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Rita Marie Barsella, RN, BSN
Nurse.com
Monday July 2, 2007
In health care, an apology can make a world of difference. When an unexpected outcome occurs or an error is made, Doug Wojcieszak, founder of The Sorry Works! Coalition, says an apology is essential to an organization's full disclosure program. Wojcieszak recently spoke at "Seeing Your Way Clear to Apology and Disclosure," a conference, hosted by The Joint Commission, that extolled the virtue of apology and full disclosure in health care's culture.
The Joint Commission requires that accredited hospitals have full disclosure policies. But policy and practice are two different things. The U.S. Department of Veterans Affairs (VA) has a system-wide practice of full disclosure. Their program was modeled after a program started by Steve Kraman, MD, at the VA hospital in Lexington, Ky. Several other hospitals, including the University of Michigan Health System, have developed similar disclosure practices. In 2005, based on the success of the VA's program, The Sorry Works! Coalition was formed.
Wojcieszak says programs that promote open communication and full disclosure are the answer to tort reform. He says lawsuits are generated by anger and the current medical malpractice crisis is actually a customer service crisis. Wojcieszak speaks from experience. He founded The Sorry Works! after the death of his brother.
Personal tragedy fuels the movement
Wojcieszak's brother was admitted to an Ohio hospital for pain. He died during his hospitalization. An autopsy revealed he had had at least two untreated myocardial infarctions as an inpatient. The family looked for answers and an explanation, but the hospital refused communication. They sued the hospital and won a sizable amount -- minus an apology.
"It made money the only thing worth fighting for," says Wojcieszak. He says to this day, his mother still grieves that they never received an apology.
According to Wojcieszak, an apology should be offered as soon as an adverse event occurs. He says the apology does not equal an admission of guilt, but it demonstrates an acknowledgment of the event and an assurance that an investigation into the root cause of the event will take place.
Wojcieszak does not advocate frivolous payouts. He says there are three core principles to successful disclosure programs such as the ones implemented at the VA and the University of Michigan --
- Quick and fair compensation when inappropriate medical care causes injury
- Vigorous defense of medically appropriate care (there should be no compensation if there is no fault)
- Learning from mistakes and implementation of changes to prevent future errors
"Medicine is not perfect, and human beings are not perfect," says Wojcieszak. "We have adverse events, and we have adverse events with errors. Right now, unfortunately, the system is set up to take good people with good intentions and turn them into bitter, ugly enemies. It produces anger by the bucketful and litigation by the truckload."
Wojcieszak says the medical community needs to stop waiting for legislation to solve the malpractice debate. He says programs involving apology and full disclosure are not rooted in legislation but start with hospitals and practitioners making a commitment to their customers -- the patients and their families.
Let the healing begin
During the two-day Joint Commission conference, several speakers addressed the value of a sincere apology, while others reinforced the need for transparency and accountability with full disclosure. It was said that just, swift compensation, when appropriate, is an important component of full disclosure.
Several speakers cautioned that apology and disclosure are not blanket protection against litigation, nor should that be the motivation for implementing disclosure programs. Rather, they said, apology and full disclosure are part of the future of healthcare improvement.
Michael S. Woods, MD, author of Healing Words: the Power of Apology in Medicine, said there is a misconception that an apology is about guilt. He said an apology is about empathy rather than guilt.
"We suffer from the 'deny and defend' medical culture," said Woods. He labeled the perception that an apology leads to liability a "myth." Woods said an apology is the "natural progression of a respectful relationship."
When an unexpected outcome occurs, Woods suggested saying "I'm sorry. I know this is not what you expected. It's not what I expected either." To be sincere and believable, Woods said apologies cannot be relegated to severe, adverse outcomes; they should be inherent to the health practitioner's daily practice.
Woods said an apology emphasizes the intrinsic importance of an individual. He said an apology is the stepping stone to disclosure.
Lucian L. Leape, MD, one of the founders of the National Patient Safety Foundation and author of the 1994 Journal of the American Medical Association article "Error in Medicine," advocated full disclosure as a means of preserving the trust he calls the "cornerstone" of the relationship between the patient and practitioner. He said an apology starts the healing process for both the patient and the practitioner.
"There is not a single study that shows that being honest with a patient makes you more likely to be sued," said Leape. "All the evidence is the other way around."
Leape concurs with Wojcieszak, saying that lawsuits often occur because patients are angry. They are angry not only because something went wrong, but also because of the way the situation was handled. He cites the rise in patient advocacy groups as a testament to the fact patients are unhappy with a system that hides information they desire and demand -- information, Leape said, that is rightfully theirs.
"There is something seriously wrong when a patient has to file a claim," said Leape. "They should never have to file a claim, much less sue."
Richard C. Boothman, JD, chief risk officer for the University of Michigan, offered testimony to the U.S. Senate in 2006 regarding medical justice. He said litigation is often a patient's only recourse for information and answers, adding that the system of waiting for a lawsuit to be filed is backward and ill-conceived. Boothman said patients have a right to information, and hospitals have an obligation to acknowledge mistakes up front.
"People go to lawyers not because they want a million-dollar payout," said Boothman. "People go to lawyers because they want answers and they don't trust their caregivers to give them answers. People go to lawyers because they don't get any information at all."
Boothman said that since 2001, the University of Michigan has successfully implemented its policy on apology and full disclosure. He said they have had a dramatic reduction in claims, they have improved their employee satisfaction rate, and they have used each incidence as a tool for improving clinical safety.
According to Boothman, patients want assurance that something will be done to correct a problem and that it will not happen to someone else. He said openness and honesty lead to safer patient care.
Rita Marie Barsella, RN, BSN, is a freelance writer. To comment on this story, e-mail jboivin@gannetthg.com.
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