The Culture of Candour: What should we do when things go wrong?

In the UK, the National Health Service (NHS) has paid out more than £4.5 billion in the past five years for medical mistakes¹. It is probable that every one of those cases would meet the threshold of the Duty of Candour.

The Duty of Candour legislation sets out the mandate for disclosure.  However, as has been demonstrated many times in the past, we need more than statutory requirements to change culture and attitude. The real challenge is putting candour into practise, instilling and supporting a culture of openness and honesty, and welcoming the opportunity to learn from,  and prevent, mistakes.

Putting candour into practise:

• Build an effective process: where an incident calls for investigation, a thorough process needs to include immediate disclosure, a thorough investigation, further care, patient involvement in the investigation, and further post-investigation disclosure.
• Communication: when mistakes are made, patients need to know why. Seven out of ten claims in the NHS involve poor communication as a main reason². So spend a greater effort on communication at all levels and in all interactions. Ensure that instructions, policies and guidelines are clear and easily understood by all.
• Put yourself in their shoes: patients and carers can feel disillusioned, fearful and let down when mistakes are made. Being honest with them about what went wrong and why will better help them make sense of events and regain some stability. It will also go a long way to foster trust, even in the shadow of mistakes.
  

Culture:

• Stop the blame culture: which is stressful and counterproductive for all involved. A culture of responsibility needs to be instilled within our framework so we can learn from mistakes and create more accountability.
• Staff support: ensure that there is full organisational support for clinical staff with training in being open and honest with patients when things go wrong, and encourage them to apologise as soon as possible.
  

Learning from our mistakes:

• Use candour as a catalyst for improvement and safety: Being candid and honest with patients and colleagues in an event of mistakes, and encouraging this as positive behaviour, leads us to feel comfortable to flag risks and speak up, which in turn reduces the chance of things going wrong and can diminish claims.
• Learn from other countries: Canada, Australia, parts of the United States and Denmark have put processes in place, which have proved to be effective. For example, health mediation has a significant role in complaints procedures in Australia so patients are more likely to have their concerns listened to and acted upon. This has led to a significant drop in court cases and claims³.
  

Healthcare clinicians, leaders and managers need to take genuine ownership of these values to encourage a wider culture of honesty and as a result, improvement of patient safety.

Creating a culture of candour includes transparency, but must also include communicating risks prior to medical treatment. My next blog will focus on the advice that should be given to patients on risks of treatment and letting them know what their alternative options are.

¹The Daily Telegraph: “Medical Blunders cost NHS billions”, 11 July 2015

² House of Commons Health Committee Report, March 2013

³Open Disclosure: A Review of the Literature, Australian Commission of Safety and Quality in Health Care, 2008 and Australian Commission of Safety and Quality in Health Care, 2011

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I’m Caroline White. I’m the Risk Control Director for International Healthcare at CNA Hardy and have over 25 years’ experience in the Healthcare sector. Follow CNA Hardy’s blog series on LinkedIn.