Reclaiming your patient’s trust after an unexpected outcome

1. Reclaiming your patient’s trust after an unexpected outcome The Medical City Good Hospital Practice Training Series 2009

2. OUTLINE of presentation • Eight steps in responding to unexpected outcomes • The importance of disclosure • Disclosure policies – who, when, what, how • What open disclosure means to our patients and staff

3. INTRODUCTION • Accidents occur in healthcare settings everyday despite efforts to reduce medical errors. • A good hospital establishes a culture of safety that • Acknowledges and reports medical errors and near misses. • Promotes teamwork among all staff members. • Ensures effective communication between staff and patients that creates a more patient-centered environment. • Enhances consistency and standardization in the delivery of health care. * *National Quality Safety Forum website. www.nashp.org/Files/GNL50.pdf. and Joint Commission on Accreditation of Healthcare Organization of safety Facts and 2007 Patient Safety Goals.

4. We must inform our patients ahead of time! • Upon admission, we must inform our patients that, despite our best efforts, no treatment is without risk or carries a 100% guarantee of success. • This fact, though hard to accept especially for very ill or anxious patients, means that patients must take an active role in their care. • Part of the information that patients must receive upon admission is how they will be informed of unexpected outcomes.

5. Why disclose unexpected outcomes to patients? • Because it is the right thing to do • Because patients / families have the right to actively participate in their care • Because patients can make rational decisions about their care only if they know the facts about their current condition • Because timely disclosure preserves the doctor/patient relationship and rebuilds trust

6. Disclosure is the 5th of 8 steps in our response EIGHT STEPS TO RESPOND TO UNEXPECTED OUTCOMES 1. Care for the patient 2. Preserve the evidence 3. Document in the medical record 4. Report the event 5. Disclose factual information 6. Analyze the event to prevent recurrence and/or improve outcome 7. Follow Through with subsequent disclosure discussion(s) 8. Heal the Health Care Team

7. The AP plays a central role in all of the steps The Attending Physician must ENSURE COMPLIANCE to policies in • Caring for the patient • Preserving the evidence • Documenting facts in the medical record • Reporting the event • Disclosing factual information • Analyzing the event to prevent recurrence and/or improve outcome • Following through with subsequent disclosure discussion(s) • Healing the Health Care Team

8. TAKING CARE OF THE PATIENT AFTER AN ADVERSE EVENT • Health care team must address current health care needs • AP must obtain necessary referrals • AP must confirm who has primary responsibility for care • AP must tell patient / family of any changes in the health care team

9. PRESERVING THE EVIDENCE Residents and nurses must • Sequester machinery (pumps, anesthesia machines) and preserve settings • Sequester equipment (syringes, IV tubing, medication vials) • Activate or acquire back-up equipment

10. DOCUMENTING IN THE MEDICAL RECORD What to Include: • “Known Facts” about adverse event • Care given in response • Treatment and follow-up plans What Not to Include: • Subjective feelings or beliefs • Avoid speculation or blame • References to Incident Report or Sentinel Event Analysis • “Confidential” information

11. REPORTING ADVERSE EVENTS • Call Safety hotline Local 8777 • Or inform Medical or Nursing Services Group heads, Unit Head AND Department Chair • Or submit a Sentinel Event Report to Medical Quality Improvement Office (MQIO) • Do Not Place in Medical Record or Discuss in Medical Record • Do Not Photocopy

12. 6. ANALYZE for Root Causes to Prevent Recurrence and/or Improve Outcome • Patient Safety Goal: Make it hard for Unanticipated Outcome to occur, easy to detect, easy to respond and report • Identify all causes of event or “Near Miss” • Develop and implement Corrective Action Plan (CAP) or refer to individual/committee responsible for CAP • Keep RCA and peer review documents and discussions “confidential” • Do not include or refer to to RCA or peer review findings in the Medical Record • Do not photocopy

