take charge of the OD process ?

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During the call to arrange the OD meeting

• Patient is very angry and abusive, “Why should I bother coming, are you going to pay me money ?”

• You subsequently become aware the patient has made an entry on your website “Don’t come to this hospital … they are butchers”

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Internal review

• Recognised complication

• Consent form could have more detailed explanation

• Slight delay in recognising deterioration, but not causative of the outcome

• Consider better processes and information around non-insured patients

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During the formal open disclosure ...

• How to manage where it is a recognised complication and you have done nothing wrong ? With responses during the meeting like ....

• Who is reimbursing me the $20,000 bill ?

• Who is paying me for my lost time from work ?

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During the discussion ...

• You have to get rid of the doctor so that this cannot happen to anybody else

• What are you doing about the doctor ?

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Next steps

• How to close the meeting ?

• What happens after the meeting ?

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Case Study 2

• 3 year old male

• Attends Private Emergency Centre at 9pm with 2 parents

• History of fever for 2 days and lethargic

• Presumed viral

• For admission – fluids and antibiotics

• Paediatrician notified by EC Doctor and will see in the morning

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Case Study 2 (cont)

• CEWT in place

• Admitted 10pm to the ward

• One parent leaves as other children at home

• Team nursing with RN and EN. The EN allocated primarily to the child as deemed low risk

• Both nurses prior experience calling this Paed late at night and challenged about whether it was necessary

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Case Study 2 (cont)

• Low level trigger on CEWT form at 1am

• Mother leaves

• Higher level trigger on CEWT at 3am, just meets criteria to escalate but not done

• Child found at handover at 7am unresponsive, with no documentation between 3am and 7am

• CPR commenced but unsuccessful

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Case Study 2 (cont)

• Coroner’s case and police attend

• Doctor presents to EDMS in the morning and says “Why was I not called, I would have come in, the death could have been prevented, the nurses are incompetent, I will be going to the family now to tell them this and ensure there is no cover up”

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During the initial discussion ...

• I want the nurses fired

• Have you started a disciplinary process ?

• What are you doing about that EN ?

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Media

• Prior to your OD meeting there is a headline in the newspaper “Family Devastated by Hospital Blunder Leaving Child Dead”

• A lawyer for the family is quoted as saying “This should not have happened … there is clear negligence and the family are entitled to significant compensation”

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How to frame ‘fault’

• Avoid the issue

• Say you wish to express your regret at the outcome and are sorry

• We were negligent

• We caused your child’s death

• This should not have happened

• I agree the death was preventable

• The nurse should have been more attentive

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During the formal open disclosure ...

• I was called by a nurse at the hospital who did not want to be identified and the nurse told me ‘You need to know ... that doctor never turns up when asked by the nurses ... It is never worth calling him and the hospital management knew all about this’

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Following an explanation of the system review ...

• How to manage when your assessment is that there are clear deficiencies in nursing management that may well have contributed to the death ? With responses during the meeting like ....

• So my child is dead and all you have done is updated some policies and instituted some training.

• Who is being held to account ?

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Compensation

• Your lawyer tells you if a nervous shock claim is made it is worth no more than $100K for both parents

• The family clearly have much higher expectations, you have heard mention of a figure of $600K

• You start to explain the compensation process and are interrupted with “How can my baby’s life be worth so little to you people ?”

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Impact of other processes

• Coroner

• Complaints Commission

• AHPRA

• Private licensing

• Health Department

Documentation of OD given the above ?

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D. Key Messages

“100 Patient Stories” Qualitative Study BMJ 2011

Most patients and family members felt that the health service incident disclosure rarely met their needs and expectations. They expected better preparation for incident disclosure, more shared dialogue about what went wrong, more follow-up support, input into when the time was ripe for closure, and more information about subsequent improvement in process.

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Perspective of Patient

• Followed a rigid format of provision of information, rather than a dialogue, seemed routine or machine like

• Did not accept or admit a mistake had been made or harm caused

• If accepted a mistake had been made or harm caused, did not accept financial responsibility for the consequences

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Open disclosure checklist

• Initial discussion with the patient

• Carried out promptly

• Offer to involve support person

• Acknowledge the event

• Expression of regret, Apology

• Limited disclosure of facts ie what we know and what we do not know

• Listen and answer questions

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Open disclosure checklist (cont.)

• What next?

• Further investigation and review ie what is being done to “fix the problem”

• Offer of support – practical and emotional

• Complaint process

• When next contact will occur

• If formal open disclosure meeting is next step, who will be attending and roles, confirmed in writing

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Open disclosure checklist (cont.)

• Formal open disclosure

• Have an agreed plan of what to say and how to respond, but maintain a fluid process

• Listen to the patient or family story and experience about the incident and its impact ie empathy and compassion

• Keep it factual

• No admissions of liability unless agreed in advance and insurer notified

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Open disclosure checklist (cont.)

• Involve executive and key clinician

• Decision made in advance about financial responsibility (immediate and longer term costs/expenses), with insurer to agree

• Be clear on patient/family expectations

• Documentation of the process

• Follow up including in writing, keep patient/family informed

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Full disclosure

• The true facts usually come out in the end

• Presume they will and be proactive in raising them yourself

• It becomes much worse if the patient perceives you have withheld some information or hears about it from another source

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More information

• Open Disclosure Framework

http://www.safetyandquality.gov.au/wp-content/uploads/2013/05/Australian-Open-Disclosure-Framework.pdf

• 100 Patient Stories

http://www.bmj.com/content/343/bmj.d4423

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