Disclosure-with-offer program provides more transparent culture
Study finds program also reduces cost
Preventing medical errors and patient harm is a top priority for most hospitals. Physicians, nurses, and other clinicians do not enter their professions to produce poor outcomes.
However, medicine is an inherently risky business, and sometimes patients are harmed. Informing patients and their families of harm—which may or may not have resulted from an error—is always difficult. Providers find disclosing harm, and sometimes errors, is complicated not only emotionally, but also legally and financially. The majority of providers currently work in a legal culture in which they aren’t allowed to speak of the event, counteracting the ideals of openness and transparency so often valued by patient safety and quality professionals.
In 2001, one hospital system began changing the way its physicians dealt with patient harm. The University of Michigan Health System (UMHS) began allowing physicians and other clinicians to disclose errors and offer compensation. The idea was to be open and honest, and if harm occurred because of an error that could have been avoided, to offer compensation up front along with an apology. The change, in many ways, created a more transparent, positive, efficient, and safe culture, according to chief risk officer Richard Boothman, JD.
Boothman says that supporting staff members and allowing them to be open and honest ultimately creates a better, more truthful risk management process, which in turn produces better patient safety and a higher-quality healthcare organization. He says that when he arrived at UMHS in 2001, he felt more could be done to effect change that would result in better care.
“As a trial lawyer, I knew that this institution, like many, was ultimately risk adverse. We were denying and defending every case, we were spending all that money in defense costs, and then we were settling anyway,” says Boothman. “So that didn’t make a lot of sense to me. The medical staff did not feel very well supported.”
The first step to quality improvement is a familiar one. “You can’t learn anything if you don’t admit you have a problem. Transparency becomes important not necessarily because it’s ‘the right thing to do.’ I don’t concern myself too much with the right thing to do because that really depends on whose shoes you’re wearing at the time,” says Boothman. “[Transparency] is a necessary component to getting better. If you engage in a visceral, knee-jerk deny-and-defend response, you will never learn anything from these cases.”
Legal concerns often restrain more important issues such as quality improvement and patient safety, says Boothman.
“I think it is impractical if not impossible to learn anything when you are geared up in that mode,” he says. “The honesty part of this doesn’t come from some high-blown ethic as much as it does from the practical reality that, in the final analysis, I don’t serve our medical staff or this institution well by allowing them to continue to make the same mistake over and over or turn a blind eye to dangerous practices or dangerous individuals.”
Lawyers “should not inhibit patient safety by worrying about complicating a case today to the point it sacrifices improvements for tomorrow,” says Boothman. He believes legal issues should not get in the way to the extent that clinicians cannot admit a problem in a hostile environment void of trust. Improvement occurs when there is trust between staff members and the organization. Such trust, he says, allows staff to recognize room for improvement.
“In 22 years of handling malpractice cases for wonderful places like the Cleveland Clinic and University of Michigan, not a single client of mine ever asked me what they should have learned from the cases I handled. And I always thought that was idiotic that I would sometimes pay millions of dollars to settle cases … but nobody learned anything from it,” says Boothman. “There was a psychological disconnect between my clients as they saw their role as caregiver and my clients when it came to dealing with cases. And my whole career I just thought that was dumb. We must learn from our patients’ experiences and the claims we handle to improve patient safety.”
How it works
As soon as UMHS learns of an error, risk management staff are assigned as point people in terms of talking to patients. They apologize, letting the patient and/or family know that UMHS will investigate the error and that whatever is learned from the investigation as well as any new practices to prevent the error in the future will be shared with them. If UMHS has made an error, compensation will also be offered.
“The key here is that it is not a one-time conversation; it is a process that occurs once the university learns of it. They have experts that help shepherd the process along, but the clinicians are also involved in the conversations, and they assure patients that they will take care of all of their economic losses,” says Allen Kachalia, MD, JD, director of quality in the Department of Medicine at Brigham and Women’s Hospital in Boston.
Staff members are proud of the program, Boothman says. “I rarely get anyone who won’t talk to a patient.”
But he warns that the program is not always easy: Tough conversations between risk managers, providers, and patients and families need to happen. And you can’t expect patients to become happy simply because you’ve done something that they expect—told the truth, says Boothman. “It’s thornier in the trenches, it’s not for sissies, but we can never lose sight of the greater benefits. And from an institutional perspective, it’s important because it’s the way we will continue to improve and make sure we do not make the same mistakes again.”
“This study wasn’t designed to determine culture,” says Kachalia, “but what we found by talking to people at the University of Michigan is that the culture is much more open and transparent about talking about errors. It seems there is a much greater dialogue around errors and how to prevent them.”
Program also reduces cost
Although Boothman strongly believes the program allows for better patient safety, it cannot be denied that it also saved UMHS money. A recent study, “Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program,” published in the August 17 Annals of Internal Medicine, compared liability claims and costs before and after the implementation of the program. The study, coauthored by Boothman, concluded that the disclosure-with-offer program at UMHS resulted in a decrease in the monthly rate of new claims from 7.03 to 4.52 per 100,000 patient encounters, and the average monthly rate of lawsuits decreased from 2.13 to 0.75 per the same number of patient encounters. Overall, monthly liability costs decreased. The study concluded that UMHS successfully implemented the program without increasing its total claims and liability costs.
“What this data shows is you can do the right thing and not have the liability problem that everyone worries about,” says Kachalia, who served as lead author of the study. “The clearest success is that they have the program running. It’s not about lowering your claims cost.”
“This is not a claims management strategy, primarily,” Boothman says. “It is of course a claims management strategy in part. But the best risk management is to make no medical mistakes. And the second risk management is to not make a mistake again. Quality of care has got to be front and center.” The study’s point is to prove that you can have this program and not go bankrupt, he adds.
“The headlines [about this program] are often something like ‘Apologies save money,’ but this is not about saving money in claims,” says Boothman. “This is about getting safer so we don’t have claims to begin with.”
Is it for everyone?
Boothman says the fear of liability and expense, along with a deep-seated culture of denying issues, makes it difficult for other hospitals to understand that they could also implement a similar program.
“As I go around the country, these concepts still encounter an emotional response, not an intellectual or rational response, which has been the inhibition for other places to give this a try,” he says.
“Our hope is that other hospitals can see that this is a large academic medical center that did this,” Kachalia says. “They were able to do this and not have their liability costs go up or skyrocket. Our hope is that other institutions will give this a try.”
Kachalia and Boothman admit, however, that one particular aspect of UMHS better allows it to offer compensation along with disclosure: UMHS has a closed medical staff, employing all of its physicians, which puts everyone on the same financial page and allows UMHS to deal with only one insurer. “We have alignment financially and ethics-wise,” says Boothman.
Also, “the UMHS program covers everybody all the way through; there’s no policy limit per se,” Boothman says. Therefore, physicians are not as fearful of admitting mistakes due to worries of possible personal financial bankruptcy.
“One of the greatest things about this program is something I don’t know quite how to measure. It’s the change in mood,” says Boothman. “The whole culture has been energized; everyone is always thinking of how to get better and better. And that’s the thing I’m most proud of.”