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THIS WEEK'S EDITION:
- Important National Meeting on Transparency and Disclosure
- Crittenden's Medical Insurance News: Sorry Works! at "forefront"
- Univ. of Illinois Medical Center to present disclosure program at meeting
- Great Article: Making Honesty the Policy
- Important Apology Tool
- Save the date!
- Question & Answer
IMPORTANT NATIONAL MEETING ON TRANSPARENCY AND DISCLOSURE
Want to learn how to overcome the hurdles facing institutions striving towards transparency and disclosure? Want to learn from national leaders who are involved in the transparency and disclosure movement? Want to have the opportunity to network with fellow professionals interested in disclosure and transparency? Then, we have the meeting for you!
The Risk Management & Patient Safety Institute (RM&PSI) - a Sorry Works! partner - will be hosting an important national meeting on transparency and disclosure March 19 and 20th. The meeting is being held at the beautiful Bellagio Resort and Casino in Las Vegas , Nevada . The Bellagio is a Vegas landmark with its world famous fountains featured in the hit movie Ocean's Eleven.
A great panel of speakers will include Douglas Borg of Duke University who will share his hospital's experience disclosing a transplant operation where the patient received the wrong organ. Dr. Ken Bottles, Chief Medical Officer of the Iowa Health System will provide an overview of transparency and the increasing gap between the public, hospitals, and physicians.
Dr. Geri Amori and Karol Wareck of RM&PSI will discuss the payer push for transparency and how to avoid blame while embracing accountability. Trial attorney Robert McKenna will review the legal ramifications of transparency and Doug Wojcieszak of The Sorry Works! Coalition will provide the customer (patient & family) perspective on disclosure.
The meeting will conclude with a moving presentation by retired Navy Commander Scott Waddle. Commander Waddle was the captain of a Navy submarine that accidentally stuck a Japanese fishing vessel, killing nine on board. Against the advice his attorney and the Navy, Commander Waddle took responsibility for the accident.
"Transparency and disclosure are hot topics today, and we are excited to have this outstanding panel of speakers provide their perspective to our attendees. This meeting will be great chance to learn how to overcome the hurdles with disclosure and transparency while providing a great networking opportunity with like-minded professionals," said Karol Wareck, Vice President of The Risk Management and Patient Safety Institute.
The conference will count for 9.5 hours of Category I credits towards the Physician's Recognition Award of the AMA. An application has been submitted to the Michigan Nurses Association CEAP. Please call RM&PSI at (517) 886-8226 for more information on contact hours.
The conference will also provide a special room rate of $219/night at the Bellagio. Indeed, this will be a great conference at a world- class facility!
For registration information, please contact RM&PSI at (517) 886- 8226. Early birds receive a registration discount before February 18th. Register today!
CRITTENDEN'S MEDICAL INSURANCE NEWS: SORRY WORKS! AT "FOREFRONT" OF DISCLOSURE MOVEMENT
We continue to make great progress with insurers. In addition to pending talks with Pro-Mutual, CNA, and PLICO, we received a great plug in Crittenden's Medical Insurance News this past week. The article said Sorry Works! is at the "forefront" of the disclosure movement. Read below and please pass onto your colleagues and friends in the insurance industry - we want more speaking engagements with them! Please help us.
CRITTENDEN’S MEDICAL INSURANCE NEWS: MOVEMENT TO APOLOGIES TO GAIN STEAM
Efforts to bring positive resolutions to adverse medical/patient outcomes — for both physicians and hospitals — will increase dramatically this year as insurers and insureds try to find a reasonable and cost effective method to mitigate frivolous lawsuits. The Sorry Works! Coalition can be expected to remain at the forefront of this movement, followed by the COPIC Insurance Co.'s 3Rs program, and the National Quality Forum (NQF). The Leapfrog Group (TLG) and Common Good's Health Courts, represented by Paul Barringer, will also have a hand in further shaping possible resolutions. More than 18 states have passed apology laws protecting a doctor's remorse from being used at trial. Case law in Vermont provides immunity for apologies. Florida , Nevada and Pennsylvania statutes require written disclosure of bad outcomes to patients. Although COPIC's 3Rs program, based on quickly recognizing, responding to, and resolving a patient injury, is credited with helping reduce the carrier's claims from 12 per 100 doctors in 1998 to 6.2 per 100 doctors in 2005, not every adverse outcome is a candidate for early intervention. Type of injury, attorney involvement or unrealistic expectations may mandate a trial.
