The seven elements are: reporting; investigation; communication; apology with resolution; process and performance improvement; data tracking; analysis, and education. The program started in 2005 and was fully implemented the following year. Since that time, McDonald says that “what could be described as charges associated with defensive medicine,” meaning laboratory and radiology tests, have been reduced by a minimum of 20%.
“This is gaining momentum,” McDonald says. “There has not been an increase in claims and lawsuits, which some people thought they'd see.”
McDonald says there are some barriers to nationwide implementation of disclosure-apology-offer programs, explaining how, in some circumstances, “the incentives for a doctor to be perfectly honest are not perfectly aligned.”
This includes public reporting methodologies where a physician might be named as the sole party responsible for an institution's systemic problems. The more the public wants to punish physicians involved with errors that are the result of systems issues, the more likely it is that some errors may get covered up, he says.
The AHRQ grant will run out at the end of June, McDonald says, adding that “we've been pretty frugal,” so he's hoping for an extension or funding from other sources to pay for more data analysis from the demo. In the meantime, he says UIC has received inquiries from hospitals in California, Colorado and Maryland about Seven Pillars.
Another program others are following is the Michigan Claims Management Model, which was started at the University of Michigan Health System in late 2001. One measurable impact the program has achieved is a reduction in the number of open malpractice claims, according to attorney Richard Boothman, a University of Michigan adjunct assistant professor and executive director of clinical safety for the system.
In 2001, the university system had 262 open claims. That number fell to 83 in 2007 and stands at 63, Boothman says.
Despite the clear increase in attention that disclose-apology-offer programs are receiving, Boothman cautions that looks can be deceiving.
“The frustrating thing is that what you will find is some people will say, 'We're already doing it,' but they don't define 'it,' ” Boothman says. “It's important to identify what the 'it' is. Despite the hundreds of headlines, it's not 'apologies save money.' ”
Boothman acknowledges the program “has favorable claim results, which is a good thing,” but that's almost “a happy coincidence” in the grand scheme of things. “The real thrust of what we're doing is that it really has to do with improving the quality of our medical care,” he says. “The most important disclosure is the one we first do to ourselves when we say, 'I could have and should have done better and I may have just hurt someone.' ”
He explains how humans are “hardwired with the fight-or-flight response” to danger or stress, noting healthcare's traditional “deny and defend” handling of malpractice suits is an extension of that. But he says that approach freezes patient-safety efforts and stifles the two best risk-management strategies: Don't injure anyone, and—if you do—don't do it again.
Most hospitals “fight everything—whether it deserves to be defended or not,” Boothman says. “Then they declare themselves victims of a broken system.”
Boothman adds, however, that it's UMHS policy to support its professionals and mount a defense when it is merited, even if business expediency says to settle. “Everything we do in healthcare is inherently risky, so—if their care was reasonable—they deserve our support,” Boothman says. “We will not settle a case if we know our care was reasonable.”
One of the foundations for disclosure-apology-offer programs is the research into why people sue their doctors conducted by Dr. Gerald Hickson and James Pichert at Vanderbilt University Medical Centers' Center for Patient and Professional Advocacy. “Families want answers,” Hickson says. “If something bad happens or something unexpected happens to your loved ones or yourself, you want to know why.”
The traditional stonewalling that occurs with the deny-and-defend response to a medical injury often triggers malpractice suits, Hickson's and Pichert's research found, because suing was the only way to get answers to their questions.
“You want an expression of human concern as an apology—not laying blame,” Hickson says. “You also want an explanation. How did this occur? What does it mean to me? How am I going to respond to this ongoing threat to my health?”
He says Vanderbilt has been offering these explanations since 1992, and “we have cut our litigation dramatically.”
Their research also showed malpractice claims “are not randomly distributed,” and they've learned to identify how individuals who “don't work well with others” draw more than their share of claims. After identifying the high-risk individuals, Hickson says they are instructed that they “must change in a profound way.”
“Some don't and don't continue to be a member of our team,” he says.