March / April 2010
Disclosure and Apology: What’s Missing?
Advancing Programs that Support Clinicians
In November 1999, I was scheduled for total ankle replacement surgery at a major medical facility in Boston, Mass. Instead of waking up with a new ankle, I awoke several days later to find that the nerve block had been delivered accidentally to my heart, causing me to go into cardiac arrest. I had been rushed into a nearby operating room that had been prepared for another patient’s cardiac surgery. I received an emergency sternotomy with cardiopulmonary bypass for cardiac resuscitation. Eventually, I made a full recovery.
That incident had a profound effect on my family, my friends, and me. I also was exposed to a side of healthcare most patients and families do not see: I witnessed the emotional impact the adverse event had on my orthopedic surgeon, the anesthesiologist, code team, and other healthcare providers. It wasn’t just business as usual for them; they suffered, too, and found themselves as unsupported as my family and I were. I knew that something needed to be done.
— Linda Kenney
Ten years following Linda Kenney’s medically induced trauma, the organization she founded to “support healing and restore hope” for patients, families, and clinicians following adverse events co-sponsored an invitational forum about ways to offer emotional support to clinicians. Collaborating with the Massachusetts Medical Society (MMS), CRICO/RMF, and ProMutual Group, Kenney’s organization, MITSS (Medically Induced Trauma Support Services), hosted the event at the MMS offices in Waltham, Mass., on March 13, 2009, during Patient Safety Awareness Week.
Sixty-seven attendees, speakers, and facilitators discussed ways to offer emotional support to clinicians who have been involved in adverse medical events, including events that resulted in harm to patients and might have been prevented. Most participants represented institutions in Mass., including hospitals, insurers, and medical societies, where they work as physicians, nurses, risk managers, patient safety officers, executives, claims representatives, employee assistance program (EAP) support staff, among other positions. Jim Conway, senior vice president at the Institute for Healthcare Improvement, and Saul Weingart, MD, vice president of patient safety and director of the Center for Patient Safety at Dana-Farber Cancer Institute, led participants through a full day of rigorous exploration and discussion.
The case studies that follow are summaries of presentations given at the forum by representatives of two organizations with established programs for clinician support: Jerry O’Keefe at Kaiser Permanente and David DeMaso, M.D., at Children’s Hospital Boston.
Kaiser and Children’s are among a small but growing number of institutions that offer programs specifically designed for support of clinicians and staff members following adverse events. The forum found that successful programs tend to be local solutions, reflecting the circumstances and culture of the institution and including some element of peer support. Brigham and Women’s Hospital in Boston relies heavily on peer support for its program, as does the University of Missouri Health System (MUHS) in Columbia, Missouri. MITSS recognized the forYOU Team at MUHS for its peer-to-peer support network with a MITSS HOPE Award, which is given annually to individuals and institutions that exemplify the organization’s mission.
Attendees also heard Paul McTague, Esq., partner at Martin, Magnuson, McCarthy & Kenney, dispel some of the myths about the legal implications of clinician support programs.
In November 2009, MITSS released Disclosure and Apology — What’s Missing? Advancing Programs that Support Clinicians, a report that summarizes presentations and learnings from the forum. The full report may be downloaded at MITSS.org and PSQH.com.
This work is still in its early stages, but attendees, presenters, and facilitators were able to establish recommendations for institutions developing clinician support programs:
- Visible support from executive and medical leaders is necessary for the success of support programs.
- Clinicians involved in disclosure and apology discussions may need special attention and are more likely to communicate effectively if they also feel supported.
- Fear of legal action need not prevent clinicians from discussing their feelings following an adverse event.
- Support programs may be characterized as an investment in an institution’s workforce, which offers an approach to making a business case for these programs.
At speaking engagements throughout the United States and overseas, Kenney has observed increasing interest in the clinician’s experience following adverse events:
Over the years, I have been overwhelmed by the stories clinicians have shared with me about the trauma they’ve experienced following adverse events. It appears that nearly every clinician has experienced the emotional impact of an event of one kind or another. In many cases, the event still haunts them. Early on, the response I often heard after describing the MITSS program was, “That’s nice; keep up the good work.” The message has shifted, and now I often hear, “We need to do a better job supporting our staff; can you help us?”
MITSS looks forward to continuing to work with clinicians and hospitals, as well as patients and families, to understand and alleviate the emotional impact of medically induced trauma. The Forum helped to reaffirm MITSS’s mission and commitment to supporting clinicians impacted by adverse events. The resulting report serves to inform the work around clinician support in the future.
For more information about clinician support and other MITSS programs, visit MITSS.org.
