Guidelines for HSE Services for the Implementation of the HSE Open Disclosure Guidance Document

people caring for people

Open Disclosure

Communicating withservice users and theirfamilies following adverseevents in healthcare

LAUNCH: 12 November 2013

The HSE and State Claims Agency launched a national policy and guidelines on Open Disclosure (OD) on 12th November 2013. Outlined below are suggestions in relation to how your organisation might effectively implement an open disclosure programme and prepare for the Open Disclosure process. The aim of this document is to assist your organisation in taking a structured, change management approach towards implementing the principles of OD, outlining your responsibilities, how you can demonstrate compliance with these responsibilities and indicating what supports are available to assist you in this process.

Responsibilities of the Organisation

Approx

Time Frame

How to demonstrate compliance

Supports available

A: Preparation

(1) Proposal document must be signed off by senior management team / management board

· Agree proposal and sign off by :

Hospital Group Management Board/Hospital Executive Management Board to include the General Manager/CEO, Director of Nursing and Clinical Director

Or

CHO Chief Officers and senior management staff in the CHO’s

Draft Proposal developed

(2)Review the results of the staff patient safety survey.

Rationale: To establish how quality and safety is perceived by staff across the organisation. This will provide a baseline for post evaluation.

· The HSE have developed and piloted a staff patient safety survey which has been rolled out across the acute hospitals.

· Consider the responses to the specific questions in the survey relating to OD and action as appropriate.

Refer to the HIQA Guide to the National Standards for Safer Better Healthcare 2012

(pages 14-16) and HIQA General Guidance on the National Standards for Safer Better Healthcare September 2012 (pages 96-98).

(3) Include OD as a service deliverable in the service/business plan

· Document as an action in service/business plan .

· Set targets/KPI’s.

Responsibilities of the Organisation

Approx Time Frame

How to demonstrate compliance

Supports available

B: Leadership

(1) The organisation at board level should make a public commitment to implementing the principles of OD.

Note: The evaluation of the 2 year OD pilot project demonstrated the importance of the leadership by and visibility of the senior management board in relation to the success of the project.

· The Hospital Group Manager/CHO Chief Officer, (CEO)/Clinical Director (CD), Director of Nursing (D.O.N.) make a publicly visible and recordable commitment to implement the principles of OD.

· Suggestions include:

· A minuted statement endorsing and committing to the implementation of OD.

· Write a statement endorsing OD in your group/CHO. This statement can then be delivered at staff information sessions and workshops in your respective group/CHO.

· Joint Statement in Organisation Newsletter.

· Board Commitment including promotional materials within the organisation i.e. posters, patient information leaflets, website, induction programmes.

· Creating an expectation that OD is a critical component in the incident management/complaints management process and that all staff are expected to engage in this process as required.

Note: See additional recommendations for CHOs in Appendix 1 of this document

Resources available on www.hse.ie/opendisclosure

Responsibilities of the Organisation

Approx

Time Frame

How to demonstrate compliance

Supports available

B. Leadership - continued

(2)Nominate leads/champions who will be responsible for leading on OD.

Note: These can be leads with existing responsibilities for clinical governance, risk management, quality and risk, complaints management. Ideally there should be leads operating at senior clinician level.

· Identify leads/champions for OD within each hospital, hospital group, CHO/NAS/ other organisation.

· Publicise within the organisation the names of the nominated leads/champions for OD.

· The OD lead/champion can liaise with senior management, local trainers and the OD National Project Team.

· Provide adequate resources to support the implementation of an open disclosure programme

Guidance and criteria to assist in the identification of OD leads/champions.

See the HSE and SCA National OD Programme Briefing Documents

1: Acute Hospitals and

2: CHO’s 16/02/2015 which provide guidance on the proposed role of an OD champion.

Workshops for OD leads

(3) Set up an internal OD committee to oversee the strategic running and outcomes of the project.

· This committee may be established as a sub committee of any existing quality, safety and risk or clinical governance committees or alternative committee or as a regular agenda item on any of these committees.

· Establish terms of reference for this committee incorporating all the principles of OD and how the OD project will be managed internally.

· The OD committee members will be familiar with the OD policy, guidelines, and supporting documents and have attended OD training to ensure they are fully aware of the commitment required.

Provide sample terms of reference for the committee

Responsibilities of the Organisation

Approx

Time Frame

How to demonstrate compliance

Supports available

(4)Ensure consumer participation/involvement on this committee.

· There should be consumer participation, involvement and documented evidence of patient feedback in relation to the implementation of OD.

The national train the trainer programme will include the training of patient representatives/patient advocates as co-trainers.

C: Local Policy

(1) Review and strengthen existing local/internal policies to ensure that they align with the OD national policy and guidelines .

(2) Ensure that the OD policy and any relevant/associated policies are aligned within risk management and clinical governance processes.

Example: Should be incorporated into existing Quality and Risk management policies such as Clinical Governance, Incident Reporting, Serious/Critical Incident Management, Complaints procedure.

