Openness is catching

Toby Reynolds reports back from an interactive session on ‘Openness and honesty: the professional duty of candour’ at the Patient First conference 2014

Like most doctors I am very worried by the idea of avoidable harm in medicine. Recent decades have brought unprecedented advances in treatment through research and innovation. Yet unfortunately many of our patients still suffer harm that could have been prevented. Clinical work is fraught with opportunity for error, either by individuals or systems. To do the best for our patients, we need to acknowledge that mistakes can happen, and do more to improve the way we learn from them, as individuals and as organisations. Although there are many areas in which we do this well, we still lag behind other safety-critical industries and have much work to do.

Much has been written about what sort of change is needed, but a good place to start is the culture, or some would say climate, in which we work. An open and honest culture allows teams to recognise and acknowledge the potential for error, learn lessons from mistakes and prevent them happening again. A closed, secretive culture motivated by fear of blame will stifle learning, both individually and across the healthcare system.

Simple as it may sound, creating an open safety culture is no easy task and will require action on many different fronts. One area in which the GMC has a contribution is by setting professional standards, specifically the draft guidance on Openness and honesty: the professional duty of candour, which has drawn on the findings of the Mid Staffordshire Inquiry and which we have developed in collaboration with the NMC.

We are currently consulting on this guidance and, as part of our consultation, last month some GMC colleagues and I ran a workshop on openness at Patient First, a national patient safety conference held at the Excel centre at London’s Docklands, which the CQC also attended.

Workshop on openness and candour at Patient First 2014 (photo courtesy @MATCHTeamtime)

Workshop on openness and candour at Patient First 2014 (photo courtesy @MATCHTeamtime)

We tried to explore some of the areas where implementing the guidance would be difficult. Setting the scene, and demonstrating how much ground there is to make up, we heard that the majority of those present (some 200 people, an even split between doctors and nurses with a few patient representatives) felt that their workplaces had some way to go in complying with the duty of candour.

We heard that one important barrier to openness, both with patients and between healthcare providers, was fear: fear of blame, even fear of litigation, but also fear of acknowledging personal fallibility. We heard too that the current working culture and attitudes have been heavily influenced by the past when secrecy and defensiveness were the norm, at least with regards to those outside the team.

Leading by example

Good leadership has a crucial role to play here: as one delegate put it “openness is catching”. An example set at the top of an organisation can both mitigate the fear of blame, and demonstrate how the good clinician is not necessarily the one who doesn’t seem to make any mistakes, but the one who learns from experience and helps make sure others do too.

Fear of talking to patients about errors is commonly cited as a barrier, but we heard that patients had reacted very positively to greater openness when they were told about changes made to address problems, as well as the problems themselves. “Our patients are proud of the change that happens from incidents,” was one comment.

Feedback is important in all change, and we heard there was work to be done to reinforce the benefits of an open safety culture. “Clinicians do not see the learning from near misses and incidents, they only see their own practice and do not see the bigger picture,” was a common theme.

Resources also came up in our conversation. We heard that there is often little acknowledgement in work planning of the time required for individual professionals to report incidents and hold meetings with patients.

Multidisciplinary safety meetings, such as morbidity and mortality meetings in surgery and other specialties, often suffer from inadequate resources, as do team training initiatives to improve safety awareness and inter-professional communication.

The difficulty of broaching conversations about mistakes, near misses and adverse events was also specifically raised. We heard that this was a barrier to openness, but also that openness was a skill that could be learned. We heard of “disclosure coaches”, senior clinician mentors who advise other clinicians about how to carry out disclosure conversations with patients and their families as well as with colleagues, and how they had helped others develop openness in their practice.

These barriers will all need addressing, within the context of a healthcare system that is currently under great stress. But my overall impression from the session was that, although there is a long way to go, we can do a lot simply by being open about our own mistakes, and by communicating better the positive impact of openness in healthcare.

In the spirit of fostering this  open safety culture I would be keen to hear your thoughts about what we could do as a profession in the comments below.
Toby Reynolds

Toby Reynolds is a trainee in anaesthesia from North East London, currently placed at the GMC for a year through the National Medical Director’s Clinical Fellow Scheme. He is writing this blog in his personal capacity, rather than as a representative of the GMC .

One response to “Openness is catching

  1. In most discussions about candour and openness, there is no reference made to the special circumstances of General Practice, where there is little independent scrutiny or objective assessment of clinical standards. As a result, each practitioner is clearly responsible for monitoring their own standards … but what is the responsibility of other partner colleagues to expose poor performance or dangerous practise? Appraisal and revalidation are not sensitive tools for spotting a dangerous doctor.
    We all have significant event meetings and discussion of near misses but what do you with a partner who never reports his ? Who do concerned partners report these to without fear of retribution ?
    There is no management structure [ nor medical defence nor BMA responsibility] to support a GP raising concerns about a partner and current legislation does not give a GP the same employment protection as their secondary care peers. They are immediately exposed to potential loss of their partnership, which by definition requires ‘ mutual trust’. A GP whistleblower commits ‘ professional suicide’ .
    Keeping concerns within the practice to avoid outside criticism is still the norm, and most GPs would leave a practice rather than than tackle a dangerous partner.
    Repeatedly, reports and recommendations refer to ‘ staff will be protected’, GP partners are NOT NHS staff and special measures should be made to offer them similar protection.
    In further discussion about candour and openness please include the unique circumstances of General practice .

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