Open Disclosure: Communicate for better outcomes
Open disclosure
These words describe a topic we wish was never needed in healthcare. However, it is a worldwide truth that among the many of episodes of care you will deliver at some point something will sadly go wrong.
Open disclosure is the process of open and honest communication regarding harms that have occurred to our patients in the course of receiving healthcare. Whilst healthcare professional usually strongly agree with the ethical principles of open disclosure, in practice it is a complex process, requiring preparation, training, skills and confidence to initiate and follow-through with these challenging conversations.(1)
Whilst we aim to support systems that are as safe as possible, and provide care that is as rigorously accurate as possible, harm can unfortunately occur during our clinical care. It is so important at those times that we don’t compound the harm with our next actions.
So what should we do when the worst happens?
Important steps include:
A sincere apology
Discussing what is known about the events and the possible outcomes in terms of ongoing care, monitoring and health
Providing the appropriate medical care following harm, without delay .
Understanding the patient’s and/or loved ones experience of the events
Investigating and communicating steps that will be taken to avoid similar events in future.
Communicating about the harm, and managing the harm happen alongside each other and we need to learn the skills to do both.
With the advent of Victorian Statutory Duty of Candour (SDC) legislation in late 2022 the expectations of open disclosure within the SDC framework are now clearer for healthcare consumers and healthcare professionals.
Organisational frameworks and timelines for managing serious adverse patient safety events (SAPSEs, a category of harms which are protected reviews under the new legislation) are also outlined in these helpful training modules.
Although current guidance specifically targets the actions required around SAPSEs, as clinicians on the frontline we need to be ready to respond to any type of healthcare harm or near miss.
How do we manage the crucial first steps of disclosure and apology?
To support the patient’s and their loved ones through a distressing process?
To rebuild trust and confidence in the treating team which is so important for ongoing healthcare decisions?
And what can we do to be prepared to provide the best care following an episode of healthcare harm?
Open disclosure conversations can be some of our most challenging.
Some tips on preparing for and completing open disclosure communication
Communication skills are vital throughout open disclosure and especially in those early stages after discovery of the harm.
Check in with yourself first (however briefly)
Being involved in an episode of patient care that results in harm can feel incredibly challenging to us as healthcare professionals who are trying to do their best every day.
Compassion for the feelings this evokes in you will help you be a better support to your patient, by avoiding rumination and overwhelm at this most crucial time, when a clear head is needed.
Think
Who can I talk to when you have a moment?
Where can I get support?
Who can help with perspective at this time?
Support your team
Similar feelings may be present in team members - supporting each other puts you all in a better place to make the next steps and decisions as safe as possible. The preparation for managing adverse events begins long before they occur.
Fostering a culture of psychological safety in your clinical teams supports open communication between team members, this enables adverse events to be addressed as early as possible.
Be sincere and clear
Say sorry - and make sure your apology is sincere.
Avoid the pitfalls of open disclosure - avoidance, speculation, minimisation of impact or apportioning blame.
Instead
discuss the known facts, expected impacts and next steps
observe and listen carefully to your patient and/or their loved ones to identify their needs, uncertainties, emotions and experience of the situation.
Responding to their cues will help you provide support for their distress. Use silence and explicit empathy to give them the space to express their understanding and concerns.
Check in regularly and ask permission to keep going, giving time to process the news.
The disclosure gap
Sometimes there is a gap between what is about the appropriate response and what is actually done. This is known as the disclosure gap. Why does it exist? Open disclosure is an ethical and logical concept, but in practice it can be complex and uncertain. Uncertainties may exist about the outcomes of harm, as well as the (legal, emotional, reputational) outcomes of the conversation. Clinicians may fear these uncertain outcomes and this can divert their focus from the open disclosure process.(2)
What can help us to address this? Committing to learn and be prepared for open disclosure is one way we can reduce the risk of a substandard response. There will be without doubt local policies. Ask your organisation what they are doing to help staff prepare to respond to these events.
What are the risks of poor open disclosure communication?
Missed opportunities to rebuild trust, affecting patient’s and relatives’ current and future engagement with healthcare
Missed opportunities for patient safety strategies to prevent recurrence
Missed opportunities for learning to improve patient safety and to improve experience of the open disclosure process
Essentially, getting open disclosure right affects more than just the current incident, and our responsibilities extend beyond the immediate response.
Complaints are something we all wish to avoid. Of note a NSW study found that, whilst the process of open disclosure itself was not associated with complaints, two related factors were:-
Not receiving an apology
The perception that open disclosure occurred too late
This reinforces the need to be ready to address the issue early and sincerely. (3)
An effective open disclosure process is about reducing the impact of healthcare harms and avoiding future harms which might result from a poorly managed process.
Whilst there will always be uncertainty about the outcomes, being prepared means knowing we have done our best to support our patients at the worst of times.
Clear and Connected’s Open Disclosure Communication sessions deliver more detail on specific communication skills that help with the process, and how they can best be used to support patients.
These are also accompanied by a handout to share with your teams. Find out more here.
Philpot S, Sherwin A, Allen S. Open disclosure. BJA Educ. 2024 May;24(5):147-154.
Iedema, R., Allen, S., Sorensen, R., & Gallagher, T. H. (2011). What prevents incident disclosure, and what can be done to promote it?. Joint Commission journal on quality and patient safety, 37(9), 409–417.
Case et al,. What Drives Patients’ Complaints About Adverse Events in Their Hospital Care? A Data Linkage Study of Australian Adults 45 Years and Older. Case et al,. J Patient Saf 2021;17: e1622–e1632
