The Incomplete Record

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Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios. and explores the essentials of clinical governance to find solutions.

I'm Dr. David Rankin, a very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding Healthcare, the essentials of Today, a patient complained. and an unrecorded mishap. We need to look after the patient first, both clinically as well as uh from a psychological perspective as well. That's Associate Professor Alice Damar.

The Vice President of Medical Affairs at United Family Healthcare, which is one of China's largest private healthcare organizations. He was previously the Chief Medical Officer at Bioan Health in Geelong and Executive Director Medical Services at Butonga helped And I'm presenting him with a difficult scenario. In surgery often the medical administrator might not be a surgeon themselves. So it is important to have that technical expertise behind you to understand what is right or wrong.

In today's scenario, you receive a complaint from a patient who recently had surgery at your hospital. The patient was assured by the surgeon that the operation was a complete success and everything went well. Unfortunately, the patient later deteriorated and a second surgeon undertook remedial surgery. The second surgeon indicated that the initial operation was not what they had expected, and the patient is concerned that the initial surgeon may not have been honest with them.

In reviewing the theatre record, you notice that the anaesthetist has made a note in the corner of the anesthetic record about a significant complication. When you ask the anesitors, they respond that they simply recorded the fact. The theatre staff corroborate the anesitist record, but the surgeon's operating note and their discharge letter to the GP make no mention of any complication.

When you asked the surgeon, they indicated that it was a busy day, and they simply forgot to record the complication in the medical notes. I started by asking Dr. Alice Damar what key issues this scenario raises. First of all, really is making sure that the patient's outcome is fine in the ongoing management. We need to look after the patient first. Both clinically as well as from a psychological perspective as well.

And we also need to look into the individual behavior of the surgeon and get our facts right. How bad was the case? Are there other cases? Do we need to follow up on the other patients? What does it mean when the second surgeon said, No, it's not what they have expected. We need to explore and unpack what that actually means. There's a perhaps a more longer term issue about the culture of safety and staff.

happy to speak up about issues because certainly it sounds like in the theatre there were other people who knew about this and why wasn't this raised? And this might be a department issue, it might be an organizational issue, so we need to explore that a little bit more. And ultimately it's about, you know, the culture, are people speaking up able to, you know, call each other and sort of is that the way we practice really?

There's certain legal issues here, depending on the impact on to the patient as well as the damages, this is something that we will be mindful of. And as a result of that, of course, there are potential media or reputational risks that we need to consider. So these would be the key issues I think we need to address one by one. Yeah, it's a complex scenario. Let's start off by looking at the people that were involved.

So we've got the surgeon, we've got the anesites, we've got the theatre staff, we've got the patients, we've got you as the medical administrator trying to sort it all out. We've probably got a head of department there to whom the surgeon ostensibly reports. So lots of people involved. How do you go about Investigating what actually happened. I think the underlying principle here is we need to consider natural justice. But we also need to do things in a timely manner to understand the fact.

from the initial provider, the first surgeon, as well as the others. In surgery often the medical administrator might not be a surgeon themselves. So it is important to have that technical expertise behind you to understand what is right or wrong. And if there's a head of department, that might be the first place you go to get some support. There needs to be an opportunity for the primary operator, so the first surgeon to explain his version of events.

But having that head of unit beside you can s help explore, does that actually make sense? Because it can sometimes get quite technical. So also you want to be able to have that other conversation with the second surgeon. What he means about it's not what he expected. Is it a complication? Is it a surgery that was Mm unnecessarily performed.

Or what exactly does that mean? As well as the anaesthetists. Also being mindful that for the second surgeon as well as the anaesthetists, we've got to be conscious that their colleagues with the first surgeon How does that play out in the future about their future relationships? They will need to work with each other. So we've got to be very mindful about that. It has to be done in a confidential manner.

So and I will be talking to the second surgeon, the anesthetist, as well as the nursing team in the first operation. And also perhaps uh theater staff. or the head of unit of the anaesthetic department who often hears about these things because they partner with surgeons, because what you also want to identify is is this a single case issue? Or is there a pattern here? And that's absolutely critical.

What you want to explore is whether this is a clinical competency issue or is it a one off that the person has perhaps not disclosed very well. So lots of things to unpack in this case. It takes quite a lot of courage for the anaesthetist to write an explicit comment criticizing the surgeon.

They work in close partnership. And for the anaesthetist to quietly write a comment on the anaesthetic record, can we explore that a little bit? Why would the anaesthetist not be more forthcoming about their comments. Sure. I think it depends, uh, in the scenario what we are not clear about is whether this is a private hospital or a public hospital.

And sometimes in the private sector, this can also be a determining factor about how anaesthetists work with their partner surgeons, because the business or the finances considerations start to kick in. But certainly it might also be a attitude behavior problem of the surgeon, whether they're open to constructive criticism or feedback.

And often these kind of things are learned behavior from the anesthetists. However, It does seem like the anesthetist knows what is right and wrong and thus still wants to make sure if there is something we can trace back to the documentation.

