Shared accountability

Reframing disclosure as a team function

To blame is human. When things don’t go as expected and a patient experiences harm from healthcare or the progression of their disease, uncertainty, personal biases, and the fear of repercussions can make it difficult for team members to share accountability and handle the situation effectively. Concerns surrounding blame also represent a significant barrier to appropriately disclosing unexpected outcomes.

Inadequate disclosure can make a patient feel that his or her clinical, emotional, or information needs are not being met. Poor communication is recognized as a leading cause of patient dissatisfaction overall. Moreover, data from the Canadian Medical Protective Association show that communication issues are often present in medical-legal cases in which the clinical care met the standard, highlighting the importance of provider- patient communication following an event.

Patient centred communication

Discussion of an unexpected clinical outcome must occur when a patient has suffered any degree of harm, there is potential for future harm, or there will be a change in the patient’s care or monitoring. This discussion can occur in stages, with the initial disclosure made as soon as reasonably possible, focusing on the available facts and next steps for further care. Following an appropriate fact finding process, a further discussion will focus on the reasons for harm based on the known facts[1].

Although disclosure is a team function, who should be involved in and who should lead the discussion depends on the circumstances of the event. The leader can be the healthcare professional who feels most responsible for what happened, the one with the most information, or one that the patient trusts. If the most responsible healthcare professional cannot attend the discussion, this should be explained to the patient.

When the need to communicate an unexpected clinical outcome has been identified, team members responding should:

  • Attend to the patient’s clinical needs and address any immediate safety issues
  • Plan ahead for the discussion to:
    • Involve an accountable leader or disclosure consultant, if needed
    • Anticipate questions (but do not script the discussion)
    • Determine if the patient requires an interpreter or other skilled personnel or would benefit from having a caregiver present for the discussion (note that consent must be obtained ahead of time)
  • Support team members during the disclosure discussion
  • Listen to the patient and express compassion at every encounter
  • Acknowledge and apologize within the context of what is known
  • Commit to improve or gather more information, as the situation warrants

Above all, healthcare professionals should avoid speculation and blame.

Communicating bad news to a patient is one of the hardest things a healthcare professional faces in practice, but proper support from leaders within a culture of accountability can help team members work together to achieve patient-centred disclosure.

Accountability in a just workplace culture

Just culture balances system and individual accountabilities. In just cultures, leaders are responsible for improving processes and for modelling and managing behaviour. For their part, individual healthcare professionals are responsible for fostering that culture, making sound behavioural choices, reporting vulnerabilities and events, and contributing to system improvements. This approach acknowledges the potential for human error and the innate fallibility of humans and complex systems. A Just Culture also allows for management of unexpected outcomes in a psychologically safe environment that respects the individual and values feedback and learning. In this setting, the goals of disclosure are focused on learning and preventing a similar event from recurring, not on punishment [2].

Because psychological safety reframes how events are viewed, teams are free to coordinate meaningful patient disclosure when the need arises.

In today’s complex healthcare environment, disclosure  is everyone’s responsibility. A culture of accountability that supports individual team members can help reduce unnecessary variation when communicating unexpected clinical outcomes to patients.

Saegis offers courses on Communicating Unexpected Outcomes for clinicians and leaders, as well as a range of programs related to just culture and communicating with patients. To learn about current offerings, visit our Programs for Physicians and Healthcare Professionals page.

[1] The Canadian Medical Protective Association. Disclosing harm from healthcare delivery: Open and honest communication with patients. Third edition, 2017.

[2] Disclosure Working Group. Canadian disclosure guidelines: being open and honest with patients and families. Edmonton, AB: Canadian Patient Safety Institute; 2011.