Discussion on the importance of Constellation and Candello’s findings.
As we have seen, the joint research project by Constellation and Candello shows that with early reporting after a harm event, expenses are lower and the life cycle of the case—how long it remains open and unresolved—is shortened significantly. (For more on this research, see also “How Reporting Harm Events Early Brings Faster Resolution and Promotes Healing,” page 2) What if the process of healing could begin right away? What could early reporting and early resolution do to help lessen the impact of the harm for patients and residents and their families, for the care teams involved, and for the health care organization? While the research shows the costs in terms of money and time, early reporting also has the potential to limit suffering for all involved.
A call for early communication: National awareness has sparked new programs and research, including Constellation’s HEAL program
Programs focused on apology, communication and resolution are not new, and, while widely praised, they are still not widely implemented as comprehensive programs. One of the first programs began at the Veterans Administration (VA) Hospital program in Lexington, Kentucky, in 1987. The VA program’s success sparked many other programs, including the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI)’s CARe program, Stanford’s Process for Early Assessment and Resolution of Loss (PEARL) program, and Constellation’s HEAL program. Of special note is the communication and resolution program at the University of Michigan Health System (UMHS). Implementing their program in 2001, they sought to decrease the financial, emotional and other costs of patient harm events, noting a study showing that for every dollar spent on compensation, 54 cents went to administrative expenses including fees for lawyers, experts and courts.1 For the purposes of this article, programs we refer to, such as those listed above, include the key elements of a comprehensive communication and resolution program: / Early reporting and investigation to determine factors that contributed to the harm / Open and transparent communication with patients, residents and families / Emotional support for care team members involved / Determination of fair compensation when standard of care was not met and harm occurred / Organizational learning and implementation of new policies and procedures to reduce future harm / No limits on types of harm events (from minor to severe cases, including death) For these programs to be successful, it is essential that the health care organizations partner with their medical professional liability (MPL) insurer to ensure proper reporting and investigation of issues, including determining root causes to help improve processes and policies in order to reduce reoccurrence of similar harm events. Of note, this partnership is necessary to make a reasonable and fair offer of compensation when it has been determined that there was a deviation from the standard of care resulting in harm. This opportunity to agree on a settlement prior to the filing of a claim or lawsuit— providing that the standard of care was not met and harm was caused—serves the interests of both the health care organizations and their care teams, as well as the patients and residents they serve. In 2015, The National Academy of Medicine (NAM; formerly the Institute of Medicine)’s committee on improving diagnosis in medicine recommended that states promote an environment that facilitates timely identification, disclosure and learning from errors, encouraging the adoption of communication and resolution programs, and enabling prompt and fair compensation for avoidable injuries.2 Constellation’s HEAL program—the impetus for the research presented in this article—is structurally and philosophically aligned with NAM’s recommendation, and with other programs that emphasize the importance of apology and communication in the healing process after harm events.
A better way forward: Moving toward a supportive, “just” culture
Culture matters. In care teams, oppressive hierarchy may influence whether team members feel comfortable to speak up. Within clinician–patient relationships, management or fear of retribution may inhibit transparent communication between the health care team, patients, residents and families. In many health care organizations, these misguided pressures can lead to a culture of silence or a tendency to “deny and defend” wrongdoing when it comes to patient harm events.
But research shows that reporting early, communicating appropriately and quickly, and supporting the emotional health of affected team members are critical to achieving a meaningful resolution—and recovering trust in the patient– clinician relationship. These practices can help health care organizations limit the extent and timeframe of malpractice claims as well. Constellation’s HEAL team actively works with policyholders to promote the establishment of a more “just” culture that advocates transparency and speaking up, and strongly encourages early reporting.
According to a 2018 statewide survey in Massachusetts, when o open communication was received, patients reported sadness, anger, anxiety, depression and feelings of betrayal at significantly higher levels than those who received open communication. Patients who received no communication reported avoiding the doctor (77%), avoiding the health care facility (80%) and avoiding medical care in general (45%).
Overall in the study, only 19% of affected patients and families reported receiving an apology.
The natural human inclination is to feel bad and apologize, yet the fear of litigation along with emotions of shame and embarrassment can keep clinicians from doing the right thing. This lack of communication can also have significant business costs: Poor patient–clinician relationships can lead to decreased visits, delayed diagnosis can result in higher medical costs, and reputations and brands can be damaged by bad reviews or hearsay. The repercussions of these harms to business can negatively impact the ability of health care organizations to serve and care for their communities.
