Being open: the importance of communication in healthcare

Last week over 7,000 medical students found themselves in limbo. Having first been told they had secured jobs for their Foundation year, they were then told that there had been an error in the computer scoring and their offers were rescinded pending further notice.

Understandably this has caused dismay and anger among students and their families, and presumably some personal trauma as individuals are faced with uncertainty. I was struck by a quote from a graduate, Anna, in the Guardian’s piece on this: 'I don't mind that they have made a mistake. People make mistakes. It's how they have handled it afterwards which is pretty unacceptable,' Anna said. The handling she refers to was the poor communication, the lack of clarity about next steps and the absence of anyone to talk to who could explain what was happening.

By coincidence, on that same day I had been reading ‘Being Open’ by Professor Albert Wu of John Hopkins University (the report, done in 2008 for the National Patient Safety Forum was never formally published but reviewed progress on recommendation 12 of Safety First: one year on by the NPSA). Professor Wu reviewed work that was done to improve communication of mistakes to patients and their families. The report says that there is consistent evidence that openness and support to patients when things go wrong is vital to patient safety, patient experience and good quality care.

But there are also a number of barriers to staff being open. When surveyed, staff cite the fear of the patient’s response; the fear of litigation; fear of blame and judgment and the lack of confidence and skill to be open even if they want to be.

The report says that more needs to be done to help healthcare staff comply with the difficult task of being open with patients when they have been harmed by their care. Sadly, the debate that has flowed from the Francis report suggests that more still needs to be done to create a culture in which staff feel able and supported to disclose harm and error.

The report chimed with Anna’s comments. It recognises that mistakes will happen but emphasises the importance of good communication when they do. Learning from experience across the US, Europe and Australasia, the study identified five important elements necessary to creating openness about unintended harm.

First, the need for a culture of safety disclosure – one where staff feel comfortable admitting where things go wrong. At John Hopkins, when patients are admitted they are shown a video that explains the fallibility of healthcare and the potential for error. This makes it easier to broach the subject of errors and harm and, importantly, staff also know that they will not be punished for errors.

Second, telling people that a mistake has been made is hard and there are skills and techniques that can make this easier. Many healthcare systems are systematically training staff to do this effectively but does enough of this happen in the UK?

The third important element is the need for staff to get real-time support themselves. The Tan Tock Seng Hospital in Singapore has a 24 hour hotline for staff through which they can report incidents and be supported by trained staff to plan the discussion with the patient concerned.

As well as this sort of practical support, emotional support is also required. The Brigham and Women’s Hospital in Boston has a peer support team to help staff that have been involved in errors.

Finally, there is the need to provide the appropriate expert and emotional support to patients and their families.

Wu’s report describes the benefits of a comprehensive approach to being open about errors, as well as reducing the anxiety that mistakes cause for staff and patients alike. Studies have shown that when mistakes are handled in a timely, open and sensitive way there is less litigation.

Hopefully, by now, the 7,000 students given the wrong information last week will now know where they stand and have plans in place for the next stage of their career. If any good is to come out of this mess, perhaps it will be a generation of doctors that have first-hand experience of the importance of communication when mistakes happen and a commitment to put this into practice. However, unless the organisations they end up working for create a culture that makes this possible, it will be learning that can’t be put into practice.

Jo is Director of Strategy at the Health Foundation.