Sorry Works! spokesperson Doug Wojcieszak will take his coalition's message this month to ProMutual Insurance Co. and to Physicians Liability Insurance Co. (PLICO) in March. Sorry Works! stresses the idea that greed is not the underlying motivator in most med mal suits, citing anger and frustration as the driving force behind patients and their families seeking court settlements when questions aren't answered and/or when they feel summarily dismissed by a hospital or physician. The Sorry Works! model encourages meetings between the doctor and the patient, listening, discussing the facts, explaining the reasons for a bad outcome, and offering condolences. The program also suggests negligence should be admitted with an apology and an offer of a settlement. Medical Protective also supports an apology framework that is not destructive to a doctor while respecting the patient and avoiding blame. However, the carrier, where Kathleen Roman is risk management education leader, also wants insureds to avoid apologies simply intended to make a patient go away. Participation in Med Pro's accredited risk management education program can grant an insured physician a 5 percent premium discount for up to three years. Aetna steps up as the first health plan to adopt TLG's Never Events program, which includes making an apology, reporting an incident to the appropriate authority, performing a root-cause analysis of the situation, and waiving any costs associated with it. TLG publicly acknowledges hospitals that commit to this program. It estimates that there are more than 1,300 rural and urban hospitals in its network. Companies such as IBM and Intel have also committed to using this program. TLG's Never Events is based on the National Quality Forum’s two-year effort to create a list of 28 Serious Reportable Events. The Centers for Medicare and Medicaid Services endorses the NQF program, as do Kaiser Permanente and Blue Cross Blue Shield. NQF's goals include developing a national strategy to measure and report healthcare quality, and standardizing performance measures so that comparable data is available nationwide.
UNIV. OF ILLINOIS MEDICAL CENTER TO DISCUSS DISCLOSURE PROGRAM AT MEETING
The Chicago Patient Safety Forum will be holding their annual meeting on March 9th, and the meeting will feature a panel discussion on full-disclosure that will review the disclosure program at the University of Illinois Medical Center. For our friends in the Chicago area and Midwest this will be a great meeting to learn more about disclosure. For more information, visit the website of the Chicago Patient Safety Forum: www.chicagopatientsafety.org.
GREAT ARTICLE: MAKING HONESTY THE POLICY
Below is a great article that appeared in the December edition of Health Leaders Magazine.
Making Honesty the Policy
Dec. 2006
Health Leaders Magazine
Many hospitals are discovering that error disclosure brings financial rewards and an imageboost - not million-dollar lawsuits. If hospitals view patient safety only in terms of taking steps to prevent errors, they’re missing a significant part of the pule. Mistakes will happen no matter what precautions a facility takes, so senior leaders must consider how their organization will react in the aftermath. Are your physicians encouraged to clam up and go on the defensive? Does your risk management office automatically assume battle position at the first hint of a lawsuit?
That's the way it's been in the industry for a long time. Hospitals have traditionally hunkered down and protected their assets when something bad happens, fearing that leveling with patients, families and attorneys will cause greater harm than keeping quiet. But some facilities are taking a different tack and owning up to mistakes sooner rather than later. Hospitals that have adopted a policy - and an attitude - of transparency are reaping legal and financial benefits while improving their image at the same time.
