Service Making a Silk Purse out of a Pigs Ear Susan Brandis Associate Professor Director Clinical Governance Gold Coast Australia Fast growing (4.6% pa) with a projected population of 560,318 by 2016 Over 7,000 voluntarily reported Clinical Incidents in 2011 12 Of these 39 severity 1 death or permanent harm Gold Coast Hospital and Health Service Gold Coast Australia Things don t always go to plan Why Open Disclosure? Our greatest glory is not in never falling, but in rising every time we fall. Confusius Forget about likes and dislikes. They are of no consequence. Just do what must be done. This may not be happiness but it is greatness. George Bernard Shaw Whether or not knowledge is global it has to be implemented locally Ulysses Panisset WHO What is it? Open Disclosure (OD) is the open discussion of incidents that have resulted in harm to a patient whilst receiving health care and consists of: An expression of regret, A factual explanation of what happened, The potential consequences, and The steps taken to prevent reoccurrence. ACSQH National Open Disclosure Standard 2003 1
Proven Benefits Provides for factual, honest & caring response to patients, their carers and families, who experience, or are affected by, serious adverse events. Assist those affected with the grief that follows from an adverse event. Reduces litigious intent. Organisational improvement closing the loop COPIC 2000, Taylor 2005, Tanner 2002, Hickson, 1994, Studdert et al 2006 Policy Relevance National Open Disclosure Standard (2003) National Safety and Quality Health Standard Australian Council Healthcare Standards Clinical Incident Management Implementation Standards (QH) Clinical Practice Improvement Payment Australian National Standard for Open Disclosure 2003 Queensland process Training of FOD consultants A 6 step process Incentive payments ($1,000AU) Differentiation between clinician disclosure & formal open disclosure mandatory to offer FOD within a few days of every serious adverse event 6 steps of Disclosure Clinician Disclosure 1. Initial meeting prior to patient/family meeting 2. Planning between OD Consultant and clinician 3. Meeting with patient/family, ODC & clinician 4. Debrief of ODC & clinician post patient meeting 5. Summary Report back to FOD Team - commitments given and proposed follow up 6. Patient/family support & follow-up of agreed outcomes Clinician Disclosure is the informal process where the treating clinician informs the patient of what has occurred, and expresses their regret for the harm caused or adverse outcome. This may be the first time the patient is made aware of the harm. offered as soon as practicable once staff are aware of an adverse event offered for all events where harm results 2
Patient Expectations Hearing sorry said sincerely Acknowledgement of their distress Telling the staff how they are feeling Being informed of the facts Knowing there is a response planned Having a contact person for further support Clinician Expectations Clinicians as the second victim To explain ourselves and give reasons as to how/what went wrong To give sufficient details/explanation To avoid litigation Re establish trust and confidence Clinicians involved in an adverse event are suffering their own grief reaction and are often unable to meet patient needs (Shapiro 2003, Clancy 2012) And the third victim Risk of harm to the next patient if the clinician is not well supported The Gold Coast Experience A just culture ensures emotional well being of all parties involved 3
2003 National Standard Reported Incidents 2011-12 2008 Qld Health Program Trained 19 OD Consultants 2010 GC 3 of 26 potential cases 2011 Refresher course relaunch 2012 39 289 7009 Severity Assessment Code SAC1- Death or Permanent Harm SAC2 - Harm SAC3 - Other incidents, near misses Key Learning's The process became a challenge Volume of incidents requiring organised disclosure Availability of both consumers & key staff Assumption that this is what the consumer wants Administrative burden, terminology Practicalities security, tissues, time & place Which slice of the cheese? 39 incidents SAC 1 21 Death 30 Medicine Surgery 9 39 Permanent Harm 4 reproductive, 3 missed diag. 1 baby, 1 surg 9 Acceptance of Offer Deaths Other Deaths Permanent Harm Accepted 2 0 3 Declined 5 7 5 Delayed 14 2 1 4
Response Attitude Question Cohort Inevitable Acceptance going to die Unfortunate accident Adaptation moving on How/where did they die? End of a troubled / good life What does the future hold? Destruction Anger, blame I want answers, Who is responsible? Enquiry Understanding What can we learn? End of Life Old old Children Fertility Diagnostic Procedural Patient Families Parents & children People Centred Approach Ask them before we start the process Make it less beaurocratic the steps became a burden Utilise different strategies phone call, letters, formal meetings Timing a delay is not always a bad thing Don t underestimate our own people Where to? Developing a triage tool and algorithm to tailor our response Enhancing a people focused approach the person, their people, our people Using practice to inform policy versus policy driving practice 5