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The Institute for Healthcare Improvement recently released a fantastic paper on disclosure and apology. The paper provides an indepth analysis of the successful and well-known disclosure programs at the University of Michigan Health System and the University of Illinois Medical Center. Also, the paper introduces us to less-well known disclosure programs such as Geisinger Health System (PA), Catholic Health Initiatives, and Brigham and Women's (Boston). The paper can be found at www.ihi.org, and below are some the best excerpts from the paper:
From the University of Illinois: "We are not just providing full disclosure and rapid settlement; we're taking each of these cases and learning from it....the way we're going to successfully manage the medical malpractice crisis is through safer care, not tort reform," said Dr. Tim McDonald of University of Illinois Medical Center.
From the University of Michigan: Boothman spent much of his time that first year meeting with medical staff, faculty, University of Michigan trial attorneys, the courts, and the plaintiff's bar in Southeastern Michigan to explain and gain acceptance for this approach. In his meetings with plaintiff's attorneys, Boothman presented the essence and significance of this new approach: he explained the University of Michigan's commitment to compensate quickly and fairly when they felt the medical care was unreasonable, but he cautioned that they would defend their staff and institution vigorously when they felt the care was reasonable. He committed to working with plaintiff's attorneys so they would understand the difference between reasonable and unreasonable care before litigation was filed.
More from University of Michigan: The University of Michigan Health System's commitment to its principles opens the door to immediate and decisive quality improvement measures and peer review opportunities. Fear of adversely impacting subsequent litigation is virtually non-existent because the University of Michigan Health System is committed to acting consistently with its own conclusions about the reasonableness of care. Unfettered by fear of litigation, patients' complaints travel through a process designed to prompt all involved to ask whether the care could have been better, whether anything can be done to avoid such complaints in the future, and whether there are lessons to be learned.
And finally from the University of Michigan: "...lawyers who tell clients to deny and defend find a willing audience because doctors' emotions rather than logic are guiding them," Boothman says. "This is a battle we're making progress on, case by case, doctor by doctor. We've had to overcome the human impulse to avoid anything we're sure is going to be uncomfortable or distasteful," he says Boothman has found the most effective way to overcome the barrier of fear is to remind doctors that full disclosure serves the best interests of the doctor and the institution. "But," he says, "this is an intellectual argument that has to overcome the emotional reticence of doing this. You've got to be able to say to a doctor, 'I serve you best by helping you avoid litigation. And if we made a mistake, the best way to avoid litigation is to make it right, right now.'
Now from Geisinger Health System: "Initially, physicians felt they had to do this (dislcosure) because it was the law (in Pennsylvania)," McKinley says, "but over time their thinking has evolved. Physicians and other providers gradually discovered that this policy actually helps them.." Geisinger has had fewer claims filed than the national average. When they observe the trends in their own data, the number of claims has decreased.
McKinley believes a case is less likely to become a lawsuit because they've had early discussions with the patient or family. "Patients and families get a full explanation, a commitment from us that we're going to correct the problem, and feedback after the root cause analysis to let them know what we've done," she says.
From Catholic Health Initiatives: To get the word out to everyone in their health system about their intention to implement their compassionate disclosure policy, Melfi (of Catholic Health Inititiaves) says, they have addressed the issue at various system meetings and conferences, including their annual Risk Management conference. "We knew we needed to get buy-in from the litigators we retain to represent our facilities," he says. At their annual defense counsel meeting, Melfi addressed the topic of disclosure with the attorneys, telling them, "This isn't going to feel right to you because it's not the way lawyers are trained." He went on to tell them, "Don't advise the facilities you represent to not disclose information out of fear of having it used against them in litigation. We fully recognize that it could be used against them, but we think that the benefit of disclosure and information sharing outweighs the risk." Melfi continues, "We told our lawyers, 'This is what we're doing, this is why we're doing it, and if you can't get comfortable with it, then we'll need to retain someone else to represent these facilities in litigation.' I've actually had litigators call me after the fact and say, 'You know what? You really get it. It really does work. Outcomes are better.'"
And more from Catholic Health Initiatives: "Although it's only one part of the picture, there is a business case for disclosing errors, too," Melfi says. "Our losses when somebody sues us are coming down. We still make mistakes, we still get sued, but the outcomes are better," he says. "When you clearly made a mistake and you're either pointing fingers or denying you did it, you inflame the situation. That causes plaintiffs to demand more money, it inflames juries, it just doesn't get better," Melfi adds. Instead, Melfi continues, "Our policy and our practice is that, if we made a mistake for which we think we have liability, the objective is not to fight that. What's important to ask is, 'How best can we compensate the patient?' We sit down and say, 'We know this happened. We're sorry that it happened. If money can make this right, how can we do that? What is reasonable and fair compensation?'"
From Brigham and Women's Hospital: "Before this policy, we were concerned about telling patients and families too much; now, we tend to be concerned about telling them too little. There's been a huge sea change. There's no such thing as too much information," she says. Physicians' fear of lawsuits was a formidable barrier to Brigham and Women's ability to openly and transparently communicate adverse outcomes and medical errors, Barnes believes. "But," she says, "the common theme that runs through patient-family depositions has been that patients and families didn't think they were given complete information. Or they had questions that were never answered. Once something bad happened, they never saw the doctor again." Barnes tries to help physicians understand that if they don't communicate openly about an adverse outcome, they are more likely, not less likely, to be sued.
"We've seen a decline in lawsuits since we implemented this policy, but I'd be the last person to say it's because of this process. Many other factors could influence this reduction. But there definitely hasn't been an increase in the claims as a result. I think we've been able to resolve some cases more quickly because we've taken on the problems at the very beginning," she says. Brigham and Women's goal in openly communicating with patients and their families "is not to decrease lawsuits but, rather, to save the relationship" with patients and families. "We want patients to continue to come to us rather than go elsewhere to seek care," Barnes says.
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