· Review any existing OD or integrated policies to align with the OD national policy and guidelines. This policy should be accompanied by a service specific implementation plan

· Identify how OD is embedded with risk management and clinical governance processes including incident management and complaints management.

· Consider how the OD process is captured in incident reporting forms/NIMS/internal incident management checklists etc.

· Consider a standard hospital group or CHO OD policy.

Resource Pack

Sample OD policy from other sites

See HSE/SCA National Policy and Guidelines launched in November 2013 and additional supporting resources available on

www.hse.ie/opendisclosure

Provide national policy in word format to assist in local policy development.

Responsibilities of Service

Approx

Time Frame

How to demonstrate compliance

Supports available

(D)Support for staff and patients/service users

Identify resources within the service which will support staff during and following the OD process including:

a) Following an adverse event

b) During the review process

(2)Identify key contact personnel who will liaise directly with the patient/family following an adverse event and during the OD process.

(3) Ensure Patient Advocacy Groups operating within the organisation e.g. Patient Focus/CAIRDE are informed of the work in relation to OD.

· Provide a list of resources including the names of identified staff support persons within the organisation.

(Staff Support Persons would benefit from training in professional debriefing and trauma counselling).

Example:

· Establish what supports are available for staff from the Occupational Health Department/EAP e.g. counselling, debriefing, general staff support mechanisms.

· Develop a list of support staff including various methods of contact e.g. email, phone, meeting times

· Consider developing a peer support programme.

· All teams should have an in-built process and programme of staff support following adverse events including informal team debriefing, assessment of the welfare of staff involved and ongoing support going forward.

· Identify key contact staff .

· Share the service/organisations commitment to OD with patient advocacy groups/patient forums.

· Invite members of these organisations to select a representative(s) to sit on the OD Committee/alternative committee.

· Provide information to the groups relating to the work on OD.

· Include these groups in promotional activities and the attendance at and delivery of training.

· Involve patient representatives in OD training programmes.

HSE Occupational Health Department/Employee Assistance Programme.

The HSE/SCA booklet “Supporting staff following an adverse event: The ‘ASSIST Me’ Model available at ww.hse.ie/opendisclosure

The following HSE Policies available at www.hse.ie.

(i) HSE Policy for Preventing and Managing Critical Incident Stress 2012.

(ii) HSE Policy for the Prevention and Management of Stress in the Workplace 2012.

Provide criteria to select key contact staff.

Responsibilities of Organisation

Approx Time Frame

How to demonstrate compliance

Supports available

E: Training

(1) Train staff as OD trainers.

(2) Identify staff within the organisation who should attend OD training i.e. staff who will be disclosing adverse events i.e. consultants and other relevant clinical staff, heads of multidisciplinary teams, leads in OD etc

(3) Align existing training programmes to incorporate OD guidance e.g. incident management, complaints management, consent

(4) All named persons identified by the organisation should attend OD training.

· Identify staff to be trained as OD trainers.

· Set targets for training each year as part of the service annual training programme.

· Ensure trainers are given protected time to deliver training and to attend updates.

· OD training should be mandatory training e.g. 40 minute information sessions for all staff and OD workshops for all managers and clinical staff i.e. any staff who may have to engage in OD discussions.

· Workshops should be CPD accredited and run at times to encourage the maximum attendance of staff. (Workshops are currently accredited)

· Maintain register of staff attendance at training.

· Revise induction programmes to incorporate OD training for all staff groups.

· When revising staff handbooks, induction checklists, complaints procedure, quality and risk management procedures incorporate OD.

· Incorporate OD into Corporate Induction Training packages locally.

Train the trainer programme and ongoing support for trainers .

Sample job specification and proposed criteria developed to assist in the selection of staff as trainers available from angela.tysall@hse.ie

Resources for training available on www.hse.ie/opendisclosure

Network for trainers.

Updates for trainers.

Telephone and email support

Electronic and on-line resource pack.

Accredited E-learning module being developed with the RCSI in 2015.

Performance and development should continue to include OD on existing training programmes

Work ongoing with undergraduate and post graduate training establishments.

Responsibilities of Organisation

Approx Time Frame

How to demonstrate compliance

Supports available

F: Visibility

Raise awareness of the principles of OD and your internal policy among staff, patients and the public, making information visible to all.

· Promote the principles of OD among staff via: newsletters, team meetings, intranet, special interest meetings, conferences, governance meetings, quality and risk committees etc (any suitable existing forums).

· Include OD in staff induction programmes (local and Corporate).

· Ongoing training of key individuals involved in discussions/promotion of OD.

· Encourage use of the e Learning tool when available (currently under development).

· Encourage the use of the online staff awareness power point presentation with voice over when available (Currently under development – available Q3-Q4 2015).

· Include in promotional materials: Patient information leaflets, websites, and posters.

· All staff to sign off on internal policies which incorporate OD.

