Keeping it real: patient-centric adverse event management

By continuously disclosing what we know, through the open disclosure process, and listening to families, it will become clear from them whether or not they believe an incident has been adequately investigated to the level they expect, and whether or not they are satisfied with the outcomes

HEALTH care in Australia encompasses a complex yet comprehensive and broad spectrum of service provision. From general practice to specialist medical, allied health, and nursing, to community and rural care providers, the gamut of health care professionals involved in ensuring the health and safety of the Australian people is as diverse as it is vast.

Central to all care provision by any one of these providers is the patient and their family. The provision of safe, high-quality care is the goal.

Sadly, however, sometimes this goal is not attained and preventable or unpreventable adverse events occur, which are devastating to the patient and their families and the care providers and health institutions themselves.

With the establishment of state-based organisations such as Safer Care Victoria, in recent times, there has been a renewed focus on the correct and best-practice management of these types of clinical incidents.

Sentinel event reporting is one such practice, a process where all health services are required to formally report and investigate the root causes of any event that causes the death or significant harm of a patient from what may be preventable failures in systems and processes. Various levels and types of incident management technique exist to support these practices. Health services employ these depending on the severity of the incident and nature of the adverse outcome to the patient.

It is now well established that all care provision should be underpinned by a patient-centred approach. The World Health Organization defines patient-centred care as care that “meets people’s expectations and respects their wishes”. However, over time, the term “patient-centredness” seems to have become somewhat of a buzz word, particularly when it comes to clinical incident management, where all too often in our daily practice we see how easily this focus on the patient is at risk of becoming lost. This is because managing an adverse clinical event is in most cases perceived to be separate from the provision of standard care.

When something goes wrong with the patient or an adverse clinical outcome occurs, how we deal with the incident should and must continue to be managed with the focus remaining on the patient’s and their family’s needs and expectations and with them fully engaged. Whether it is a minor or significant clinical incident, it is essential to exhaustively investigate the causes, until we understand what happened, why it happened, and how we can learn from what happened to improve the standard of care.

It may be countered that in such a seemingly institution-driven process, why a patient-centric approach even matters.

The simple answer is that the patient and their family are the ones that we as health care professionals and/or health care institutions are obliged to present the answers to on the questions of how, why and what we are going to do in future to prevent similar failures. While it is certainly of interest to the organisation, if a patient and family perspective is adopted, it is logical to see that this means the response is more likely to be more contemporaneous, immediate and more likely to be followed through to close the loop. This is in addition to the already available dearth of literature evidence that shows clear associations between patient-centred care models with improved health care outcomes, enhanced patient–clinician relationships, greater adherence to treatment, improved quality of life, reduced length of hospital stay, and lower health costs (here, here and here).

Health care is a high risk profession. It’s risky because it’s driven by people. Regardless of how much technology and how many machines are available at the multiple touchpoints of a patient’s journey, health care is a people profession. As a result, mistakes, errors and adverse incidents will occur. If something unanticipated has occurred, health care teams have an obligation, not so much to themselves, not so much to their organisations, but to the patient and their families to determine what happened and how they can actively ensure that it does not happen again.

Much like the airline industry, health care needs to operate within a high reliability environment. This means that there is an expectation that consistency is at the core of best practice. What happens each day must be of high reliability, so that the routine expectation of all people who are providing care or those receiving the care is that things will go well and that systems will not fail.

It is easy to comprehend that the unacknowledged expectation when flying in a plane is that you are going to get to the other end of the flight safely. This is why the pilot and copilot pride themselves on completing their safety checklist 100% of the time. However, what really matters to an individual who is actually on that plane on any given day, is that the pilot and the copilot complete their safety checklists on that particular day.

In contrast, in health care we often accept, and indeed justify, that a certain percentage of failure is inevitable. This is evident in the observation that achieving 100% compliance with systemic and process safety measures is often not achieved or in fact may not be strived for; as an example, a 98% completion rate of safety checklists may often be accepted as good enough. The risk this presents is that internal hospital or procedural centre performance metric monitoring could be falsely reassuring if a safety procedure is “completed 98% or 99% of the time”. While this may seem acceptable and a high percentage from an organisational compliance perspective, for the individual patient who is having surgery on any given day what matters is that the checklists are completed on that particular day – an assurance that can’t be met if it they are not being completed 100% of the time.

