KAREN KOLEGA: Oh, thank you, Joan. It's very exciting to be here. I love this series and excited to give great information today.
JOAN M. PORCARO: Thank you, Karen. We're also joined by Dr. Debbie Ketchum, and she serves as a Clinical Engagement Specialist at PeriGen. Welcome, Debbie.
DEBBIE KETCHUM: Thank you, Joan. And good to see you, KK. I love being here with you both.
JOAN M. PORCARO: And again, welcome to both of you. I've asked you to join me here today to discuss the approach our care team should take when an adverse event happens. So, our conversation today will take us to a discussion on disclosure and I want to start with that first question. What is disclosure?
DEBBIE KETCHUM: Oh. Great way to start, Joan. I was thinking about disclosure as a nurse and a manager. That was always my question when something happened. Is this a time for disclosure? And what does that look like? And in health care risk management, disclosure refers to the communication of information about an adverse event or errors to patients, their families, or legal representatives.
Transparent disclosure is crucial for building the trust, maintaining ethical standards, and mitigating potential legal consequences. It involves providing a clear and honest account of what happened, the potential consequences and steps taken to prevent reoccurrence. Disclosure can contribute to improved safety and satisfaction for our patients.
KAREN KOLEGA: Deb, I think that's a really great, robust definition. One of the things I was contemplating when we were preparing for this is that we see some variance in what may be disclosed after an event. And it, honestly, varies from hospital to hospital, depending on the organizational culture and practice.
I mentioned this as culture is such a vital component of the practices and attitudes that are surrounding disclosure. Many facilities and clinicians are on a safety journey and open organizational culture around disclosure is often part of that safety journey. So, I absolutely love what you have to say about the definition.
JOAN M. PORCARO: Deb and I had a chance to connect earlier, and we were talking about that variation that often, in the world of risk management is a bit concerning. And when working with so many different teams over the years, I remember many a time someone from the floor saying, well, but it really didn't hurt the patient. So, do we really still have to do disclosure?
And I asked a couple questions to the effect of, did you have to monitor the patient? And did it actually reach the patient? And how did you interact with the patient after the event? And even though there was no permanent or even temporary harm, would disclosure have, to your point, created a little bit of a safer journey and also better communication. So, thank you, both, for that. So, when we think about what is a significant event and we think about the world of OB, what kinds of events rise to the level where disclosure would really be essential?
DEBBIE KETCHUM: Well, Joan, you can correct me if I'm wrong, but I believe that a significant event in health care typically refers to an occurrence that has or could have resulted in unintended harm to a patient. These events are often referred to as an adverse event incident or errors. And in the context of obstetrics, a significant event could include any occurrence during pregnancy, childbirth, or the postpartum period that has a potential to result in unintended harm to the birthing patient or the baby.
And common health care examples in general are medication errors, like I spoke of earlier, and surgical complications or even misdiagnosis.
KAREN KOLEGA: Yeah. And from my perspective, when think about significant events or as Deb so well stated, in the hospital setting, we all often call them adverse events. It's typically referring to an occurrence or an incidence that has notable consequences or impact on patient safety. And they can vary widely, but typically include unexpected harm or injury to the patient like medical errors, including medication errors, surgical complications, or falls.
However, it can also include unusual or unexpected outcomes. Certainly, these events that cause unexpected harm or injury to a patient should rise to the level of disclosure to the patient and patient's family. And I don't think that that's an area where people have confusion or have a lot of questions.
But this is where I have to reflect a bit and try to put myself in the mindset of those who are not employed in the health care system. What would I want to know as a patient or a patient's family member. Would I want to know if they were given a wrong medication, even if it didn't cause harm? Anytime that I had those questions as a clinician and I wondered whether or not disclosure was warranted, I would reach out to risk management because they are the experts, and they have the guidance to help and determine whether or not we need to escalate as needed.
JOAN M. PORCARO: So significant events happen. And how best can the maternal health team discuss such events with their patients? Are there any special considerations for OB patients?
DEBBIE KETCHUM: Joan, such a great question. And I like the part 2. Are there special considerations for OB patients. But I would say all patients deserve the same respect in regard to disclosure when discussing significant adverse events in obstetrics or otherwise with patients. Be open and transparent.
