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Focus on... the Cayman Islands

Medicolegal issues take many shapes and forms. Casebook recently caught up with Lizzette Yearwood, the Chief Executive Officer of the Health Services Authority in the Cayman Islands, and Andria Dilbert, Director of Corporate Services at the organisation, to address some of the most topical issues

Many of the challenges in modern healthcare seem to be in the face of damaging “rises” – in the number of clinical negligence claims, the cost of healthcare, and patient expectations. But while these challenges are becoming globally ubiquitous, the nature of the response is often unique.

Lizzette Yearwood has been CEO of the Cayman Islands Health Services Authority (HSA) since 2009 and has dedicated her time to tackling risk management and reducing the likelihood of doctors facing litigation.

Eyes and ears

“Early intervention is the key for us,” says Mrs Yearwood. “As well as monitoring risk management on a departmental level – I chair a quarterly risk management committee, at which we monitor and discuss untoward events reported via the incident reporting and patient services programs.

“Our patient services representative is able to co-ordinate face-to-face meetings with patients and their families, where we can address the concerns they have. This often involves resolving patient misconceptions – which are commonly the source of claims against our doctors.”

Andria Dilbert’s role as Director of Corporate Services includes the overseeing of the day-to-day management of areas of possible risk, incident reporting and quality assurance.

She says: “Because of earlier intervention, we have seen many instances in which incidents that could have escalated were defused and patients happier – as they are able to gain a greater understanding. When we speak to our patients and give them an explanation, they tend to be more settled with the outcome.

“A few doctors still fear that an open conversation will expose them to litigation. Fortunately, it is being accepted more and more that a good explanation at the beginning will help to avoid many more difficult questions later on.”

Because of earlier intervention, we have seen many instances in which incidents that could have escalated were defused and patients happier

Open disclosure

MPS has long championed the role of open and honest communication between doctor, colleague and patient in helping to reduce the chances of a claim or complaint being brought against you. There are challenges in convincing doctors to adopt this approach, but for those who do the outcome is usually positive.

Mrs Yearwood says: “Open disclosure is important but it is a concept that has taken some time to gain traction. We have physicians from many other countries working in our hospitals and some embrace it more quickly than others. There is fear that the focus is on mistakes or where things went wrong; whereas, the emphasis is on acknowledging the patient’s concern.

“We have seen for ourselves when a doctor has a good relationship with the patient, the patient is less likely to make a claim against them – that empathy – and it’s not a case of apologising for what you did, and accepting liability, but that you are sorry the incident happened. Sometimes that is all the patient wants to hear – that you understand their pain, their anxiety. That can often avoid any claim.”

Mrs Dilbert says that there are a number of doctors showing a willingness to selfreport following an adverse incident.

When a doctor has a good relationship with the patient, the patient is less likely to make a claim against them

Blowing the whistle

Raising concerns about colleagues or policies and procedures in the workplace is often crucial for safeguarding patient safety, yet understandably there are concerns over being viewed as untrustworthy and disloyal to one’s peers. Whistleblowing can be a lonely endeavour.

“We have tried over the years to take a non-punitive approach to anyone bringing their concerns to us,” says Yearwood. “People need to know they will be protected when raising concerns and our stance has made people more open and honest.

“It is a small community in the Cayman Islands; everyone knows everybody or is related in some way. It is important for healthcare staff to know they can bring their concerns to us and that we will deal with them seriously and confidentially.”

“A question we get asked frequently is how protected are the conversations in case reviews,” says Mrs Dilbert. “What happens if someone finds out what has been discussed, say by way of a Freedom of Information (FOI) request? While there is some protection in the FOI Law for these kinds of discussions, the FOI Law also seeks to ‘promote greater public understanding of the processes or decisions of public authorities’; therefore, there remains some uncertainty over the disclosure of the details of quality assurance reviews. So that remains a concern, even though everyone recognises it’s important to speak openly about what has happened.”

More with less

The global recession has meant that many countries across the world are facing unique challenges in working with limited resources. It is no different in the Cayman Islands. “Doing more with less is a common theme among most countries now because of the growing cost of healthcare,” says Mrs Yearwood. “We have taken a number of different approaches at trying to reduce the cost while ensuring quality remains high.

Doing more with less is a common theme among most countries now because of the growing cost of healthcare
“This includes the standardisation of our hospital equipment, which has been an initiative that has helped to bring about greater efficiency while safeguarding patient care. We have also embarked on more public-private partnerships. We recently partnered with a private company to provide MRI services with a 1.5 Tesla magnet and to upgrade 3.0 later – an investment that simply would have been very costly for a public hospital to do alone. Through such partnerships we can offer our physicians the tools they need to provide a better service to patients.”

Mrs Yearwood also describes how the practice of sending patients to the US mainland – where the cost of healthcare is high – is being replaced by an approach that sees more specialists being available in the Cayman Islands to provide care locally.

“This actually provides a better service to patients because it is important for them to have their support at home. To be away from relatives and friends for, say, a cancer patient, is very difficult.”

Empowering physicians has also aided in the co-ordination and management of resources. With new structures in place that has seen clinicians appointed as heads of various departments, decisions are being made by those best placed to make them. Mrs Yearwood says: “Doctors have really embraced this approach as they do more than provide clinical care – they are making key decisions too. We have input across the specialties where it really matters. They are the ones providing the care and they know the patient’s needs.”

Words: Gareth Gillespie