By Lorri Zipperer, MA
With year-end comes the time to get serious again after the craziness of the holidays, to reflect and for some of us, to write. Thinking back on sessions I attended at the NPSF Congress in 2014, a session that has stuck with me was Susan Anderson and Geri Amori’s presentation about disclosure. Entitled “The Art and Science of Disclosure,” I knew it would be interesting. (With a bachelor’s degree in studio art, I find anything with “art” in the title to be interesting.)
I also knew that Ms. Amori has an interesting method of presenting content that melds the science of her topics with a creative and engaging approach to bringing them home to her audience. She staged a successful presentation for NPSF in 2004, when Linda Kenney and Rick van Pelt first presented their experience as a patient and a physician involved in a medical adverse event. The disclosure of that error serves as the foundation for Medically Induced Trauma Support Services (MITSS), which Ms. Kenney founded as a resource to provide support to other patients and health professionals dealing with the consequences of medical error. (Kenney and van Pelt 2005) Ms. Amori has also co-authored a chapter with me on what we can learn from improvisation to inform knowledge sharing in the health care space. (Amori et al. 2014).
Disclosure is a complex issue. Sensitive to the personal and emotional nature of the topic, the presenters touched upon what makes discussions of error with patients and families successful, such as respect, trust, humbleness, responsibility, empathy, accuracy, non-defensiveness and healing. Noting that a successful disclosure may still result in litigation or payout and not necessarily make everyone happy, they turned to the primary focus of their talk — what gets in the way of effective disclosure.
The presentation primarily focused on the challenges to effective disclosure:
- Admitting that disclosure is appropriate
- Preparing providers
- Surprising organizers with unexpected participants
- Cultural differences
- Unexpected occurrences at the disclosure
- Communication challenges
- Demanding remuneration at the onset
- Scaring people!
- Denying the need for the conversation
- Debriefing ineffectively or inappropriately
- Assuming the patients and families are happy
The presenters polled the attendees to get a sense of their experience in actually conducting disclosures and then spent extra time on the three barriers that the group saw as most prevalent. In each instance, Ms. Amori introduced the psychological factors that contribute to the problem. To bring a real-world feel to the discussion, Ms. Anderson then shared her experiences at University of Michigan as a member of the team of early adopters there who practice early disclosure and resolution and have noted success on addressing the challenges to disclosure.
- Admitting that disclosure is appropriate: Stressors to beginning the process center around getting clinicians to recognize that it’s the right thing to do—even if the disclosure concerns a known complication or a near miss. Practical advice: Michigan doesn’t keep disclosure training in a silo, it is built into many training and educational opportunities on various levels throughout the organization like Grand Rounds and residency training. They share disclosure success stories regularly. Their support program is available to all in configurations for both teams and individuals.
- Preparing providers: Because clinicians care and believe they did the right thing — they think they are ready for anything and don’t need to practice or prepare for the disclosure. In general clinicians can’t take in the enormity of the situation — their own error is a challenge to their belief in their abilities and the high standards to which they hold themselves. They may believe because they care they don’t need to practice the disclosure. Practical advice: Make sure the participants in the disclosure have all the information they need and how the process will unfold. It is essential they are aware of the facts, understand the context of the event and how it transpired. It’s best to avoid surprise reactions at any point in the discussion.
- Surprising organizers with unexpected participants: Attendees shared their perceptions as to why unexpected people (attorneys, friends, clinicians outside the care circle) arrive for disclosures. Patients feel weak, they don’t trust the proceedings, they are angry. Power is at play in disclosure. Patients and families see health care as having all the power. Surprises give them some leverage. They see power associated with the expectation that money will change hands. Practical advice: A little meeting management can go a long way. Do the best you can to confirm who will be at the meeting and find a private, quiet space that works for that size group. If someone does join you who wasn’t anticipated — don’t overreact.
The session ended with a role-playing exercise that explored how these and other challenges in the session might reveal themselves in an actual situation.
Do you see ways to employ storytelling and role play not only to support learning from error, but to help your staff be comfortable with the process of disclosure? Comment on this post below.
Lorri Zipperer, MA, is the principal at Zipperer Project Management in Albuquerque, NM, specializing in knowledge management efforts and bringing multidisciplinary teams together to envision, design, and implement knowledge sharing initiatives. Among her publications, Ms. Zipperer recently served as editor for two texts, Knowledge Management in Healthcare and Patient Safety: Perspectives on Evidence, Information and Knowledge Transfer, both published earlier this year by Gower Publishing (UK).
Kenney LK, van Pelt RA. 2005. To err is human; the need for trauma support is, too. Patient Safety Qual Healthc. January/February.2:6, 8-9. http://www.psqh.com/janfeb05/consumers.html
Amori G, Chindlund J, Zipperer L. 2014. Strategies for knowledge sharing: lessons from improvisation. In: Zipperer, L. ed. Knowledge Management in Health Care. London, UK. Gower.