Going beyond saying you're sorry

When preventable medical errors occur, most hospitals rely—many times begrudgingly—on the usual deny-and-defend approach. They shut down nearly all communication, turn the matter over to attorneys and often relegate patients and their families to legal battles that can drag on for years. It's an approach that's isolating and frustrating for patients and clinicians alike.

But in recent years, a few hospitals have seen real success in circumventing the usual policies and instead opting for full transparency, quick remediation and improvement of the systems that caused the error.

Research has shown that these institutions, which include 859-bed University of Michigan Health System, Ann Arbor, and 485-bed University of Illinois Medical Center at Chicago, have improved patient safety, lowered liability costs, reduced their total number of claims and improved patients' experiences.

So why haven't more hospitals shifted over to this model?

The reasons, according to experts, are numerous and include fear of large financial penalties and difficulties associated with bringing multiple malpractice insurers to the table.

Those issues don't figure into the equation in the same way at UMHS, which is self-insured and has a closed-staff model. Also, because it is a large academic institution that employs its staff, any settlements usually occur in the system's name, thereby freeing physicians from the fear of crushing financial consequences.

A decade ago, Rick Boothman joined the system as chief risk officer and led an overhaul of what had been a traditional claims management system. When it was determined that adverse events had been caused by inappropriate care, the system's risk officers and clinicians would discuss it openly and honestly with patients, and offer remediation based on the severity of the harm. They also linked the process to system improvements and peer review.

In August 2010, Boothman and others from UMHS published a study in the Annals of Internal Medicine, which showed the results of 10 years spent using the disclose-and-offer approach.

The system's total number of claims that resulted in lawsuits plummeted from 233 a year before implementation in 2001 to 106 a year after full implementation in 2003, down 55%. Median time to claim resolution fell from 1.36 years before implementation to less than a year after the program was in place. And the total number of open claims fell 56%, from 261 in 2001 to 114 in 2005, and then another 27% to 83 in August 2007.

“Why is this idea gaining traction so slowly?” Boothman asks. “At Michigan, we do employ our physicians and that gives us somewhat of an advantage. But what I do have is the luxury to say to caregivers that, although they will be held professionally accountable, they don't face financial ruin if an error occurs. It's ridiculous to expect that in such a punitive environment, physicians would feel free to be unvarnished and unguarded when things go wrong.”

The University of Illinois Medical Center at Chicago implemented its approach, known as the “seven pillars,” in 2006. Modeled after the University of Michigan program, UIC's model stresses open reporting of adverse events by staff and patients, open and prompt communication, and learning from errors.

Dr. Timothy McDonald, UIC's chief safety and risk officer for health affairs, along with several other hospital staff members, published the “seven pillars” process, two years after implementation, in the April 2009 issue of the journal BMJ Quality & Safety. They found the model enhanced incident reporting among employees and resulted in no increase in lawsuits.

“When harm occurs, we reach out right away, even when the care was appropriate,” McDonald says. “Then we do our investigation, and if we determine the standard of care was not met, we make an offer.”

Remediation varies widely, he says. In one recent example, while inserting a breathing tube, a clinician knocked out several teeth from a patient. Afterward, the hospital informed the patient and his family that the incident should not have occurred and that they would not be billed for the procedure. In addition, UIC arranged and paid for follow-up dental care.

In more serious instances, a cash settlement is offered. “We have cases where we have settled for millions of dollars in just a few months,” McDonald says. “Every case is different. We are not formulaic at all.”

Sometimes patients and their families want to be part of correcting the problems that led to the error. A father of one patient harmed by a medical error now sits on UIC's root cause-analysis committee, serving as the voice of the community.

Response from patients and their family members varies, too. Some are understandably wary, some are angry and others express thankfulness for an organization's honesty.

“We've seen the whole spectrum of human emotion,” the University of Michigan's Boothman says. “The truth is when you admit to a medical error, you can't expect graciousness. You don't do this because you want to be patted on the back. You do it because it's necessary on the institution level and necessary on the individual level.”

Boothman and McDonald bristle at the idea that their approaches are simply an “I'm sorry.”

“Sorry alone is not enough and it doesn't work,” McDonald says. “You need full transparency, you need to pay for your mistakes and give patients what they need, and you need to learn from those errors internally.”

Dr. Steve Kraman, professor at the University of Kentucky College of Medicine, Lexington, and former chief of staff at the Lexington VA Medical Center, where he led a disclose-and-offer policy for 16 years, likens the approach to the golden rule.

“There's no script or special training—we're just asking what we would want if we were in their shoes,” Kraman says.

In spite of these successes, the changes put in place at UMHS and UIC can seem far from feasible at many hospitals.

HHS' Agency for Healthcare Research and Quality recognized those difficulties, as well as the link between patient safety and medical liability programs, and in June 2010, the agency allocated roughly $23 million to fund seven demonstration projects and 13 planning grants to develop and test new patient-safety and medical liability reform models.

UIC's McDonald is heading up one such grant. He was awarded nearly $3 million to roll out the “seven pillars” in nine Chicago-area hospitals. None of those hospitals are self-insured, says Dr. David Mayer, associate professor of anesthesiology and associate dean for curriculum at UIC. That's important, says Mayer, who is also working on the grant, because the changes will be translatable in other non-academic hospitals.

Dr. Kenneth Sands, senior vice president and chairman of the department for healthcare quality at Beth Israel Deaconess Medical Center, Boston, and Dr. Alan Woodward, president of the Massachusetts Medical Society, were awarded one of AHRQ's planning grants for about $274,000.

With help from the University of Michigan's Boothman, they used the funds to conduct in-depth interviews with 27 key stakeholders, identify a list of barriers to implementation and draft a road map to implement a disclose-and-offer policy in Massachusetts hospitals. They unveiled the road map at a conference on March 17.

“Our goal was to gather information and see if this works so well in one setting like Michigan, what are the barriers for uptake in other settings,” Sands says. “We wanted to see why this wasn't catching on like wildfire.”

The interviews uncovered a number of issues, such as lack of understanding about how a disclose-and-offer system works, physician discomfort and state liability laws. Also, the state of Michigan has what is referred to as a six-month “cooling off” period that requires a waiting period before filing a lawsuit. That gives institutions a chance to work toward a resolution, and Massachusetts doesn't have that, Sands says.

There are legislative efforts under way in Massachusetts to facilitate the process, but there is plenty that can be done in the meantime to cultivate an environment that encourages adoption, Woodward says. The next step is to build a coalition with other interested parties that want to move in this direction, and there are many, he says.

“The point is, if you take the fear out of the system, people are much more prone to have open and honest communication,” Woodward explains.

The University of Michigan Health System, meanwhile, has plateaued at roughly 83 to 93 open claims at any given time, Boothman says. The system reached that mark in 2007 and hasn't been able to make any further progress since then, he adds. The next step toward lowering that number will be to focus on improving shared decisionmaking and making sure patients are informed and have realistic expectations.

Boothman is hopeful that by taking those steps, UMHS can halve its number of open claims within the next four years.

He also says more hospitals and insurers are coming around to the idea of full disclosure of errors. In addition to providing guidance for the Massachusetts grant, he is also working with groups in New York and Washington state.

“I think it is finally sinking in that we can debate other options, but all of them are counter to patient safety except this one,” Boothman says. “This starts with acknowledging the problem, and that is essential to improvement. You can't tell the world, ‘I didn't do it,' and then turn around and try to fix what went wrong. If we are going to get better, we have to quit the baloney.”