13. 7. FOLLOW THROUGH: Subsequent Disclosure Discussion The AP, supported by the Medical Services group and Risk Management Office, is responsible for subsequent disclosure discussion. • Goal: Meet ongoing Health Care Needs and continue to address patient’s/family’s questions, concerns • Keep Promises: Call Back as promised or as needed • Keep Promises: Hold subsequent Disclosure Discussion(s) as promised or as needed, preferably within 3-4 weeks from time of complaint • Determine the “Who, When, and Where” of the Disclosure Discussion based on current patient needs and latest results of Event Analysis • Begin subsequent Disclosure Discussion(s) by informing patient/family how their questions, concerns are being addressed • Tell patient that there are administrative policies and mechanisms to handle these situations

14. 8. HEAL the Health Care Team Staff members will be trained and supported in dealing with the consequences of disclosure. Advice to staff members • Acknowledge Effect on Health Care Team Members • Unanticipated Outcomes are disturbing to all involved • Recognize needs to discuss feelings about outcome with your family, friends, and colleagues • Identify resources to help in healing • Allow time for resolution of feelings • Distinguish between discussion of your feelings and facts of care

15. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY When to disclose? The need for disclosure must be considered whenever any one of these instances occur: • When a patient experiences an unexpected outcome of care • When a patient experiences significant complications arising from a confirmed mistake • When disclosure of such information is important to a patient’s well-being or relevant to future treatment

16. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY Who will inform Patient? • Whenever any 1 of the 3 conditions apply, the Attending Physician must initiate the disclosure protocol and inform the MSG leadership of disclosure plans • The Attending Physician is mainly responsible for disclosing information to patient/family. If AP is not immediately available, staff members on duty must exert all efforts to personally inform him/her of the adverse event. • If no physician-patient relationship exists at the time of the adverse event, the hospital Risk Manager can designate the person/s who will communicate with patient / family.

17. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY Who will inform Patient? Aside from the AP, the initial disclosure meeting may include the ff: • Health care provider(s) involved in the adverse event • Provider(s) with responsibility for ongoing care • Person(s) with ability to answer questions The Risk Management Office and Customer Service Department may assist persons involved in Disclosure Discussion in preparing, coordinating or conducting discussion, depending upon: • Communication skills • Rapport with patient and family • Language barriers

18. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY Who will inform Patient? Persons involved in Disclosure Discussion may need assistance in preparing, coordinating or conducting discussion, depending upon: • Communication skills • Rapport with patient and family • Language barriers The MSG leadership may recommend to the AP the persons who will assist the AP in the Disclosure Discussion.

19. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY What should be disclosed? Disclose only factual information. The extent of factual information to be disclosed should be determined by how much is needed for a patient / family to make reasoned decisions about their care at the time of disclosure. As soon as an adverse event occurs and disclosure is deemed necessary, the AP must conduct an educational / psychosocial needs assessment to determine the content, timing and manner of disclosure.

20. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY What are factual information? • Objective Information • Documented in Medical Record • Learned through the Event Analysis unless “Confidential” • Outcome and prognosis The AP and rest of discussion disclosure team must clarify beforehand what is “Confidential” and who will discuss what with the patient/family.

21. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY How to disclose Unanticipated Outcomes? • Express empathy • Convey compassion for patient’s and family’s pain and suffering • “I’m sorry that you…” or “I am sorry that this happened…” • Focus on patient’s and family’s needs • Avoid “I am sorry that I…” • Extend sympathy to family of deceased patient • May express verbally or in writing • May send flowers • May attend funeral

22. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY What NOT to disclose • What not to communicate • Subjective information • Conjectures or beliefs • “Confidential” information, such as • Results of protected Peer Review, Quality Improvement, or Risk Management Committees deliberations • Information provided in confidence by a third party • Confidential information about a health care organization or its operations • Health or employment information about a provider or employee (201 files)

