When a provider makes a tragic mistake that harms a patient, most healthcare organization executives and their staffs are told to hide. If they say anything, they will be more likely to be sued, they think.
Instead of promptly reaching out to empathize and console with food, housing, money, and social support for those whose lives are irreversibly altered, hospital executives and staff often take a "willful blindness" posture.
They don't acknowledge, disclose, or apologize. Instead, they repeat phrases like, "It will blow over," "It wasn't our fault," or "No one will find out."
They advise care teams to act defensively, to avoid saying anything that will expose them "to the media." They think "I'll look bad," and tell everyone "I'm unavailable." Or "Our attorneys will handle it."
But these phrases, attitudes, and behaviors are just the ones that will make litigation more likely and prolonged, with potentially higher damages and more animosity, says James Conway, senior vice president for the Institute for Healthcare Improvement. And these responses can add more anxiety and suffering to the affected patients and their families.
In the 2011 edition of his 2010 white paper, "Respectful Management of Serious Clinical Adverse Events," released late last month, Conway and three co-authors explain their year-long research and case studies in which hospital officials have used the above phrases to try to escape blame for an adverse event. And they reveal that when hospital systems have tried new strategies to reach out instead of run for cover, the situation dramatically improves.
"If you know what happened, and there's no debate about what happened, how do you work with the family on a rapid case resolution including compensation?" Conway said in an interview.
"That's why we titled the report 'Respectful Management,' he says. "It's about how you would want to be treated in such a situation."
In other industries, the idea is often called "service recovery," as in compensation or a refund for a purchase that didn't work. In the setting of a hospital adverse event, where the stakes are much higher, "you may not even know if there was an error or not, but someone is in critical condition you didn't expect to be," he says.
"Now there are practical issues. A family member has to stay in town, so are you helping them with hotel bills and meals? What about transportation? How do you send the message, 'We're there for you?' You need to remove any barriers associated with this unanticipated outcome," he adds.
Based on his travels around the country speaking with hospital executives, staff, and victims of medical errors, Conway estimates that only about 25% of hospitals have any kind of integrated response or crisis management plan, or a rapid compensation or reimbursement plan to follow in the aftermath.
Conway and co-authors say that the IHI has "met patients, family members, and healthcare staff who are rightfully angry and frustrated, often for many years, over a lack of resolution and healing and the disrespectful treatment they received in the aftermath of preventable harm or unanticipated outcomes. They have asked us, 'Where is the outrage? I walked my son into the hospital and I brought him home dead. Why wouldn't anyone talk to me?'"
Hospitals and healthcare organizations have a choice. They can "continue to go into defensive, reactive, survival mode or to go into proactive, learning, developmental mode," the report says.
Conway elaborates: Quite often, when he has spoken with families, loved ones, and patients who were harmed by a hospital adverse event, "they tell us that the reason they sued was because of the way they were treated, and the distance that developed in the aftermath of that adverse event."
"What we're seeing around the country is that organizations get so consumed by this discussion about whether or not [the tragic result] was preventable, and the family is not being supported, and they're getting angrier and angrier and angrier. Then all of a sudden you have someone who is dramatically more likely to sue."
The staff is often a second victim of the hospital's overall response, Conway says. Avoidant postures after an adverse event are sure to perpetuate a lack of trust that can tear apart not just the organization and its staff, but also the reputations they've built over time.
In the latest edition of the report, Conway and co-authors offer a series of checklists, questions, and elements to better prepare hospitals to respond to adverse events. It contains several case studies of the proper way for a hospital CEO to phrase regrets.
For example, Paul Wiles, CEO of Novant Health in Winston-Salem, NC, says that after MRSA-related deaths in his neonatal ICU, "I am accountable for those unnecessary deaths in our ICU. It's my responsibility to establish a culture of safety. Up until the time I read the documents about the young mother's loss of her newborn son, I had been unintentionally relinquishing that duty—in effect delegating it to others without letting them know they had a responsibility to perform.
"I'm responsible, as CEO, for creating the environment in which every staff person prioritizes proper hand hygiene, and mourns the human consequences of failure. That's my job, more so than the clinical staff who provide care."
Although some healthcare organizations have provided case studies for the paper, others told Conway they don't want to talk publicly about their experiences—even though they're experimenting with the responses that he espouses. At least not yet.
The paper includes tips on how to talk with the media, how to respond to events that happen in other facilities, and what the process of disclosing facts cases should be.
Conway is in a position to know about the impact of an adverse event on a hospital, as well as on patients and family members. He was COO of Boston's Dana Farber Cancer Institute in 1994 when Betsy Lehman, a 39-year-old Boston Globe health reporter died of complications after a chemotherapy overdose she received while undergoing breast cancer treatment there. The incident received an enormous amount of media attention.
As he watched what the horrible error did not just to the patient but to the Dana Farber staff, Conway decided to spend the rest of his career working on error prevention.
The whole idea, he says, is to help everyone move through the event rather than force it to drag out. The patient, family and loved ones, and the hospital staff "need to move on, and healing can begin when they know what happened. And that's clearly a point we're making in this paper.