“When we don’t talk with patients and families after a harm event, they may fill in the blanks, thinking we don’t really care or that we are hiding something. This all results in additional harm. We can do better,” says Laurie Drill-Mellum, MD, MPH, chief medical officer emerita at Constellation. A patient who has been hurt but whose experience is not valued and investigated by their care team will feel more pain and sadness, will lose trust in their care team and the organization, and may proceed separately to file a claim to seek retribution for the harm. Patients may experience financial harm as well, including increased medical and household expenses, and decreased income. Clinicians and care teams are also greatly affected when they are involved in—or witness to—harm events. Their reputation and job satisfaction can be negatively impacted, and they may have sleeping problems, low confidence and anxiety. A clinician who avoids taking responsibility for harm done, or who is afraid that apologizing or taking responsibility will negatively impact their career, their reputation or their insurance rate, may be experiencing a natural human reaction but is also adding to the lingering shame, blame and guilt they may feel going forward. In addition, research shows that clinicians who have experienced a claim are at risk for subsequent claims, likely due to the emotional impact felt. (See fig. 1) As inferred from the research findings displayed in the graph below, resolving a case early, within the first year, may help to decrease the risk of subsequent occurrences and/or claim developments.
As demonstrated in this research, the importance of early reporting to shorten the life cycle of a case cannot be understated when we consider the devastating emotional impact of harm events as they are prolonged. Organizations that do not actively support reporting of events—with policies and procedures in place—may experience reputation damage and loss of patients, in addition to facing malpractice claims that may come much later, making it more difficult to investigate, determine whether the standard of care was met, and conduct a root-cause analysis. Further, when organizations do not support clinicians in processing the emotional impact of harm events, they are at risk for losing clinicians who may decide to leave medicine altogether. And the cost to replace a physician is high— between $500,000 and $1.5 million or two to three times their annual salary.3
About Constellation’s HEAL program
This research project validates Constellation’s firsthand experience that early reporting brings earlier resolution and closure for all involved.
The HEAL program is a strong proponent of building a culture that promotes speaking up, early reporting, prompt investigation and acting on lessons learned. To achieve this, 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.
Further, Constellation believes that its comprehensive program offers healthier, more compassionate and more meaningful closure for patients, residents and families, care teams and health care organizations. HEAL aims to replace silence, doubt, fear and frustration with an honest, human-centered acknowledgement of what happened, its impact and what to expect next.
Constellation’s HEAL program was created to find a better way forward after harm events occur. These unexpected outcomes affect not just the patient, but also many people within health care organizations. Constellation has also seen that harm events can significantly affect an organization’s bottom line and threaten their business viability, which can then affect thousands of patients seeking care. Poor and slow handling of harm events can affect productivity, and can lead to physician or clinician burnout, as they roil in the emotional impacts inevitable after being a part of, or the cause of something, when their patient or resident was harmed. This can occur even if the potential of harm was known and disclosed, and even if the standard of care was met.
A main goal of Constellation’s HEAL program is to attend to harm events sooner so the patients, residents and families, clinicians, administrators—everyone involved—can get to a point of resolution and move toward healing. In addition, Constellation knows from experience that reporting harm events right away is key to learning from mistakes so they can be prevented from recurring in the future.
“If we don’t know about something we can’t attend to it,” says Dr. Drill-Mellum. “If patients and families don’t tell us when something happened, and the first time we hear about it is years later through an attorney, then we have lost the chance— as clinicians and as organizations—to address the issue and help investigate and resolve it right away. If it’s years later, we need to rely on people’s memories, and that may not give us the data and information that can help us ensure that the harm event doesn’t happen again to others.”
Constellation has observed that reducing the life cycle of a case—which was found to occur with early reporting—can have profound effects on everyone involved, reducing the emotional impact and duration as well as the number of claims and suits, especially those that proceed to litigation.
At each step of the way, the HEAL program is a collaborative effort between the health care organization and Constellation. The program, which was implemented in January 2020, accelerates evaluation of the standard of care, helps health care team members with communication with the patient and family, ensures providers and care teams are supported, and then identifies strategies to avoid risk in the future.