23. MAKING AN INITIAL DISCLOSURE TO PATIENT / FAMILY What NOT to disclose • Speculation and blame • Cause(s) of unanticipated outcome may not always be preventable • May be result of disease process or risky life-saving treatment, or not preventable e.g. some falls) • Unanticipated outcome is not always due to negligence • Error, if one occurred, may not be cause of unanticipated outcome • Results of administrative actions • Findings of investigations • Sanctions applied to staff • Tell patient this is confidential information

24. What staff must do when communicating to patients • Contain own emotional response • Focus on patient’s needs • Convey receptive attitude (open posture: arms uncrossed, concerned expression, eye contact) • Avoid defensive or accusatory reaction if care is questioned • Acknowledge that an adverse event has occurred • Acknowledge that the patient is unhappy with the outcome • Express regret for what has occurred

25. What staff must do when communicating to patients • Plan for follow-up care and more discussions and communicate the plan. If cause of unanticipated outcome or prognosis is not yet known, assure patient/family that additional facts will be shared when available. • Give estimate of how long analysis process may take if asked.Patient expectations may not be realistic. If expectations not met, can lead to breakdown of trust, fear of abandonment or cover-up, patient dissatisfaction, lawsuit. Make appointment for phone call and/or visit to update patient. “I will call you in two weeks (for example) to give you an update.” • Encourage patient/family to call if they have questions or have not heard back from provider. • Give name of contact person in hospital.

26. What staff must do when communicating to patients • Respond to patients complaints • Assure patients that TMC staff are dedicated to quality care and take patient’s complaints seriously • Refer complaint to Customer Service Department • Explain how to lodge complaint • Do not offer opinion on need for Lawsuit or Worth of injury • Verify patient’s/family’s understanding of outcome and prognosis “This is upsetting news. I want to make sure that I have clearly communicated what we know so far. What is your understanding of what happened? About your current condition?”

27. Critical elements to support open disclosure • Honest and ongoing communication • There is an exemption from disciplinary action for those professionals reporting adverse events or medical errors, except where there is a criminal offence • Legal privilege is provided for reports and information identifying adverse events • Quality improvement processes

28. A system that supports open disclosure must result in • Lesser likelihood of litigation • Feeling relief from guilt • Promoting trust • Strengthening doctor-patient relationships • Provide an environment where patients and their support person receive the information they need to understand what happened • Professionals learn from errors • Professionals can be given support

29. A system that supports open disclosure must result in • Creating an environment where patients, health care professionals and managers all feel supported when things go wrong • Building investigative processes to identify why adverse events occur • Bringing about any necessary changes in systems of clinical care, based on the lessons learned

30. For hospital staff, open disclosure must • Be planned and/or closely supported by staff who have received open disclosure training or have experience in carrying out open disclosure • Be managed and supported by the Risk Management Office, Customer Service Department and Safety Office • Involve senior clinical staff • Be conducted by staff who have excellent communication and listening skills

31. For hospital staff, open disclosure must • Be conducted in circumstances where clinicians involved in the adverse event have already established a good relationship and understanding with the patient and the patient’s family • Be a sub-component of an established clinical governance system • Encompasses careful pre-planning, responding to patient needs, adequate follow-up, and internal as well as independent counseling support • Include consideration of paying for patients’ and/or family members’ immediate expenses

32. For hospital staff, open disclosure must Address professional barriers, such as • Litigation fears – malpractice liability • Disciplinary criticism and/or action • Lack of commitment by top management • Lack of explicit staff and manager support • Being reported to external organizations • Not knowing how to talk to patients regarding error • Lack of institutional support • Fear of risk to reputation • Loss of respect from peers/colleagues • Anxiety of exposing individual fault • Fear of loss of referrals • Fear of reprisal for whistle blowing • Fear of punishment for breaching professional code of silence

33. For patients, open disclosure must • Allow staff to show respect to the patient / family by offering an immediate and sincere expressions of regret • Be conducted as much as possible by those originally involved in the patient's care • Allow patients to indicate the matters they want to see clarified and action taken on • Allow staff to give carefully structured timely feedback

