1. MEDICAL QUALITY ASSURANCE COMMISSION: Error Disclosure
Washington Association Medical Staff Services
April 27, 2017
Jimi Bush: Performance and Outreach Manager

2. Objectives Discuss common health care communication tools;
Discuss how communication can transcend throughout the health care community as a whole;
Discuss error disclosure in the health care community;
Review the communication and communication and resolution program guidelines from the commission;
Practice disclosing an error;

3. Disclosing harmful events
We disclose errors and harmful events because it protects patient safety
Improves the culture of health care
Open
Transparent
Patients want jargon-free statement that an error occurred and;
A basic description of what the error was and why it happened;
Patients dislike explanations that seem evasive.
Supportive
Committed to learning
Teamwork
Respect

4. Errors as a Learning Tool
Only 18% of the physicians had received education or training on disclosing errors to patients 1.
Overall, 86% were somewhat or very interested in receiving such education or training 1.

5. Emotional Impact Depression Suicide Men 12.8% higher 3.8 times higher
Physicians suicide and depression rates compared to a non-clinical professional (2013)
Depression
Suicide
Men
12.8% higher
3.8 times higher
Women
19.5% higher
3-4 times higher
A recent study of 184 medical residents found that making a medical error was associated with a significant decrease in quality of life and increased rates of depression and burnout 1 .
It is difficult to recognize one’s mistake, but it is necessary to face the situation.

6. Patient Satisfaction
The core elements comprising patient satisfaction include 1 :
Expectations: Providing an opportunity for the patient to tell their story.
Communication: when members of the healthcare team took the problem seriously, explained information clearly, and tried to understand the patient’s experience, and provided viable options.
Control: when patients are encouraged to express their ideas, concerns and expectations.
Time spent: satisfaction rates improved as the length of the healthcare visit increases.
Referrals: when their healthcare team initiates referrals relieving the patient of this responsibility.
Continuity of care: Patient satisfaction increases when they receive continuing care from the same healthcare provider(s).
Dignity: patients who are treated with respect and who are invited to partner in their healthcare decisions report greater satisfaction.

7. Why is Team Communication Important?
Communication among healthcare team members influences the quality of working relationships, job satisfaction and profound impacts patient safety 1.
When communication about tasks and responsibilities are done well, evidence has shown significant reduction in nurse turnover 2 and improved job satisfaction 3.
There is a direct relationship between clinicians’ level of satisfaction and their ability to build rapport and express care and warmth with patients 4.

8. Medical Commission Communication Guideline
Take-Home Points
Overview
Help practitioners learn to communicate effectively.
Health care organizations should support communication training for all employees.
Look at three areas of communication:
Office visit;
Difficult patients;
Communicating with seriously ill patients;
Ineffective communication is a primary cause of complaints filed with the Commission.
A practitioner who communicates effectively creates stronger relationships with patients and provides safer care.

9. Communication Guideline: The Office Visit
Take a deep breath
Sit down, lean forward, make eye contact
Give your complete attention
Be empathetic
Slow down
Keep it simple
Tell the truth
Never answer a feeling with a fact
Watch the patient’s body and face
Be prepared for a reaction
Make a positive statement
Make a partnership statement

10. A Collaborative Approach to Reducing Medical Error and Enhancing Patient Safety Guideline
Physicians wonder whether to take personal responsibility for an error, especially given that most errors are not failures of individual providers but rather breakdowns in the system of care.
A new regulatory model is needed, one that focuses less on punishment and more on improving systems and preventing error.
The Commission believes that a more effective regulatory approach is to work directly with entities in the health care system to foster open communication.

11. A Collaborative Approach to Reducing Medical Error and Enhancing Patient Safety Guideline
Communication and Resolution Programs (CRP)
Promote a patient-centered response to unanticipated outcomes:
When a patient is harmed by medical care, providers should be able to tell the patient exactly what happened, what steps will be taken to address the event, and how similar outcomes will be prevented.
CRPs are characterized by:
Open and prompt communication;
Support for involved patients, families, and care providers;
Rapid investigation and closure of gaps that contributed to the unanticipated outcome;
Proactive resolution;
Providers must:
Report unanticipated outcomes as soon as they occur;
Participate in efforts to understand whether the unanticipated outcome was due to medical error or system failure;
Participate in efforts to prevent recurrences;

12. Steps in disclosing an error
Acknowledge the error;
Conduct blame-free team conversation;
Explain the error to the patient/ family in an explicit, jargon free, way;
Immediate investigation to determine the factors that led to the event;
Communicating the findings of the investigation to the patient and the patient’s family;
Explain what you/the health care system will do to correct the error
Explain what you/ health care system will do to prevent the error from occurring again
Apologize;
A change to the system to prevent the event from re-occurring;
Shared learning;

13. NURSE
A helpful mnemonic summarizes what to do in responding and accepting patient emotions.
Name the emotion
Understand
Respect
Support
Explore

14. N Naming the emotion NURSE mnemonic
Begin by naming a patient emotion for yourself.
Name the emotion as to talk to the patient.
Read non-verbal clues that patients display.
Be suggestive, not declarative.

15. U Understand NURSE mnemonic Builds the relationship
Avoid premature reassurance
Understanding may involve
Exploration
Active listening
Use of silence

16. R Respecting NURSE mnemonic Non-verbal Verbal helps
Respecting emotions is an important step in showing empathy
Strong emotion deserves strong acknowledgement

17. S Supporting NURSE mnemonic Concern Articulate understanding
Willingness to help
Acknowledge efforts to cope

18. E Exploring NURSE mnemonic
It is not necessary to have had the experience to empathize
Put yourself in the patient’s position
Communicate that understanding back to the patient

19. RESPECT Model Be flexible with regard to issues of control
Rapport
Connect on a social level
See the patients point of view
Consciously attempt to suspend judgement
Recognize and avoid making assumptions
Empathy
Remember that the patient has come to you for help
Seek out and understand rational for behavior or illness
Verbally acknowledge and legitimize the patient’s feelings
Support
Ask about and try to understand barriers to care and compliance
Help the patient overcome barriers
Involve family members if appropriate
Reassure the patient you are and will be available to help
Partnership
Be flexible with regard to issues of control
Negotiate roles when necessary
Stress that you will be working together to address medical problems
Explanation
Check often for understanding
Use verbal clarification techniques
Cultural competence
Respect the patient and their cultural beliefs
Understand that the patient’s view of you may be defined by ethical or cultural stereotypes.
Be aware of your own bias and preconceptions.
Know your limitations in addressing issues across cultures.
Understand your personal style and recognize when it may not be working.
Trust
Self disclosure may be an issue for some patients who are not accustomed to western medical approaches
Take the necessary time and consciously work to establish trust

20. Table Top Exercise Divide yourself into groups
I will provide each group a scenario
Practice discussing the workplace error as a team (5 Min)
Do so in a blame free way
Think about how this error happened and how you plan to disclose the error
Practice disclosing the error to a patient / family member / supervisor / licensee as an inter-professional team (5 min)
Think about the RESPECT model

21. NOW STOP
One person from each group move to a different table-You are the affected party
The group will disclose the error to you

22. Feedback
What were key observations from discussing the error as a team?
What were the key observations from disclosing the error to the affected party?
Affected parties: Did the group disclose the error honestly, clearly and compassionately?
What are strengths and challenges of open disclosure of (medical) errors?
What are the strengths and challenges of inter-professional teams around error disclosure?
Do you experience professional barriers that make error disclosure challenging?

23. Questions?