Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration

Abstract Objective This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies. Background In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies. Search Strategy and Inclusion Criteria To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject‐relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer‐reviewed articles. Main Results and Synthesis The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication‐and‐resolution programmes, complaints procedures, patients‐as‐partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support, and desired outcomes. Patient Contribution This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Patient Contribution: This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.
communication, health care incident, hospital strategies, patients, restoration

| INTRODUCTION
In 1999, the Institute of Medicine published its landmark publication 'To err is human', which showed a high rate of medical error in health care in the United States of America and the need for improved patient safety. 1 The analysis from 'To err is human', together with several medical tragedies worldwide (such as the Bundaberg Hospital Scandal), functioned to draw attention to the need for safe health care. 2 Institutions, nations and states launched initiatives to improve openness and disclosure after medical error, such as communicationand-resolution programmes (CRPs) and apology laws. 3,4 Scholars have differed in how they distinguish between types of health care incidents and which terminology they have used. Examples include medical error, patient safety incident and adverse event. 1,[5][6][7] Each of these terms contains within it contextual particularities: something that may seem a medical mistake to a patient may be considered a complication in the eyes of a health care professional. From a patient perspective, a broad range of health care incidents are relevant. We have therefore chosen to use the term 'health care incident', defined by the Australian Council for Safety and Quality in Health Care as 'an event or circumstance during health care which could have, or did, result in unintended or unnecessary harm to a person and/or a complaint, loss or damage'. 8 We use this term to, indeed, include a variety of incidents and errors that involve medical treatment, medication, communication, management, and service or interpersonal skills of health care professionals.
The strategies used by hospitals did not always provide patients and family members (abbreviated to P/F) with a way to come to terms with what had happened. 9 Some scholars asserted that the patient perspective was completely lacking. 10 The term 'strategies' is used in this article to include all hospital programmes, processes, policies and interventions. The terms can be used interchangeably. One study demonstrated the need among patients to be communicated with openly about a health care incident (i.e., open disclosure, an open discussion between the patient and the health care professional about the health care incident). 11 The study showed that, despite momentum for open disclosure in Australia, P/F 'only rarely experienced incident disclosure communication as appropriate and effective'. 11 This raises the question of how to meet patients' needs after a health care incident, to prevent unnecessary legal proceedings and subsequent costs and additional psychological, physical or financial harm. 4,12 Dauer and Bismark 13 distinguished four patient motives for taking legal action after a health care incident: correction; sanction; communication; and restoration. Different strategies after a health care incident link to a variety of these motives. For example, learning programmes and safety culture have a strong link with a patient's desire for correction and prevention. 14 Disciplinary proceedings or a calamity procedure in turn link to sanctioning either a health care professional or a care facility. 15 Open disclosure processes and compensation payments, among others, link to communication and restoration. The present study aims to provide a closer look at this last category of strategies, specifically concentrating on strategies without a financial or material component. We call these 'nonmaterial strategies': strategies aimed at restoring the harm that was done, using means such as communication, supporting doctors in open disclosure or mediation.
Earlier research has focused on nonmaterial strategies (e.g., when looking at open disclosure 16 ); yet, an overview of these strategies is lacking, especially with regard to how P/F evaluated them. This is important because it would allow health care institutions to reason from the patients' point of view and would allow them a voice. 17 This in turn may prevent unnecessary legal proceedings and may provide an understanding of fundamental aspects that provide for a good strategy. These fundamental aspects can inform future policy and strategies for all hospitals adhering to the words: 'listening to patients illuminates the way forward'. 4 This scoping review provides an overview of strategies adopted by hospitals that target effective communication and nonmaterial restoration and P/F's evaluation of these strategies.

| METHODS
A scoping review fitted the aim of this study because it provides an unprecedented overview of studies that deal with nonmaterial, patient-directed strategies after a health care incident 18 using a variety of methods. 19 No scoping review protocol exists, but the review essentially followed the methodological framework with its five stages set out by Arksey

| Stage 3: Study selection
For the study selection, this review used inclusion and exclusion criteria and followed an iterative process. Studies were included for analysis when published in English, focused on humans, focused on hospitals as health care institutions (to allow comparability) and published between 2000 and 11 June 2019, because of increased attention to and implementation of nonmaterial strategies. The three key concepts further informed the inclusion of studies. Each included study had to focus on a strategy (including interventions, programmes, processes or policies) internal to a hospital, in the aftermath of a health care incident, which had a nonmaterial and patient-centred focus and had been evaluated by P/F. Studies were excluded if no full text was available (despite an attempt to contact authors) or if one of the inclusion criteria was not fulfilled. The scoping review specifically excluded studies that lacked an internal hospital strategy or had not been evaluated by P/F. Hybrid studies that included a material subfocus were included. Quality assessment of the studies was not conducted because this scoping review aimed to provide a descriptive overview of the available research. 20 In consultation with coauthors, we decided to exclude journal articles that were not peer-reviewed because these studies did not contain relevant information for this study. Grey literature was not searched because no systematic or scoping review had been performed in the past, so the main aim was to outline current academic publications.  Table 1 in the Results section. The table includes information on the author, year of publication, study location, main objective, hospital strategy, design/method, sample size, setting and main outcome. To add to the validity of the study and provide a certain level of consultation, three experts from Australia, the United States of America and Europe were asked to assess inclusion and add missing literature. This did not lead to the inclusion of any additional studies.

