Apology and Disclosure. How a Medical Ombuds Can Help Bring a Policy to Life
May / June 2008
Apology and Disclosure
How a Medical Ombuds Can Help Bring a Policy to Life
In the March/April issue of Patient Safety & Quality Healthcare, the article “Conflict Management from the Heart: A Day in the Life of a Medical Ombuds/Mediator” presented a fictional yet representative case of a medical error involving the unexpected death of a young cardiac patient. In the first installment, the surgeon contacted the medical ombuds to ask for help in preparing for his first meeting with the grieving family while causative factors were still unknown. In this installment, the patient’s death has been attributed to a medical error, and the surgeon again seeks the assistance of the ombuds to help prepare for the disclosure meeting.
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Medical ombuds are often asked why a caregiver should be open and honest in disclosing the truth about a medical error to a patient and family. Simply put, disclosure is the right thing to do when a patient has been harmed. When a patient and his or her family endure harmful medical errors, both ethical and practical considerations suggest that their doctors should tell them the truth about what has happened. Ethically, doctors have a duty to be honest with their patients stemming from fiduciary responsibilities within the physician-patient relationship (Levinson & Gallagher, 2007). Practically, informing patients about medical errors is critical to ensure informed decision-making about subsequent treatment (Levinson & Gallagher, 2007); to allow patients and families to begin a process of grieving and healing (Gallagher, 2003; Leape, 2005); and to foster trust between patients and providers (Leape, 2005; Massachusetts Coalition, 2006). Further, through disclosure of information about failures, errors, and adverse events, a hospital will develop the data to make the institutional insights necessary to reduce the likelihood of repeating the same mistakes in the future (Joint Commission, 2005; Roberts, 2007).
When disclosure of medical errors is accompanied by an apology, the aftermath can be a positive and restorative experience for patients and their doctors. This kind of healing experience, regrettably, takes place infrequently. Even though many physicians and members of the public report errors in their own or a family member’s care, neither group sees medical errors as a key problem in the healthcare system (Blendon et al. 2002). While on one hand, medical errors are not seen as being of critical importance, public survey data cited in the Institute of Medicine’s report To Err Is Human, found that an astounding 44,000 to 98,000 Americans die annually as a consequence of preventable medical errors, costing an estimated $17 to $29 billion annually (Kohn, 2000). Apologies and disclosure of errors reduce both the financial cost and human toll of medical errors.
An Example from Manufacturing
The case of the Toro Company, a lawn mower manufacturer, serves as a notable example for the healthcare industry of how an expensive, litigious system can transform into one that reduces costs and fosters trust, openness, and relationship building. Toro shifted its management of product liability claims away from a litigation-based system to a compensation and settlement approach. When a person is injured by a Toro mower, representatives of Toro visit him or her to acknowledge suffering, express sympathy and regret for the accident, answer any questions about the product, and offer monetary compensation to those harmed (Jones, 2004). This strategy for handling claims, according to Toro, has been a very positive business and customer relations experience. The change in claims management has saved the company $100 million in litigation costs between 1991 and 2005 (Jones, 2004). The average expenditure on an injury claim has dropped from $115,000 to $35,000, a decrease of almost 70% (Jones, 2004). By some estimates, other lawn mower manufacturers typically spend $200,000 to $300,000 per claim on legal expenses alone (Jones, 2004). Toro’s settlement program has also improved the relationships between the company and its customers, leading even those who have been harmed to walk away from an incident with healed relationships and good-will toward Toro (Jones, 2004). Healthcare organizations have the power to make similarly transformative system changes to better manage medical errors.
Physician Training and Support
For a physician to walk into a room and sit down beside a frightened, angry, and anxious family and apologize for injuring or killing a loved one as a result of a medical error is an act that the vast majority of physicians today are wholly untrained for and uncomfortable performing. And yet, data shows that when a party responsible for harm to another offers a full and sincere apology, the chances that the harmed party will remain angry and sue decreased significantly (Robbennolt, 2003; Massachusetts Coalition, 2006). The ability to engage in open, compassionate conversations with patients and families about medical conditions and care, to be honest about problems that may have arisen, to take responsibility for harm to a patient, and to offer heartfelt apologies are characteristics of a trustworthy physician, a good caregiver, and the kind of person who contributes to improving public trust in the healthcare system. This also happens to be the profile of a physician who is likely to face fewer malpractice claims than his or her colleagues (Levinson & Roter et al., 1997; Leape, 2005; Ambady et al, 2002).
Opening the lines of truthful communication can be a very powerful and cathartic experience for patients, families, and caregivers. It can foster trust in the medical system, reduce litigation costs, and even reduce the occurrence of medical errors. The question becomes: How do we equip physicians with the support they require to converse compassionately and sincerely with their patients and families?
One answer to this question is legal reform to reduce the risk that apologies will be used against caregivers in court. Steps have been taken in 11 states to protect certain apologies from being used as evidence in a trial (Leibman & Hyman, 2005). However, since this represents only about 1 in 5 states, and many of the existing laws do not protect against full apologies but only partial ones, some lawyers and risk managers may continue to fear the potential negative consequences of these kinds of admissions (Leibman & Hyman, 2005). Continued reform in this area can help incentivize apology. However, legal reform by itself cannot provide caregivers with the tools necessary to use apologies and disclosure effectively.
