A Medical Administrator’s View of Open Disclosure

As a medical administrator, I have been involved in two Open Disclosure processes. These events required a small team who were able to offer an initial apology, instigate immediate response, including ensuring no financial cost to the patient, investigate the event, using Root Cause Analysis processes, and report back to the patient the outcomes explaining why the event occurred and what was to be done to prevent future similar events. On one occasion the relevant clinician was deeply involved. On the other occasion the clinician declined direct involvement, and therefore some of the questions posed by the patient could not be answered.

Both times the patient was very grateful to have been properly informed and to learn of steps to prevent a recurrence. Each time, however, there was much emotion (tears) from all sides especially during the final meeting. On both occasions it was the patient’s support person who was most upset to go back over the incident, the patient remaining calm and interested to find out what had happened.

From start to finish each process took about a month. When done well, Open Disclosure is difficult, time consuming, and emotional. Support is needed not only for the victim but also staff, especially the doctor.

It seems though that the term has come to mean any process applied to the handling of frequent complications that occur in health care.

All clinicians especially proceduralists have felt the discomfort of explaining unintended poor outcomes or surgical complications to patients. This discussion is expected, fair and a far better approach than avoiding the conversation. Call it Open Disclosure if you wish, but it is just the right thing to do.

Is there evidence that Open Disclosure reduces claims?

Studies have surveyed a variety of populations to determine their views as to the impact that open disclosure would have on litigation (US health insurer members¹, parents of children presenting to ED^2, medical outpatients; German citizens). The findings in these studies generally reflect a view that open disclosure reduces litigation. However, all these studies are subject to significant criticism in that they deal with hypothetical scenarios in simulated populations rather than observing actual outcomes following open disclosure adoption. A similar study by Studdert in 2007³ found that the study population (senior experts in health care risk management) predicted that in cases involving serious injury, claim numbers would increase. Other studies have looked at the motivation to litigate and sought to extrapolate these results to open disclosure outcomes.

The most widely cited study followed the Lexington (Kentucky USA) Veterans Hospital in 1987⁴ where a full disclosure policy was implemented. The policy also included an early offer of compensation where sub-standard care resulted in harm, which potentially confounded the effect that open disclosure had on a variety of litigation outcomes. The study found that the costs of litigation were reduced, although the number of claims were not.

The University of Michigan Health System⁵ adopted a similar approach providing open disclosure coupled with an early offer of settlement if substandard care was found to be causal to the harm. Significant improvements were also made to risk management handling as well. They experienced a reduction in the absolute number of claims, litigation costs were more than halved and time to settlement was reduced. Whether these laudable outcomes were related to open disclosure or to a variety of other factors is not clear.

An excellent Canadian review article by Jill Taylor⁶ summarises the major publications on this topic (at Appendix A) up until October 2007.

Also see our special feature article: "Open Disclosure".

Dr Patrick Lockie is a medical administrator, a Member of MDA National and our President's Medical Liaison Council (VIC).

¹ Mazor, KM et al. Disclosure of medical errors: what factors influence how patients respond? J Gen Intern Med. 2006 Jul; 21(7): 704-10

² Hobgood, C et al. Parental preferences for error disclosure, reporting, and legal action after medical error in the case of their children. Pediatrics. 2005 Dec; 116(6): 1276-86.

³ Studdert, DM et al. Disclosure of medical injury to patients: an improbable risk management strategy. Health Aff (Milwood)2007; 26:215-226

⁴ Kraman SS, Hamm G. Risk Management: extreme honesty may be the best policy. Ann Intern Med. 1999 Dec 21; 131(12): 963-7.

⁵ Boothman RC et al. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sci Law. 2009 Jan; 2(2): 125-59

⁶ Taylor, J. The impact of disclosure of adverse events on litigation and settlement: A review for the Canadian Patient Safety Institute. Available here.