A multitude of real-life management of clinical incidents have shown us that core to the thinking of a patient-centric approach to incident management is open disclosure. This can be related to the patient-centred care model illustrated by Hudson and colleagues. Hudson’s conceptual model shows that there are four inter-related dimensions to delivering patient-centred care, notably, including the sharing of power and responsibility with the patient and building an open therapeutic alliance between the patient and the clinician. The application of these dimensions following the end of a care episode and throughout the management of a clinical incident following that episode of care provision could be easily achievable through the act of genuine open disclosure. When open disclosure can be so deeply embedded in the culture of a health care organisation, it forms a key component of the very foundation that the organisation and its systems are built upon, it becomes ingrained in the inherent nature of its executive and its frontline staff.

By its very nature, open disclosure drives an open, continuous discussion, dialogue and genuine engagement with the patient and their family. In this state of thinking, we are not only communicating to them about what happened, but listening to them about what their concerns are, what they want to know, what their priorities are, and creating an opportunity for genuine connection and provision of support to the patient and their family at the time of an adverse event.

Starting with the premise that open disclosure must be at the core of health care, and fundamental in good incident management, health care leaders set the tone of how incident management is done. Taking a patient-centric approach means we are more likely to escalate, raise concerns, speak up, and then to immediately act.

A common example where this is crucial in practice is when clinicians determine whether a patient’s next of kin will be contacted at the time of a patient’s fall. If the fall occurs in the late hours of the night or early hours of the morning, there is often a question as to whether next of kin should be woken up or whether it can wait till later. This is a very common, practical example we still experience in our daily practices today as a common position still held by senior clinicians.

Interestingly, if those same clinicians are asked hypothetically when they would like to be contacted if one of their own loved ones has a fall in a health care institution, invariably the answer comes back as “immediately”. This is the difference considering incidents from a patient-centred approach makes. It reframes our thinking from what we believe is the right action for a patient or their family to what the patient and the family actually wants and needs. These are an example of the types of fundamental, nuanced cases we see at the frontline, of the discrepancies of a patient-centred approach to incident management that is not as yet picked up in reports of incident analysis and, hence, are all the more important for us to learn from.

An important commitment that health care leaders and providers can make when they undertake a clinical incident investigation is to use two main drivers to determine the level of the investigation that will occur.

One is legislatively determined and/or is driven by regulation in that there is a requirement to do certain types of reviews, such as conducting root cause analysis for all sentinel events. In terms of the second driver, usually it’s the gradient severity of incident that drives the type of investigation that is undertaken. These could range from such types of investigations as conducting root cause analysis, in-depth assessments, and cluster reviews to local case investigations.

Taking a patient-centric approach to incident management, however, means that the real driver is the patient and their family. By continuously disclosing what we know, through the open disclosure process, and listening to families, it will become clear from them whether or not they believe an incident has been adequately investigated to the level they expect, and whether or not they are satisfied with the outcomes. Therefore, the review should only really be closed when the patient and/or their family have determined that the incident can be closed satisfactorily.

While this can be seen as problematic by some, or as wishful thinking by others, if a patient-centric approach is always in the front of mind, we can see how this could invariably lead to a better approach to incident management.

Notwithstanding all this, it is often a challenge to involve patients and their families as part of incident management. Challenges range from logistical difficulties to navigating sensitivities at a time that is highly emotional, distressing and unpredictable for all involved. However, as with patient-centric care, with patient-centric incident management, it remains our responsibility and duty to ensure ongoing accountability for the patient and family that has been affected.

For example, the time it takes from an incident to when open disclosure begins is critical. The longer that takes and the less clarity and compassion that is shown through the process, the less likely the patient and/or their family will be able to be engaged. Just as importantly, initial engagement by a patient or family is not an indication that they will continue to remain engaged. By ensuring that continuous engagement and communication occurs, levels of distress can be reduced, and the authenticity of the health professionals and their organisation’s intentions become apparent. This may make all the difference to the individuals concerned in such situations of devastation, uncertainty and volatile emotions.

Both health care leaders and providers hold a responsibility to embed a patient-centric incident management approach as part of continuing to care for the patient, and as a fundamental part of the episode of care, despite an incident having occurred. A patient-centric approach to incident management and involvement of the clinician in the review process also gives the clinicians dealing with the incident the opportunity to escalate their concerns, to know they are going to be heard, that their concerns resonate with the organisation, and that they are a crucial part of the review, as this will be seen as a continuation of the episode of care they started.

With such simplicity and clear benefit to all concerned, it is hard to justify why patient-centred incident management should not become a norm in health care.

Associate Professor Luis Prado is Chief Medical Officer and Executive Director (Academic and Medical Services) at Epworth HealthCare.

Dr Sidney Chandrasiri is Group Director (Academic and Medical Services) and Deputy Chief Medical Officer at Epworth HealthCare.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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