Around the world, concerns about the quality and safety of patient care are reaching new heights, according to Dr Margaret Chan, Director-General of the World Health Organization.
In a keynote address to the 29th International Conference of the International Society for Quality in Health Care, being held in Geneva this week, Chan said patient safety is on the agenda for next year’s World Health Assembly.
Solutions for improving patient safety are often simple and comparatively inexpensive to introduce, she said. “For example, measures such as hand hygiene and safety checklists can be rapidly introduced. They also bring rapid results. I can think of no other dimension of clinical care that responds so well to simple, common-sense interventions.”
Meanwhile, with a number of policy measures aiming to promote a more open disclosure of errors in Australian health services, researchers have been investigating some of the communication issues involved.
In the article below, Dr Kate Bower and Professor Rick Iedema from the UTS Centre for Health Communication, report on some of their research findings, and invite patients, relatives, carers and clinicians to share their experiences of healthcare errors and open disclosure.
Understanding the barriers to open disclosure
Kate Bower and Rick Iedema write:
The principles of open disclosure are simple: when an incident that may have caused harm to a patient has occurred, the healthcare provider should provide an explanation of what went wrong, apologise, and have a plan for both the patient and the hospital to prevent a similar incident from happening again.
Yet communication about incidents with patients and relatives is rarely simple.
Researchers at the Centre for Health Communication at the University of Technology Sydney in collaboration with the Australian Commission for Safety and Quality in Healthcare (ACSQH) conducted the largest qualitative interview study ever undertaken on the issue, speaking to more than one hundred patients and relatives about their experiences of incidents and open disclosure – the 100 Patient Stories study.
The study found that when open disclosure is done well, patients and families are more satisfied with the health service and generally forgiving of medical errors (unless the harm caused necessitates obtaining funds for continued care). They are also less likely to pursue a complaint or litigation against the health service.
Key factors of a successful open disclosure are an adequate explanation of what went wrong, a genuine apology and good follow-up, particularly for any proposed improvements to the system. Generally speaking, the better the communication the more satisfied patients and relatives will be with the disclosure.
However, the study also concluded that open disclosure is not happening as well or as frequently as it should.
Researchers believe that one of the reasons why speaking openly about incidents is not happening as often as it should is because patients and their families often have very different views from their clinicians about what constitutes an error or incident.
In addition, patients and families are much more likely to rate the incident as more serious (in terms of harm caused) than their clinicians. This means there is frequently a gap between when patients and families expect a disclosure and when clinicians believe it is appropriate.
Current guidelines suggest that incidents which cause harm should be disclosed, therefore the differences between patients and clinicians with regard to the definition and severity of incidents means that disclosure is not happening as frequently as patients and relatives would like.
Another reason why open disclosure does not always happen is the culture of some health services. We know that a positive culture that values honesty, openness and transparency is essential to good open disclosure practices and that strong leadership and quality training programs are important in achieving this.
Following this study, the Commission undertook a review of the national Open Disclosure Standard. The review noted the importance of patient’s perceptions of harm, a genuine apology, as well as quality leadership and training, as necessary elements of an open disclosure policy.
One of the key differences in the revised standard will be advice to include the phrase ‘I am/we are sorry’ when speaking with patients or their relatives, showing that policy makers are recognising the importance of a sincere and genuine apology in repairing trust between clinicians and patients.
Following consultation with a range of stakeholders across Australia including consumers, healthcare providers, public and private health services, and indemnity insurers, the revised Standard will be released in 2013.
Open disclosure is also a component of a new national health service accreditation scheme commencing in 2013 (see Standard 1, Criterion 1.16).
The revised Standard is certainly a step in the right direction, but more research is needed to better understand the barriers to successful open disclosure at the frontline and what can be done to eliminate them.
At the Centre for Health Communication, we are currently working on a new research project aimed at doing exactly this. The project, called Strengthening communication in healthcare incident disclosure, is focused on reducing barriers to disclosure and strengthening communication between clinicians and patients and families.
We are talking to clinicians (doctors, nurses, allied health professionals) who have been involved in an incident, along with patients and relatives who have experienced an incident in hospital or other healthcare setting.
We can learn a lot from talking to doctors and nurses who are successful at talking openly with patients and families after an incident, as we can by talking to clinicians who have not reported or disclosed an error. These conversations allow us insight into the complexity of the healthcare system in which these incidents occur.
We also still have much to learn from talking with patients and families about incidents, particularly with regard to communication. From interviews done so far, we are starting to understand the complexity of communication between patients and their healthcare providers, as more than unidirectional information giving.
Ultimately, the project is an opportunity to speak with people who have experienced incidents to learn what is needed for them to recover, move on with their lives, or deal with their grief. Almost always the answer is good honest communication.
If you have been involved in an incident as a patient, relative or carer or as a clinician in any Australian healthcare setting and would like to share your story with us, you can contact us here.