IHI releases guidance on disclosing adverse events to patients, families
Are you ready to deal with a crisis?
"The good news is, I see hospitals all over the country, and a lot of them are doing a dramatically better job in disclosures. I think the first thing we need to do is celebrate that people are dramatically more open about what happened than they were even five years ago," says Jim Conway, senior vice president at the Institute for Healthcare Improvement (IHI), senior consultant at the Dana-Farber Cancer Institute, and lead author of the IHI's new white paper "Respectful Management of Serious Clinical Adverse Events."1
He tempers his statement by adding that it's not happening everywhere, that leadership must set the tone, and disclosure is not just about disclosing, but providing ongoing support to the family, bringing the situation to resolution, and learning that leads to clinical, systemic or operational improvement.
In talking to people who have been "at the sharp end of a tragedy," he says he consistently hears three questions:
- I want to know what happened.
- I want to know why it happened.
- I want to know what's happening to prevent it from happening again.
The white paper encourages hospitals to have a plan and team in place so that when an adverse event occurs, you are working with an existing clinical crisis management plan.
"In the spirit of 'never worry alone,' organizations should establish a standing Crisis Management Team (CMT) that can assemble immediately in response to a serious clinical event," the authors of the white paper wrote. That team should be under the direction of the CEO and include "the chief operating officer, chief medical officer, chief nursing officer, chief public relations officer, legal counsel/legal advisor, patient representative, representatives from risk management/quality improvement/patient safety, the relevant service chief or clinical leader, and others as appropriate for the incident (such as physicians, nurses, pharmacists, mental health professionals, etc.)."
According to the white paper, the team should:
- "check in daily, even multiple times a day;
- maintain highly disciplined documentation and a daily log;
- engage outside help through colleagues and consultants who have developed or helped develop effective crisis management plans;
- listen and be prepared to hear things they don't want to hear, possibly seeking the advice of an objective facilitator;
- embrace speed and flexibility;
- stay close to conversations internally and externally;
- consider implications for hospital and professional billing;
- imagine the worst and mitigate as possible;
- communicate internally and externally;
- be prepared for inquiry from or the arrival of external accrediting and regulatory agencies; and
- ensure knowledge management and improvement."
According to the paper, key steps in creating a crisis management plan include:
- Take stock of plans that you already have within your organization, such as internal and external disaster plans, as models to draw from.
- Analyze the last two serious events that happened in your organization:
- What worked?
- What didn't work?
- What could have gone better?
- What did you learn?
- Prepare a high-level outline of your plan based on that assessment (see Appendices A and B of the white paper).
- Test the plan with either an actual or hypothetical near miss, an adverse event with minor temporary harm, or an event that happened in another facility.
- Refine and build your plan based on what you learn in your test.
- Continue to test the plan through drills, including unannounced drills, using cases noted in Step 4.
- Use the plan to respond to clinical crises, and look at what worked and what could be better.
- Revise the plan.
Involve patient/family in RCA
Conway says affected patients and families should "absolutely" be involved in your root-cause analysis following an adverse event because "there's nobody who knows more about what was going on in the hours and days before an event than the family that was sitting at the side of their loved one for the last 24 hours." Some organizations have them in the room with the RCA team but Conway says there are different ways to involve them, such as interviewing patients/families and bringing their perspective back to the team. "Whether they're sitting as part of the RCA team really needs to be figured out on a case-by-case basis," he says.
The person doing the disclosure, most importantly, should be someone the family is familiar with, Conway says, even if they had nothing to do with the event. That may be the primary care physician or the attending physician. The disclosure also should never be done with one person, he says.
The first meeting is about expressing an empathetic apology '"I'm sorry. Something has happened. We want to let you know we're doing everything we can,'" Conway says.
Support staff
The first priority in managing adverse events involves patients and their families. The second is staff. This is an area, Conway says, most people in health care have not had a lot of experience with.
Your institution should support staff. As part of your hospital's crisis management plan, you should have a "swat team that surrounds staff and helps staff deal with what's happened, but also to prepare for the actual disclosure," Conway says. Never should staff be thrown into a room to disclose "without having gone through the process of having them be supported."
The hospital, too, has to support the staff member after the event. "Debrief with them, talk with them, see how they're doing, because any time you are involved in a disclosure, it's a moving experience," he says.
The long-term goal, of course, is to eliminate adverse events, "but until we eliminate them, the overarching principle is that all parties who were engaged in these events would say they were respected," Conway says the patient, the family, the staff, and the community.
Very few organizations, he says, have a comprehensive approach to support staff after an adverse event. "That could be everything from hugging them, to listening and responding to them, to making sure they're safe," he says.
He says he's surprised by the number of hospitals that still do not include staff involved with the error in the RCA. "What we know is the vast majority of adverse events are the result of bad systems, not bad people." The RCA process promotes healing for everyone involved, he says.
Quality improvement staff have a huge role to play in planning an approach to disclosure. "At the end of the day, this is about learning and improvement." That must be communicated to patients and family, staff, and in all the organization's communications, both external and internal.
"When serious clinical adverse events occur, communication priorities should include the following: those most directly affected; employees, as sometimes they can be victims, too; those indirectly affected families, relatives, neighbors, friends; customers, suppliers, government, regulators, third parties; and the news media and other channels of external communications," the authors of the white paper wrote. "Core constituencies should never learn anything from the news media; they should receive the information directly. E-mail, Twitter, and other social media have changed everything most obviously, the speed and content of communications. Many people want and need to believe in you; make that possible."
Reference
- Conway J, Federico F, Stewart K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2010. (Available on www.IHI.org.)
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