In order to equip physicians to speak freely and openly, education and training are of the utmost importance. The Association of American Medical Colleges in the 2000-2001 calendar year reported that a mere 12 out of 125 medical schools in the United States had a required communication skills course for their students (Liebman & Hyman, 2005). If caregivers are to become the trustworthy and honest physicians that patients deserve, they must be trained in how to conduct difficult conversations, how to admit fault and weakness, and how to show compassion to those they have harmed. These skills are not innate. To teach caregivers how to disclose and communicate effectively, they will need to learn to take a step outside their own comfort zones and recognize the human connection between themselves and their patients. They will need to start thinking about what it would feel like to be in their patient’s or family’s position and realize that their patients want to be treated with honesty and compassion (Leape, 2005; Massachusetts Coalition, 2006). Meeting these needs demands that physicians be trained in how to disclose and how to apologize after a medical error has taken place. Within healthcare organizations, services such as the medical ombuds/mediator program can serve as an example of what may be possible. In the case of Dr. Greene and the Franks, through disclosure and apology training; coaching; and support offered by the in-house medical ombuds, Dr. Greene had the support he needed to engage in difficult conversations with a distraught family about the medical error that lead to their son’s death. The support he received from the ombuds permitted him to maintain confidence in his ability, not be overcome by fear, and to accept responsibility. The ombuds can provide critical support to a physician fearing the worst: being sued, losing his reputation as a good doctor, and experiencing guilt and anxiety for harming a patient (Gallagher, 2003). The communications between Dr. Greene and the grieving parents sitting before him also fulfilled deep seated needs of the family to know the truth about the circumstances surrounding their son’s death and to be apologized to sincerely (Leape, 2005; Gallagher, 2003). It is how we would want to be treated if the unexpected outcome occurred to a family member or ourselves. Our patients deserve no less.
Carole Houk is an attorney and conflict management systems designer based in Washington, D.C. Her firm, Carole Houk International LLC (CHI), specializes in the design of integrated conflict management systems for organizations, with a particular focus on the healthcare industry. She co-developed the concept and designed the operating protocols and training for the first Medical Ombuds/Mediator Program for the early resolution of patient-provider disputes within acute care hospitals in the United States. This innovative program has shown impressive results in its first seven years of operation at the National Naval Medical Center in Bethesda, Maryland, as well as at dozens of Kaiser Permanente medical centers. Houk has been an adjunct professor at the Georgetown University Law Center, Hamline University School of Law, and Pepperdine Law School’s Straus Institute of Dispute Resolution. She may be contacted at chouk@chi-resolutions.com.
Leigh Ana Amerson is an experienced medical ombuds/mediator, having served as one of 29 pioneering healthcare ombudsman/mediators (HCOM) for Kaiser Permanente in their Mid Atlantic States Region. Prior to her role as an HCOM, she worked for Kaiser Permanente as a consultant in compliance, HIPAA, and customer service. In 2006, AmersonÝwas selected to present the HCOM program at the jointly sponsored Kaiser Permanente – Harvard conference ‘Seize the Moment’ – Reaching Excellence in Patient Safety. She currently works as a healthcare consultant with Carole Houk International and can be reached at lamerson@chi-resolutions.com.
Lauren Edelstein is a second year master’s degree candidate in conflict resolution at Georgetown University where she is studying conflict management, communication, and process design in healthcare and bioethics. She is currently interning with CHI.
References
Ambady, N., LaPlante, D., et al. (2002). Surgeons’ tone of voice: A clue to malpractice history. Surgery, 132(1), 5-9.
Blendon, R. J., DeRoches, C. M., et al. (2002). Views of practicing physicians and the public on medical errors. New England Journal of Medicine, 347(24), 1933-1940.
Gallagher, T. H., Waterman, A. D., Ebers, A. G., Fraser, V. J., & Levinson, W. (2003). Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA, 289, 1001, 1005.
Joint Commission on the Accreditation of Healthcare Organizations. (2005). Health care at the crossroads: Strategies for improving the medical liability system and preventing patient injury. Joint Commission Resources, 4-16.
Jones, A. (2004). Product liability: House calls. Corporate Counsel, 4(10), 88.
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (2000). To err is human: Building a safer health system. Report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, D.C.: National Academy Press. Also available at http://www.nap.edu/catalog.php?record_id=9728#toc.
Leape, L. L. (2005). Understanding the power of apology: How saying “I’m sorry” helps health patients and caregivers. Focus on Patient Safety, 8(4), 2-8.
Levinson, W. & Gallagher, T. H. (2007). Disclosing medical errors to patients: a status report in 2007. CMAJ, 177(3), 265-267.
Levinson, W., Roter, D., et al. (1997). Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. JAMA, 277(7), 553-559.
Liebman, C. B. & Hyman C. S. (2005). Medical error disclosure, mediation skills, and malpractice litigation: A demonstration project in Pennsylvania. The Pew Project on Medical Liability in Pennsylvania. http://www.medliabilitypa.org; 9.
Massachusetts Coalition for the Prevention of Medical Errors. (2006). When things go wrong. Boston, MA: Author 8-20.
Robbennolt, J. K. (2003). Apologies and legal settlement: An empirical examination, Michigan Law Review, 102, 460-516.
Roberts, R. G. (2007). The art of apology: When and how to seek forgiveness. Family Practice Management, 14(7), 44-49.