Safety of care
Reporting to quality improvement committees in hospitals
An article for physicians by physicians
Originally published June 2004 / Revised May 2008
Quality improvement activities can be expected to improve patient care, but care should be taken to avoid undue medico-legal risk.
Of interest to all physicians
Recently, the interest and publicity around patient safety has increased the emphasis on physicians' responsibilities in responding to adverse events.
An event which results in unintended harm to the patient, and is related to the care and/or services provided to the patient rather than to the patient's underlying medical condition.
The CMPA has for many years encouraged members to disclose to patients the occurrence and nature of adverse clinical outcomes.
Although this issue of disclosure continues to be of significant importance to physicians, the focus for patient safety is now turning to identifying systemic issues associated with adverse outcomes and preventing similar future events. This focus broadens both the kind of information to be provided and the audience to whom it will be given.
Disclosure to patients vs. reporting to quality improvement committees
Quality improvement committees in hospitals and institutions in different provinces/territories may have different titles, for example: Quality of Care, Critical Incident Review, Risk Management committees.
Many hospitals, health authorities and others have introduced disclosure policies as part of their quality improvement initiatives. Physicians should be aware, however, that the reporting of adverse outcomes to quality improvement committees must be distinguished from the disclosure of adverse events to patients. The disclosure to patients relates to the prompt, factual and non-judgmental disclosure of the clinical information about the particular adverse event to the involved patient. On the other hand, quality improvement committees, to be effective, usually request additional information about other contributing factors and sometimes ask for supposition as to the cause and possible preventive measures. The ultimate goal of these quality improvement activities should be to improve practices and procedures.
Statutory protection of information
Of concern to physicians is the potential that any report or information gathered or discussed in preparation for a report to the quality improvement committee may be disclosed in subsequent legal or disciplinary proceedings related to the event. All Canadian provinces/territories have some legislated protection for information reported to quality improvement committees that is intended to prevent it from being used in subsequent legal or disciplinary proceedings. The degree of statutory protection varies with the legislation in each jurisdiction.
Most often, any statutory protection extends only to the activities conducted by a quality improvement committee that is established in accordance with the provisions of the applicable legislation. Therefore, protection would not generally apply to any other hospital activities or processes including other patient safety initiatives, or investigations conducted by a hospital administrator or chief of staff.
In Québec, in addition to the answers given to risk managers in the course of their duties or to the risk and quality management committee, only the files and minutes of the council of physicians, dentists and pharmacists and each of its committees are confidential. However, representatives of a professional order in the performance of duties assigned to them by law may have access to this information.
Reports outside quality improvement committees
Reports made to or produced by individuals or groups other than those properly constituted under a hospital quality improvement committee may be vulnerable to production and therefore may not be protected even in jurisdictions where legislation exists. Similarly, statutory protection generally does not apply to non-hospital facilities, organizations or activities. Information disclosed pursuant to hospital disclosure policies may also not be protected by legislation; check your legislation.
Physicians should also be aware that information communicated in informal discussions with colleagues, administrators or staff — even if it was in preparation for a report to the quality improvement committee — might also be compellable. Even in jurisdictions where statutory protection exists, the information may still be subject to a legal challenge and the court could judge that protection would not apply in the specific facts of the case.
While the CMPA supports quality improvement activities, a certain amount of prudence will encourage participation yet protect those participating from undue risk. The following are some suggestions:
- Confirm that the review is being conducted by a hospital quality improvement committee as defined by legislation in your jurisdiction
- Avoid the use of terms such as error, mistake and negligence
- Limit the contents of any report to the known facts of the case
- Be non-judgmental
- Identify any information that is speculative (e.g. time estimates)
- Avoid speculation about what may have happened if a different course of action had been taken
- Do not comment on the care provided by others
- Do not file any reports on patients' charts
- Do not circulate the information collected or reports produced outside of the properly constituted committee
- Clarify what information is to be reported, how will it be stored and who will have access to it
- Confirm how the results and any conclusions will be communicated
- Understand your obligations under your local policy
Generally, "close calls" that do not result in harm need not be disclosed to patients.
An event with the potential for harm that did not result in harm because it did not reach the patient due to timely intervention or good fortune (sometimes called a near miss).
Some regulatory authorities or hospital policies may require reporting of such events to quality improvement committees. Physicians should be aware of reporting obligations, both within their own jurisdiction and their own institution.
The evolution to a culture of safety away from the current blame and shame model is underway. Quality improvement activities and other patient safety initiatives promise to improve patient care and decrease adverse outcomes. To encourage the participation of physicians in these activities, a balance must be found between the risk and the clear benefits of participating.
The bottom line
- The CMPA has for many years encouraged members to discuss with patients the nature of adverse clinical outcomes and to disclose adverse events.
- The advice about the reporting of adverse events to quality improvement committees is different than that for the disclosure of adverse events to patients.
- All Canadian provinces/territories have some legislated protection for information reported to quality improvement committees, but the degree of statutory protection varies with the legislation in each jurisdiction.
- Physicians should be aware of reporting obligations, both within their own jurisdiction and their own institution.
- The CMPA supports quality improvement activities as these initiatives hold the promise to improve care and decrease adverse events; however, a certain amount of prudence will protect those participating from undue risk.
- If you have any questions or concerns about disclosing information to patients or discussing events in quality improvement committees, contact the CMPA.
Disclosing harm from healthcare delivery: Open and honest communication with patients. This CMPA publication has suggestions to help members meet their patients' clinical, information and emotional needs after an adverse event.