Journal of Health Services Research & Policy >
Volume 13, Number 4 >
Pp. 227-232
Original research |
Faculty of Nursing, Midwifery and Health, University of Technology, Sydney;
1 Faculty of Humanities and Social Sciences, University of Technology, Sydney;
2 Faculty of Medicine, Dentistry and Health Sciences, School of Nursing and Social Work, University of Melbourne, Melbourne;
3 School of Nursing and Midwifery, University of Queensland, and Blue Care Research and Practice Development Centre, Australia
Correspondence to: Roslyn.Sorensen{at}uts.edu.au
Objectives: To understand the views of doctors, nurses, allied health professionals and health managers of open disclosure of medical errors.
Methods: Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia.
Results: Health professionals are positive about open disclosure and are applying the model to patient–clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals.
Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.
 | Introduction |
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Open disclosure is defined as providing an open, consistent approach to communicating with patients following an adverse event. It includes expressing regret for what has happened and keeping the patient informed by providing feedback on investigations, prevention and systems improvement.9 Ideally, providers should ‘communicate more effectively with patients,... learn from mistakes (and) respond to the concerns of patients and families...’.13 While these expectations appear quite straightforward, in practice clinicians and patients can have contradictory needs and getting agreement may require negotiation.14 For example, patients may expect fuller details of the error than clinicians are prepared to provide. Implementing open disclosure means managers must acknowledge the factors that can inhibit disclosure and work to overcome them.15
Managers may be reticent about disclosing error if it increases patient litigation. Although researchers disagree on this point,16,17 recent empirical work suggests that, at best, open disclosure will bring financial benefit by reducing litigation, and at worst it will have a neutral effect.18,19 Notwithstanding this climate of uncertainty, open disclosure is being seen less as a discretionary activity and more as expected good practice.20 Managers are obliged to actively develop strategies not only to implement policy but also to evaluate the implications.
Uncertainty about the origin of error and differences about strategies to ameliorate its cause complicate the matter. Some commentators believe that open disclosure itself will ‘fill the cracks’ through which errors can fall17 while others see a more ingrained pattern of error built into day-to-day work.21,22 The persistent range of errors reported support the latter view: clinical errors are common, well-known and serious but often ignored.23
Responding to patients' and clinicians' needs, and reducing the risk of error calls for clinical and non-clinical managers to engage in the negotiations and remedial actions involved in open disclosure. This inevitably brings the relationship between error and working conditions into consideration.24 It moves actions beyond concern for clinician competence to systemic issues such as workload, supervision, communication and rapid organizational change. The problems inherent in the existing structures and processes are often long-term and externally influenced.23,24
Our objective was to understand the views on open disclosure held by doctors, nurses, allied health professionals and health service managers, and understand the factors that affect implementation of such a policy.
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We transcribed the interviews from audio files, supplemented by interviewers' summary reports, and three team members independently coded the transcripts. The codings were then grouped, tabulated and consolidated for verification, comparison and refinement by these three team members who analysed the data using a grounded theory approach.26
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The coherence of the open disclosure model as a full cycle of related actions underpins the rationale for its use:
So if there's a complaint, um the... there's going to be that... that full cycle with you know, meetings, feedback to family, then the investigation,... closing that communication loop, and... and hopefully resolving a complaint. (Patient Safety Officer)The next excerpt demonstrates the possibilities open disclosure provides for re-orienting patient–clinician communication from a provider to a patient perspective, encouraging patients to focus the inquiry on their own interests. By taking the lead, patients identify issues that are important to them, which in turn encourages providers to be more forthcoming about non-technical matters that subtly challenge clinicians' authority in the encounter:
It is that difference that when we are saying that ‘we are doing this’ (i.e. open disclosure), we've been admitting to our mistakes for a long time, but we haven't been doing it in a way that is helpful to the patient. (Anaesthetist)These patient-focused discussions begin to engage clinicians' interest in patients' perceptions of outcomes. This engagement is a central consideration as it potentially triggers reflexivity in the clinicians involved in the event about their own clinical competencies and their social capacities in relation to patient concerns:
One of the factors that I think we missed until we really started... evaluating and looking at the issue of clinician engagement was the fact that if you go around the other way as well, i.e. the patient, then you might actually drive clinician engagement by establishing the patient perspective... (Clinical Governance Director)
The flexible nature of disclosure appears to entice clinicians to experiment with its component parts and to respond to the practice changes that are implied. The model's flexibility enables new processes to emerge which give clinicians scope to adapt it to their own conditions. This may result in a better fit between policy objectives and diverse resources:
