Action 1.12 states

The health service organisation:

  1. Uses an open disclosure program that is consistent with the Australian Open Disclosure Framework
  2. Monitors and acts to improve the effectiveness of open disclosure processes

Intent

An open disclosure process is used to enable the health service and clinicians to communicate openly with patients following unexpected healthcare outcomes and harm.

Reflective questions

How are clinicians trained and supported to discuss with patients incidents that caused harm?

How is information from the open disclosure program used to improve safety and quality?

Key tasks

  • Adopt and implement the Australian Open Disclosure Framework in a way that reflects the context of service provision.

  • Ensure that members of the workforce who will be involved in open disclosure are trained.

  • Periodically conduct audits that focus on the management of clinical incidents and consistency with the Australian Open Disclosure Framework.

Strategies for improvement

Hospitals

Open disclosure is a discussion with a patient or carer about an incident that resulted in harm to the patient. Open disclosure is:

  • A patient and consumer right
  • An essential professional requirement and institutional obligation
  • A normal part of an episode of care should the unexpected occur
  • An attribute of a high-quality service organisation and an important part of healthcare quality improvement.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Governing bodies should lead the implementation of an effective open disclosure program by:

  • Requiring organisations to adopt the Australian Open Disclosure Framework
  • Ensuring that enough resources are allocated to support implementation of the framework
  • Ensuring that the responsibility for implementing the framework is allocated to an individual or committee
  • Ensuring that there is a system in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Reviewing regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Leading a ‘just culture’ marked by openness and constructive learning from mistakes.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Implement a monitoring and reporting process for open disclosure events to ensure that they are followed up and improvements are actioned
  • Review open disclosure events to find out how the open disclosure program could be improved
  • Provide access to training and support for relevant members of the workforce who have responsibility for managing issues involving open disclosure within the organisation
  • Provide access to, or require proof of, training for any credentialed clinicians who will be involved in open disclosure processes
  • Learn from system errors that culminate in poor patient outcomes.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.

Day Procedure Services

Open disclosure is a discussion with a patient or carer about an incident that resulted in harm to the patient. Open disclosure is:

  • A patient and consumer right
  • An essential professional requirement and institutional obligation
  • A normal part of an episode of care should the unexpected occur
  • An attribute of a high-quality service organisation and an important part of healthcare quality improvement.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Ensure that responsibility for implementing the framework is allocated to an individual or committee
  • Ensure that a system is in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Review regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Provide training and support for the relevant members of the workforce who will be involved in open disclosure in the organisation, including those responsible for managing open disclosure issues.

In a day procedure service, open disclosure incidents are most likely to occur in the theatre setting, and involve the surgeon or anaesthetist. The organisation should ensure that credentialed medical and other practitioners are aware of policies, procedures, protocols and by-laws regarding open disclosure, and cover this requirement through their contractual arrangements.

The performance of credentialed medical and other practitioners who participate in open disclosure incidents should be monitored by a medical advisory committee or through the incident management and investigation system.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt the established open disclosure framework.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt and implement the Australian Open Disclosure Framework in a way that reflects the context of services provided.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Ensure that responsibility for implementing the framework is allocated to an individual or committee
  • Ensure that a system is in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Review regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Periodically conduct audits that focus on the management of clinical incidents and consistency with the Australian Open Disclosure Framework
  • Provide training and support for the relevant members of the workforce who will be involved in open disclosure in the organisation, including those responsible for managing open disclosure issues.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.

Hospitals

Open disclosure is a discussion with a patient or carer about an incident that resulted in harm to the patient. Open disclosure is:

  • A patient and consumer right
  • An essential professional requirement and institutional obligation
  • A normal part of an episode of care should the unexpected occur
  • An attribute of a high-quality service organisation and an important part of healthcare quality improvement.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Governing bodies should lead the implementation of an effective open disclosure program by:

  • Requiring organisations to adopt the Australian Open Disclosure Framework
  • Ensuring that enough resources are allocated to support implementation of the framework
  • Ensuring that the responsibility for implementing the framework is allocated to an individual or committee
  • Ensuring that there is a system in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Reviewing regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Leading a ‘just culture’ marked by openness and constructive learning from mistakes.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Implement a monitoring and reporting process for open disclosure events to ensure that they are followed up and improvements are actioned
  • Review open disclosure events to find out how the open disclosure program could be improved
  • Provide access to training and support for relevant members of the workforce who have responsibility for managing issues involving open disclosure within the organisation
  • Provide access to, or require proof of, training for any credentialed clinicians who will be involved in open disclosure processes
  • Learn from system errors that culminate in poor patient outcomes.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.

Day Procedure Services

Open disclosure is a discussion with a patient or carer about an incident that resulted in harm to the patient. Open disclosure is:

  • A patient and consumer right
  • An essential professional requirement and institutional obligation
  • A normal part of an episode of care should the unexpected occur
  • An attribute of a high-quality service organisation and an important part of healthcare quality improvement.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Ensure that responsibility for implementing the framework is allocated to an individual or committee
  • Ensure that a system is in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Review regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Provide training and support for the relevant members of the workforce who will be involved in open disclosure in the organisation, including those responsible for managing open disclosure issues.

In a day procedure service, open disclosure incidents are most likely to occur in the theatre setting, and involve the surgeon or anaesthetist. The organisation should ensure that credentialed medical and other practitioners are aware of policies, procedures, protocols and by-laws regarding open disclosure, and cover this requirement through their contractual arrangements.

The performance of credentialed medical and other practitioners who participate in open disclosure incidents should be monitored by a medical advisory committee or through the incident management and investigation system.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt the established open disclosure framework.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt and implement the Australian Open Disclosure Framework in a way that reflects the context of services provided.

An open disclosure discussion should include:

  • The elements of an apology or expression of regret (including the word ‘sorry’)
  • A factual explanation of what happened
  • An opportunity for the patient to relate their experience
  • An explanation of the steps being taken to manage the event and prevent a recurrence.

Health service organisations implementing an open disclosure program should:

  • Develop or adapt policies, procedures or protocols that are consistent with the Australian Open Disclosure Framework
  • Ensure that responsibility for implementing the framework is allocated to an individual or committee
  • Ensure that a system is in place for monitoring compliance with the framework; all variations from the framework should be investigated and addressed
  • Review regular reports on open disclosure to ensure that the principles and processes of the framework are met
  • Periodically conduct audits that focus on the management of clinical incidents and consistency with the Australian Open Disclosure Framework
  • Provide training and support for the relevant members of the workforce who will be involved in open disclosure in the organisation, including those responsible for managing open disclosure issues.

Examples of evidence

Select only examples currently in use:

  • Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework
  • Reports on open disclosure that are produced by the health service organisation
  • Information and data on open disclosure presented to the governing body and relevant committees
  • Committee and meeting records about issues and outcomes relating to open disclosure.