Common Factors | Fall 2022

Trust and Transparency After the Harm

Rebuilding the patient–physician relationship is possible.
By Amber Wuollet

The appointment began like many appointments do: a patient needing care. A young mother of two met with her family medicine physician, Dr. A*, and shared her symptoms of abdominal pain and tenderness. Dr. A noted the patient’s concerns and performed a test. After receiving the results of the test, Dr. A did not follow up with the patient. When the patient’s symptoms worsened several months later, she presented to Dr. B*, another family medicine physician at the same hospital. Dr. B did not perform an examination, so it was not until a subsequent appointment several months later that the patient’s cancer was diagnosed. By this point, both radiation treatment and surgery were necessary for treatment. Soon after, the hospital’s practice manager became aware of the delayed diagnosis and alerted the hospital’s risk manager via the organization’s incident reporting system. The risk manager, in turn, contacted Constellation to begin the HEAL process, Constellation’s early intervention program. The hospital’s focus on integrity contributed to the fast action taken to address the situation. According to the risk manager, the organization has clear and consistent messaging from leadership to embrace transparency and respect. “If we did something wrong, we want to make it right,” she said. “It’s my habit to reach out to Constellation whenever something like this happens.”

Time for the experts to review the case
To begin the HEAL process, an expert review was begun. The expert opinions obtained by Constellation indicated the standard of care had not been met in the care provided by either Dr. A or Dr. B. Earlier diagnosis would likely have prevented the need for the radiation treatment that became necessary by the time the patient’s cancer was ultimately diagnosed.
The expert reviews were key in moving the patient’s case forward quickly. “If we hadn’t used HEAL, we wouldn’t have definitively known that the standard of care was not met. That was instrumental,” the risk manager said. By confirming that the standard of care was not met in the patient’s care, the team was able to take the next steps toward resolution.
Constellation’s philosophy of supporting health care providers means defending care when the standard of care is met and facilitating early resolution when the standard of care has not been met. In both scenarios, however, the expert reviews facilitate deeper analysis of harm events that often leads to procedural changes and improved outcomes in the future.

A need for communication to begin the healing
As the HEAL process continued, the hospital risk manager embraced the communication assistance offered by the HEAL program. Dr. A, who was the primary care provider in this case, had decades of experience and previous exposure to the antiquated “deny and defend” approach used with patients and families in the past. So it was no surprise to the hospital’s risk manager that Dr. A’s initial response was: “Our insurance company is telling us to tell the patient?”
Once on board with this approach and open to working in this new way, Dr. A collaborated with Constellation’s early intervention consultant, who skillfully guided the care team through the preparations for a difficult patient meeting. The team talked through how to empathetically communicate with the patient, setting up both the guardrails and the flexibility Dr. A needed to feel confident for this sensitive discussion.
While Constellation prepared Dr. A for the conversation, the hospital’s practice manager coordinated the meeting with a reluctant and understandably upset patient. By leveraging an empathetic and transparent approach, Dr. A and the patient were able to have a productive first meeting, talking through the events of the patient’s care and starting to rebuild trust. Empowering clinicians to speak from the heart and giving them the space to offer an apology can be a powerful starting place for healing on both sides.
Resolution can mean many different things to different people. Each harm event is unique, and it is important to consider the perspectives of all those involved. In this case, compensation was a part of the resolution, but that is not always the case. This part of the resolution was handled by Constellation’s early intervention consultant, who worked directly with the patient regarding reasonable compensation. Consistent and clear communication between Constellation, the care team and the patient was vital to the healing process.
Four months later, the patient’s radiation and surgery were complete, and she was cancer free when she received her settlement payment. It was a new beginning for the patient, who later reached out to Constellation’s early intervention consultant to thank him for his support and transparency during the process.

Resolution and a new beginning for both physician and patient
The patient also reached out to Dr. A—to set up her next appointment. It speaks volumes of the healing process that the patient’s trust in her care provider was not broken, but strengthened, during this challenging time.
The hospital closed the loop of healing by taking steps to prevent a similar misstep from happening again. The transparency of the care team and insight provided by the expert reviews resulted in changes to the processes that had contributed to the oversight. Learning from adverse outcomes to prevent recurrence is another powerful way to heal all those involved.
The approach of “deny and defend” has been ingrained in the health care industry for decades. This archaic philosophy siloes clinicians away from their patients and colleagues, and creates a culture of silence and shame. By empowering health care professionals, we empower the entire health care system, so that physicians like Dr. A and Dr. B can feel the strength of a team behind them and benefit from the guidance of those with experience in adverse outcomes.
The involved risk manager reiterated, “We wanted to make it a team effort. That was really important for the dignity and respect of our clinicians.”
The reality of medicine is that it doesn’t always go as planned, and even the most tenured, established clinicians will experience adverse outcomes during their careers. By bringing these harm events to light and quickly working together as a team to resolve them, we help create a future of transparency, support and progress in health care.

*The designations of Dr. A and Dr. B represent the order of care in this case and do not reflect the clinician’s real names.

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