| Stage 5: Analysing and reporting the results
In reporting the results, the analysis focused on basic study characteristics, the content of the specific types of hospital strategies and finally on a thematic analysis of patient essentials in these hospital strategies. In the thematic analysis, priority was assigned to the content of the evaluation by P/F and what they considered essential.   The Results section contains the study characteristics, the types of hospital interventions and the elements in hospital strategies that patients consider essential.

| Study characteristics
The 16 included studies were from the United States of America (seven studies), Australia (six studies), the Netherlands (two studies) and Germany (one study). Ten studies used interviews as their research method, four studies used surveys, one study was a case study and one study used a mixed-method approach.

this implementation was based on the Australian
Open Disclosure Standard that aims at 'more consistent and effective communication after adverse events'. 24 The fourth study looked into the regional implementation of the NSW Health Open Disclosure Policy. 27 Two related Australian studies focused on the years after the government endorsement of open disclosure and analysed hospital strategies in terms of patients' experiences. 11,28 Institutional programme One study analysed one case of a health care incident and institutioninitiated open disclosure in a USA hospital. 23 The study did not contain information on the specific aims of the hospital strategy, but the author mentioned 'widespread consensus' regarding honest and clear disclosure combined with an apology. 23 Open disclosure of large-scale adverse events

| Complaints handling
Two studies focused on complaints handling in Dutch hospitals. 9,30 These hospitals were obligated by law to have complaints committees, which aimed to 'warrant easily accessible nonlegal complaints facilities for patients' and 'to restore patients' satisfaction with and trust […] in health care'. 30 The complaints committees formed a bridge between informal patient support and formal legal procedures and were supposed to provide an independent review of the situation. 9,30 The first study addressed P/F expectations about the complaints handling procedure before any initial conversations. 30 The other study compared findings from the first study to new quantitative data on patients' actual experiences with a concluded complaint procedure. 9

| Patients as partners
The review included two studies that assigned P/F an active role in improving open disclosure and preventing health care incidents. 31,32 The first strategy incorporated P/F as teachers in medical error disclosure and prevention, and aimed to improve health care professionals' communication skills to become more patient-centred and assign patients an active voice. 31 The other study addressed the inclusion of P/F in medical error event analysis and disclosure and aimed to investigate and prevent health care incidents, but also to support the healing process of P/F by involving them in the process. 32

| Mediation
The final study discussed mediation. 33 Mediation was defined as a 'confidential, voluntary process in which an impartial, third party-the mediator-helps participants negotiate their differences […]' and it could lead to a binding contract. 33 The main aim of mediation was 'to resolve medical malpractice lawsuits'. 33

| Patient essentials in hospital strategies
Despite the variability of strategies, an analysis on the basis of P/F

Apology or expression of regret
Interpersonal communication also included an apology. P/F emphasized the value of an apology in the evaluation of open disclosure, CRPs and complaints procedures. P/F considered it important that health care professionals admitted that an error was made 30 and apologized. 11,23,24,32 One study on collaborative learning highlighted the value for P/F of a sense of accountability. 31 Another study stipulated that the benefit of apologies made to P/F was strongly dependent on the identity and perceived candour of the one making the apology. 26

Appreciation for formal open disclosure
Some open disclosure studies suggested that P/F preferred to have a formal 28 open disclosure process, especially but not limited to situations where a health care incident had severe consequences. 24 One study mentioned an 'appropriate level of formality'. 11 This level of formality allowed P/F to properly prepare for disclosure and to be sure that it took place. P/F in one study considered a formal approach to occur when they were taken seriously and communication was proper, which they considered a sign of respect. 16 The blur between informal and formal disclosure sometimes confused patients as to whether open disclosure actually came about. 26 In one study, almost half of P/F considered disclosure insufficiently formal. 16 In another study, however, most patients indicated that they experienced an informal open disclosure conversation that diminished anger and a feeling of dishonesty. 27 In addition, Friele et al. 9,30 showed that too much formality in formal complaints procedures might distract from the genuine conversation with the health care professional.

