Implementing open disclosure

Bridging the gap between the development of an Open Disclosure policy and its successful implementation is dependent on a supported and resourced implementation programme, write Angela Tysall and Ann Duffy.

On November 12, 2013, Dr James Reilly, Minister for Health, launched the national policy and guidelines on Open Disclosure. These documents were developed by the HSE and State Claims Agency following a two year pilot programme at two large acute hospitals, the Mater Misericordiae University Hospital, Dublin and Cork University Hospital. They also incorporate international learning and best practice guidelines. Open disclosure is a requirement of the national standards for safer better healthcare 2012 and is also a provision of the National Healthcare Charter 2012. The Open Disclosure policy and guidelines are currently being implemented on a phased basis across all health and social care services in the Republic of Ireland.

The Open Disclosure policy and guidelines are currently being implemented on a phased basis across all health and social care services in the Republic of Ireland.

The learning from the pilot programme demonstrated that health care professionals are positive about open disclosure. However, in reality open disclosure does not always happen. Evidence globally has demonstrated that staff experience difficulties with open disclosure because of (i) a fear of litigation, (ii) fear of reputational damage and impact on professional advancement (iii) lack of training and guidance in relation to managing the open disclosure process and (iv) the influence of the culture in the organisation. Approaches to open disclosure can vary from organisation to organisation.It is important that health and social care services foster a positive, supportive work environment where good communication, support and mutual respect is the norm. A just culture supports a disclosure culture.  Where a true just culture exists no one is ever hesitant to speak up on behalf of a patient and everyone has a high degree of confidence that their concerns will be heard respectfully and acted upon.

Health and social care services have a responsibility to ensure that there are effective systems, processes and resources in place to identify, manage and reduce risks to members of the public and staff. This requires a culture that encourages the notification of adverse events when they occur and which also promotes open, honest and timely communication between staff and patients following an adverse event.

Patients have specific information needs when they have been involved in an adverse event. They expect

• An acknowledgement that an adverse event has occurred
• An explanation as to why it happened
• An apology
• Reassurance regarding their ongoing care
• Involvement in their ongoing care plan
• Information and reassurance in relation to the steps being taken or planned by the healthcare provider to try to prevent a recurrence of the event
• To be involved in and kept informed in relation to any reviews being undertaken by the healthcare provider and to be provided with a copy of the review report

The learning from the pilot programme demonstrated that health care professionals are positive about open disclosure.

Patients prefer this communication via open dialogue.

“Financial compensation was never on our agenda. Money would never have compensated us for losing our wonderful and precious son. Instead we simply wanted answers, information, explanations, solid reassurances that what went wrong would never happen again. We wanted a proper and meaningful apology”. (Mrs Loretta Evans speaking at a patient safety conference in 2011)

Having an Open Disclosure policy in place may not ensure that open disclosure always happens. Implementing this policy requires a cultural shift and a change management approach with the need for health and social care services to develop an organisational structure with the capabilities to support and manage this process and to identify and address any factors which may impede implementation. The successful implementation of the principles of open disclosure will depend on the following factors:

• Leadership and visibility of the senior management team in the organisation including senior managers at hospital group/PCCC/division level.
• Training programmes to support and facilitate organisational and individual learning.
• The alignment of internal open disclosure policies with the national policy.
• Embedding an open disclosure policy organisation wide.
• Having adequate support systems in place for staff and patients/families affected by adverse events.
• Approaching open disclosure as an ethical practice that prioritises organisational and individual learning from adverse events and not as an organisational risk management strategy solely.
• Recognition that the principal drivers for open disclosure are the needs, expectations and rights of patients.
• Having good systems of clinical governance in place.

Bridging the gap between the development of an Open Disclosure policy and its successful implementation is dependant on a supported and resourced implementation programme. We are currently delivering an implementation programme to 31 acute hospitals and five PCCC areas.  For further information on this programme and the resources available please contact angela.tysall@hse.ie and/or aduffy@ntma.ie.