FEATURE PATIENT SAFETY

Transparency and courageous leadership: how to improve patient safety

In light of the recently implemented statutory duty of candour, victim’ phenomenon: the psychological Dr Mohsin Choudry, the RCP’s national medical director’s clinical fellow effects of involvement in serious incidents and Dr Kevin Stewart, clinical director of the RCP’s Clinical Effectiveness on clinicians can mean that they pose a risk and Evaluation Unit, assess the legal and professional duty of clinicians to patients in the immediate aftermath of and how to improve patient safety. They report on the RCP’s recent an event, and can damage safety culture by suppressing transparency or promoting patient safety seminar, which provided perspectives from doctors, defensive practice in the longer term. Unfair patients and managers, and consider why clinicians have nothing to or unbalanced treatment by investigators, fear from embracing disclosure and transparency. regulators and the media, all of which had been experienced by our speaker, exacerbate A defining moment in recent medical RCP patient safety seminar the situation and damage transparency. This history was the publication of the United The Patient Safety Committee at the RCP has created a culture in the medical profession, States Institute of Medicine’s 1999 report hosted its first patient safety seminar in to quote Dr Lucian Leape, professor at Harvard To err is human which estimated that June 2015, to attempt to understand some School of Public Health, in which ‘the single 44,000–98,000 people died from medical of the barriers to increased transparency. greatest impediment to error prevention … is error in hospitals in the United Stated per We welcomed three leading voices on that we punish people for making mistakes.’ annum. This report launched the modern patient safety, each giving their experiences From a patient representative perspective patient safety movement, however 16 of adverse events, the challenges to we heard from Peter Walsh, chief years later little has changed. International transparency, the pitfalls that they have of Action Against Medical Accidents (AvMA), personally encountered and the systemic studies estimate that around 10% of a charity supporting patients and families learning that has subsequently emerged. who have suffered adverse events and who hospital patients still suffer some sort of We heard about the personal and usually had experienced unsatisfactory adverse event. A medical adverse event professional challenges faced by a consultant dealings with the NHS or clinicians. AvMA is widely defined as an unintentional or surgeon who talked, on the condition of campaigned heavily for the government to untoward outcome, resulting in actual or anonymity, of his experiences of dealing with introduce a legal duty of candour for the NHS potential physical or psychological harm the aftermath of the death of a young patient in England, something which many clinicians following medical intervention, treatment due to a complex clinical situation. Attempts might think unnecessary, threatening or or drug administration. to engage with the family were unsuccessful, even counterproductive. Peter shared some and made worse by a referral to the General tragic stories of patients whose families had The need for change Medical Council (GMC). It was clear from spent many years trying to get adequate Efforts to reduce harm from adverse events hearing him speak that given the opportunity responses from trusts following adverse have had disappointing results and rates to be candid is just as important to a clinician events, sometimes not even being able to get of reporting of adverse events by clinicians as to a patient. He described a further accounts of what had actually happened. especially have remained low. In the wake experience during another difficult case, which The stories seemed to contain a mixture of of the Francis Inquiry into the events at the led to adverse comments by an external descriptions of inefficient complaints handling Mid Staffordshire Foundation Trust, attention clinical ‘expert’ and some highly personalised systems and deliberate attempts to prevent the attacks in the media. Although colleagues has focussed on the need for increased truth emerging, in order to preserve the trusts’ were supportive, no formal mentoring or reputations. Many of the accounts mirrored transparency when adverse events have support programme existed in his trust and that had been heard at the Francis occurred, both to promote learning to reduce he had not received any formal training on Inquiry. AvMA argued that a legal duty of future risks and to ensure that the duty to disclosure or candour. Our speaker detailed candour was the only thing that would make inform patients and their families after an the highly stressful emotional, professional senior leaders and managers in NHS trusts take adverse event is fulfilled. and psychological impact of these events their obligations to be transparent seriously The NHS in England is now subject to a legal which are recognised as the ‘second victim’ and would reduce, not increase, the risk of legal duty of candour that obliges organisations to phenomenon and represent a real barrier proceedings. Peter was also strongly supportive inform patients and their families if adverse to increased transparency. His personal and of training for clinicians in the communication events have occurred, and which reinforces candid account reinforced what we already skills necessary to fulfil the duty of candour. the ethical duty that clinicians already hold. know from the literature about the ‘second Blair Sadler, former CEO for 26 years at the