Really open and transparent communication is the key. And maternal health teams should provide timely disclosure, communication that is prompt and honest about the event, providing information as soon as possible in a clear and understandable language. Provide empathy and compassion is key. Approach the conversation with empathy and compassion. Acknowledge the emotional impact that this may have on the patient and their family.
Even if it's something you think might be minor, you never know the level of fear they have of just being in the hospital setting. So even hearing you were given the wrong medication, looks like you don't have any significant side effects, we're going to monitor you. What has that done to their trust? But be open, honest, empathetic, and compassionate.
It's also to be supportive and give supportive resources, if necessary. Answer their questions, provide counseling or support groups to help the patient and their family with any emotional aspects of an event, and follow-up communication is essential. Keep the patient and the family informed about ongoing investigation and steps taken to prevent similar events in the future.
And I recognized that events have different levels. But take these things into consideration. Timely disclosure, empathy and compassion, supportive resources, and follow-up communication is necessary.
KAREN KOLEGA: Deb, that's really well stated. I'm at a point like, what she said. You mentioned patient and family. And I think that is a key takeaway for me. It's important that we have those open communications not only with the patient, but their family and be aware of their families, how they define family. So, family and support persons.
DEBBIE KETCHUM: A great point, KK.
KAREN KOLEGA: Thanks. And I think it leads to a question for you, Joan. Because we really do, in these kinds of situations, rely so heavily on our risk management colleagues. Tell me, in all your years of experience, what do you see as some of the barriers to disclosure?
JOAN M. PORCARO: Well, thank you, KK. I think that there's barriers that exist for all the involved parties. The patient, the care team, the providers. Some of the ones that come to mind for me is the psychological barrier. And that might be that there is some fear that there will be retaliation or there will be concern that the patient doesn't feel psychologically safe in the organization.
And we talked about this already. A belief that the incident just didn't cause enough injury, therefore, is disclosure really necessary. And again, looking at each incident that happens, you do have to really explore as a multidisciplinary team looking at what happened and what the next steps should be as you move through that relationship with the patient.
There’re also the legal barriers. Folks sometimes will be concerned about litigation. But actually, when we think about having a good open communication, oftentimes, that communication can reduce some of the risk for that litigation. And some providers, they're just not comfortable in delivering that type of news.
Some providers are maybe a little better at it or have a little bit more comfort. But I always like to say that disclosure is a bit of a team sport. And together, we can put together the best process for delivering disclosure. And it may be that another person will be able to be the communicator in that scenario.
You've got language proficiency concerns, cultural barriers. Sometimes just not having training. A lot of times throughout my career, I've encountered where providers and even frontline managers may not have an understanding of how disclosure should be delivered. And they're just not comfortable.
And I think also we have to think a little bit about bias. And sometimes that might look like a paternalistic attitude. There's also relationship bias, and correct me if I'm wrong, KK or Deb, but sometimes your relationship in the OB setting is you might have been the care team in three different children's delivery for one family.
And so, you have this relationship with that family and that preexisting relationship, and it might create some degree of relationship bias. So, something to consider. And then we have religious factors, status in the community. Just an overall concern about what does this mean for the patient from their perspective. What does this mean for my future care.
DEBBIE KETCHUM: So, when I was listening to your information there from KK's question, I was thinking about, and maybe this has to do with training. But as a barrier for me as a bedside nurse and then moving into nursing leadership, I always had a little bit of a hesitation or a barrier in moving forward right away because I needed to understand my level of authority in such situations.
Basically, what is my swim lane? Does the disclosure belong to me as a responsible party to the provider? Do I support my staff in this, and what ways. And so, I think that did come a long way after I got more training and more experience. But one thing that never really shifted is that I've always found it best to involve risk very early on to support this question. Also, an additional question I always wonder is how much information is too much. How little information is too little. And is there really such a thing of either one or the other.
KAREN KOLEGA: And when think about in context of what we're talking about right here, there's barriers. I think that the disclosure process requires that we have well-developed interpersonal communication skills. An organizational culture of safety and an environment of support. I think you need all of those things as elements going into this.
