A hip-replacement patient of Bruce Haupt, an orthopedic surgeon practicing in South Charleston, W.Va., died while recuperating. Haupt's procedure went smoothly and no medical errors occurred, but the patient's distraught family filed a quality-of-care complaint against the hospital and him. Because it was a communications-related complaint, both parties agreed to go through Medicare's mediation program to resolve it.
Haupt says mediation was a worthwhile experience. "As professionals, we tend to get so focused on our job, it becomes so familiar that we forget there are people on the other side," he says. "We tend to not be as sensitive to the emotional needs of the patients or family members. Mediation is a nonadversarial way to review your own approaches to treatment."
Most healthcare providers have experienced difficult patient communications, worked with confused families or received mixed signals. Communications breakdowns can easily happen when people are ill, upset or stressed about their medical condition. A patient may misunderstand a diagnosis, plan of care or treatment. In addition to causing problems with adherence that can adversely affect patient outcomes, misunderstandings can and do lead to formal complaints. And dealing with complaints can mean lost time and productivity.
The CMS instituted its mediation program in 2003. It offers physicians, providers and Medicare beneficiaries the chance to resolve their misunderstandings face-to-face, without litigation or financial penalties.
Mediation offers an alternative method for addressing beneficiary quality-of-care complaints by providing a confidential forum to discuss the experiences that have led to the complaint. Mediation is only offered in cases where an initial physician review indicates no serious medical error. Some examples of such disputes include:
* A patient complains about the inability of a nurse to establish an intravenous line for a blood transfusion.
* A patient is concerned that he wasn't told about the complications that could occur with a surgical procedure.
* A patient is unhappy because she felt that hospital staff ignored her, failed to treat her with respect and didn't listen when she said she wasn't ready for discharge.
Tu Tran, a gastroenterologist practicing in Paramount, Calif., had one such experience with a patient of his. "Getting the issue out on the table, mediating it and resolving it is often the smartest and most expeditious way to reach an agreement," he says. "By using mediation, my patient's dissatisfaction was relieved and I was saved from more time-consuming processes. It was a beneficial process for both of us."
The CMS contracts with quality-improvement organizations in every state to handle beneficiary complaints and to direct appropriate cases to mediation. QIOs are staffed by physicians, nurses and experts in case review, health communication and data analysis. Participation is at no cost to either party and is strictly confidential; nothing discovered in the proceedings can be used in court. The Medicare beneficiary, physician and/or other providers must voluntarily agree to participate.
If a Medicare beneficiary complaint is deemed eligible for mediation, healthcare providers should consider the many compelling reasons to consider this alternative form of dispute resolution. In addition to increasing patient satisfaction and avoiding possible litigation or costly reparation, mediation improves communication and motivates beneficiaries to continue provider relationships; provides a unique opportunity to hear beneficiary concerns and gain new insight about how to be more effective; and can initiate systemic quality-improvement efforts that benefit all patients.
The time and resources spent on mediation are usually not overwhelming and would appear to be a worthwhile investment in return for the potential rewards of generating good will, understanding and the constructive resolution of a complaint. A mediation session typically takes two to four hours, significantly less time than a traditional medical record review or legal proceedings. Every effort is made to schedule a mediation session at a neutral location convenient for both parties. Mediation can also take place via telephone.
Confidentiality is a key component of mediation. In order for mediation to be successful, both parties must feel as free and open as possible in their attempts to work through their conflict. No record is kept of the proceedings, and any notes taken during the session are destroyed. Nothing said during the mediation can be used against either party in a court of law. All parties, including the mediator, need to agree that all statements made during the process will be kept confidential unless the parties agree otherwise. If and when the parties reach an agreement, however, that agreement and its particulars are released to the QIO in order to monitor any terms that relate to quality-improvement efforts. The QIO handles agreements according to the federal regulations governing the confidentiality of QIO documents and materials, which are also not subject to release in any civil court proceedings.
Participation in the Medicare Mediation Program is growing, and while current data are sparse, early results on participant satisfaction are quite encouraging. Case report evidence suggests that those who participate in mediation are satisfied with the outcomes as well as the process. The CMS will continue to monitor provider and beneficiary satisfaction with the mediation program as this important and innovative program develops further.
William Rollow is director of the Quality Improvement Group, Office of Clinical Standards and Quality at the CMS, Baltimore.