Support
P/F considered support important-to 'get the right people in the room'. 4 The importance of the presence and support of specific people was apparent for CRPs and open disclosure processes, but also in programmes that included patients to improve disclosure. 32 The attending health care professional should play a leading part in any initial disclosure and P/F preferred to have a support person 11,24,26 with them during meetings regarding medical injury, for example, an attorney. 4 In addition, P/F identified needs specific to them, such as having a health care professional during open disclosure that was sensitive to the patients' expectations and (cultural and linguistic) context, and who had been involved in their previous care. 24 P/F did not appreciate being prevented from meeting the staff responsible for their care. 16 Australian studies regarding open disclosure also considered it important to discuss finances 26 and to receive an offer for tangible support. 16 However, a high financial compensation offer could discredit the truthfulness of an apology and not meet the patient's wishes-'money offers change the tenor of patients' view of disclosure and apology'. 29 This study further showed that despite a CRP aiding resolution, the relationship between patients and health care professionals could deteriorate regardless of the CRP. Finally, the mediation study suggested that plaintiffs and other participants in mediation generally considered this intervention to be 'fair, satisfying, and responsive to their interests'. 33 However, some of the plaintiffs (3 out of 12) felt pressured into the mediated agreement. 33 34 and the importance of an apology. 12,35 The importance that patients placed on interpersonal communication corresponded to the goals of open disclosure processes.

| DISCUSSION
They aimed for open discussion, transparency, better communication, an apology and preserving trust. In a comparable sense, CRPs aimed to meet the patient's needs, and complaints procedures aspire to provide an independent, nonlegal process to repair the patients' trust.
The appreciation of the aforementioned goals is evident in the evaluation by P/F. This is reflected, for example, in the substantial appreciation of sensitive and shared dialogue, 'a human approach' 27 and attention paid to the perspective of P/F. These elements seem to result in rebuilding the relationship between P/F and health care professionals and rebuilding trust.
A new finding is the specific and detailed preferences that P/F can have for using specific words. 4,22,32 For example, 'reconciliation' is better than 'resolution' and P/F prefer nontechnical language. 4,32 Also, words like 'resolved' are to be avoided, since P/F emphasized that for them, the situation is never resolved. 17

| Organisation of strategies
The second essentiality mentioned by P/F concerns the organisation of hospital strategies and getting 'the right people in the room'. 4 16 In any regard, a certain level of formality or preparedness seems to signify respect and provides the opportunity for P/F to prepare for the meeting. However, other studies indicated that patients prefer an informal complaints procedure by a complaints officer over a more formal process with a complaints committee. 36,37 This idea is addressed in one of the studies on the complaints procedure: Formality should not preclude an open conversation with the involved health care professional. 9

| Outcomes
Finally, P/F have certain desired outcomes: investigation, making changes, prevention, information, closure and financial compensation. Several of the outcomes highlighted by P/F-such as DIJKSTRA ET AL.
| 273 investigation and prevention-link back to underlying goals of particular hospital strategies. 24,26,27,32 Some of these strategies also aimed to accomplish closure, healing and rebuilding trust 25,30,32 aside from providing a financial reparation. 25 Generally, most patients who experienced a health care incident desired quality improvement and change so that a similar event will never happen again. Studies showed that P/F considered the improvement of care to be most important. [38][39][40] However, studies also showed that only a minority of P/F received feedback on changes made to clinical practice. 39,41 This scoping review confirms this finding. 4,9,11,30,32 One intriguing finding regarding the appreciation of financial outcomes by P/F is that the more generous an offer of compensation, the more P/F considered the apology to be serving self-interest. However, this finding did not lead to an increase in financial claims and malpractice lawsuits, which is consistent with a recent study that showed no increased liability and new claims for operating CRPs. 42

| Methodological considerations
The review has some methodological considerations that need mentioning. To ensure comparability, health care institutions were limited to hospitals. The study only included articles written in English, and articles were not selected based on the methodological quality of the studies. In addition, the study did not explore grey literature. Furthermore, there was considerable overlap between the data used for several of the included studies. Seven of sixteen studies could be traced back to three empirical databases, which reduced potential dispersion. In addition, institutional and cultural differences could influence the type of hospital strategy and how P/F evaluated them, but this has not been explored in the current analysis. Lastly, many of the studies that addressed patients' perceptions of open disclosure were not based on a particular hospital strategy, but rather on a general strategy evaluation. Therefore, these studies could not be included, though they might have provided interesting insights.
Consequently, the rigorous approach in this review might have unintentionally excluded interesting studies. In future research, an additional review targeting general strategies as well as grey literature would be recommended.

| CONCLUSION
This scoping review revealed a multitude of nonmaterial, patient- dealing with financial compensation offers should be sensitive to the way these offers can reflect on other forms of nonmaterial restoration, such as authenticity of an apology.