And when I talk about support, I'm talking about the presence of role models and guidance, leading by example. If you have positive past experience with the disclosure process, and like all other areas, training and system learning are important. And Joan, you already noted that. And if we're unable to attain any or all of these, they can certainly be barriers to disclosure.
And Joan, one of the ones that really stuck in my mind that you mentioned is fear. Because I think that's very real in the health care space. If nurses have not experienced working in a just culture, situations like this can bring a lot of anxiety. So, I feel like there's a little bit of an elephant in the room because certainly, we have, as of late, the RaDonda Vaught case in 2017 where the nurse did disclose. And it was found to be criminally negligent and had three years' probation.
So, knowing that people do have fear surrounding disclosure. And that's real. So, I think it's important that we lean into those that have really great communication skills. You've seen either them do it or they can mentor you. And always, as Deb said, and I've said, you need to collaborate with your risk manager when navigating these new waters.
JOAN M. PORCARO: Thank you. KK. So, what are some of the basic steps in the disclosure process for you?
DEBBIE KETCHUM: Yeah. I can take that. Some of the basic steps in the disclosure process that I have used and been trained for is prompt recognition like we spoke of before. But quickly identifying any adverse event or incident that requires disclosure and ensuring awareness within the health care team.
Notification of appropriate individuals within the health care team, including the supervisor, risk management, and legal have an immediate response. Take immediate action to address a patient's well-being. And it's very important to prevent further harm, put actions in place. Gather information, collect the relevant details about the event, including what happened and why it happened, and the potential impact on the patient.
And you would consider having a disclosure meeting with the care teams and with the patient and first maybe the care teams and plan your process and how you're going to go in. What you're going to say, how you're going to provide a supportive, trusting environment during that space, and provide the open and honest communication. Conduct the disclosure meeting with openness, honesty, and empathy. Clearly communicate the facts and acknowledge any mistakes and express regret.
JOAN M. PORCARO: Karen, any thoughts?
KAREN KOLEGA: Again, think Deb stated it very, very well and comprehensively. So, no. Again, what she said is fantastic.
JOAN M. PORCARO: So how should a provider or a clinician or a nurse document the disclosure experience?
KAREN KOLEGA: So again, Joan, I'm going to say that this is one where I would love to hear your risk management perspectives, especially when it comes around documentation. That's always one that people are very, very concerned about doing right. So, it's always helpful for our continued learning to hear from your risk management perspective. And I almost always take away a gem to add to my practice.
DEBBIE KETCHUM: I agree. Yeah. That's great.
JOAN M. PORCARO: All right. Well, this topic of documentation with disclosure is one of those passion topics for me. A lot of times, I can understand that the care team is actively working with the patient. And documentation comes a little bit later. The experience that they've provided the patient with that disclosure indeed was exceptional.
But then when I go look for information about it in the chart to have some documented evidence that there was a disclosure that had taken place, I don't often find the same intense summary. And so, when I talk about documenting the disclosure process, I always want to remind folks, it's not a one-time step. You may have to come back a couple times throughout that patient's experience following the adverse event to check in and then document those key points.
And some of the ones that are pretty standard, obviously, if you're documenting and that the provider is putting that documentation in, the time, the date, and the location of the discussion. I want to know what the names are of all the parties that were in attendance and their relationship. Whether it be the relationship to the health care organization or to the patient.
Interpreters. If we're utilizing interpreters, it's essential to have the names of the interpreters and maybe the agency they're coming to the organization from. So that if we need that information down the road, we would have it readily available. What language? What was the dialect used by the interpreters? What assistive devices or services helped with that communication?
Often, when I'm setting up a disclosure meeting with the team to figure out what are our next steps and how we will approach the communication with the patient and family, I'd like always somebody to be called out to be the scribe and a timekeeper. And these roles would be described to the patient and family. And so that they know that someone may be in that room, and they are just monitoring our time in the room.
And the other person might be writing notes so that we make sure that any conversations or promises made essentially about getting back at a certain time that we're documenting what that conversation the next time will look like. And then I always want to mention the old saying, read the room. Describe really what the care team is seeing.
It might be that the parent was crying, or the family member was angry and describe what that anger looked like. It's also important to communicate what was provided. What's that summary of what was said to the patient regarding that unanticipated adverse outcome. And then the family and the patients may have questions as well.
