Open Disclosure

Open disclosure is a hot and sexy topic for CICM examiners, as it ends up being an important part of the role of the intensivist. We tend to see many complications from other specialties, and we tend to perform many procedures with a high risk of complications. Our trainees are variably supervised and variably trained, giving rise to situations such as those in Question 28 from the second paper of 2014 or Question 18 from the second paper of 2010. Both SAQs concern a situation where one needs to counsel a junior trainee who caused a lifethreatening complication. 

Question 5 from the second paper of 2015 was the first and only CICM Part II SAQ to engage in a discussion of open disclosure. For those in NSW, the HETI module on Open Disclosure is a reasonable resource. For those unwilling or unable to subject themselves to a 30-minute flash animation followed by a quiz, the CEC offers an excellent Open Disclosure Handbook which will probably suffice as a pre-exam reading resource. This handbook was used as the main source for the information offered below. An alternative short-form overview of this topic can be found in the excellent LITFL summary

Definition of open disclosure

  • The CEC defines open disclosure as " a process for ensuring that open, honest, empathic and timely discussions occur between patients and/or their support person(s) and health care staff following a patient safety incident". This wording is slightly different from the college answer to Question 5 from the second paper of 2015. As far as the great oracle of Google is concerned, the exact phrasing of the college answer appears to be unique and is not plagiarised from anywhere. 

Importance of open disclosure

This again comes straight from the CEC  Open Disclosure Handbook, specifically from page 18 ("Why does open disclosure matter?")

  • Importance for patients:
    • A meaningful apology
    • An explanation when things go wrong
    • An acknowledgement of their concerns and distress
      A reassurance that the organisation will learn lessons to prevent harm happening to someone else
    • A reduction of the trauma experienced (hopefully)
    • An opportunity to ask questions and to have those questions answered
    • An increased respect for and trust in the organisation
    • A reassurance that they will continue to be treated according to their clinical needs
  • Importance for clinicians:
    • Improved confidence in effective communication when things go wrong
    • Support in making ab apology 
    • Satisfaction in an appropriate and formalised communication process
    • An improved understanding of incidents from the perspective of the patient and/or their support person(s)
    • An improved relationship with the patient and/or their support person(s) through demonstrating integrity
    • Developing a good reputation for managing a difficult situation well
  • Importance for organisations:
    • Development of a reputation of respect and trust for the organisation and/or team
    • A culture of openness and safety is reinforced
    • The costs of litigation are potentially reduced
    • The patient experience and satisfaction with the organisation are improved
    • Development of a reputation for supporting staff when things go wrong
    • Improvement of internal processes which prevent future events

Essential elements of open disclosure:

  • An apology (the college were particularly insistent we include this in our answers and CEC views it as an "essential element")
  • A factual explanation of what happened.
  • An opportunity for the patient to relate his or her experience.
  • A discussion of the potential consequences.
  • An explanation of the steps being taken to manage the event and prevent recurrence.

Clinician disclosure

  • This is an  informal process which is conducted by a senior clinician and which takes place as soon as possible (ideally, within 24 hours) of the event. The NSW CES recommends we use the "STARS" tool, developed by the Patient Safety Unit at Queensland Health.  
    • Sorry: Acknowledge what happened, apologise for it, acknowledge the impact of the incident
    • Tell me about it: ask about the experience of those involved
    • Answer questions from those involved
    • Respond: discuss the plan for what will be done to ameliorate harm
    • Summarise: conclude the discussion with a summary of events, and plan future discussions.

Formal open disclosure

  • Formal open disclosure: a structured process, involving a multidisciplinary team and a senior administrator trained in formal open disclosure. This thing has many stages:
    • Preparation:
      • Notification of all relevant staff, eg. Director of Clinical Governance, senior managers, etc
      • Initiation of the process is documented
      • Notification of the managers responsible for insurable risk
      • Appointment of a coordinator for the process
      • Appointment of an open disclosure advisor
      • Appointment of a person who will lead the discussion
      • Arrangement of a formal discussion
      • Meeting of the open disclosure team to prepare their approach
    • Formal discussion:
      • Introduce all attendees
      • Acknowledge the patient safety incident
      • Offer a sincere apology 
      • Explain the formal open disclosure process
      • Opportunity for the patient/family to recount their experience
      • Appropriate empathetic response and explanation of events
      • Provide the findings of any review or investigation 
      • Discuss and agree on a plan for care
      • Arrange follow up discussions
    • Follow-up with clinical team:
      • Meet the clinical team involved after the formal discussion
      • Outline the points discussed and the outcomes
      • Provide an opportunity for clinicians to debrief
    • Completion:
      • The patient or their representative may indicate that they are satisfied that open disclosure is complete
      • Otherwise, various complaints processes may be followed (eg. HCCC)
      • A final investigation report should be completed
      • Lessons learned from the safety incident need to be communicated widely
      • System improvesments should be implemented by the clinical governance administrators

    References

    The CEC  Open Disclosure Handbook

    Australian Commission on Safety and Quality in Health Care (ACSQHC) Australian Open Disclosure Framework, Sydney, 2013

    Disclosure Working Group. Canadian disclosure guidelines: being open with patients and families. Canadian Patient Safety Institute, 2011.