“Science is difficult. Business is complicated. Accountability is not.”
- Hank McKinnell, Pfizer CEO, 2003
In health care, accountability after an error or adverse event is difficult, complicated, and uncomfortable, and can pose legal challenges. This article addresses the steps in the disclosure and apology process after an error or adverse event. It also provides components for effective interpersonal communication, as well as practical application tips.
The process of disclosure and apology started in 1987 at the Veterans Affairs Medical Center in Lexington, Kentucky. The VAMC’s program was untried and untested, and was launched as a proactive approach to medical errors after the organization lost two large malpractice claims. Since that time, multiple programs have proven that disclosures and apologies work to improve patient safety. Disclosure/apology literature demonstrates that patients want accurate information, compassion, and emotional support following an adverse event. Studies associate a decrease in claim processing time and litigation volume with these programs; however, the experts who conducted those studies believe that financial gain is a byproduct of the programs’ better approach to patient communication, and should not represent their primary driver. Disclosure/apology processes, in other words, have evolved from a risk-management strategy into an expectation of high-quality health care.
To achieve those goals, the following four steps are implemented in the disclosure/apology process:
1. Preparation
2. Discussion
3. Documentation
4. Follow-up
PREPARATION
In preparation for a disclosure/apology communication, medical records will need to be reviewed and discussed with the involved providers and staff. Explanations should be prepared for every issue, breakdown, or situation. Patient questions and concerns should be known or anticipated, and addressed. If possible, these conversations should take place within a pre-established quality-improvement program to minimize the risk of litigation discovery and to encourage frank and honest dialogue.
At the outset, there should be a determination of who should be present at the discussion, and why. If, during preparation, a provider expresses discomfort or appears defensive, it is important that this be discussed with leadership, and that the provider either be given coaching or appointed a proxy to step in for them. Proxies should be considered whenever a provider is unable to deliver an authentic disclosure/apology, or is so uncomfortable with delivering it that honest and transparent communication is impossible. Proxies should be administrative leaders, such as chief medical officers or chief operations officers.
All parties should meet and agree on their roles and what will be discussed. This step should involve either role-play or facilitated coaching, usually managed by an individual who has been trained in medical disclosure/apology and conducted on a one-to-one basis. Coaching is more effective when conducted in person, but can also be accomplished via voice or video call; it includes assistance with the preparation of the actual discussion, observation and feedback on nonverbal language, and, if more than one professional is involved in the communication, planning of the sequencing and interactions between the parties.
Agreement on where and when communication will take place should occur between all health-care parties and the patient, including anyone who will be accompanying the patient. The entire communication process could be jeopardized if any party shows up late or to the wrong location.
The “welcome,” “disclosure/apology introduction,” and “small talk” portions of the conversation should be discussed and prepared in advance, keeping in mind that:
• The purpose of the “welcome” is to put the patient at ease by identifying the parties and their roles, addressing the importance of the conversation, and encouraging the patient to express any concerns and ask any questions they may have.
• The “disclosure/apology introduction” frames the conversation by identifying its purpose and providing an outline of what will be discussed.
• Small talk includes any conversation that may have to occur if one or more of the parties is late. This conversation should be carefully thought out in advance, in order to identify appropriate and inappropriate topics beforehand. It may also be inappropriate to engage in small talk at all, which must be decided on an individual basis and in light of variables like the severity of the outcome of the error or adverse event, the comfort level of the provider, and the mindset of the patient and their family.
Three important additional points are, first, that a hold should be placed on billing for the treatment provided, until the investigation is concluded and the provider and administrative leadership are in agreement on how to proceed; the provider should not independently make agreements with or assurances to the patient; and providers are encouraged to notify Physicians Insurance Risk Management consultants and Claims staff immediately, who should also participate in the preparation process.
Validation statements like, “I hear you," or, "I understand that you are frustrated," are the best responses to a patient’s expressions of frustration and anger.
DISCUSSION
While it is impossible to provide guidance on the specifics or particular sequence of any given disclosure/apology communication with a patient—many providers ask for scripts, which are discouraged because they undercut patient engagement—there are a few general elements to keep in mind.
The discussion should occur promptly, within 24 to 48 hours after the discovery of an error or adverse event if possible. The discussion should only include known facts. If there has not been an investigation into the facts of a situation, the discussion about it should not include an apology, though it is still important that sympathy and regret be expressed.
The general elements of a disclosure/apology discussion include:
- Expression of empathy. An expression of empathy is different from an apology. Empathy conveys regret that an event happened, while an apology assumes responsibility and offers to make amends for it. Both expressions include the words, “I am sorry,” but empathy is based on feelings, whereas apologies are based on admission of fault.
- Acknowledgement of the error or adverse event.
- Expression of sympathy or regret. If an investigation into the facts has not yet occurred, an apology is premature and inappropriate. Instead, it is appropriate to express sympathy or regret, and share that an investigation will occur and that the provider will follow up after it is completed.
- Identification of the process of investigation—that is, what has already been done or will be done by the provider(s) in order to understand and analyze what occurred.
- A general and/or specific apology, if an investigation has occurred and it is determined that responsibility lies with the provider.
- Identification (potentially) of what could have been done differently in order to prevent the error or adverse event.
- Sharing of actions already taken, or that will be taken, in order to prevent a future occurrence.
- Encouragement of the patient to ask questions. Open-ended questions should be used, such as:
- “Is there something you would like to ask?”
- “What else would you like to talk about?”
- “Can I provide you with more information?”
- Encouragement of the patient to express their feelings, frustrations, and anger.
- Discussion of follow-up, including those accountable for it and the time frame within which it will occur. It is important to provide realistic and achievable time frames for any follow-up actions, as failure to meet agreed upon time frames may further damage the relationship with the patient.
- Summary of the entire discussion, including contact information for all parties.
It is important to keep from becoming defensive, and to allow the patient to express his or her feelings. Validation statements like, “I hear you,” or, “I understand that you are frustrated,” are the best responses to a patient’s expressions of frustration and anger. It is important not to engage in an argument or begin blaming others or the system, even in response to what may feel like an attack from a patient.
DOCUMENTATION
Documentation of the disclosure/apology communication should include the location of the communication, the length of time it took, who was present at it, and a summary of the communication, including patient concerns, requests, and demands and the agreed-upon follow up plan. This documentation should be maintained in a separate file outside of the medical record.
FOLLOW-UP
If follow-up is decided upon, a plan should be drafted for it, including the specific steps or actions it will involve, who will undertake them, who is accountable for seeing follow-up through, and the time frame within which the patient should expect to hear from him or her.
New Communication Planning Resource Available
Effective communication is a core clinical competency and a key to patient satisfaction. This competency is necessary to build and sustain relationships, to enable patient engagement, and to optimize patient adherence, all of which have a direct impact on patient outcomes. Communication skills don’t always come naturally for most people. They are learned and strengthened through practice, metacognitive exercise, and solicited feedback.
Physicians Insurance now offers a communication-planning sample document, developed by Deb Lessard, that focuses on interpersonal communication and can be applied in a variety of practice situations. To obtain a sample, contact your risk management consultant.