What’s New in the Patient Safety World
October 2017
More Support for Disclosure and Apology
We have been advocates of disclosure and apology after serious adverse events for over two decades. Not only is such transparency ethically the right thing to do but evidence has been accumulating that such disclosure, along with sincere apology, does not lead to higher liability costs. In fact, “communication-and-resolution programs” may even save money. Such programs communicate with patients when adverse events occur, investigate and explain what happened and, where appropriate, apologize and proactively offer compensation.
In our January 3,
2017 Patient Safety Tip of the Week “What’s
Happening to “I’m Sorry”?”
we discussed several communication-and-resolution programs, including
the successes of some but also the barriers encountered in implementing others.
A new publication in Health Affairs describes the process and outcomes from communication-and-resolution programs program used by two academic medical centers and two of their community hospitals in Massachusetts (Mello 2017). 91% of the program events did not meet compensation eligibility criteria, and those events that did were not costly to resolve (the median payment was $75,000). Only 5 percent of events led to malpractice claims or lawsuits. Overall, clinicians were supportive of the program but desired better communication about it from staff members. 39.6% of clinicians said they were not familiar or not very familiar with the CARe program but, of those who were familiar, 89.8% gave it a moderately-to-strongly positive rating.
In our January 3, 2017 Patient Safety Tip of the Week “What’s Happening to “I’m Sorry”?” we discussed a couple other studies by Mello and colleagues. Results from a demonstration project in New York City were less impressive (Mello 2016a). The communication-and-resolution program implemented in surgical departments of 5 NYC acute care hospitals was quite successful in handling events not caused by substandard care, but less consistent in offering compensation in cases involving substandard care. But one striking finding in that study was that clinician awareness of the communication-and-resolution program was quite low and many felt the program did not likely help avoid a lawsuit. The authors felt that, in those cases where there were violations of standard of care, there was difficulty adhering to the principle that compensation should be proactively offered.
The current study by Mello et al. on the Massachusetts experience emphasizes the importance of adherence to the program and commitment to offer compensation proactively. The Massachusetts hospitals were able to adhere to their CRP commitments more consistently than hospitals in the earlier demonstration project in New York. In the New York hospitals resistance by insurers and physicians were noted as factors preventing them from making offers.
The other prior paper by Mello and colleagues was a study of a communication-and-resolution program (CRP) involving six hospitals and clinics and a liability insurer in Washington State (Mello 2016b). It found that sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP. Barriers included the insurer's distance from the point of care, passive rather than active support from top leaders, coordinating across departments and organizations, workload, nonparticipation by some physicians, and overcoming distrust.
The Massachusetts experience is reassuring and hopefully will go a long way to assuage some of the negative attitudes discussed in our January 3, 2017 Patient Safety Tip of the Week “What’s Happening to “I’m Sorry”?”. We strongly support these programs as “the right thing to do”.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious
Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple
Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup
to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error
Disclosure by Surgeons”
June 2012 “Oregon
Adverse Event Disclosure Guide”
December 17, 2013 “The
Second Victim”
July 14, 2015 “NPSF’s
RCA2 Guidelines”
June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
August 9, 2016 “More
on the Second Victim”
January 3, 2017 “What’s
Happening to “I’m Sorry”?”
Other very valuable resources on disclosure and apology:
- IHI’s “Respectful Management of Serious Clinical Adverse Events” (Conway 2010)
- The Canadian Disclosure Guidelines (Canadian Patient Safety Institute 2008)
- The Harvard Disclosure Guidelines (Massachusetts Coalition for the Prevention of Medical Errors 2006)
- The ACPE Toolkit (American College of Physician Executives)
- Oregon Patient Safety Commission Oregon Adverse Event Disclosure Guide.
References:
Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs. Health Affairs 2017; 36: 1795-1803
http://content.healthaffairs.org/content/36/10/1795.abstract
Mello MM, Armstrong SJ, Greenberg Y, McCotter PI, Gallagher TH. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. Health Services Research 2016; 51(Suppl S3): 2550-2568 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27807858
Mello MM, Greenberg Y, Senecal SK, Cohn JS. Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. Health Services Research 2016; 51(Suppl S3): 2583-2599 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27781266
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