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Improving Healthcare Systems’ Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership

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ABSTRACT

BACKGROUND

The Department of Veterans Affairs (VA) mandates disclosure of large-scale adverse events to patients, even if risk of harm is not clearly present. Concerns about past disclosures warranted further examination of the impact of this policy.

OBJECTIVE

Through a collaborative partnership between VA leaders, policymakers, researchers and stakeholders, the objective was to empirically identify critical aspects of disclosure processes as a first step towards improving future disclosures.

DESIGN

Semi-structured interviews were conducted with participants at nine VA facilities where recent disclosures took place.

PARTICIPANTS

Ninety-seven stakeholders participated in the interviews: 38 employees, 28 leaders (from facilities, regions and national offices), 27 Veteran patients and family members, and four congressional staff members.

APPROACH

Facility and regional leaders were interviewed by telephone, followed by a two-day site visit where employees, patients and family members were interviewed face-to-face. National leaders and congressional staff also completed telephone interviews. Interviews were analyzed using rapid qualitative assessment processes. Themes were mapped to the stages of the Crisis and Emergency Risk Communication model: pre-crisis, initial event, maintenance, resolution and evaluation.

KEY RESULTS

Many areas for improvement during disclosure were identified, such as preparing facilities better (pre-crisis), creating rapid communications, modifying disclosure language, addressing perceptions of harm, reducing complexity, and seeking assistance from others (initial event), managing communication with other stakeholders (maintenance), minimizing effects on staff and improving trust (resolution), and addressing facilities’ needs (evaluation).

CONCLUSIONS

Through the partnership, five recommendations to improve disclosures during each stage of communication have been widely disseminated throughout the VA using non-academic strategies. Some improvements have been made; other recommendations will be addressed through implementation of a large-scale adverse event disclosure toolkit. These toolkit strategies will enable leaders to provide timely and transparent information to patients and families, while reducing the burden on employees and the healthcare system during these events.

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Acknowledgements

This study was supported by the Department of Veterans Affairs, Health Services Research and Development Service, SDR 11–440. The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of the Department of Veterans Affairs or the United States Government.

Drs. Elwy, Bokhour, Maguire, Asch and Gifford are supported by the HIV/Hepatitis Quality Enhancement Research Initiative, Veterans Health Administration.

Dr. Elwy is also an investigator with the Implementation Research Institute, at the George Warren Brown School of Social Work, Washington University in St. Louis, through an award from the National Institute of Mental Health (R25 MH080916-01A2) and the Department of Veterans Affairs, Health Services Research & Development Service, Quality Enhancement Research Initiative.

Conflicts of Interests

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (Mailstop152), Bedford, MA, 01730, USA

    A. Rani Elwy Ph.D., Barbara G. Bokhour Ph.D., Elizabeth M. Maguire M.S.W. & Allen L. Gifford MD

  2. Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA

    A. Rani Elwy Ph.D., Barbara G. Bokhour Ph.D. & Allen L. Gifford MD

  3. HIV/Hepatitis Quality Enhancement Research Initiative, Veterans Health Administration, Washington, DC, USA

    A. Rani Elwy Ph.D., Barbara G. Bokhour Ph.D., Steven M. Asch M.D., M.P.H. & Allen L. Gifford MD

  4. Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA

    Todd H. Wagner Ph.D.

  5. Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA

    Todd H. Wagner Ph.D. & Steven M. Asch M.D., M.P.H.

  6. Stanford University School of Medicine, Palo Alto, CA, USA

    Todd H. Wagner Ph.D. & Steven M. Asch M.D., M.P.H.

  7. University of Washington School of Medicine, Seattle, WA, USA

    Thomas H. Gallagher M.D.

  8. Clinical Public Health Program, Office of Public Health, Veterans Health Administration, Department of Veterans Affairs, Washington, DC, USA

    Janet M. Durfee A.P.R.N., R.N. & Richard A. Martinello M.D.

  9. Yale University School of Medicine, New Haven, CT, USA

    Richard A. Martinello M.D.

  10. Office of the Principal Deputy Under Secretary for Health, Veterans Health Administration, Department of Veterans Affairs, Washington, DC, USA

    Susan Schiffner R.N. & Robert L. Jesse M.D., Ph.D.

Authors
  1. A. Rani Elwy Ph.D.
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  2. Barbara G. Bokhour Ph.D.
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  3. Elizabeth M. Maguire M.S.W.
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  4. Todd H. Wagner Ph.D.
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  5. Steven M. Asch M.D., M.P.H.
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  6. Allen L. Gifford MD
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  7. Thomas H. Gallagher M.D.
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  8. Janet M. Durfee A.P.R.N., R.N.
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  9. Richard A. Martinello M.D.
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  10. Susan Schiffner R.N.
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  11. Robert L. Jesse M.D., Ph.D.
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Corresponding author

Correspondence to A. Rani Elwy Ph.D..

Additional information

RLJ is now in another position with the VHA. SS has retired.

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Elwy, A.R., Bokhour, B.G., Maguire, E.M. et al. Improving Healthcare Systems’ Disclosures of Large-Scale Adverse Events: A Department of Veterans Affairs Leadership, Policymaker, Research and Stakeholder Partnership. J GEN INTERN MED 29 (Suppl 4), 895–903 (2014). https://doi.org/10.1007/s11606-014-3034-3

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  • DOI: https://doi.org/10.1007/s11606-014-3034-3

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