Apologies at work
Although he didn't know it at the time, Steve Kraman, M.D., became a pioneer in medical error disclosure in 1987. As chief of staff of the Lexington (Ky.) VA Medical Center, Kraman worked with the hospital's attorney and the risk management committee to craft a policy that ensured that hospital administration knew about adverse outcomes as soon as possible so they could gather evidence in case of a lawsuit.
The policy didn't last a year. When presented with a clear case of wrongful death, Kraman says, "We didn't feel comfortable with what we'd planned to do - simply file it away - because the family had no way of knowing." Instead, Kraman called the family, told them a problem had been discovered, and invited them to bring an attorney in for a meeting. "We explained what happened, apologized on behalf of the facility, told them what we'd done to try to prevent things from happening in the future, and told them they were owed compensation," says Kraman. Within a few weeks, the attorneys arrived at a settlement that both sides thought was fair. The case became a model for the hospital's disclosure policy, and the VA system later used the model for its own mandatory disclosure initiative.
"The normal practice was to circle the wagons, hide everything and make it hard for people to sue," Kraman says. In 1999, he compared Lexington's claims experience to the rest of the VA, and although his research showed Lexington paid more settlements than average for similar hospitals, total costs were lower. "We ended up paying reasonable amounts based on actual loss, and almost no expenses went to long, drawn-out court cases," says Kraman, now a professor at the University of Kentucky College of Medicine. He adds that disclosure sessions often ended with handshakes and even hugs from patients grateful for hearing the truth. "It sounds almost 'Pollyannaish,' but if you treat people decently they generally respond in kind," he says.
The difficult trek to the high road
Slowly, hospitals across the country, and even some malpractice insurers, are following in Lexington's footsteps. But making the move to transparency isn't easy; numerous fears and bad habits have to be overcome.
Experts agree the biggest problem is that hospitals and physicians don't understand what causes people to sue. A common assumption is that patients and family members want million-dollar settlements. To avoid a lawsuit, providers have historically remained tight-lipped when an error occurs. Patients, in turn, head straight to an attorney's office when they perceive the hospital has something to hide. "It's generally not about money," says Kraman. "A doctor at the hospital that they've put their trust into all of a sudden slams the door when a mistake is made, and they feel they've been abandoned."
Many providers also fear that exposing safety records to scrutiny will result in more lawsuits, but this concern is largely unfounded. Hospitals with disclosure policies often see a reduction in the number of lawsuits and a decrease in settlement outlays. The University of Michigan Health System's young disclosure program, for example, has seen a steady drop in claims since being instituted by Chief Risk Officer Richard C. Boothman in 2002. The average claims processing time of the Ann Arbor system, which staffs approximately 800 beds, is down from 20.3 months in 2001 to 9.5 months, and average litigation costs have dropped by more than half.
Still another roadblock to transparency is the belief that apologizing guarantees a bad result in court, but Geri Amori, Ph.D., senior director of the Risk Management and Patient Safety Institute in Lansing, Mich., debunks this myth. "People think saying 'I'm sorry' will give the plaintiff more money," she says. Instead, a physician who proves willing to communicate early on and to admit wrongdoing may appear more favorable to a judge and jury than someone who is withdrawn and unresponsive, Amori says, adding that admitting a fact is different than taking responsibility for a liability.
Gaining steam
Hospitals aren't the only ones acknowledging the potential benefits of open discourse. Denver-based COPIC Insurance Company offers member physicians a voluntary disclosure option that includes formal disclosure and offers the patient immediate compensation up to $30,000. Between October 2000 and December 2004, patients were reimbursed for 305 incidents at an average cost of $5,326. No cases resulted in litigation.
According to the American Society for Healthcare Risk Management, 17 states have apology immunity laws on the books designed to protect physicians. To Doug Wojcieszak, founder of The Sorry Works! Coalition, a disclosure advocacy group, the real value of such laws is the peace of mind they give physicians. "The laws help physicians get over their cultural inhibitions, but if a doctor admits fault and takes responsibility, they shouldn't pretend like that didn't happen when they get to court," he says.
