Open Disclosure Workshop: Best Practice Guidance for Healthcare Professionals

2. Section 1 Introduction

4. Introduction • Background • Housekeeping - Fire exits - Breaks/Refreshments - Toilets • Workbooks • Ground Rules • Attendees #Hello My Name is ... and personal expectations

5. Workshop Objectives 1. To provide an overview of the national open disclosure programme . 2.To build understanding as to how the principles of open disclosure link into existing HSE Quality, Patient Safety and Risk procedures/frameworks 3. To provide best practice guidance on how to implement the principles of open disclosure. 4. To provide information and training via case scenarios and role play on delivering on the principles of open disclosure.

6. Objectives (continued) 5. To demonstrate the benefits for patients/service users, their families and staff. 6. To practice the key skills required when engaging in open disclosure discussions 7. To explore the key components involved in the open disclosure process 8. To provide awareness on the resources available.

7. Workshop Programme • An overview of open disclosure. • Open disclosure – the drivers • The patient/service user perspective • The Clinician’s perspective • The Disclosure Process • Summary and close

8. DVD:“And you weren’t even going to tell me”

9. Section 2 An Overview of Open Disclosure

10. The reality of poor communication “Our family did not get open disclosure.  We felt excluded and badly treated and none of the undertakings to give us answers were honoured.  We pursued the legal route for three years but that was fraught with lack of conclusions and we feared for our financial security”.

11. Definition of Open Disclosure? Anopen, consistent approach to communicating with patients when things go wrong in healthcare. This includesexpressingregretfor what has happened, keeping the patientinformed, providing feedback on investigations and the steps taken toprevent a recurrenceof the adverse event.” (Australian Commission on Safety and Quality in Health Care)

12. What is Open Disclosure/Open Communication? Open disclosure describes the way staff communicate with patients who have experienced harm during health care – this harm may or may not be as a result of error/failure Open disclosure is a discussion and an exchange of information that may take place in one conversation or over one or more meetings CARE COMPASSION TRUST

13. CARE COMPASSION TRUST LEARNING KINDNESS EMPATHY

14. What is an Adverse Event? “An incident which resulted in harm, that may or may not be the result of error” HSE Incident Management Framework - Guidance 2018

15. Adverse events: How common are they? • Studies conducted in North America, Britain, Europe, Australia and New Zealand have shown that the percentage of adverse events occurring in hospitals is between 3 and 17% with an average of 10%. • Most medical errors are related to system problems, not individual negligence or misconduct, and are preventable. • Fifty per cent, or one in every two, adverse events can be prevented.

16. The Irish National Adverse Event Study 2009 – published 2016 • 1574 patients (53% women) – 8 hospitals • The prevalence of adverse events in admissions was 12.2% • Over 70% of events were considered preventable. • Two-thirds were rated as having a mild-to-moderate impact on the patient, 9.9% causing permanent impairment and 6.7% contributing to death.

17. Principles of Open Disclosure

18. Why are these principles being advocated? • They form the basis of a professional and ethical response • A “Blame and Shame” culture can interfere with finding the contributory factors and root cause of an adverse outcome • To promote a Just culture • International evidence demonstrates that effective open disclosure does improve the patient experience (MPS Mastering Adverse Outcomes Workshop)

19. Quote from Atul Gawande (Surgeon) “We look for medicine to be an orderly field of knowledge and procedure but it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals and at the same time lives on the line.” (Complications: A surgeons notes on an imperfect science 2003)

20. Section 3 Open Disclosure The Drivers

21. Recommendations by the Patient Safety Commission 2008 • National Standards to be developed and implemented • Legislation to provide legal protection • Open communication training for all healthcare professionals • Support and counselling programmes • Research in to the impact on patients and families.

22. Our natural instinct “Open disclosure represents the best of Irish healthcare. I think our instinct is to be open with patients and open disclosure guides staff to do what they know is right even in difficult circumstances when an error has occurred” Dr Philip Crowley: National Director of Quality Improvement HSE QID January 2018

23. Open Disclosure: The Drivers • “Open disclosure is the professional, ethical and human response to patients involved in/affected by adverse events/adverse outcomes in healthcare “ • It is what patients want and expect • Learning from past experiences

24. Open Disclosure: The Drivers • HSE Policy • Professional and Regulatory • NMBI - code • Medical Council - code • HIQA - standards • CORU - code • Mental Health Commission • Pre Hospital Emergency Care Council • Pharmaceutical Society of Ireland (PSI) - code

25. Open Disclosure: The Drivers • The Department of Health: Government Policy • Indemnifying Bodies: SCA/MPS/MDU/MEDISEC • Royal Colleges: RCSI, RCPI, ICO, ICGP, Faculty of Radiologists • WHO • Media

26. HSE “A Patient can expect open and appropriate communication throughout your care especially when plans change or if something goes wrong.” (National Healthcare Charter: You and Your Health Service, 2010 - Revised 2012.) “Open and honest communication (Open Disclosure) is initiated as soon as practicable after the incident has been identified. The planned review process has been described and communicated to all persons affected”. (HSE Incident Management Framework 2018) “

27. Department of Health “Open Disclosure can be viewed as an integral element of patient safety incident management and it is government policy that a system of open disclosure is in place and supported across the health system” (2018) January 2018

28. State Claims Agency “At the heart of open disclosure lies the concept of open, honest and timely communication. Patients and relatives must receive a meaningful explanation following an adverse event”. (Ciarán Breen, Director of the SCA 2015)

