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Creating an Office Practice Policy for Patient Disclosure of Unanticipated Outcomes

Purpose for policy development:

Why have a policy?

A policy reflects the practice’s philosophy and values regarding patient communication and patient participation in their care. A policy allows the practice to have a proactive approach to managing unanticipated patient outcomes. It ensures prompt reporting and consistent handling of all disclosable outcomes. A policy identifies who will be responsible for disclosure, where and when disclosure will take place and what information will be disclosed to patients and their families. A policy will set forth guidelines to ensure that the rights and needs of patients are met during a disclosure conversation.

There is no disclosure communications “roadmap” or “template” for all situations. Many guidelines do exist that will assist your practice in developing an effective patient communication policy that encompasses disclosure of unanticipated outcomes.

Approach to policy development:

When writing a policy that will contain guidelines on patient communication of unanticipated outcomes, positive and proactive language should be used. Gear the policy to ensuring the best interests of the patient are served. A continued focus on maintaining the patient’s ongoing involvement in their care is critical to proactive management of an unanticipated outcome. A policy with well thought out guidelines coupled with comprehensive staff training will best serve the organization and the patient.

Key Policy Elements:

  1. Practice Philosophy
    The policy should have a brief statement that discusses the practice’s philosophy regarding patient care and communication. Does the practice encourage open, honest and constant/consistent communications with patients? Does the practice foster informed decision–making? Is there an informed consent process that involves the patient in daily decisions that affect the overall treatment plan, obtains the patient’s cooperation and facilitates an open forum for patient and family questions or concerns?
  2. Policy Statement:
    Describe what the policy is, when it applies and what it is intended to accomplish.
  3. Definitions of Terms:
    Define key terms used within the practice’s policy and procedure.
  4. Criteria for Disclosure
    Establish a guideline for what warrants a patient disclosure discussion, e.g., a change in treatment plan; unanticipated outcome.
  5. Defining Personnel Roles
    • Receptionist
    • Practice Manager
    • Senior Clinicians
    • Midlevel Providers
    • Physician
    Staff members regardless of their job responsibilities may find themselves participants in a patient disclosure discussion concerning unanticipated outcomes. Outline staff expectations, e.g., how to manage the patient encounters; to whom should the patient be directed.
  6. Patient Contact Algorithm
    Set forth guidelines for patient contacts:
    1. Initial Patient Contact
      The staff member who encounters the initial patient contact needs to be prepared for this encounter whether it is expected or unexpected and whether it is by telephone, in person or through a representative. Dealing with difficult conversations and emotions is a communication skill for which all staff members should receive education.
    2. Directing the Patient to the Appropriate Individual(s)
      Depending on the tone and urgency of the initial patient contact, the staff member must also make the decision of whom to direct the patient or patient’s representative. A well thought out decision tree that is part of a policy guideline will be beneficial to reduce staff hesitation and confusion during this critical patient encounter.
      Regardless of the setting or circumstances, maintaining patient confidentiality in all patient communications regarding their care or treatment is a must.
  7. Investigate Unanticipated Outcome
    • Complete root cause analysis if needed
    • Review and communicate details of investigation with appropriate staff members
  8. Planning the Disclosure Discussion
    • Who - Who will be part of the disclosure conversation?
      In most circumstances, the primary physician will lead the explanation. As part of their day to day duties, the receptionist may be the first patient contact when an unanticipated outcome is announced.
    • When - When must it occur?
      e.g., Is it emergent? Is there an opportunity to do some planning?
    • Setting - What is the best setting?
      e.g., Office, Conference Room, Patient Room
    • Special Needs/Accommodations- Are there special accommodations or support services needed by the patient during the disclosure conversation?
      e.g., Patient capacity, Hearing impaired, Physically Impaired, Limited English Proficiency
  9. Disclosure Communication Content
    The actual content of the conversation will be dependent on the events being discussed. Research has provided us with a summary of what patients want during a disclosure conversation…acknowledge the unanticipated outcome occurred, empathize, take responsibility/apologize, prevent future recurrence.
    Based on that knowledge, here are some key policy points to assure a successful disclosure conversation will occur:
    1. A brief, factual discussion of the unanticipated outcome. Acknowledge the occurrence, when and where and how it occurred if known (if details are not known, do not guess, complete a thorough investigation)
    2. Presentation of sincere concern, regret and empathy
    3. Apologize if warranted
    4. How the outcome will affect the patient’s current treatment plan
    5. Address patient concerns
    6. Review any steps that may have already been taken to prevent or minimize a recurrence
    7. Review next steps:
      1. Who will the patient hear from next
      2. When will the patient hear from them
      3. Outline any additional support services available or already requested for the patient
      4. Who should they contact when they have questions or concerns
  10. Documentation
    A policy should provide guidance for documentation of the disclosure discussion in the medical record. The discussion can be documented on a disclosure documentation template or form to assure continuity in documenting important elements of the discussion and placed in the patient’s medical record or the elements may be directly documented into the visit notes. A comprehensive note or template should include:
    1. Who was present (titles and relationship to patient)?
    2. When did the discussion occur (time and date)?
    3. What occurred to prompt the disclosure discussion?
    4. What information was provided to the patient and/or representatives?
    5. What questions were asked by the patient?
    6. What responses were given to the patient?
    7. Any planned follow-up (change in treatment, next informational meeting or communications, who will contact the patient next)
    8. Who the patient should contact with questions?
    It is important to be factual, avoid documenting personal opinions and accusative statements.
  11. Follow Up
    A policy should include designating follow up responsibilities to those individuals involved in the disclosure discussion.
    • Who will manage the ongoing care of the patient.
    • Who will manage the ongoing communications related to the disclosure discussion, questions and complaints that may arise from the patient or family members.
    • Who will ensure follow up meetings and closure.
    • Who will coordinate the process to assure continuity.
    A policy should include how staff may access personal support.
    • Peer Support
    • Employee Assistance Programs

Associated Templates or Forms:

  • Coordinating Policies [Patient Communication; Patient Informed Consent; Patient Confidentiality]