The Program for Clinician Support at Kaiser Permanente
Kaiser Permanente, the nation’s largest integrated health system, has had a program in place since 2004 for support of clinicians and staff following adverse events. Jerry O’Keefe, national director of Kaiser’s employee assistance program (EAP), describes how the support program is woven into Kaiser’s culture, saying, “We can’t afford not to do it; it’s the right thing to do; it’s expected; we’ve created a culture that believes in it.” In addition to critical event response, the program encompasses outreach, training, and pre-event simulation and is supported by a strong business case.
Kaiser initiated the program as part of its response to the Institute of Medicine’s report about medical error, To Err Is Human: Building a Safer Health System (2000). Kaiser recognized that supporting its most valuable resource — providers and staff members—would potentially help reduce medial errors, improve the quality of care, increase productivity, and foster goodwill, trust, and appreciation. The program is aligned with Kaiser’s commitment to sustaining a healthy workforce and helps fulfill a state mandate in California to attend to physician well-being. Receiving support for their emotional needs helps providers and staff members restore their professional confidence following a crisis and return to productive work more quickly and effectively than if they were left to suffer on their own.
Teams and departments also work better in a culture that includes this kind of employee assistance. O’Keefe observes that the aftermath of critical incidents and adverse outcomes can “shine a bright light on pre-existing circumstances” in a department or among care team members, revealing past grievances, anger, and frustration. Pre-event training, which includes simulation of adverse events and emotional reactions, and post-event support help resolve conflict and lead to better communication and performance.
Enhanced productivity of individuals and teams, and improved employee satisfaction and retention all help make the business case for this program.
Kaiser’s program enjoys the support of executive and departmental leadership in addition to other powerful stakeholders such as labor. Labor unions are crucial supporters, as 75% of Kaiser Permanente employees are unionized, including all nurses. The EAP works actively to sustain the support of these groups and individuals by continually reaching out with targeted information, training, and evaluation. Constant communication keeps the program relevant and top-of-mind. According to O’Keefe, “A constant finger on the pulse sustains culture change.” The program also maintains its status by being written into the policy and procedures for adverse event response.
O’Keefe describes the EAP’s work in this area as managing and reconciling the “art and science” of critical event response. The science involves being clear with providers about discoverability and steering them to safe and appropriate outlets for discussion of the facts of an event: risk management, quality, medical/legal, ombudsmen, defense counsel, spouses, and domestic partners. The art lies in helping individuals evaluate and process their reactions as well as identifying individuals who may be in need but not seeking help. Anticipating problems and reaching out to individuals is different from the traditional role the EAP, but Kaiser has found it to be important in adverse event response. O’Keefe says, “We don’t want to take the chance that we’ll miss something, that someone will be left alone.”
When an adverse event occurs, Kaiser’s Situation Management Team leads all aspects of the response and contacts the EAP. Before working directly with members of the care team, EAP staff members work behind the scene to learn as much about the event and individuals’ circumstances as possible to provide context. O’Keefe comments that some of the information gathering may seem excessive at the time, but allows the EAP to be most effective in its work. In collaboration with managers and the Situation Management Team, the EAP considers possible effects on all staff working on all shifts and provides appropriate interventions and follow-up. The EAP has a “best case” plan for providing support, but stays flexible about logistics, adapting to immediate circumstances and the needs of individuals.
Kaiser’s EAP also takes a flexible approach to the kinds of support it provides. The EAP has a targeted assistance program for physicians and also helps nurses with peer support by supplying guidance, consultation, and direction, in addition to debriefing, one-on-one counseling, referral, and coordination with the institution’s chaplaincy and social services.
Kaiser’s approach to employee support includes honoring the individual’s perception of an event. What constitutes an adverse outcome or critical event is not the same for everyone, and reactions will be highly individual. Caregivers and staff members who were not directly involved may still feel ripple effects from an adverse event. Similarly, different kinds of events — adverse clinical events, intense regulatory scrutiny, negative media exposure, and others — may cause anxiety and the need for support.
Kaiser’s EAP has learned valuable lessons during its six years of supporting clinicians and staff members after critical events. O’Keefe recommends careful planning in the early stages of program development, securing leadership support at all levels, and clarifying the roles of responders prior to rolling out the program. EAPs need to stay flexible and partner closely with the risk and quality departments. In addition to vigilance and outreach, it is important to follow up periodically with partners, providers, and staff members even after an event is considered closed.
The Program for Clinician Support
at Children’s Hospital Boston
The Office of Clinician Support (OCS) at Children’s Hospital Boston is a free, on-site service, available to anyone at Children’s who does clinical work with patients, for help with any problem they may be having, whether it is work-related or personal. David DeMaso, M.D., psychiatrist-in-chief and chairman of psychiatry at Children’s, has been head of the OCS since the program began in 2004. The OCS evolved from earlier programs as DeMaso, who started at Children’s as consulting psychiatrist to the medical service, found himself called upon to provide broader services to groups of clinicians as well as individuals. That evolved into the Office of Physician Support and then the OCS, which was part of Children’s response to a significant adverse event. The OCS has broad responsibility and works together with Children’s employee assistance program (EAP), various sources of peer support, and other hospital departments, especially quality, patient safety, and legal services.
