Cheryl Clark, for HealthLeaders Media , May 22, 2014
Patients who have been
harmed by medical errors, and their family members, could be recruited to
hospital internal quality review proceedings and their suffering could be used
to prevent future mistakes. It's a good, but potentially disastrous idea.
Hospital
quality expert R. Adams Dudley, MD, was
flapping his official UCSF identification badge that hung from a lanyard around
his neck. He told the group at a recent patient safety meeting that when a
hospital patient is harmed, "maybe they and their families should be given
one of these."
The point he was trying to make was
this:
It's not enough for healthcare
providers to merely be honest and apologize when a patient suffers harm, a
strategy slowly replacing
the standard "deny-and-defend" practice that persists in most hospitals, he says.
And it's not enough to do the thorough
root cause analysis, even offering compensation right away, which some
organizations are starting to do to avoid litigation and help patients grapple
with the tragedy.
They need to do more if they're truly
serious about being honest and preventing errors going forward, and this is
what Dudley thinks might be the next step to take.
"What if, when someone is harmed
in our hospitals, we say not only, 'we're sorry you were harmed', but 'here's a badge. Now you're part
of our team. Now, if you choose, you can be a patient advocate, come to
our staff meetings, talk about what happened, [and] attend patient safety
conferences. We'll e-mail you the meeting schedule.'"
We want you to help tell us how we can prevent this
from happening to someone else, he says.
'They Know We Messed Up'
"What better way for us to open
ourselves to really, truly be transparent than to say that the people we let
watch us should be the ones who know we can mess up, because we messed up with
them?"
Dudley's patient badge isn't
figurative. It should be a real piece of plastic that lets these patients and
their families inside the hospital's inner sanctum, so they may walk the halls
with the doctors and nurses. It's
important symbolically and psychologically, he acknowledges.
"If we really believe that we [as
providers] should be held accountable, why wouldn't we be willing to talk about
these issues in front of the people who no doubt feel a strong need to check us
out?"
But what if patients and their families
see providers arguing with each other about what went wrong, pointing fingers
to assign blame? Wouldn't it be a bad idea to allow patients or their families
to see that discord?
Not at all, Dudley says.
"If one specialist thinks one
thing, and another thinks another, there's no reason to hide that. That's just
part of medicine. It happens all the time." It's part of the process of
getting to the truth, he says.
Dudley, founder of the California
Hospital Assessment and Reporting Task Force (CHART) and many other research initiatives
geared to performance improvement, is known for his sometimes unconventional
ideas. He acknowledges that many hospital officials will write them off as just
more craziness from California's wacky healthcare system, he jokes.
But increasingly, this idea is taking
off in a few places, although not quite as intimately as Dudley describes. Patients and their family
members are being recruited in very public ways to the patient safety movement
—although rarely inside the hospital's often tense and internecine adverse
event review committees —to use their experiences to help fix flaws in the
system.
Former Patient Outsiders Are Now
Insiders
Helen Haskell
of Mothers Against Medical Error, whose son died from one, now sits on numerous
national safety panels. The parents of Rory Staunton,
the 12-year-old who died of sepsis that a New York hospital failed to
recognize, began a working relationship with state regulators and the Centers
for Disease Control and Prevention to increase sepsis early detection.
Then
there's ePatient Dave, MRSA
survivor Jeanine Thomas
and dozens of other national examples of outsiders who are now insiders.
Of course, there's a point at which
this could be a disaster, accomplishing the opposite of its intent, provoking nonproductive
disruption from patients and family members who are still too angry and
confused to make cogent contributions. Dudley acknowledges that he hasn't even
proposed the idea yet to UCSF, although he might.
Because of that concern, I ran the idea
by attorney Richard Boothman, chief risk officer and director for clinical
safety at the 925-bed University of Michigan Health System. In 2001, Boothman
replaced what he says was the classic "deny-and-defend" model for
responding to adverse events with "the Michigan
Model," in which patients are told up front what happened,
followed by three specific actions:
1.
Compensate
patients quickly and fairly when unreasonable medical care caused injury.
2.
If
the care was reasonable or did not adversely affect the clinical outcome
support caregivers and the organization vigorously. (A child with an ear
infection who has a severe reaction to an appropriate antibiotic)
3.
Reduce
patient injuries [and therefore claims] by learning through patients'
experiences.
The result, published in the Annals of
Internal Medicine in August, 2010, was that the average rate of new claims
dropped from 7.03 to 4.52 per 100,000 patient encounters and the rate of
lawsuits dropped from 2.13 to .75.
Also, median time from claim reporting to resolution dropped
from 1.36 years to .95 years. And costs incurred for paying total liability,
patient compensation, and non-compensation-related legal costs all declined,
from $405,921 per lawsuit before the program was implemented to $228,308 after,
a trend that persists.
But Boothman, who attended the same
patient safety meeting where Dudley waved his badge, says, "It sounds
great until you try it." UMHS did try it a year ago and encountered two insurmountable problems.
First, he says, "there's a
practical problem that hit us right in the chops. When something bad happens,
the clock starts ticking, and we have an immediate need to do our investigation
to understand what happened so no one else gets hurt.
But patients are dealing with new
medical needs, or sometimes they [or family members] are grieving. It sometimes takes them six
months before they can talk with us, and I can't wait six months. I
won't put other patients at risk."
Second, UMHS found "nobody will be honest unless
they feel they're in a safe place. You have to create an environment
where people can speculate, sometimes offer wild ideas about what
happened."
He gives this real UMHS example:
"A doctor operated on the wrong spine level, and during the event review
everyone involved—doctors, nurses, techs—were in one room going minute by
minute to figure out what happened. Afterwards, two nurses called me in tears
saying 'You never got the truth.
"That surgeon was working in two
different operating rooms at one time, and the residents were in over their
heads. The surgeon got disoriented and operated on the wrong level.' "
"Well, why didn't you say anything?" Boothman asked them.
They didn't dare, they replied. "The surgeon was sitting
across from us."
That's the problem, Boothman says.
"If you put a grieving
angry patient in a room like that and expect anyone will speak openly,
it will never happen."
I like Dudley's idea because I think patients who believe they've
suffered a hospital-caused harm see the system suddenly pivot against them.
Where before they may have felt
important and secure, now they see backs turned and calls unanswered. The idea
of letting them inside, making them members of this special club so they won't
feel abandoned and victimized, and litigious, seems like it couldn't hurt.
But maybe there have to be limits to
how far providers actually let them in.
Cheryl Clark is senior quality editor
and California correspondent for HealthLeaders Media. She is a member of the
Association of Health Care Journalists.