You can see whether it is and making sure that it's a legally they're covered as well. So you need to talk to the surgeon. How much information do you collect or gather? How much of your investigation do you undertake before you sit down and talk to the surgeon?

In my opinion, uh th the first case is really about because you want to do things in a timely manner, because at some stage you need to have the conversation with the patient. They have made a complaint. So y it's not something you can drag on. You want to do a quick and dirty to understand the facts of the case first, and then have the conversation with the surgeon. These kind of conversations, it's not necessarily a one-off.

It doesn't preclude a second conversation down the line when more facts. gets exposed. And the issues you deal with might be a little bit different. And it's important to treat this as an ongoing issue rather than a one off. It can be very difficult not to daub people in and create difficult relationships when you present the surgeon with the evidence.

So in your initial conversation with the surgeon, do you focus on what the patient has complained about or what the anaesthetist wrote or their failure to communicate with the GP? How would you phrase this initial conversation with the surgeon?

I think in a sense the patient complaints opened the door for us because that is one of the entry points. And of course we need to respond. If a patient complaints about any individual, we do have a responsibility to share that complaint Back with the provider. And in that manner we can use this as an opening to have the conversation with the surgeon and say, hey, we've got a complaint here. This is what's in the medical records. What's your version of events? That is an easy starting point.

And then we can go back to the records and say, Ah, but then I don't see this here. It it seems a lot more complicated. Why do we need a second surgery? And I think opening it up in a very open manner and allowing the first surgeon To talk about what happened in that situation I think would be a much better approach.

And certainly I would avoid saying, Oh, you know, who said what but rather frame it in a way it's factual. These are the things that it's understanding rather than who said what. Yeah. When do you bring in an independent expert? I think when we say independent, it's a little bit relative. So whether it's internal, external, depends partly whether you have the expertise in house. If it's a large hospital with other surgeons with similar skill sets, it's probably okay in the first instance.

to get another surgeon who's a pure same clinical sub speciality to give an opinion. Now of course we need to be mindful because the always a department or a team, whether they want to, I guess, protect their own, this is a very real potential. But this is what medical administrators do, together with the head of department, and of course head of department might be protecting his staff as well.

But sometimes it's having that radar to say, hang on a sec, does this actually sound right? I think if you don't feel that you're getting an honest appraisal of what's actually happening, then it is much better just to go external. To go external and get independent advice. It can be done in a very confidential manner anyway.

Just to give an idea of what's happening. One of the challenges here is that if it's not written down it didn't happen is the sort of the mantra that we talk about medical records. But in this case the It wasn't written down but it did happen. How can you be sure that it's not happening on a regular basis? That the surgeon's just not recording complications that occur because you've got nothing on record.

You're absolutely right. And David, I think with one of these things it's really particularly difficult. And what we might end up needing to do is to take a review of the cases of the surgeon to look at the outcomes of patients. I mean complications, it might not be documented, but let's say we review the last twenty cases or thirty cases. off that surgeon. It might be procedure specific, it might be more general. You take guidance from the head of department.

But you want to look at complication rates. And while it might not be there in operation record or the progress notes, if patients deteriorate, you will know because it will also be in things like your viral signs. you might need additional consultations, the nursing records. It might be unplanned readmissions or unplanned back to theatre operations. So all those are signals that for that medical administrator you can have a look. Is there a problem? Then those are all hints.

It may also be that the staff that work with him with the surgeon roll their eyes and say, Oh my goodness, um, didn't he write that down? Exactly. Exactly. And that's why my comment about the O T staff as well as the head of the anesthetic department often is a good place, you know, because they hear about all the things and then Nisitors might sometimes share their concerns with the head of department. So that is a a good place to find out some facts as well.

So the medical records, the sort of definitive repository of what happened Do you go back and alter the medical record, edit the medical record, put a note in there so that future reviews can realise that the complication wasn't documented? Aaron Powell I think your question there had a few different

I guess suggestions. But be very careful about you know certainly you wouldn't want to change or falsify medical records. That is a massive no no. However, it doesn't seem to be preclude the organization or the doctor from adding information in as long as it is dated and clearly documented that this is a retrospective entry. that wasn't there. It is probably not a bad approach because you still want the information documented. Yes, it is retrospective. We are trying to fix the problem.

So it's not, you know, falsifying or altering the medical records, but perhaps in the form of an addendum might be appropriate. It's always a tension as to whether or not investigations should become part of the patient record or whether they're an independent file. Uh ultimately open disclosure, certainly in Australia and New Zealand, is a standard of care. At what extent of open disclosure should we consider? If it's real open disclosure, potentially parts of the

Findings of the investigation should be provided to the patient anyway. And there's a lot of literature to suggest if we're open with patients. Ultimately in the long term, this is better for patient satisfaction, experience, as well as the organization's reputation, as well as finances.

So these are all things that we need to consider. Let's pick that up then. The patient has asked for a copy of their medical records, including their operation notes, and any investigations that were performed before and after surgery. Do you give them a copy of their medical record?