Provide e learning package (Later Q3-4 2015)

Provide resource pack including a Patient information leaflet and staff briefing document - available at www.hse.ie/opendisclosure

Update online supports.

Responsibilities of Organisation

Approx

Time Frame

How to demonstrate compliance

Supports available

G. Audit

Ongoing Audit of OD .

Suggested areas to audit as follows:

· The Patient/Service User experience of the OD process –

· Staff experience of the OD process

· Management of OD as per the 10 principles

· Documentation of OD

· Include audit of OD as part of ongoing internal audit processes.

· 6 monthly audits of NIMS forms in relation to OD with review of documentation in clinical record.

· Follow up conversations with service users and families following OD meetings to assess experience.

· Follow up conversations with staff involved in OD meetings to assess experience

Provide sample audit tools.

Liaise with national audit programmes.

H. Evaluation

Evaluate the impact of OD in relation to:

(a)Patient/service user experience

(b)Staff experience

(c) Number of claims

(d) Management of complaints/impact on escalation of complaints.

· Discuss process with staff and service users.

· Establish learning.

· Liaise with National Project Team

Responsibilities of Organisation

Approx

Time Frame

How to demonstrate compliance

Supports available

I: Clinical Governance

Meeting the requirements of Clinical Governance in relation to OD

Consider what structures/processes are in place to:

(a)Ensure that OD happens

(b)Manage situations when there is a difference of opinion as to whether OD should occur or not

(c)Ensure OD is integrated with other clinical governance systems and processes including:

· Clinical incident reporting and management procedures,

· Systems analysis reviews,

· Complaints management

· Privacy and confidentiality procedures.

(d) Ensure accountability and clinical ownership for OD

(e) Promote learning e.g. reflective practice, discussion of cases, patient stories.

(f) Involve patients in the roll out of open disclosure e.g. patient stories, patient representatives on training programmes.

NOTE: Assessment of OD standard 3.5 HIQA National Standards for Better Safer Healthcare 2012 pg. 87-88 available at http://www.hiqa.ie/standards/health/safer-better-healthcare

Proposal agreed by: ___________________________

Date: …………………………….

___________________________

_____________________________

a) Implement a plan for open disclosure in non-hospital settings. This should start with a primary care open disclosure implementation project, led by the National Director for Primary Care and implemented through a ‘train-the-trainer’ approach led by the national open disclosure leads in the HSE and SCA. The project should give a specific focus to GPs and offer training and guidance for GPs in partnership with ICGP, the IMO and MPS. The objective is that within five years open disclosure will be implemented in primary and community care.

b) Take the learning from this as the basis for implementing open disclosure into mental health services, disability services and residential care for older people. It will be necessary to draw up guidance that is specific to each sector.

c) Ensure that open disclosure is effectively integrated into the work of primary care teams and across the wider community healthcare organisations.

d) Align and coordinate open disclosure between hospital and primary/community care so that it is an integral part of communication during handover and hospital discharge, for example, to ensure that GPs are aware that if an adverse event has occurred that open disclosure has taken place.

e) Seek funding for a primary care open disclosure implementation project, with the objective of sharing learning and good practice approaches across all primary care teams.

f) Develop the ‘train-the-trainer’ programme for community healthcare organisations to include sector-specific guidance, case scenarios and resources relevant to primary care teams and GPs – Note: Train the trainer training is available by contacting the national project leads at angela.tysall@hse.ie or aduffy@ntma.ie

g) Draw together evidence, case scenarios that are relevant to a diversity of health and social care settings, and particularly in providing guidance on implementing open disclosure and communicating with people with mental health difficulties, people with physical and sensory disabilities and older people, and consider the implications of this in relation to consent policy.

PROPOSAL FOR HEALTH AND SOCIAL CARE SERVICES

A GUIDE TO THE SUCCESSFUL IMPLEMENTATION OF THE HSE OPEN DISCLOSURE POLICY USING A CHANGE MANAGEMENT APPROACH

A CHANGE MANAGEMENT APPROACH

HSE National Open Disclosure Policy launched

12th November, 2013

INDEX

Content: Page:

A. Preparation 3

B. Leadership4

C. Local Policy6

D. Support for Staff and Patients/Service Users 7

E. Training 9

F. Visibility 10

G. Audit 11

H. Evaluation 11

I. Clinical Governance 12

Appendix A: Additional Recommendations for Community Healthcare Organisations 14

Proposal for Health and Social Care Services: Implementing the Principles of OD

Appendix A

Additional Recommendations for Community Healthcare Organisations

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1

AT/AD HSE Quality Improvement Division and State Claims Agency

Revised AT November 2016

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LAUNCH: 12 November 2013

Main Heading: Arial Regular (32pt)

Presenter’s Name: Arial Regular (20pt)

Job Title and Date: Arial Regular (14pt)

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people caring for people

Open Disclosure

Communicating withservice users and theirfamilies following adverseevents in healthcare