Firstly, we looked at the Australian Standard, we worked with [named person], the project officer of [named state], and started to think about how we could contextualize the processes within our own environment. We don't follow the text book with open disclosure. (Nursing Director)
Development of supportive service systems
Miscommunication and duplication of effort are not uncommon when several people are involved in clinician–patient communication.27 Miscommunication can lessen as the model becomes embedded across the organization and its component parts become integrated:
... so, that is where I think we have gained by making it hospital-wide because it's not a project any longer. It's become our practice. (Quality Coordinator)By integrating, making transparent and systematizing the handling of complaints, error investigations, and clinical and administrative teamwork in managing the implications of errors, providers are free to focus on immediate patient needs and to coordinate activities. Centralizing advice about the model and its procedures helped integration and gave a reference point for those new to open disclosure. This connected to future encounters in the form of organizational learning:
It's either the CLO [client liaison officer] or the PSO [patient safety officer] that needs to be involved in every meeting, because... we're the... we're the thread to keep it all together. (Patient Safety Officer)New actions developed through open disclosure were transplanted to patient–clinician communication encounters generally, thereby encouraging more consistent and standardized practices. As a result, participants' views were coalescing around disclosure principles and processes, with identifiable and replicable components:
Open disclosure is really the formalization of a process of communication between clinicians and patients which should really underpin all communication regardless of whether it relates to specific adverse incidents, or anything. (Medical Director)Individual and system competencies can reinforce and consolidate open disclosure, enhance professional motivation to engage with disclosure and its implications, and guide skills development. Where clinicians know of and accept not only their own responsibilities, but also the roles of others and the outcomes expected, patients' and families' needs can be more easily met (Table 1).
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Not all errors were dealt with openly. Even though open disclosure has gained traction in the health services studied, some issues remain hidden. Issues that continue to be dealt with secretly do not elicit ‘emotional information’ important to the individuals involved. Knowledge critical to understanding the environment of clinical work and improving workforce and systems competencies does not reach the public arena. Secret processes removed from the locus of the event deal with hard facts managed off-site by trusted individuals to contain repercussions:
... It [the error] goes immediately, within 24 hours, to the Department of Health as a reportable incident. And that information is always kept confidential, hidden away in sealed envelopes. It's a highly sensitive sort of information. And it's not emotional information... and the people that are on those [root cause analysis] teams are very carefully selected. [Patient representative]
The imperative for anonymity inherent in incident reporting sits uneasily with the moral imperative of disclosure.
Open disclosure is not yet commonly practised such that errors fail to trigger comprehensive system overhaul. A further impediment is the propensity of some senior medical staff to waver on their commitment:
... when [the doctors] were asked by the accreditors, they pop up and say, ‘Yes, we practice Open Disclosure’, you know, it wouldn't go any further than the toe nail. [Laughs] (Patient representative)
Saying the right words but falsely portraying knowledge and commitment to open disclosure continues to privilege practitioners' concerns over those of patients. This wavering shifts the burden of disclosure onto more junior staff who may not be central to the event. Hence, the catharsis that patients and clinicians can experience from revealing and apologising for an error is foregone. Patients regard as important the person responsible for the error explaining and apologising for it. Proxies do not offer the direct accountability for and explanation of actions that open disclosure seeks to elicit. The non-commitment of senior staff may undesirably influence junior staff if open disclosure is seen as a token activity.
Determining a clear cause for error is not easy; cause is often indirect and responsibility for it dispersed. This dispels assumptions that errors are single isolated incidents. Addressing the causes of errors and knowing what errors to apologise for and by whom is less straightforward than policy implies:
We had a long chat with the patient and found out that things were even worse than we thought... But this, this incorrect disclosure, this hasty disclosure, had actually caused harm. (Medical Director)
The level of resources for health services contributes to the problem. The limited presence of senior clinicians can leave junior medical and nursing staff without support or supervision and exposed to the risk of error. Not only are junior staff left to cope with often inadequate levels of supervision, they also lack skills in knowing how to respond to the patient's needs and to their own:
It would be the senior clinician involved; the junior staff member, no – we wouldn't involve them at all. (Patient Safety Officer)
Protecting junior staff from harm is understandable but limiting opportunities to learn from mistakes may be detrimental to clinicians' long-term emotional adjustment. Denying staff relief and redemption that can follow from admitting and apologising for error that our respondents describe as cathartic, suggests such (over)protection itself may be harmful, leaving junior staff with emotional burdens that may remain unresolved throughout their careers.