Being proactive: The HEAL Prepare Toolkit
Being prepared before harm events occur is essential to enabling and empowering teams to report events early, allowing for the process of discovery to begin in a timely matter when the facts of the case are more apparent. This is supported by our research that reporting early can help limit the life cycle of a case, as well as lowering expenses overall. Education around early reporting and investigation is a key goal of Constellation. For policyholders who are proactive and want to improve their preparedness before harm events occur, Constellation offers the HEAL Prepare Toolkit—a self-guided, multiyear educational program to help assess care team readiness and help organizations build best practices. “It’s inevitable that harm events will happen, so anything we can do to better prepare—especially for those first crucial moments— can help everyone involved,” says Dr. Drill-Mellum.
The HEAL Prepare Toolkit offers learning and education in
seven key steps, with most time spent in the learning units in
step four:
- Take the HEAL risk assessment.
- Review your scoring and recommendations.
- Develop a preparedness action plan.
- Review the four learning units: 1) Culture, 2) Event
Response, 3) Communicating After Harm Events
and 4) Moving Forward. - Retake the initial assessment.
- Receive your updated scorecard for success.
- Implement and move forward.
When the life cycle of a claim is shorter, so is the cycle of emotional pain for clinicians
The research shows early reporting leads to a shorter life cycle for a claim; this also leads to a shorter timeframe for what can be intense emotional pain—for patients, residents and families, care teams and organizations. “A harm event can be like a festering wound, like an abscess,” says Dr. Drill-Mellum. “If you open it up—and sooner is better than later—and give it some sunlight and let people attend to it, it’s going to heal. There may be a scar, it isn’t forgotten, but it helps us move on.”
Also adding to the emotional healing are the HEAL services available to policyholders. Clinician peer support helps connect physicians and other health care team members involved in harm events with peers who have walked similar journeys and are trained in supporting their peers with empathy, kindness and support strategies. Whether the case leads to a claim or suit, or not, the impact on the physician can be the same. “Physicians are sworn to help, heal and serve our patients, so when we inadvertently harm someone, we feel deep pain, too,” says Dr. Drill-Mellum.
Risk consultation can help clinicians learn the contributing factors that led to the harm event. Communication assistance helps them learn the best ways to be open and transparent with their patients, residents and families, which can often strengthen their relationships and help them build trust. It can also help them move through and better process feelings of guilt and shame. They can learn when an apology is important, and learn skills to make their communication compassionate and meaningful—understanding that offering an apology is not always about accepting responsibility or blame. Expert case review helps accelerate learning as to whether the standard of care was met. Either way, they can better understand next steps and be prepared to move forward with the case.
Summary
The MPL industry has, for some time, been discussing a better way to respond to harm events, based on promising evidence of success from captives or self-insured entities including the University of Michigan and the University of Illinois. For years, organized medical associations including the AMA and patient safety/experience entities have been advocating for apology and communication/transparency programs as ethical imperatives. Still, little progress has been made, and the opportunity exists to seed these programs more comprehensively across more health care organizations. Our industry is wired to look for threats and avoid them. This places us in a position to partner with health care organizations to demonstrate that early intervention can bring positive results on many levels—from retaining trust within patient–clinician relationships and decreasing the duration of emotional stress, to improving business viability and allowing for process improvements that can help reduce the reoccurrence of harm. All of this shows that it is imperative that we limit the life cycle of harm events. This research demonstrates that early reporting shortens the life cycle of an event and reduces expenses, which benefits patients, their families, and the clinicians who care for them. In this era of clinician shortage and transactional care—leading to burnout, poor experience for all involved, as well as increasing costs—the practice of early reporting and prompt event investigation is critical to the future of care itself. Working together, MPL companies and health care organizations can truly make a difference.
References:
- Boothman RC, Blackwell AC, Campbell DA Jr, Commiskey E, Anderson S. A better approach to medical malpractice
claims? The University of Michigan experience. J Health Life Sci Law. 2009;2(2):125-59. http://www.med.umich.edu/news/
newsroom/Boothman%20et%20al.pdf - Committee on Diagnostic Error in Health Care. The path to improve diagnosis and reduce diagnostic error. In Balogh
EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2015. https://
www.ncbi.nlm.nih.gov/books/NBK338589/ - American Medical Association. 2017. STEPS Forward: Creating the organizational foundation for joy in medicine.
https://edhub.ama-assn.org/steps-forward/module/2702510