Can I get an “I’m sorry” with a side of accountability?
Health care’s long-overdue transition to using communication and resolution programs when addressing harm
By Molly Craig and Evan Benjamin, MD, MS
Apologizing is hard, but doing it well is even harder. From the outset, we are predisposed to find reasons to delay or avoid saying we are sorry. Apologies can feel risky and uncomfortable! Our transgressions put the spotlight on negative aspects of our behavior, leaving our egos temporarily vulnerable in the hands of another.
In his book On Apology, Dr. Aaron Lazare, professor of psychiatry at the University of Massachusetts Medical School, presents evidence for the growing importance and frequency of apologies. He argues that an effective apology has up to four parts: acknowledgement of the offense; explanation; expressions of remorse; and reparation. An apology done well can lead to forgiveness, reconciliation, and strong relationship building. An apology done poorly can have the opposite effect.
The importance of a good apology should not be understated. Restaurant and hospitality industries are the masters of this. Researchers at the Carey School of Business found that 37% of upset customers were satisfied when offered a refund or credit; the number increased to 74% when the staff added an apology. It is a common understanding within these industries that saying sorry is the most effective, cheapest way to customer service recovery after a bad experience. Researchers from the Nottingham School of Economics found that 23% of dissatisfied customers withdrew negative comments after being offered five pounds, while 45% withdrew their comments after the company offered a formal apology.
If a good apology has both emotional and financial benefit, why is it not utilized more in health care?
For many years, medical professionals were advised not to acknowledge incidents of possible malpractice because this was thought to make the hospital more vulnerable to lawsuits.
Traditionally, the healthcare industry has tended to evaluate medical errors through a “deny and defend” approach. For many years, medical professionals were advised not to acknowledge incidents of possible malpractice because this was thought to make the hospital more vulnerable to lawsuits. Accountability was viewed as an admission of liability, rather than a chance to resolve, learn, and prevent future errors. Consequently, quality and safety of patient care suffered as chances to hide medical error were favored over chances to learn from it.
In 2017, the Betsy Lehman Center at the Massachusetts Department of Public Health released a research report identifying 62,000 preventable harm events and more than $617 million in excess health care insurance claims. Despite changes in national laws and hospital policies that have made it easier for providers to apologize after a medical mistake, only 19% of their survey respondents received an apology after the medical error. Twenty-five percent were offered emotional or financial support services. However, in instances where providers exhibited greater open communication, patients reported less emotional harm and health care avoidance.
In instances where providers exhibited greater open communication, patients reported less emotional harm and health care avoidance.
In recognition of these gaps, some hospital systems have implemented Communication and Resolution Programs (CRPs). The intention of these programs is to promote open communication between health care providers and patients and families after adverse events. A CRP calls for early reporting of adverse events; communication to and emotional support for patients, families, and clinicians; transparent learning about the causes of harm; and offers of compensation when substandard care causes patient harm. The core function of a CRP is to increase patient safety and quality of treatment.
However, while CRP implementation has grown substantially, there is a concern about consistency of the CRP process among organizations. Research work on implemented CRPs indicates that organizations may apply some, but not all, CRP practices to a given case, or are less likely to use CRP in cases where patients are unlikely to assert a malpractice claim. When a CRP is done selectively and not comprehensively, it raises criticism that a CRP is just a claims insurance tool attempting to lower medical liability costs, when, in fact, it is about caring for patients and preventing recurrence of harm. Cherry-picking cases also makes it more difficult to evaluate the effectiveness of the model overall.
Good ideas require researched frameworks. Rigorous metrics for assessing communication-and-resolution practices and outcomes would help institutions increase their fidelity to these programs. Addressing this need, Ariadne Labs in partnership with the Institute for Healthcare improvement (IHI) and Collaborative for Accountability and Improvement (CAI) have developed an evidence-based CRP framework called the Pathway to Accountability, Compassion, and Transparency (PACT) program. The PACT collaborative has research-backed metrics assessing CRP components and provides healthcare organizations with intensive support in developing comprehensive, highly reliable CRPs. In Fall of 2021, PACT is launching a learning collaborative based on the IHI breakthrough series model with the first wave of health care organizations committed to taking the necessary next steps.
The PACT collaborative represents a new era in patient safety and accountability in health care. Aside from aligning with hospitals’ overarching goals of doing the right things by patients, the systematic use of CRPs is also integral for retaining the long-term trust of the patient and families affected by a harm event or an unexpected negative outcome. It is also more likely that a patient will remain a continual consumer of health care rather than exiting the system all together.
Furthermore, consistent use of fair and just accountability practices are cited by the Mayo Clinic researchers in 2020 as a strategy to reduce burnout among health care providers. Burnout rates still remain at critical levels in 2021, with over 42% physicians reporting feeling burned-out. “High functioning CRPs ensure clinicians get the support they need after harm events, and benefit all of us by ensuring learning occurs after care breakdowns,” said Thomas H. Gallagher, MD, MACP, executive director of CAI. By developing a network of system leaders who are supported and empowered in establishing these programs, we can improve the safety and care of both patients and clinicians. This is also an essential ingredient for health systems transparently learning from errors so history is not repeated.
By developing a network of system leaders who are supported and empowered in establishing these programs, we can improve the safety and care of both patients and clinicians.
Finally, while PACT’s emphasis is on aligning care with patient goals and preferences to improve the quality of patient care and experience, there is an equally important second focus: to ensure institutional resources are being properly and strategically used for their fullest possible benefits. CRPs are found to lower defense costs and are proven not to increase overall liability costs, so shifting to a consistent use of these practices further fuels the financial incentive.
CRPs are long overdue for a dose of consistency and structure. CRPs represent a way forward out of a “deny and defend” approach of dealing with harmed patients. CRPs implemented in a systematic, comprehensive manner restore patients’ trust in the system, create learning methodologies for preventing recurrence of harm, and support patients and providers involved in harm events. A good apology, done authentically and with appropriate claims of responsibility and offer of resolution, shows further commitment to ethical and business objectives held by hospitals and their leaders.
Molly Craig is a summer intern with the office of the Chief Medical Officer at Ariadne Labs and a rising senior biology and public health major at Williams College.
Evan Benjamin, MD, MS, FACP, is the Chief Medical Officer at Ariadne Labs, an Associate Professor of Medicine at Harvard Medical School, and an Associate Professor of Health Policy and Management at the Harvard T.H. Chan School of Public Health.
To learn more about the PACT Collaborative, visit www.ariadnelabs.org/pact/
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