We are frequently asked whether we have “trained” our staff in disclosure and apology. Is it better for institutions to approach this topic with shallow and wide education and organizational development, or to provide more intensive and deep education for a selected group of clinicians?
Our initial approach was to provide a more intensive, focused course on disclosure and apology to a group of physicians, nurses, and social workers who were in key leadership roles in their departments. After doing several rounds of these types of trainings over a few years, we realized that this approach was hard to sustain and would only get us so far in changing the culture of a large organization.
We realized that for clinicians, the Communication and Apology conversation after an adverse event is a low frequency conversation that can be anxiety provoking and a “just-in-time” coaching model was a better approach for us. We established a pager number (3-HELP) that is available at all times (24 hours per day/7 days per week). The page responders will be the CQO, the Senior Director of Patient Safety or designee. We can then provide real time coaching tips for the conversation, for the next steps in the CARe process, and for the documentation of the conversation in the medical record. This approach also ensures that we have the opportunity to offer support to the clinician through our Peer Support program if needed.
We have also worked to strategically shift more of the focus on the reporting and investigation of adverse events toward the communication with patient and family. While we felt we were really good at gathering facts and dissecting the “whys” of an event, we lacked rigor in our appreciation and understanding of the communication and the impact of that communication on the patient and family. One way we thought to improve on this was through our online safety/incident reporting tool. Several years ago we began to require an answer to the question “Was the event communicated to the patient and family?” and then to ask for detail about the communication. This is an active cue to clinicians that the communication step is as important as the reporting and investigation. If the clinician indicates that the conversation had not yet happened, we can follow up to ensure that the conversation did ultimately occur.
We have also built information about our transparency work as well as our approach to communication and apology in the aftermath of an adverse event into our new employee orientation and into orientation of new physicians in our GME programs. Additionally, our approach to communication and apology is a part of the hospital policy on adverse event management.
Pat Folcarelli, RN, PhD, Senior Director of Patient Safety, BIDMC
Kenneth Sands, MD, MPH, Chief Quality Officer, BIDMC