29. Medical Protection Society

30. MEDISEC "At Medisec, we welcome and support the principles of Open Disclosure, and encourage our members to engage with patients in an open, honest and transparent manner when things go wrong. We believe that timely and clear communication with a patient about an adverse event benefits all parties. Patients are facilitated by understanding what occurred and receiving an apology, if appropriate. Open disclosure also represents a vital learning opportunity for the doctor concerned, leading to safer and more robust practice going forward." ( 2018)

31. Medical Council “Patients and their families, where appropriate, are entitled to honest, open and prompt communication with them about adverse events that may have caused them harm.” Guide to The Professional Conduct and Ethics for Registered Medical Practitioners 2016)

32. The Nursing and Midwifery Board of Ireland “Safe quality practice is promoted by nurses and midwives actively participating in incident reporting, adverse event reviews and open disclosure” (Code of Professional Conduct and Ethics for Registered Nurses Midwives December 2014)

33. HIQA National Standards for Safer Better Healthcare 2012 Standard: 3.5: “Service providers fully and openly inform and support service users as soon as possible after an adverse event affecting them has occurred, or becomes known and continue to provide information and support as needed.”

34. CORU: “If a service user suffers harm, speak openly and honestly to them as soon as possible about what happened, their condition and their ongoing care plan” (The Codes for Dietitians 2014, Speech and Language Therapists 2014 and Occupational Therapists 2014)

35. Pre Hospital Emergency Care Council (PHECC) PHECC wholly endorses the HSE principles of open disclosure. PHECC is committed to the process of open disclosure as included in the Education and Training Standards since 2007. We believe that the open disclosure process encourages the reporting of adverse events which leads to a manifestation of the patients’ autonomy and ultimately leads to opportunities for systems improvement and delivery of the highest standards of care delivery. In addition PHECC is committed to information being available following the incident review as being an essential component of an open disclosure policy. (statement from PHECC April 2015)

36. Mental Health Commission “The Mental Health Commission fully endorses Open Disclosure and communicating authentically, compassionately and respectfully with service users, families and staff involved in patient safety incidents. The Commission and HIQA jointly developed National Standards for the Conduct of Reviews of Patient Safety Incidents (2017). The National Standards cover reviews of patient safety incidents which fit into a service’s overall incident management process; this includes reporting, open disclosure and notification to external bodies.” (2018)

37. Legislation to support Open Disclosure Protective legislative provisions in Part 4 of the the Civil Liability Amendment Act 2017 1. Open disclosure: (a) shall not constitute an express or implied admission of fault or liability (b) shall not, notwithstanding any other enactment or rule of law, be admissible as evidence of fault or liability and (c) shall not invalidate insurance or otherwise affect the cover provided by such policy

38. Provisions of legislation 2. Information provided, and an apology where it is made, shall not • constitute an express or implied admission, by a health practitioner, of fault, professional misconduct, poor professional performance, unfitness to practise • be admissible as evidence of fault, professional misconduct, poor professional performance, unfitness to practise, in proceedings to determine a complaint, application or allegation

39. Legal Services Regulations Act 2015 This act contains the following protections for an apology in clinical negligence claims:   (1) An apology made in connection with an allegation of clinical negligence— (a) shall not constitute an express or implied admission of fault or liability, and (b) shall not, despite any provision to the contrary in any contract of insurance and despite any other enactment, invalidate or otherwise affect any insurance coverage that is, or but for the apology would be, available in respect of the matter alleged. 2) Despite any other enactment, evidence of an apology referred to in subsection (1) is not admissible as evidence of fault or liability of any person in any proceedings in a clinical negligence action.”.

40. Section 4 The Patient/Service User’s Perspective

41. Exercise 1 • Watch the DVD – (approximately 4-5 minutes) • Focus on the patient – Mrs Ling • As you are watching it think about what the patient’s needs are. • What does the patient require/expect from her GP during the consultation? • What does the patient expect following the consultation in relation to her ongoing care?

42. The Open Disclosure Process using the MPS A.S.S.I.S.T Model of Communication: A – Acknowledge – problem and impact S – Sorry – express regret S – Story – hear patient’s story and summarise back to them I – Inquire – seek questions to be answered, provide answers, give information, S – Solution – seek patient’s ideas on the way forward - agree a plan T – Travel – avoid abandonment – continued care – increased contact.

43. Do patients want to know? At least 98% want to be told the truthHobgood et al 2005, Mazor et al 2004

44. What do patients / service users want? • A timely and comprehensive explanation of what happened and why • Someone to acknowledge and apologise if things went wrong • A reassurance that steps have been taken to ensure the event will not happen again

45. Benefits for Patients/Service Users

46. Why do patients sue? • To get answers • The need for acknowledgement and apology • Patients felt rushed • Felt less time spent/ignored • The attitude of staff • Patients wanted their perception of the event validated

47. Why do patients sue? • The experience of “second harm” • To seek financial compensation • To enforce accountability • To correct deficient standards of care • To try to prevent a recurrence of the event

48. Quote from a Patient Advocate Open disclosure is not about blame. It is not about accepting the blame. It is not about apportioning blame. It is about integrity and being truly professional And the reason: You hold our lives in your hands and we, as patients, want to hold you in high regard.”

49. Exercise 2: • Watch the DVD – same scenario as before (Exercise 1) • GP consultation now using the A.S.S.I.S.T model • Record the terminology used by the Dr which applied to the various components of the A.S.S.I.S.T model.

50. Exercise 3: • Read the case scenario provided. • In your allocated groups of three you will take turns in playing the role of (a) Doctor, (b) Patient and (c) Observer • You will be allocated 5 minutes for each role play. • Do not be concerned if you have not completed the consultation. • At the end of 5 minutes provide feedback on the consultation using the A.S.S.I.S.T Model. • You will then swap roles. • There will be a general feedback session at the end of the session when all three persons have experienced the role of the Doctor, Patient and Observer.