In Congress, a bill sponsored by Sens. Barack Obama, D-Ill., and Hillary Rodham Clinton, D-N.Y., aims to address medical malpractice issues via disclosure. Boothman, who helped draft the legislation, says the bill would help circumvent arguments about settlement caps by providing grants that would boost patient safety through transparency.
Healthcare executives, too, are realizing that much more than money is at stake. The hospital that's seen as a facility that cares, even when things go bad, will find it easier to build solid patient relationships. Changing how hospitals address mistakes can potentially improve the working environment of clinicians, as well.
"When doctors and nurses make a mistake and hurt somebody, they can beat themselves up pretty badly," says Kraman. "If you're told to shut up and hide, that never goes away. This is a way of making it right so they can get on with it."
Kara Olsen is a staff writer with HealthLeaders magazine and managing editor of HealthLeaders Online News. She may be reached at kolsen@healthleadersmedia.com.
IMPORTANT APOLOGY TOOL
Dr. Bill Sage, formerly of Columbia Law School now with the University of Texas Law School, provided the following information below. Many of you know that Dr. Sage along with his colleagues Carol Liebman and Chris Hyman did an enormous amount of research and study on the medical liability crisis in Pennsylvania. One of their main conclusions was that physicians could avoid most lawsuits with improved communication and customer service. The trick is how to apologize, and Dr. Sage forwarded us a link for the report (see below) to provide to you, our readers, as a tool to use in learning how to apologize and also to use in teaching your colleagues and staff members. Thanks, Bill! Read below.
Medical Error Disclosure, Mediation Skills, and Malpractice
Litigation: A Demonstration Project in Pennsylvania
March 2005
by Carol Liebman and Chris Stern Hyman
The Project on Medical Liability
This report outlines procedures that could ease the state's malpractice insurance crisis while improving patient safety and benefiting relatives, doctors and hospitals.
The report notes that ineffective communication is often a primary reason patients and families sue. Citing extensive research, the report recommends open, meaningful communication by health professionals about medical errors and mediation to avoid costly lawsuits.
The results of the research come as Pennsylvania hospitals struggle to comply with a precedent-setting 2002 law requiring them to explain to patients or their relatives the circumstances and repercussions behind serious health complications or deaths caused by medical errors.
For a copy of the report, visit the following link: http://www.pewtrusts.org/pdf/LiebmanReport.pdf.
SAVE THE DATE!
Save the date - May 9th is the tenative date for the next Sorry Works! audio conference. Stay tuned for more details.
QUESTION & ANSWER
Welcome to this week's Q&A with Dr. Geri Amori, RM&PSI Senior Director (www.rmpsi.com) and experienced risk manager, educator, and counselor and Doug Wojcieszak, Founder and Spokesperson of The Sorry Works! Coalition (www.sorryworks.net). This week's question comes from the recently completed Sorry Works! audio conference. Over the next few weeks will be sharing some of the questions we received from the audio conference.
Question: How many different adverse events do we have to disclose and apologize for? What if a drug error was caught and stopped before it reached the patient – do we disclose and apologize for this event? What if a drug error reaches the patient but there is no damage or injury done – do we disclose and apologize for this event?
Geri: You appear to be asking about what types of situations should be disclosed. That is a good question and one that is frequently debated.
People generally agree that any sentinel event is unanticipated and should be disclosed, if for no other reason than the seriousness of the injury. The Patient Safety Standard, however, is for the disclosure of unanticipated events (not just sentinel events). The definition for unanticipated events I hear most often cited, is the one that was published in the 2003 Joint Commission Journal of Quality and Safety. It states: "...may have been caused by human or system error—that is, it is not immediately possible to clearly and decisively rule out error." (Barron WM, Kuczewski MG. Unanticipated harm to patients; deciding when to disclose outcomes. Joint Commission Journal of Quality and Safety. 2003: 29 (10): 551-5.)