The premise of Children’s OCS is that stress and burnout lead to suboptimal attitudes and practices, which compromise patient care and sometimes patient safety. The OCS offers proactive training and support to decrease stress and improve patient care. DeMaso believes that self-understanding promotes resiliency. He observes, “Too often in medical settings, people seek quick solutions before they really understand what is going on. The premise of a lot of what we do [at the OCS] is to help people understand what they’re facing.”
The OCS is a safe place where clinicians can voice concerns, organize and evaluate their thoughts, assess their feelings, and reach decisions. This work is done in the context of self-awareness, transparency, and problem solving. As they listen to individuals who come for help, DeMaso and his colleague, Linda Coyne, RN, MSW, listen also for trends indicating larger problems that may have impact on patient care and the culture within the hospital.
Clinicians who come to the OCS for help relative to adverse events come with different mind sets, from certainty that they have committed an error that caused harm, to ambiguity about what role they played in an event, to doubts about what may or may not have been a preventable outcome. DeMaso emphasizes the importance of understanding the context for all of these circumstances. The work environment at Children’s is high volume, high tech, and high demand. Recent budget reductions have increased pressure on clinicians to do more with less. Their patients tend to be extremely sick, and parents are often highly stressed and frightened. The environment has lots of safety and quality requirements. Clinicians working in this environment tend to be altruistic high-achievers who have high expectations for their own performance and a deep sense of responsibility for the well being of patients and families. An adverse event will often cause these clinicians to doubt their practice, fear losing their job or license, fear facing legal actions, and dread losing the respect of their peers.
When dealing with the aftermath of an actual adverse event, DeMaso and Coyne watch for symptoms in individuals who were in close proximity to the event as well as those involved indirectly. DeMaso describes what he often sees in these circumstances as traumatic stress and hyper-arousal.
DeMaso and Coyne are also alert to the “re-traumatizing” effect of debriefing and investigation. Regardless of how supportive and nice the investigators may be, the process of reliving the effect, sometimes repeatedly, may contribute to a post-traumatic stress response.
DeMaso reports that the beneficial effects of peer support can’t be over-estimated. He describes the power of what he calls the “modeling surprise,” when a colleague, especially in a position of power, shares his or her own story of error or adverse outcome with a clinician dealing with a recent event. For each clinician involved, telling his or her own story and examining all contributing factors can help develop understanding and, in time, resiliency. In addition to simply listening, counselors can help by correcting cognitive distortions, either in individual sessions or during group interventions.
Peer support can take many forms. At Children’s, Collaborative Office Rounds offer peer support in the course of discussing cases on a regular basis with a pediatrician and child psychiatrist as facilitators. Two of these groups at Children’s have been meeting for 20 years, which seems to require consistent leadership within the group. DeMaso points out that other triggers for meetings, such as the Joint Commission requirement for team meetings, offer opportunities for collaboration and support. Even if the meeting is only 10 minutes long, it’s an opportunity for peer engagement.
The OCS has worked with others at Children’s to help clinicians develop knowledge and resilience proactively, without reference to a specific event. Simulation training programs prepare clinicians to act as coaches for their peers when bad things happen. For this program, Children’s Institute for Professionalism and Ethical Practice has developed specific scenarios and hires professional actors to play the roles of patients and families, improvising as clinicians react spontaneously to events in the scenarios. The OCS facilitates numerous support groups and educational programs for specific needs and to enhance collaboration and communication while reducing stress in the work environment. On a number of occasions, the OCS has provided consultation and coaching regarding difficult personnel and systems issues that impact adversely on program management, staff morale, and patient care.
The OCS at Children’s surveyed its clients about satisfaction with their office visits in 2005, 2006, and 2008. With an overall 36% response rate, the OCS has seen improvement since 2005 and mean scores in 2008 of 95 to 100 on a 100-point scale. The single question that received a lesser score — 84.80 — asked if clients experienced reduced stress after consultation. DeMaso comments that many problems can’t be fixed quickly or completely. He points out, “You can’t get rid of all your stress, but even a few minutes of support can help reduce it. That kind of outreach can begin to change the culture. It can help people be more alert and work together. It can help banish the ‘cone of silence’ that’s been true for a long time. This is just one example of one program that can be helpful. OCS can be a first step.”
Susan Carr is editor and associate publisher of Patient Safety & Quality Healthcare and co-author with MITSS of Disclosure and Apology — What’s Missing? Advancing Programs that Support Clinicians. Carr may be contacted at email@example.com.