34. For patients, open disclosure must • Prevent the fragmentation of health care by a) preventing different staff from expressing conflicting perspectives on the causes of the adverse event b) preventing revelations of adverse events to outside institutions without pre-emptive communication with TMC c) minimizing different staff engaging consumers in repeated questioning about the case • Involve staff who are good listeners and ensure patients / family can express their grief, guilt or anger

35. Summary of presentation • Open and timely disclosure rebuilds the trust of patients and their families after an unexpected outcome. • Timely and effective disclosure of unexpected outcomes to our patients depends on • Visible and sustained support from management and the entire hospital system • Attending Physicians who are enabled and supported by the hospital • Enlightened patients who are co-responsible for their care • Substantial and direct relationship to quality improvement and patient safety programs

36. Are you ready to reclaim your patient’s trust?(select all correct answers) 1. The following are examples of unexpected outcomes • Infection following clean surgery • Septicemia after perforated appendicitis • Excess drug administration • Erective dysfunction after prostatectomy Answer/s? 2. The following are true about unexpected outcomes • They always result from medical errors. • They are always associated with sentinel events. • Staff negligence is often the root cause. • None of the above. Answer/s?

37. Are you ready to reclaim your patient’s trust?(select all correct answers) 3. The AP must ensure that the following measures are taken BEFORE conducting initial disclosure of unexpected outcomes: • Continue caring for the patient • Sequester any equipment or drugs involved in the adverse event. • Document facts in the medical record • Report the event to the Safety or the Risk Management Office Answer/s? 4. The AP must ensure that the following measures are taken AFTER conducting initial disclosure of unexpected outcomes: • Plan for subsequent disclosure. • Help analyze the adverse event to prevent recurrence. • Help heal the health care team. • Participate in quality improvement and safety efforts. Answer/s?

38. Are you ready to reclaim your patient’s trust?(select all correct answers) 5. The need for disclosure must be considered whenever any one of these instances occur: • When a patient experiences an unexpected outcome of care • When a patient experiences significant complications arising from a confirmed mistake • When disclosure of such information is important to a patient’s well-being or relevant to future treatment • When disclosure enables a patient to participate in his/her care Answer/s? 6. In communicating to patients who experience unexpected outcomes staff members must • Contain their own emotional response • Focus on patient’s ongoing health care needs • Acknowledge that the patient is unhappy with the outcome • Express regret for what has occurred Answer/s?

39. Are you ready to reclaim your patient’s trust?(select all correct answers) 7. A system that supports open disclosure must result in • Expulsion of all errant staff members • Higher levels of trust and openness among doctors and patients • Professionals learning from errors • Professionals being support before, during and after disclosure Answer/s? 8. For patients, open disclosure must • Allows staff to show respect to the patient / family by offering an immediate and sincere expressions of regret • Enable patients to be compensated or given discounts • Allow patients to indicate the matters they want to see clarified and action taken on • Allow staff to give carefully structured timely feedback Answer/s?

40. 8 out of 8 – trustworthy patient’s champion! 6 or 7 out of 8 – a budding pride of The Medical City 4 or 5 out of 8 – you will need help when your patients experience unexpected outcomes 2 or 3 out of 8 – you owe it to your patients and staff to master this GHP module* 0 or 1 out of 8 – don’t leave without passing this one* * Please go over the slides again. Answers: A only D A, B, C, D A, B, C, D A, B, C, D A, B, C, D B, C, D A, C, D Are you ready to reclaim your patient’s trust?

41. This SIM Card certifies that______(please overwrite with your name, thank you)__,MDhas successfully completed the Self Instructional Module on Reclaiming your Patient’s Trust after an Unexpected Outcome.(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement

42. Suggested support for health care team Standing committee to handle concerns (lawyer, psychiatrist, admin, peers) (admin, professional, legal, emotional concerns) Legal retainers for residents, consultants Psychiatry retainer Psychiatry to develop debriefing protocol for health care team