disclosure in individual trusts
A
s part of the commissioning brief for this project we were asked to produce some short evidence- based pragmatic guidance which NHS managers may wish to consider in relation to developing and implementing local policy for open disclosure. The lack of a robust evidence base in relation to the majority of individual Being Open principles, and the arguments presented in this work for the problems associated with the use of such guidance to improve or guide practice, means that the following suggestions are based largely on expert opinion and consensus. In using them organisations should be mindful of their extensive and inherent limitations. As such, they are tentative observations. These would need to be revisited and revised as the evidence base in relation to specific principles develops.Organisations may wish to consider assembling a multidisciplinary team to establish the working definitions to which the policy will apply. As part of this they may wish to consider the following factors in team composition. All levels of the organisation, from the board down, should be represented, including senior and junior doctors and nurses, and service managers including clinical governance and risk management. Consideration should be given to the inclusion of lay members to keep policy and practice focused on the needs of patients and families who have experienced harm. This is supported by the findings from both reviews and our interviews with stakeholders.
In considering the specific principles of the Being Open guidance, we suggest the following points for consideration by trusts.
Acknowledgement Try to ensure that everyone in the organisation is working to the same definition of an event that requires disclosure and that patients and families are also clear about the events that will be disclosed. Explore and acknowledge the difficulties associated with definitions. Consider a small group who can discuss any contentious events, perhaps with lay representation to enhance transparency.
Truthfulness, timeliness and clarity of communication Try to ensure that patients and families are given information relating to events as soon as possible. Although investigations may be ongoing, convey this uncertainty to families and keep them updated with facts as they emerge.
Apology Apologies are important to families. These should be sincere and issued as soon as any error or mistake is established. Trusts may wish to provide regular updates and support to ensure that clinicians and risk management are clear about both professional and legal obligations in relation to open disclosure.
Recognising patient and carer expectations If the expectations of the patients and carers are established before, during and after treatment, this may help in discussing perceptions of harm and error when outcomes are unexpected. This can be facilitated by ensuring that accurate information is given, that patients and families understand possible outcomes and risks and that information is updated if and when necessary to manage expectations.
Professional support Trusts may wish to consider the availability of professional support for those involved in disclosure. This may take the form of individuals who model good practice within the institution or specific training available in open disclosure. There is little evidence for any particular model of training over another, but given the observed complexity of decision-making in relation to disclosure and disclosure work, opportunities to practise conversations and apply reflexive thinking alongside reflection on real disclosure are likely to provide the most useful approaches. Consider multidisciplinary training and support. Working alongside patient groups and advocates to ensure that such training is also focused on the needs of patients is also likely to be important.
Risk management and systems improvement Patients may have useful insights into systems informed by a unique perspective and as experts in their own care. Viewing the disclosure process as a conversation will allow patients and families to add their views on factors which may have contributed to errors or harms.
Multidisciplinary responsibility Errors are usually systemic in nature, involving a number of team members. There is no evidence to support any particular discipline as being more effective in disclosure. Trusts may consider exploring the use of team disclosure and consulting with patients about the information they require to tailor the best approach and the best team to be involved in the disclosure process.
Clinical governance Try to ensure that the focus of disclosures remains in the realm of quality. Counting and recording disclosures is important but not at the expense of monitoring quality. A more reflective approach to capturing performance of the organisation in relation to disclosure processes is likely to yield more sophisticated insights into quality and help to inform future efforts to improve. Asking individuals how the process met their needs and what could be improved, in the case of both individuals enacting disclosures and families, may be useful.
Confidentiality Try to ensure that issues of confidentiality are not invoked to prevent patients from
accessing information or discussions which they need to understand error or harm. Being unable to discuss an error with those directly involved can be a particular frustration for families, for whom this may be part of the process of coming to terms with what has happened to them. Try to support clinicians to be able to talk directly with patients and families.
Continuity of care The focus of open disclosure should be on the care of patients rather than on mitigating organisational risk. Preserving continuity of care by respecting patient choice and consulting with them about what their care preferences are moving forward after an adverse event are likely to contribute to maintaining the patient–provider relationship in the best interests of the patient.