Further learning gained from implementation of the Australian open disclosure framework has resulted in additional principles of open disclosure for Victorian public health services.
Flexibility within the framework
The open disclosure process needs to be flexible but underpinned by a strong and central framework that is understood by all. It is important to reduce risks associated with variations of an accepted and agreed open disclosure process that may arise from poor communication or documentation.
Most health services may only implement open disclosure for serious adverse events and different clinicians are likely to be involved on each occasion. Communication tools such as a ‘ready reference’, brochures or brief guidelines, help clinicians to re-familiarise themselves with the health service’s open disclosure policy and procedures.
Understanding of responsibilities
Staff awareness of their respective roles and responsibilities in the open disclosure process ensures that the right people give the right information at the right time.
Relationship with investigations
Open disclosure is closely linked with the incident management process that takes place in response to adverse events. It is also incorporated into the health service’s clinical governance policy framework.
Health services will vary in their individual approaches but there are three important and interrelated components to the incident management process:
- Patients are informed about what occurred in a sensitive, open and honest way. This includes an apology or expression of regret.
- The incident severity rating determines whether the level of investigation required is a root cause analysis, an in-depth case review or a local investigation and aggregate review.
- Measures are identified to address apparent weaknesses in the system with a commitment to address these.
Just culture approach
The open disclosure process should incorporate the principles of ‘just culture’. This approach focuses on ‘what was at fault’ rather than ‘who was at fault’. Blaming individuals when adverse events occur is unproductive and may have the effect of:
- creating an environment of fear and distrust in which the reporting of adverse events is unlikely to occur
- obscuring the underlying or root cause of the incident that must be addressed to prevent recurrence
- disregarding the implication of organisational and system issues which contribute to adverse events.
Health professionals need to be consistent in their understanding of ‘just culture’ in order to sensitively communicate its principles to patients who may not have encountered this approach before.
Open disclosure procedure
In general, the open disclosure procedure should be invoked whenever a patient has suffered an adverse event. It should be flexible enough to respond appropriately to any adverse event regardless of its severity rating. Considerations to be taken into account include:
- patient’s need and right to know
- clinician’s duty to apply professional ethical judgement to their work
- clinical team’s preparedness to discuss and analyse unexpected outcomes over and above the adverse event’s medical-technical dimensions
organisation’s obligations under clinical governance to engage staff in lifelong learning and practice improvement.