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 “” 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 “” 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 “”. 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 “”
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”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “”
Other very valuable resources on disclosure and apology:
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
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
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