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Making Honesty the Policy

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If hospitals view patient safety only in terms of taking steps to prevent errors, they’re missing a significant part of the pule. Mistakes will happen no matter what precautions a facility takes, so senior leaders must consider how their organization will react in the aftermath. Are your physicians encouraged to clam up and go on the defensive? Does your risk management office automatically assume battle position at the first hint of a lawsuit?

That’s the way it’s been in the industry for a long time. Hospitals have traditionally hunkered down and protected their assets when something bad happens, fearing that leveling with patients, families and attorneys will cause greater harm than keeping quiet. But some facilities are taking a different tack and owning up to mistakes sooner rather than later. Hospitals that have adopted a policy—and an attitude—of transparency are reaping legal and financial benefits while improving their image at the same time.

Apologies at work

Although he didn’t know it at the time, Steve Kraman, M.D., became a pioneer in medical error disclosure in 1987. As chief of staff of the Lexington (Ky.) VA Medical Center, Kraman worked with the hospital’s attorney and the risk management committee to craft a policy that ensured that hospital administration knew about adverse outcomes as soon as possible so they could gather evidence in case of a lawsuit.

The policy didn’t last a year. When presented with a clear case of wrongful death, Kraman says, “We didn’t feel comfortable with what we’d planned to do—simply file it away—because the family had no way of knowing.” Instead, Kraman called the family, told them a problem had been discovered, and invited them to bring an attorney in for a meeting. “We explained what happened, apologized on behalf of the facility, told them what we’d done to try to prevent things from happening in the future, and told them they were owed compensation,” says Kraman. Within a few weeks, the attorneys arrived at a settlement that both sides thought was fair. The case became a model for the hospital’s disclosure policy, and the VA system later used the model for its own mandatory disclosure initiative.

“The normal practice was to circle the wagons, hide everything and make it hard for people to sue,” Kraman says. In 1999, he compared Lexington’s claims experience to the rest of the VA, and although his research showed Lexington paid more settlements than average for similar hospitals, total costs were lower. “We ended up paying reasonable amounts based on actual loss, and almost no expenses went to long, drawn-out court cases,” says Kraman, now a professor at the University of Kentucky College of Medicine. He adds that disclosure sessions often ended with handshakes and even hugs from patients grateful for hearing the truth. “It sounds almost ‘Pollyannaish,’ but if you treat people decently they generally respond in kind,” he says.

The difficult trek to the high road

Slowly, hospitals across the country, and even some malpractice insurers, are following in Lexington’s footsteps. But making the move to transparency isn’t easy; numerous fears and bad habits have to be overcome.

Experts agree the biggest problem is that hospitals and physicians don’t understand what causes people to sue. A common assumption is that patients and family members want million-dollar settlements. To avoid a lawsuit, providers have historically remained tight-lipped when an error occurs. Patients, in turn, head straight to an attorney’s office when they perceive the hospital has something to hide. “It’s generally not about money,” says Kraman. “A doctor at the hospital that they’ve put their trust into all of a sudden slams the door when a mistake is made, and they feel they’ve been abandoned.”

Many providers also fear that exposing safety records to scrutiny will result in more lawsuits, but this concern is largely unfounded. Hospitals with disclosure policies often see a reduction in the number of lawsuits and a decrease in settlement outlays. The University of Michigan Health System’s young disclosure program, for example, has seen a steady drop in claims since being instituted by Chief Risk Officer Richard C. Boothman in 2002 (see chart above). The average claims processing time of the Ann Arbor system, which staffs approximately 800 beds, is down from 20.3 months in 2001 to 9.5 months, and average litigation costs have dropped by more than half.

Still another roadblock to transparency is the belief that apologizing guarantees a bad result in court, but Geri Amori, Ph.D., senior director of the Risk Management and Patient Safety Institute in Lansing, Mich., debunks this myth. “People think saying ‘I’m sorry’ will give the plaintiff more money,” she says. Instead, a physician who proves willing to communicate early on and to admit wrongdoing may appear more favorable to a judge and jury than someone who is withdrawn and unresponsive, Amori says, adding that admitting a fact is different than taking responsibility for a liability.

Gaining steam

Hospitals aren’t the only ones acknowledging the potential benefits of open discourse. Denver-based COPIC Insurance Company offers member physicians a voluntary disclosure option that includes formal disclosure and offers the patient immediate compensation up to $30,000. Between October 2000 and December 2004, patients were reimbursed for 305 incidents at an average cost of $5,326. No cases resulted in litigation.

According to the American Society for Healthcare Risk Management, 17 states have apology immunity laws on the books designed to protect physicians. To Doug Wojcieszak, founder of The Sorry Works! Coalition, a disclosure advocacy group, the real value of such laws is the peace of mind they give physicians. “The laws help physicians get over their cultural inhibitions, but if a doctor admits fault and takes responsibility, they shouldn’t pretend like that didn’t happen when they get to court,” he says.

In Congress, a bill sponsored by Sens. Barack Obama, D-Ill., and Hillary Rodham Clinton, D-N.Y., aims to address medical malpractice issues via disclosure. Boothman, who helped draft the legislation, says the bill would help circumvent arguments about settlement caps by providing grants that would boost patient safety through transparency.

Healthcare executives, too, are realizing that much more than money is at stake. The hospital that’s seen as a facility that cares, even when things go bad, will find it easier to build solid patient relationships. Changing how hospitals address mistakes can potentially improve the working environment of clinicians, as well. “When doctors and nurses make a mistake and hurt somebody, they can beat themselves up pretty badly,” says Kraman. “If you’re told to shut up and hide, that never goes away. This is a way of making it right so they can get on with it.”

Kara Olsen is a staff writer with HealthLeaders magazine and managing editor of HealthLeaders Online News. She may be reached at kolsen@healthleadersmedia.com.