Photo by Kyle Sudu | Unsplash
For better or worse, I am seldom at a loss for words. But there I was, a third-year medical student, with absolutely no idea what to say.
A middle-aged man was admitted to our medicine service following an intraoperative myocardial infarction (MI) suffered during a routine surgical procedure. This was not a typical cardiac event — it resulted from a ventilator malfunction leading to a positive pressure pneumothorax which then caused the MI.
The patient was told about the intraoperative cardiac event but was unaware that an equipment malfunction had precipitated it. The patient’s post-MI chest pain while hospitalized led to discovery of a three-vessel coronary artery disease, and he underwent bypass surgery. The physicians told him how fortunate he was that this cardiac event happened in the hospital — otherwise, he could have dropped dead of a heart attack on the sidewalk!
Was I, a lowly third-year medical student, supposed to tell the patient there was more to the story?
In the 30 years since I confronted this dilemma, my profound sense of discomfort on how to respond motivated me to focus my career on transparency after care problems. Truth be told, I did worry that this might be a foolish career move. What if the field quickly embraced transparency, requiring me to move onto another topic?
This has not been the case. We struggle as individuals and organizations to turn commitment to the concept of transparency into practice. When confronted with uncomfortable information about a breakdown in care or other problem, we reflexively look the other way, keep our heads down, and hope the situation blows over.
Our challenges with openness have significant consequences. Progress in improving health care safety and quality is slowed when a lack of openness impedes learning. It also compounds the suffering of patients who have been harmed by health care, heightens the distress of involved clinicians, and undermines the public trust.
While the importance of transparency has not been ignored, the primary strategy historically consisted of exhorting clinicians to summon the courage to disclose errors to patients. While patients expected and valued disclosure and apology after errors, it became clear they expected a much more robust response. Programs coupling disclosure with early offers of financial compensation for harm caused by substandard care appeared and have evolved into the Communication and Resolution Program (CRP) model.
Awareness has also increased about related areas of openness. How can we facilitate patients in sharing their care concerns? How do we encourage clinicians to speak up about problems in a colleague’s care, communication skills, or professionalism? The 2015 Lucian Leape Institute white paper, Shining A Light: Safer Health care Through Transparency, recognized the linkages between these dimensions of transparency and focused attention on practical strategies for moving forward.
But important gaps persist. What should the next generation of transparency in health care look like? I have five recommendations:
- Implement a “transparency bundle” — Bundling steps to ensure consistent implementation, such as those to prevent ventilator-associated pneumonia, is a significant advance in patient safety. Transparency practices after care breakdowns should also be taught and implemented as a bundle: communication between patients and providers, between providers and peers, between providers and institutions, and across organizations.
- Recognize that openness alone is insufficient — While openness has intrinsic value, its focus should be on advancing the higher goals of improved quality, safety, and health care value and developing trusting patient-provider relationships. Seen through this lens, openness is the first, but far from only, step in responding to care problems.
- Prioritize empathy and compassion when sharing information — Sharing information about a care problem with patients, families, peers, and the institution comes more naturally than responding to the emotions such situations evoke. The key first step clinicians can take towards implementing the transparency bundle is to improve their emotion-handling skills.
- Invest time, resources, and attention — Achieving the next generation of transparency practices requires significant investments both by organizations (policies and culture that are just and psychologically safe, training, systems and processes) and by individuals (awareness of resources supporting transparency, skills to approach these situations, and willingness to take action rather than look away), with leadership from the top.
- Apply improvement principles to transparency practices — Transparency is critical to health care quality and safety, but basic improvement strategies are infrequently applied to tracking and enhancing the practices of the transparency bundle. Measures related to CRPs, as well as tools measuring clinicians’ willingness to speak up, are in development, including a transparency dashboard.
If we succeed in implementing the next generation of transparency in health care, future medical students will not face the unsettling scenario I did 30 years ago. More importantly, patients, providers, and the public will all be the beneficiaries.
Thomas H. Gallagher, MD, is a professor in the Department of Medicine at the University of Washington, and Executive Director of the Collaborative for Accountability and Improvement. He’ll be a featured guest on WIHI — The Measure of an Apology: New Metrics to Redress Medical Harm (April 18, 2019, 2:00 PM ET).
You may also be interested in:
IHI Patient Safety Congress (May 15–17, 2019 in Houston, TX, USA)
Facing the Fear of Transparency