Disclosure, Apology, and Resolution—No Turning Back Now
Rick Boothman has been thinking about when he knew that the University of Michigan Health System, where he is executive director of clinical safety, had reached the “point of no return” about openly discussing preventable harm with patients. In his keynote to the MITSS Annual Dinner in November, Boothman explained that he had been struck by something he heard during a meeting in Washington, which led him to reflect on Michigan’s commitment to this approach:
Back in September, Tom Gallagher and Tim McDonald arranged for a group of us to talk with some folks from the U.S. Senate. Many of us were anxious to give them the details and numbers from our experience with the Michigan Model, but Alan Woodward made a simple statement that really got me thinking. He told the folks from the Senate that not a single hospital that’s tried this has ever gone back. No one who has had the courage to do this, has ever gone back. What a profound observation. And it got me to thinking about when I realized we were not going back.
The Michigan Model Boothman refers to is a commitment to timely and open disclosure of information to everyone—including clinicians and patients and their families— following unanticipated adverse medical events. When appropriate, the program includes apology and compensation for patients who have been harmed.
Boothman, who started this program at Michigan in 2001, describes events that lead him to believe there is “no turning back” for Michigan:
I knew we weren’t going back when I received the first email of many, from residents telling me that they chose the UM [University of Michigan] because it matters to them that we’re principled and honest with our patients and ourselves.
I knew we weren’t going back when a neurosurgery resident responsible for delivering a ten-fold overdose of heparin to a woman, figured it out, immediately self-reported, and then as she lay dying, asked to explain and apologize to the family. I knew we weren’t going back when that patient’s sister walked out with that sobbing resident, hugged him and said, “We’ve watched you for days taking care of my sister. It’s clear you care. You will help a lot of people in your life. Remember my sister, but don’t you dare quit.”
I knew we weren’t going back when I presented a graph of the cases and costs to leadership and instead of usual comments about overhead and the cost of doing business, I heard a member of our C-suite utter, “God help us for the people we’ve harmed.”
Although health systems that have initiated these programs may not be turning back, and more are joining the trend, they still are early pioneers in this movement. There is evidence, including data from the University of Michigan, that institutions can save money when they implement these programs. Boothman emphasizes that other rewards are more important. Using a well-known story about President George Bush and an irate Iraqi journalist who threw a shoe at Bush during a press conference, Boothman describes the power for all concerned of moments of true compassion and connection between individuals. Reflecting on how the chaotic scene that followed the thrown shoe might have been different, Boothman asks, “What if?”:
What if, in the chaos that followed the incident, as that man was being wrestled to the floor and beaten, the United States President had stepped down from the dais, parted the crowd . . . and helped him up? And what if, recognizing the depth of emotion that compelled that journalist to do something so risky, so dangerous, so desperate—the same emotion that was driving thousands of Iraqis to protest in the streets—what if our President had invited him to meet privately to talk about how he and his fellow Iraqis viewed the United States’ occupation of their country?
Boothman recasts that scene as a missed opportunity for connection, learning, understanding, and comfort:
What are we afraid of? What prevents us from making such basic human connections?
Other Resources
In addition to the leadership of Boothman and others, there is research underway that may persuade others to join this movement and may help guide efforts to implement effective programs to replace traditional “deny and defend” responses to patient harm.
In addition to Boothman’s address at MITSS (available in video and text on the MITSS website), the January issue of Health Affairs is titled, “Exploring Alternatives to Malpractice Litigation.” In one of the articles, “Communication-and-Resolution Programs, The Challenges and Lessons Learned from Six Early Adopters,” Mello, Boothman, McDonald et al., report on what has been learned so far by six early adopters of these programs, including the University of Michigan.
On a different note, ProPublica published two stories in January investigating the availability of legal representation to patients who have been harmed. “Patient Harm: When an Attorney Won’t Take Your Case” and “Ten Patient Stories: When Attorneys Refused My Medical Malpractice Case” are part of ProPublica’s ongoing patient safety series. Most often, attorneys reject potential cases because the dollar amount of projected damages isn’t high enough to make it worth their while. In one of the 10 stories, a patient who has been unable to find legal representation and has become frustrated with the process observes,
The solution is very simple. Be honest when errors take place, and compensate victims fairly, then peace will come a lot sooner for everyone, including doctors.
PSQH has published a variety of articles about disclosure and apology programs, as well as stories about problems with the malpractice system in the U.S. The following stories and others are available online:
Massachusetts Alliance Studies Pilot Programs in Communication, Apology and Resolution
By Melinda B. Van Niel, MBA
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MITSS: Supporting Patients and Families for More than a Decade
By Winifred N. Tobin
Disclosure and Apology: What’s Missing?
Advancing Programs that Support Clinicians
By Susan Carr
Conflict Management From the Heart
ADay in the Life of a Medical Ombuds/Mediator
By Carole S. Houk, JD, LLM; Leigh Ana Amerson, BA
Apology and Disclosure
How a Medical Ombuds Can Help Bring a Policy to Life
By Carole S. Houk, JD, LLM; Leigh Ana Amerson, BA; and Lauren M. Edelstein
We’re Not Your Enemy
An Appeal from a Consumer to Re-imagine Tort Reform
By Susan S. Sheridan, MIM, MBA; and Martin J. Hatlie, JD