In the days of “deny and defend,” when it appeared a patient had been harmed during medical care, hospitals practiced the opposite of patient engagement, often pretending nothing had happened. Although the transformation is not yet complete, increasing numbers of organizations now run toward, not away from, those affected by unexpected bad outcomes. Some hospitals engage with patients and families directly about patient harm, speaking honestly about the event, investigating to understand what happened and why, and offering apology and compensation when appropriate. Organizations that use this approach, referred to as disclosure, apology and offer (DA&O) or communication and resolution programs (CRPs), also provide support for clinicians and staff members affected by the event.
Since 2012, the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) has offered a version of DA&O called CARe(communication, apology and resolution) and supported a growing number of member organizations. MACRMI’s members include Beth Israel Deaconess Medical Center (BIDMC), Baystate Medical Center, leading malpractice insurers CRICO and Coverys, as well as the Massachusetts Bar Association, Medical Society, and Health & Hospital Association.
At its 7thannual CARe Forum, held on May 7, 2019, MACRMI offered two case simulations followed by in-depth discussions led by Rick Boothman, J.D. The DA&O movement derives from Boothman’s work at the University of Michigan Health System, where he served as risk manager for 17 years. He established the “Michigan Model” in 2002, which serves as a model for MACRMI and other similar programs. Boothman recently retired from Michigan and now consults with health systems, insurers and others interested in developing programs similar to the Michigan Model.
Cases represent two scenarios
The case simulations presented at the CARe Forum represent two scenarios. The first involved an error in medication administration that resulted in severe, permanent effects to the patient’s health and functional abilities. The patient received an apology and prompt compensation. In the second case, family members felt a woman’s death had been preventable, brought on by substandard care. After careful review, all agreed that clinicians had done a poor job of communicating with the family but that the patient had received appropriate medical care and not been harmed through clinical mismanagement.
The second scenario—where the clinical “standard of care” was met but poor communication caused the family to feel distressed and distrustful—represents the majority of CARe cases handled by MACRMI hospitals. Although these cases may, strictly speaking, not involve clinical errors, they do require empathy, honesty, respectful communication and possibly apology to allow everyone to accept that the case has been resolved. BIDMC, a participant in the simulated case, considers poor communication to be a preventable medical error.
Response requires compassion and honest fact-finding
Describing the challenge of responding to the family in the second scenario, Boothman and Pat Folcarelli, R.N., Ph.D.,vice president for health care quality at BIDMC, agreed that compassion and empathy alone will not resolve these cases. Folcarelli observed an inherent tension in what’s required of the administrators and clinicians in these discussions, saying, “You have to be compassionate and at the same time, driven by the facts.” It may take time for the facts to be revealed and fully understood, which is challenging for everyone involved. Compassion must go hand-in-hand with a dedication to understanding what happened in these complex cases.
With this tension in mind, when screening applicants for risk management positions at Michigan, Boothman was watchful for people whose empathy and desire to please could interfere with a fair analysis of the reasonableness of the clinical care and possiblybe counterproductive to learning from these events. Response to unexpected outcomes must be grounded firmly in the clinical mission of the organization and dedicated to preventing harm in the future. Discovering and sharing the true story, whatever it is, behind an adverse outcome protects both clinicians and patients. If an error has occurred and caused harm, patients must know the truth and be compensated quickly and fairly. Clinicians and the organization should use their understanding of what happened to make sure it doesn’t happen again. If the care was appropriate (no error), being honest with the patient and family protects the clinical team from unfair criticism. It may also allow the patient and family to heal through better understanding. Boothman says, “The work requires people who can accept and embrace the human part of this but not let those emotions trump a solid analysis of the clinical care.” That requires engaging in difficult conversations where fact-finding and speaking truthfully coexist with compassion for people undergoing painful emotional upheavals—thus the importance of hiring the right people, training them thoroughly and supporting their emotional needs.In addition to helping with CARe implementation, MACRMI offers tools to help others develop peer-support programs for clinicians and staff members who feel the emotional effects of unexpected bad outcomes.
Ashley Yeats, M.D., chief medical officer at Beth Israel Deaconess Hospital, Milton, an attending physician in emergency medicine at BIDMC, and chair of MACRMI, wrapped up the day’s program by restating the challenge these conversations pose and offering, on behalf of MACRMI, to help:
When meeting with these patients, it’s about being able to hold that pain, grief and the sadness, not only of the patients and families, but also of the providers. In both cases, you know you’ve done the right thing when everyone leaves the room feeling just a little bit better. It doesn’t mean being able to bring someone back or undoing a mistake. You will hold a lot of people’s pain. At the end of the day, this is about trust, transparency, and authenticity. This takes persistence and courage. This is messy work. Through MACRMI, a group of providers, caregivers, attorneys, insurers, and patient advocates have sat around the table together and worked on this for 10 years. We are offering ourselves to support you and help you through this.