The theme of the January 2014 issue of Health Affairs is “Exploring Alternatives to Malpractice Litigation”. Included in this issue are 5 useful articles that deal with disclosure and apology (to patients and families) after medical errors. The term “disclosure and apology” is now also competing with the term “communication and resolution” which, though accurate, sounds a little too legalese for our taste. The “resolution” part includes compensation to the patient or family when the standard of care was not met. Several studies have now shown that the ultimate costs of such programs are less than one would see with historical malpractice settlements. More importantly, it’s the right thing to do!
We’ve been advocates of disclosure and apology since the early 1990’s. But despite the evidence base in the literature supporting the trend to disclose medical errors and apologize to patients and families, physicians and hospitals and administrators (often based on legal counsel) have been slow to adopt this approach.
Hendrich and colleagues (Hendrich 2014) describe how one health system, Ascension Health, implemented a full disclosure policy beginning with demonstration projects in 5 of their labor and delivery units. It is an excellent account of the barriers they met during implementation and how they were able to increase the rate of full disclosure by 221% in 2 years. Key success factors included insurers’ acceptance of the full disclosure protocol, consistent and ongoing leadership by local practitioners and hospitals, the establishment of a well-trained local investigation and disclosure team, and disclosure training for practitioners. The article and an accompanying blog (Henkel 2014) discuss how the concept of disclosure and apology fits in with the Ethical and Religious Directives for Catholic Healthcare Services, 5th ed. as well as Just Culture, the AMA Code of Ethics, Joint Commission standards, etc. They learned from their experience that disclosure is a healing process, both for mothers involved and the healthcare individuals involved (see also our December 17, 2013 Patient Safety Tip of the Week “The Second Victim”).
One “communication and resolution” program implemented in general surgery at 5 New York City hospitals (Mello 2014a) was able to improve rates of disclosure and surveillance for adverse events within about 2 years but had difficulty implementing the program’s compensation component. Like the experience at Ascension Health, strong support from top leadership at the hospital, support from insurers, and adequate staff resources were critical success factors. Educating clinical staff about how the program can benefit them is important. Very important, however, is that the hospital and its leadership be able to tolerate risk and support the “communication and resolution” concepts.
A related paper (Mello 2014b) studied communication and resolution programs implemented by six early adopters. The participants interviewed identified several factors that contributed to their programs’ success: the presence of a strong institutional champion, investing in building and marketing the program to skeptical clinicians, and making it clear that the results of such transformative change will take time.
Yet another paper (Etchegaray 2014) focused on the role that patients and families might have in participating in the analysis of events following an adverse event. Results from interviews with patients, family members, clinicians, and administrators were subsequently discussed at a one-day national conference. Conference participants concluded that increasing the involvement of patients and their families in the event analysis process was desirable but needed to be structured in a patient-centered way to be successful. They provide suggestions on how that might be accomplished.
Lastly, Sage and colleagues offer recommendations from many of those who have been involved in developing and implementing communication and resolution programs (Sage 2014). They discuss the importance of the legal system supporting such programs and many of the legal aspects, such as allaying providers’ fears by protecting apologies from use in court, facilitating patient participation by ensuring legal representation, and discussing how such programs may affect providers’ reputation and economic concerns.
Overall, the papers in this issue of Health Affairs are both useful and provocative and should be very helpful to you if you have not yet become and adopter of “disclosure and apology” or “communication and resolution”.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “ ”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
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.
Hendrich A, McCoy CK, Gale J, et al. Ascension Health’s Demonstration Of Full Disclosure Protocol For Unexpected Events During Labor And Delivery Shows Promise.
Health Affairs 2014; 33: 39-45
Henkel R, Slosar JP, Haydar Z, Hendrich A, Santos P. The Moral Imperative to Disclose Medical Error: Doing the Right Thing. Health Affairs Blog January 7, 2014
Mello MM, Senecal SK, Kuznetsov Y, Cohn JS. Implementing Hospital-Based Communication-and-Resolution Programs: Lessons Learned in New York City. Health Affairs 2014; 33: 30-38
Mello MM, Boothman RC, McDonald T, et al. Communication-and-Resolution Programs: The Challenges and Lessons Learned From Six Early Adopters. Health Affairs 2014; 33: 20-29
Etchegaray JM, Ottosen MJ, Burress L, et al. Structuring Patient and Family Involvement in Medical Error Event Disclosure and Analysis. Health Affairs 2014; 33: 46-52
Sage WM, Gallagher TH, Armstrong S, et al. How Policy Makers Can Smooth The Way For Communication-And- Resolution Programs. Health Affairs 2014; 33: 11-19
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