Exacerbating these impediments are the multiple agencies that now exist to report to and investigate error, as risk management concerns escalate. Duplication can occur when multiple agencies produce similar recommendations and confusion when they conflict:
... you've got so many flipping agencies that somebody can just ring up and, you know, make a complaint whether it is baseless or not and it gets investigated. (Nursing Director)
As with enabling factors, the three types of impediments that inhibit clinicians and managers from implementing and institutionalizing open disclosure procedures are both individual and systems-related. They are affected by the environment within which practitioners work (Table 2).
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| Discussion |
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TopIntroductionMethodsResultsDiscussionConclusionAcknowledgementsReferences |
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Participants' views of their experience of open disclosure in health services in Australia brought forth concepts converging around properties of meaning that related, firstly, to attitudes and actions that constructively led to open disclosure and secondly to attitudes and actions that constrained these practices. The current literature emphasizes policy development and clinician–patient communication as the main dimensions of activity. Our data reveal a third dimension of organizing competencies. This dimension includes the individual competencies of the health workforce to engage with the model of open disclosure and the systems competencies of health services to connect policy intentions with their enactment in practice. Health services also need competencies to remove impediments that, in our findings, include hiding errors, wavering commitment and exacerbating the problem. This analysis enables us to conceptualize these competencies as ‘organizing capabilities’ that enable open disclosure processes to unfold. We describe the environment within which implementing open disclosure occurs as constituted by three dimensions (Figure 1), namely the policy, organizing and practice dimensions.
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Enabling capacities move implementation away from relying solely on individual champions, to establishing an organizational capability geared to policy objectives. This organizing capability becomes the prerequisite for policy implementation. In the case of open disclosure, workforce competencies connect to disclosure itself and enable the model to be grounded in local practice. This occurs as providers engage with the model, reorient care and communication to take patients' beliefs, attitudes and behaviours into account, become skilled in clinician–patient interaction and develop standards of practice. As practitioners engage with the model, they pool their experiences, identify common elements and begin to define and refine practice and standards.
Workforce competencies deepen and spread via systems' competencies that enable communicating, planning, resourcing and executing remedial action to occur, as well as recording information and disseminating it to others. Systems competencies are complemented by support personnel who advise, guide and monitor progress as health professionals get to know of their changing responsibilities and accountabilities. Through feedback systems managers and clinicians can compare approaches, know what works and standardize processes.
An enabling capacity is also associated with removing impediments, imperative in health systems moving from provider to patient-focused models of care. In this regard, as incident reporting and investigating systems bed down, their acceptance, and indeed managers' and clinician's reliance on them, will act to develop and reinforce a service-wide culture of acknowledging problems and learning what to do about them. This emerging culture closely aligns with systems' competencies as managers and clinicians negotiate local arrangements about managing error and its aftermath. These arrangements will take account of the emotional burden of disclosure on clinicians that receives scant attention in health28 by modelling and guiding junior trainee involvement and supporting staff and patients/families involved in the difficult process of revealing and apologising for error.
Responsibility and accountability
Describing these enabling capacities is only one part of an organizing prerequisite. Advocating a systems approach to reducing error will not work if everyone or no-one is responsible. Our data suggest that leadership and teamwork are fundamental in devising standards and systems that emerge as back-end actions to the disclosure event. They reinforce the role of those directly managing clinical work in committing clinical units to re-orient their expectations and practices, in particular those of senior medical clinicians. The pivotal role of clinical managers obligates health service organizations to negotiate, skill and empower them to interpret policy, connect people and systems, enact practice and evaluate it. It is clinical managers who span the organizational boundaries within and between horizontal and vertical teams. Consequently they are most likely to shape the rules, norms and values that accompany close-knit coordinated work that clinicians share. Innovations, like open disclosure, can be put at risk if this organizing capability is ignored or is assumed to exist.
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| Acknowledgements |
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| Footnotes |
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