People tend to agree that serious injury and serious unanticipated events should be disclosed. After that the debate begins. When is an event unanticipated? If it is a known complication of a procedure is it unanticipated? When is it serious? Does it have to be serious to disclose it? Will disclosing it result in greater lack of trust?
Last week I was working with a group of doctors who were debating these questions. One doctor was arguing that if the patient wasn't likely to find out, trust would be destroyed if they were told they had been given an incorrect medication, even if they had a bad reaction to it. Another physician argued that if no injury occurred, there was truly no reason to disclose an error.
Although it may sound confusing, if we return to the primary purpose for disclosure, our decisions get somewhat easier. The primary purpose of disclosure is to maintain trust in the care relationship. We do this by giving patients and families the information they should have to make decisions about care or action, including seeking legitimate compensation. If we have harmed them in some way that has cost them in time, health, or ability to live, then we owe them some type of remuneration, in care or perhaps in money. If we have harmed them in some way that will cost in their ability to trust us, then we owe them...in this case we owe them the information. We may not owe them money.
So how does this play out in the situations you mentioned above?
If the patient is given an incorrect medication and they have no reaction to it, it is not likely you need to run in immediately while they are in dire pain and tell them about it. Consider, however, that the patient is likely to request a copy of their records for future care. How are they going to react when they see they received an incorrect medication and weren't told about it…or the next physician comments on it…or their lawyer (perhaps because of workers' comp, or a motor vehicle accident, or whatever) comments on it. Do you want the patient to begin to question all of your care?
If an error is caught and stopped before it reaches the patient, then is there a trust issue? Probably not. The one exception I can imagine is if a treatment or drug is about to be administered when suddenly the person at the sharp end, recognizing the error, emits an expletive of horror and the patient/family wonders what has just happened. In that case, I would strongly recommend sharing the source of the surprise!
What about that known but rare complication that is mentioned in one phrase in the consent? I have yet to meet a human who believes that they will be that one person in 1000! Most people choose to believe they have a better shot at winning the lottery! If they did think they were going to be so unlucky, they would never have a procedure! So, do we need to disclose known complications? Of course. We can refer back to the consent. We can talk about our earlier discussions. We can express sorrow and concern. We cannot ignore the human element.
Leaving the group of physicians last week, I was humbled by one physician's comment. He said, "I've been to a lot of these trainings and done a lot of reading. Tonight I got something a little different. Tonight I realized that the bottom line is to focus on our humanity. If we think about what is the humane and right thing to do, it will help guide our decisions and our conversations."
I hope we have been able to give you guidelines that will help you answer your question.
Doug: Geri gave a very thorough answer. The question deals with basically "where to draw the line on disclosure?" For me that line in many cases is drawn if the error reaches the patient or family, either physically, verbally, or emotionally. Physical is easy - wrong drug given to patient, sponge left in during surgery, incorrect diagnosis, etc, etc. What do I mean by verbally or emotionally? Geri picked up on this point in her comments...if the wrong drug is about to be given, the nurse or technician catches it but says, "Holy cow, I can't believe they prescribed this dosage! " A statement like that is potentially going to trouble the patient or family - the customers - and strain that trust they have placed in your institution. That trust needs to be rebuilt by disclosing, but as Geri said, money or compensation is probably not necessary in such cases. Like wise, the old saying goes most communication is non-verbal - or emotional as I like to say. A nurse sees the wrong drug prescribed, gets a startled look on her face, and hurries out the room...guaranteed the patient and family picked up on those emotional or non-verbal cues and will have questions that need to be answered. In such cases, the patient or family is going to wonder is there something wrong with them or did they do something wrong. Disclosing will put their minds as ease as well as rebuilt trust and confidence in your institution and staff.
Finally - and perhaps most importantly - when you are deciding whether to disclose or not, remember at that moment in time you are in complete control of your destiny. If you forego disclosure (for whatever reason) you potentially lose control of your destiny because someone else (a colleague, family member of the patient, attorney, etc) may disclose the events and do so in a light that is not favorable to you.
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