Sorry Works! Tip: Include Disclosure in Quality & Risk Reviews
In hospitals and insurers all across the country, quality and risk committees are continually looking at serious events to learn from potential mistakes and system problems and spread knowledge inside and outside the walls. All good stuff. These reviews typically explore the clinical facts in great detail -- which is great. After so many years of deny and defend and justification of bad care, it is very refreshing to see healthcare professionals taking an honest look at adverse events. Here's a tip: Your quality and risk committees should review the details of post-event discussions with patients and families as closely as they review the clinical facts. Because the care prior to the event could have been good, but if the conversations and behavior post-event are bad you still might get sued. Make post-event discussions and disclosure part of the required reporting to the quality and risk committees. In addition to providing the clinical facts, front-line staff need to share details of conversations they had with the patient and family, including potential next steps. Moreover, we can learn from the details of post-events discussions and interactions with patients/families just like we can learn from details of care rendered pre-event. Finally, by requiring that the details of post-event discussions be reported to quality and risk committees, we are sending a message to front-line staff that disclosure is important and expected!