I don't think we have a choice either. Certainly more so. Pretty much all jurisdictions require hospitals to provide a copy of their medical records To the patient, if it is requested, And again coming back to the principles of open disclosure Well, this is something we should provide to the patient as part of the healing process anyway, and to explain what happened. And I think something about, okay, this has happened, but what are we doing to improve the situation?

How are we going to manage yourself, the patient? You know how we're going to make sure that your care going forward is appropriate and we're gonna look after you. But we acknowledge this these issues and how are we making changes to the system itself?

so that this doesn't happen to someone else. I think those are all parts of the conversations that you need to have during an open disclosure process. And of course open disclosure has that element of expression of regret, which is important in terms of moving on for the patient. The patients complained. How helpful are you going to be in resolving their concerns? You could simply give them a copy of the medical records and say, here it is.

Or you could write to them and say, Thank you, we're now investigating it. By the way you might like to look at the anaesthetist's note, hint hint. So how do you respond to this patient? I think this is a little bit tricky because there needs to be a balance between what we should do and what is right and providing the medical record, but not going too far to the point of saying to the patient

Here, this is a case you can sue the hospital for or to go after our doctors. As a medical administrator or any hospital administrator, we should also have the interests of the hospital and its staff. as points of consideration as well. I think definitely when a complaint comes in, you acknowledge the complaint. And what you would likely want to do is to invite the patient as well as the support person to come into the hospital to have that open conversation.

So that you can lead and steer that conversation and take the individuals out of that conversation and focus on the facts. It's about moving forward, said So we need to address that in a considerate manner. So bringing that patient in and having a face to face conversation would be my recommendation. And certainly we can provide that copy of the medical records to the person as well. I don't think we need to highlight

Oh, this is a problem area is that you need to talk to your lawyers about about suing us. I don't think that's the purpose of the conversation. It's a real tension between protecting the surgeon, likely your employee And supporting the patient who's undergone harm as a consequence of the treatment provided by the specialist. Where does your loyalty lie? I think it is to both.

So first and foremost, we need to do the right thing by the patient. However, during that process, if it comes to light that there are some individual behavioral issues, We also need to address that in a respectful manner. It's not just the surgeon, but any potential bad behavior or is it a systems issue, unpacking that and approaching that in a more systematic manner.

And I mentioned about that natural justice principles when you're doing that investigation. We're also very conscious of that. And there's also the I guess the concept of the second victim. So others who are involved in the clinical care who've seen a poor outcome occur How does that come through on our staff? I think we need to be conscious of that. And there are a lot of employee assistance programs in organisations. If they require it, we can provide support that way as well.

You mentioned earlier the culture of the organization. It's unfortunate that the patient had to complain before you became aware of this incident. Clearly the anesitist Perhaps in the expectation or even hope that somebody would spot it. The theatre staff never raised it with you before, or said that they were concerned. So tell us about your, I guess, observations about the culture in this hospital and what you would see as an ideal culture and a clinical governance perspective.

I think having a safety culture means having a strong speaker culture. What we also need to understand is while we focus on the anesthetist because he made a documentation, As you s rightly say, there are a lot of other people, the nurses did they actually mention this to the theatre in charge nurse or anyone at all? Because if something serious has happened, other people in that O T would have known about it and would they have said anything.

We also need to consider whether we have the right systems in place. Do we have a good incident management system? So a reporting system. So say for example in a lot of jurisdictions, the public sector, you would have things like RISMAN or VIMS. that allows easy anonymous reporting of the issue. Have we put in place these systems for staff to notify the supervisors or management about these issues?

And of course, even though you might have the IT system to support these processes, it still comes back to culture. And the leadership of the organization need to consider, are we walking the talk? Encouraging the staff to speak up to ensure that there are no repercussions if they raise issues, any safety concerns. This is not a flicker switch. Kind of issue. It takes years to develop that culture, starting from the leadership, making it very clear this is important for us.

and how we will recognise also those who are reporting. Safety. At what point or what trigger would you raise a concern with APRA about the surgeon's practice and recording process? I think if we're considering porting to opera they are very strict Criteria. what is a reportable offense. And those are the very clear sort of guidances, right? Perhaps if the physician is or the surgeon is operating when they are, let's say, intoxicated, that that's a very clear

I guess sign that you need to speak to Opera. However, in this situation, I'd be very cautious. about whether we actually go to opera about this thing. Is this a one off or a pattern of behavior? Or the other thing is, is he consistently providing care that is significantly deviating from standards. I think that test is the critical question here. And there has to be a

It's a little bit subjective and if it was one case I'd probably be hesitant myself. But if it's a pattern of behavior which upon feedback and opportunities to provide the the individual the opportunities to improve and it still happens, then I would take this consideration a lot more seriously. Thank you very much, Alistair. Once again a very difficult and challenging problem for any medical administrator. Thank you for your time. Thank you very much, David.

That was Associate Professor Alistair Ma, the Vice President of Medical Affairs at United Family Healthcare, which is one of China's largest private. Operators. And that brings us to the end of this episode of Safeguarding Healthcare. doctor David Rankin. Follow Safeguarding Healthcare free on Apple Podcasts, Google Podcasts, Spotify or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian College of Medical Administration.