So, I always want those questions to be memorialized. Basically, a summary of those questions. And what was posed by the patient and family. And then what did the care team say to the family about it. How did they respond?
DEBBIE KETCHUM: To an understanding that the disclosure should be thorough and include details of the disclosure meeting, the information provided to the patient, and any agreements or decisions that were made collaboratively, should this be in the health care record or in a separate risk document? Like incident report or both. What should go in the record versus an incident report?
JOAN M. PORCARO: Great question, Deb. And as the communication with the patient is actually part of the care process, disclosure would be documented in that medical record. And when we're thinking about it, really in either form, the medical record or the incident report, we really want factual information. We want to make sure that the patient was reassured that all the information provided was reliable information.
And then indeed, they would be notified promptly if there is any new information. So, when I'm looking at this incident report, obviously, there may be some behind the scenes work that's being done that would be private notes that maybe risk management or others are working on. But essentially, being able to make sure that the facts are in both documents. And then making sure that the next steps will be outlined.
The other thing I'm just going to pause, and mention is something that is lovingly referred to as chart wars, where we really want to avoid. There is no blaming in that documentation. That no one is actually calling out any comment that if they were the decision maker or writing the plan of care or establishing the clinical rationale, that it should have been done this way and not the way that it was done. We want to avoid chart wars. It really presents a very chaotic team dynamic that we want to avoid.
DEBBIE KETCHUM: Thank you for bringing up the topic of chart wars. That's pretty important. Yeah.
JOAN M. PORCARO: So, let's switch gears a little bit and talk about, when these events happen, we obviously have a patient who has been experiencing this event and their family. But what about the second victim? Any thoughts?
DEBBIE KETCHUM: Yeah. This one is near and dear to my heart, as is patient quality, safety, and optimal outcomes. But I think about the second victim phenomenon, which is such a harsh reality of the health care profession, and many civil servants’ professions as well. As clinicians are involved in or review medical errors and gain understanding of what has unfolded, appropriate moral distress, sadness, and concern does develop. And such errors occasionally result in an intense period of professional and personal anguish, even among the strongest caregivers. Second victims have also taken their own lives due to intense grief and sorrow.
KAREN KOLEGA: Yeah. Joan, I too am happy that you brought this forward because it's something that I think we need to keep breathing life into. That thought about the second victim. I think about when I was a younger nurse, it just was not addressed. Generally, the coping and well-being of nurses just was not a topic. I mean, think about some of the events that I was involved in and the manager or the director was like, should we call the chaplain?
Which is a great move, but it's just one piece of what we need to do to support the nursing workforce. When you're a nurse on the floor, and even leaders, some days really bad situations happen at work, and you hope and hope and hope that you can clear your head on the ride home. I remember during the pandemic, there was a viral video on social media. I think many of our listeners probably saw it, where a woman took a video of her sister who had just finished shift. She was an L&D nurse.
And she was just sitting in the mudroom of the hallway on a chair and just exhausted and spent and weeping after her shift. So, this is long overdue attention for nursing. Study after study shows that nurses are suffering from depression and other detrimental mental effects related to the workplace, we are making strides, which is great. There are now many programs that address well-being, work-life balance. Yet this will continue to be an issue until the nation gets to a place where nursing ratios respect the workload and the acuity of care provided by nurses.
There are several states that have indeed looked at legislating minimum staffing requirements. So, we have a lot of movement in the right direction.
DEBBIE KETCHUM: Joan and KK, what should health care facilities or physician practices do if they currently do not have a disclosure program? And where do they start?
KAREN KOLEGA: Well, that's a great question. I'd like to look at topics from the staff nurse's perspective as they're often at the sharp end of these disclosure issues. When I think about the day-to-day, they're the ones in the situation going, do I, don't I. Also logically, if there's no disclosure program, then the leadership has not yet made this a priority to put a program in place.
So, I often think a starting place for many things in a hospital setting is in a shared governance meeting and in collaboration with risk management. Ask questions in meetings about developing a disclosure program. We had a disclosure station at our annual competency fair. So, we had a well-developed disclosure program.
But not only do you need the program, then you need that maintenance. So that you continually educate and reinforce concepts around disclosure and the facility expectations.
