A Better Way Forward After Harm Events
Have you ever been involved in a patient or resident harm event and felt like you could do better if you had the right tools and support? The HEAL® program equips health care teams to act promptly and effectively after harm events to achieve meaningful resolution.
A Delayed Diagnosis Causes Unintentional Ripples of Hurt
A patient and her primary care physician did not receive communication about an abnormal mammogram due to a faulty radiology communication system. The woman’s breast cancer was not timely diagnosed leading to a poor outcome. The radiologist involved in the care was deeply affected by the adverse event. While she had correctly read the mammogram, she felt guilt over the failure of the communication system and the possibility that many more patients could be affected. She wanted to reach out to the patient, explain what had gone wrong and how she intended to make sure it didn’t happen again, but she was afraid. Sadly, in health care, sometimes things go wrong. It’s certainly not intended. This could be an adverse outcome from a risk or complication of a procedure or a system error like this one.
“But when we take a very careful look at a harm or adverse event, what’s best is to treat everyone as fairly and as soon as possible to resolve these events. And sometimes it’s just being heard,” says Laurie Drill-Mellum, Chief Medical Officer at Constellation®.
“In the past, involved clinicians were told not to talk to the patient or family about the adverse outcome. But people need to be heard. Patients and their families need to hear an apology for things that have gone wrong or unexpected and to hear an explanation of the situation. And sometimes all people really want is the truth and to be heard,” continues Drill-Mellum.
Oftentimes, harm events cause unintentional ripples of hurt—for patients/residents, care teams, and the health care organization. At Constellation, we believe there’s a better way to navigate an unexpected outcome, a way that creates a path to healing for everyone involved. That’s why we created HEAL, a program focused on acting promptly after a patient/resident harm event occurs, to both shorten the life cycle of an event and to reduce the sequence of negative impacts it may cause.
“We initially thought about how we could change the professional liability mantra of denying and defending adverse outcomes and implement a different philosophy moving forward so that we are able to care for those clinicians that are also injured in the harm event, as well as for the patients/residents that actually are harmed,” says Bill McDonough, President and CEO of Constellation. “How do we mainstream it so that people are able to understand that we’re no longer thinking litigiously? At Constellation, we believe that we can help change the way we attend to these harm events, and we are willing to take the lead on this. We’re willing to show our peers and the industry that there is a new and better way,” says McDonough.
“We initially thought about how we could change the professional liability mantra of denying and defending adverse outcomes and implement a different philosophy moving forward so that we are able to care for those clinicians that are also injured in the harm event, as well as for the patients/residents that actually are harmed.”Bill McDonough, President & CEO of Constellation
A Better Way Forward After Harm Events
The HEAL program embraces four key principles:
- Honor everyone involved
- Empower each person to be part of the solution
- Act early and decisively to limit harm
- Learn from each experience to better protect patients/residents and care teams
One of the goals of the HEAL program is to attend to harm events sooner so the patients/residents, families, clinicians, administrators–everyone involved–can get to a point of resolution and move towards healing. The program equips health care teams to act promptly and effectively after harm events to achieve meaningful resolution. Our HEAL program aims to replace silence, doubt, fear and frustration with an honest, human-centered acknowledgement of what happened, its impact, and what to expect next. Learn more about HEAL core services.
Moving Forward After Harm Events
Our claim team reached out to the radiologist involved in the delayed breast cancer diagnosis case and connected her with one of our clinician peer support professionals, who helped her manage the intense emotions she felt about the adverse event and use that energy towards performance improvement. One of our risk consultants worked with both the radiology and primary care practices to analyze their follow-up and communication systems, re-engineer safer systems and implement safety audits to ensure the systems worked without failures.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
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