Only a dozen or so Massachusetts hospitals have adopted communication, apology and resolution to guide their interactions with patients and families following a medical error, and these programs have been even slower to catch on at ambulatory practices.
That’s why it was noteworthy when Atrius Health, the state’s largest ambulatory network, set out last year to provide formal support for the system to its 750 physicians.
“We’ve seen about 30 cases go through since then — too few for a formal evaluation,” says Dr. Beverly Loudin at Atrius Health, who is leading the effort. But she says the experience so far fits the general trend in recent years, which has been toward an increase in the number of errors reported at Atrius — reflecting the professional staff’s growing confidence in the safety reporting system — and a decrease in overall malpractice costs.
“The drop in malpractice expense was not our reason for doing this,” says Loudin, medical director for patient safety and risk management at the organization of three community-based medical groups, which serves more than 675,000 eastern Massachusetts patients. “From our standpoint, apology and disclosure is just the right thing to do for our patients. But for the financial folks, the economics are important too.”
Communication, apology and resolution, of course, is the practice of being open and honest with patients and their families in the aftermath of preventable medical harm. The idea is to disclose the error as soon as it is discovered, and keep families informed while the event is investigated to identify causes and take preventive measures.
Hospitals that have adopted such a system say it helps both staff and patients come to terms with an error, and can also reduce malpractice payouts —even in instances where the institution may be liable—by averting lengthy court cases.
But nearly all the experience with the technique to date has come from hospital settings, which makes the Atrius Health experience worth watching for several reasons.
At the simplest level, success at Atrius Health would provide additional validation for systems like Communication, Apology and Resolution (CARe), the specific protocol developed by the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) that was used at Atrius Health.
More importantly, it would show how communication, apology and resolution could be modified to work in ambulatory medicine. “If you look at the data,” Loudin says, “close to 50 percent of malpractice claims originate in the ambulatory setting, not in the hospital, and most of the providers involved are primary care physicians.”
In ambulatory practices, patients may come in only once or twice a year, so mistakes often aren’t discovered until months after the fact. By then, a patient could have seen multiple outside providers—all working with separate record systems—making it harder to find out just where the care breakdowns occurred.
The types of mistakes can also differ. Hospitals tend to make errors of commission—giving a patient too much medicine on the spot, for example. And while ambulatory practices can also make those kinds of mistakes, they may be more vulnerable to errors of omission, such as a follow-up exam that was never scheduled, a worrisome test result that was overlooked, or a missed or delayed diagnosis.
To ensure its program took account of such differences, Atrius Health sought funding from CRICO, its insurer, and then approached the Institute for Professionalism & Ethical Practice (IPEP), an educational institute based at Boston Children’s Hospital, to create specialized training for the medical directors of the various Atrius Health sites.
Dr. Sigall Bell, IPEP’s director of patient safety and quality initiatives and a physician at Beth Israel Deaconess Medical Center, said IPEP worked with Atrius Health to develop a customized version of the apologies course using scenarios based on actual Atrius Health cases. And the training included simulations where the doctors had to explain an error to an injured “patient” played by a skilled actor. “The actors were so good that you honestly felt like you were talking to a patient who had had something horrible happen,” says Loudin.
The simulations helped doctors learn about the human side of these difficult conversations. “When a person is traumatized,” Bell explains, “their ability to hear and retain information is naturally compromised. That’s true for both patients and clinicians. And for clinicians approaching disclosure conversations, feedback from patients in real life scenarios is virtually non-existent. That’s why having the ‘patient’ in the room is more powerful than hearing the same thing from another doctor or supervisor.”
The initial six-hour training sessions were completed by every site medical director at Atrius Health. A few months later, they returned for further training on how to convey what they had learned to others. And Loudin conducted nearly 90 separate educational sessions—minus the simulations—about the CARe program with the rest of the Atrius Health providers.
IPEP video featuring interviews with both patients and trainees who participated in one of their training sessions, talking about the value of patient involvement.
Now, Loudin is thinking about extending the training to all employees who touch patients. “I tell the providers that when something bad happens, it doesn’t just affect the patient and you. Many times there are other people at your site who have an equally close relationship to that patient, and they will be affected too.”
Melinda Van Niel, project manager for MACRMI, says she hopes the Atrius Health example will encourage other outpatient practices to move toward CARe. “Then this approach would become the status quo, rather than ‘deny and defend,’ ” she says.
Primary care groups that are interested may want to start by sending a small group of staff members to one of IPEP’s workshops, says Elaine Meyer, Ph.D., the institute’s director and a clinical psychologist at Boston Children’s Hospital.
The group offers a moderated online session in disclosure and apology. It also offers in-person workshops on “difficult conversations” that are known collectively as the Program to Enhance Relational and Communication Skills, or PERCS.
For groups that want to dig deeper, Meyer adds, IPEP can always develop customized training as it did for Atrius Health.
“This was not why any of us went into medicine, to hold such difficult conversations,” Meyer adds. “This is the nightmare conversation, the one you hope to avoid. But if it happens, you definitely want to be as well prepared, capable and compassionate as possible, for the sake of our patients and our own sense of professional self-esteem.”
This article was originally published by the Betsy Lehman Center for Patient Safety. The Betsy Lehman Center for Patient Safety is a state agency that uses communications, research, and data to catalyze the efforts of providers, policymakers, and consumers working toward safer health care in Massachusetts.