DEBBIE KETCHUM Yeah. Great point.
KAREN KOLEGA: It would be important to first become a bit more versed in best practices and guidelines around disclosure. And there's several professional organizations out there for safety and risk. For example, we refer to it as ASHRM. That's the American Society for Health Care Risk Management. They have tools available.
IHI is the Institute for Healthcare Improvement, also a great source for tools. And ECRI is a nonprofit organization improving the safety and quality of care across all health care settings. And it's a worldwide organization. So, there are some good resources to start getting yourself more educated and versed about disclosure and best practices.
JOAN M. PORCARO: Thank you, Karen. I think you've called out three really very exceptional organizations that can provide some support to a health care hospital or a physician practice that's wanting to develop a program. And again, you can develop your own program. As you already mentioned, the best practice would be to utilize a multidisciplinary approach when you're establishing your business case to have such a program.
You want leadership buy-in. And certainly, you want that adoption of the program to transcend through the organization. Looking at what kind of tools you're going to need and how you're going to implement. How you'll communicate the program widely within the organization. And then evaluating your process and program overall each year.
There’re formal programs that offer training such as CANDOR, that's C-A-N-D-O-R through the Agency for Healthcare Research and Quality. CANDOR stands for Communication and Optimal Resolution. And this CANDOR process is one that a health care institution and practitioners can use to respond in a timely and thorough way and essentially, be able to have the tools available.
And if you're at their website, they do provide a lot of that information as general information to the public. And so probably, we're coming to a close already with our time. So, can I ask one key takeaway from each of you?
KAREN KOLEGA: Sure. Happy to. I think it's always a great thing to be able to do that. This one's really easy for me because it was very influential for me. And I think it's just an incredible resource of information. So, if you've never been exposed to the Josie King story, all you have to do is google Josie King, and you're going to come up with-- there's a website. It is a very sad story, but some really great things came out of it because of how they handled the disclosure process. And we have absolutely had changes in how we deliver health care based on the Josie King story.
DEBBIE KETCHUM: Thanks for sharing that one, KK. That's pretty exceptional. I have a few takeaways. I want to say many, but because it's just such an important topic. But I do feel it's necessary to reinforce what you mentioned above, Joan, about the AHRQ site on disclosure and the CANDOR method, the communication optimal resolution process.
Because as you mentioned, if you go to their site, there's resources there. The audience may find it helpful that there's actual video example of what disclosure looks like. And with not just a compliant patient that's just going to take the information. So, it gives you a good two-way communication and how to modify your communication.
It's helpful to watch if you're found in the role of disclosing an event to a patient or training your staff. And second, have a supportive culture and safety-- I think that really having a supportive culture of safety environment is essential. As we discussed, there are barriers to full disclosure, that include fear of retribution for reporting adverse events, lack of training, culture of blame, fear of lawsuits.
And best practices include health care facilities having a responsive process to inform and aid in the patient, their loved ones and clinicians, and support a blame-free culture that is non-punitive and encourages staff to report adverse events and near misses even close calls without the fear of retaliation.
And lastly, another important takeaway in closing out our time together on the topic of disclosure is to really take time to be thoughtful about addressing the second victim phenomenon. If you have been a second victim dealing with the emotional aftermath of the adverse event, it's crucial to seek support from colleagues, your supervisors, or your mental health professionals. Open communication about your feelings, self-reflection, and accessing available resources can help you cope and navigate the emotional impact of such experiences.
JOAN M. PORCARO: Well, first, I want to thank both Karen and Debbie for their time today. Many thanks to you, Karen.
KAREN KOLEGA: Joan, it's always a pleasure. I do want to ask that our listening audience, if you have any thoughts, comments, we would love to hear them. This is a really important topic.
DEBBIE KETCHUM: Yeah. Thank you very much, Joan. It was wonderful to be here too, with KK and you to talk about such an important topic. I feel like we could probably go on for days and share stories, but at least we have this moment in time together with our audience.
JOAN M. PORCARO: And in closing, I do want to take a moment and thank our audience for joining us in these episodes. And those who have tuned into our discussion, I hope you'll be joining us for other topics in the coming weeks. And again, thank you for listening to our podcast series, WTW Vital Signs.
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