105-659 / Open disclosure following adverse events in healthcare.

Ireland
GOP Information  
 
Organisation sharing the GOP
Related practices from PaSQ database
Health Service Executive (HSE) and the State Claims Agency (SCA).

Topic

Quality improvement project
Professional learning program on quality and safety
Category
Communication
There is no specified text here
GOP Description
 
Implementation level
National
Clinical settings
Acute hospitals.
Objectives
The project objective is to provide training and support for doctors and other healthcare professionals to support them in engaging in the open disclosure process with a view to the development of a national guidance document and national policy on Open Disclosure.
Population
Doctors and other healthcare professionals working in acute hospitals in Ireland.
Methods
 
Methodology
Project leads were identified in the HSE and SCA.
A national project team was established.
Two acute pilot sites were identified.
Initial Executive Management Board meetings to undertake proposal sign up and commitment to the project.
Awareness session delivery on site.
Open disclosure training on site.
Follow up meetings with various applicable committees e.g. Quality and Risk / Governance Committees.
Ongoing supports from HSE and SCA project leads.
Timeframe implementation
2 year pilot programme – 2010 – 2012. The pilot ended in October 2012 and the current emphasis is on the development of a national guidance document and policy in relation to Open Disclosure. Work has already commenced with several hospital sites in Ireland and on the national implementation strategy.
Implementation tools available
Awareness sessions delivered on site.
Open disclosure training delivered on site.

Implementation cost
Not known
Results
 
Method used to measure the results
Internal evaluation: All training and awareness sessions delivered by the national leads were evaluated using a feedback evaluation form addressing specific aspects of both session types.
External evaluation: An external healthcare consultant was employed by the SCA to undertake the evaluation of year 1 of the project. It is anticipated that the overall project will be externally evaluated by a recognised leader / body in open disclosure. This is currently being scoped.
Results
Feedback regarding the training and awareness sessions delivered. An external evaluation of year 1 of the pilot project was also undertaken.
Analysis of the results
•    A clear commitment from both pilot sites to implement Open Disclosure
•    A lack of understanding of what is meant by Open Disclosure
•    Staff support following adverse events need to improve
•    Leadership paramount
•    Lack of training
•    Uncertainty regarding what to disclose
•    Fear regarding the area of apology
Implementation barriers
 
Did you find implementation barriers?
Yes
Please describe implementation barriers
•    Time constraints for staff to attend sessions
•    Leadership visibility issues

The roll out of Open Disclosure across all healthcare organisations is planned and the learning from the pilot programme will be incorporated into the national implementation strategy regarding same.
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
Other information
 
Other information about the GOP that you would like to add (Link or attached document)
The Open Disclosure project is more than a pilot, it is also a change management project that requires a significant cultural shift. The roll out of Open Disclosure across all healthcare organisations is planned and the learning from the pilot project will be incorporated into the national implementation strategy regarding same.


There is no specified text here
Contact information
 
Name: Elaine O' Connor
Position/function: Programme Manager
Department: Safety and Quality Improvement Directorate
Organisation: Health Information and Quality Authority
City: Dublin
Country: Ireland
Region: Leinster
E-mail: eoconnor@hiqa.ie
Phone: 00 353 1 814 7435
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