10 Commentary February 2016 Rady Children’s Hospital in San Diego and a Patients should be informed promptly and ambiguity should not prevent us from being senior fellow at the Institute for Healthcare openly of significant harm, regardless of candid with our patients. Improvement, spoke about his experiences of whether the information has been requested leading an organisation through several high- or a complaint made. Conclusions profile situations where harm had occurred to The insights gained from the patient safety a significant number of patients and many Professional duty and the seminar are numerous. We heard from three others were put at risk. There were obvious mechanics of the duty of candour champions of candour and transparency, parallels with the events at Mid Staffordshire, A professional duty of candour for clinicians each with their own unique experience but although his organisation’s response was very has been in place for many years and has striving towards a common goal. There are different. In the United States, where the risk been enforced by both the GMC’s Good clearly still significant barriers to increased of legal proceedings is much higher than in Medical Practice, and the joint GMC and transparency in many parts of the NHS the UK, the prevailing atmosphere has been Nursing and Midwifery Council guidance which will impede progress, despite legal and to suppress transparency, as clinicians are entitled ‘Openness and honesty when things professional duties of candour. Clinicians will told that disclosing too much to patients and go wrong: the professional duty of candour’. be reluctant to act in a transparent way if a families will put them and their organisations According to the Medical Defence Union, ‘blame culture’ is allowed to persist, and if they at risk of litigation, although the evidence is 99% of doctors are aware of their ethical do not feel that they will be treated fairly in obligations to patients to provide an apology, that increased transparency actually reduces any investigation by their organisations or by 90% have apologised to a patient involved in litigation risk. Blair spoke of the value of regulators. There are lessons here not just for an incident with 78% stating no repercussions leaders of organisations responding quickly trust management, but for the GMC, the Care when they had told patients about an incident. and transparently when it became clear that Quality Commission and others. Courageous, There is potential for confusion among serious events had occurred, even when the transparent leadership as described by Blair full facts were not yet known. doctors, managers and patients about when Sadler is difficult to find in many parts of our He described three ‘victims’ in any and how each duty applies as the statutory system. We believe now that the has healthcare crisis who should be treated in duty is different to the professional one. been made clear, it will create the momentum the following order of importance: patients Whilst the statutory duty of candour is for healthcare professionals to exhibit such and their families, the staff suffering from ultimately the responsibility of an organisation, leadership, as providers’ compliance with the post-event stress and finally the organisation, doctors, in particular those in more senior roles, law will create a culture of candour, openness whose reputation could be seriously damaged. are relied on to discharge it on behalf of the and honesty at all levels. Blair gave the example of a mystery virus organisation. Seniors are in a position to ensure ‘Second victim’ effects in clinicians need in the children’s intensive care unit and the appropriate actions and investigations to be recognised as a barrier to transparency the subsequent deaths of several patients. are carried out to prevent further harm. There and processes put in place to mitigate Without having much information he called in are a number of guidelines in place to advise these and to support affected clinicians. patients’ families and the media so he could clinicians on the duty of candour: On a more practical level the complexity explain what was known so far and what he > It is important to spend time considering of the communication processes need to and his board were going to do to investigate the appropriate response and logistics of be recognised and we have to ensure that the matter further. Blair set the of the situation. For example, who should there is adequate training for clinicians in the personally speaking with every family member be present while the discussions with the involved confidentially and of personally being patient takes place. necessary communication skills. The overriding message from our seminar available to support staff. The public response > Consider who will lead the investigation, and was that although being transparent is to this was compassion and empathy rather which managers need to be informed. than adversarial, and the reputation of the difficult, it is also the right thing to do and, > When there is uncertainty, this should not organisation was enhanced as a result. as professionals, we have an obligation be an excuse for no disclosure. Clinicians to exhibit leadership to colleagues in the England’s duty of candour should not wait until the outcome of an interests of improved patient safety. We would investigation before apologising. Introduced in November 2014 as a statutory encourage all our colleagues to take a lead in > An apology is not an admission of liability. duty for all primary, secondary, social and ensuring we are candid with our patients at private care providers, the duty of candour is > Timing and location should be considered every opportunity in order to firmly root this intended to ensure that healthcare providers and appropriate. into our everyday practice rather than see it are open and honest with patients when > Offer all patients support, be it emotional or as ‘compliance’. As Don Berwick, President things go wrong with patient care. This gives formal psychological support, with a single Emeritus and Senior Fellow at the Institute patients the legal right to be informed of an point of contact. For Healthcare Improvement, recently said: ‘A error or an adverse event, which has caused rule-bound organisation cannot be truly safe. them at least ‘moderate’ harm, defined Questions remain about exactly how much [Safety] requires things more important than by the National Patient Safety Agency as information to share with patients, when a rules: things like maturity, curiosity, dialogue, ‘significant but not permanent harm’. The law disclosure may cause more harm and when an daylight, reflection, teamwork, hope and trust. imposes this duty on the organisation (not the omission may be misleading due to a real time It’s a tougher job for leaders than simply individual) although in most instances it will be lack of evidence. With time and more open writing and enforcing rules. The difference is, clinicians who communicate with patients and discussions, we physicians may feel that these it works’. n families on behalf of their organisations. questions have firm answers, but the current

February 2016 Commentary 11