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Best Practices in Transparency: Case Study 1
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Transparency Between Clinicians and Patients

Apology and Disclosure:
Advancing Transparency at the University of Michigan Health System

Founded around a medical school that opened in 1850, the University of Michigan Health System (UMHS) has long been at the cutting edge of scientific research and clinical care. In 2001, UMHS took a bold step forward in advancing patient safety by launching a novel program for responding to medical errors. The program’s cornerstone is honesty
and open communication, with a focus on balanced assessment and communication of the reasonableness of care and disclosure of any fault.

Richard Boothman, JD, chief risk officer at UMHS, describes the idea behind the Michigan Model as: “Reach out to those harmed, be honest, explain where appropriate, disclose our mistakes, and learn from our experiences.”

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Implementing the Michigan Model

Boothman began implementing the approach that became the Michigan Model soon after accepting the position as assistant general counsel at the organization. His initial forays into convening open conversations with patients about errors were not warmly embraced by all leaders within the health system and general counsel’s office. However, clinicians who had experienced Boothman’s approach were strongly supportive, and the program was formalized. “The caregivers saw that it was the right thing to do. And once they actually had permission from a lawyer, honesty came naturally for most, reminding them why they became physicians in the first place,” he says.

According to Boothman, although open communication about errors with patients and families is the thrust of the approach, the first disclosure is among the clinicians and administration within the organization. UMHS uses a number of strategies to identify possible medical errors, including patient complaints, reports from clinicians, and regular reviews of patient safety metrics. When an unanticipated outcome is identified, risk managers contact the patient and family, ensure appropriate care is provided, and facilitate open and honest dialogue. The patient and family are invited to a conversation with clinicians about the event, receive an apology when warranted, and, where indicated, are offered financial compensation when appropriate for injuries that have occurred during the provision of medical care. Data and findings related to the case are entered into the organization’s patient safety and peer review systems.

 

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The Rewards of Transparency

Although many leaders and clinicians were initially concerned that full disclosure about errors would invite more claims and larger settlements (Studdert et al. 2007), the opposite has been the case. A study of the claims and costs at UMHS found a significant reduction in both the average monthly rate of new claims and the average monthly cost for liability (Kachalia et al. 2010).

The Michigan Model has demonstrated a number of compelling, nonfinancial benefits for injured patients and their clinicians. According to Boothman, these benefits are more compelling than the monetary ones. “The financial benefits in medical malpractice claims of the Michigan Model pale in comparison to the safety and quality benefits. Specifically, the value of the resulting culture of openness transcends that of the decreased number and cost of claims.” The ability to openly discuss the specific details of a case—which is effectively stopped short with litigation—allows timely closure for all involved. Patients and families are not left wondering about the specifics of what happened. They are given an opportunity to ask questions about the events that occurred and a chance to understand, rather than guess at, the underlying causes. Clinicians have an opportunity to apologize and express their regret. Disclosure has moral benefits within the organization and beyond. “We’ve learned that when you act ethically, you tend to pull everyone up, too,” says Boothman.

Finally, full transparency with patients promotes clinical improvement by encouraging the discovery of problems so that they can be proactively addressed. “Importantly, we’ve learned what accountability feels like—and though that doesn’t always feel very good . . . that discomfort drives us and leaves us confident that we will improve our care, not just our excuses,” Boothman explains. Full transparency allows clinicians, executives, and the organization as a whole to learn from an adverse outcome and address flaws in care processes to improve the safety of future patients. The resulting culture has fueled remarkable progress in peer review and led to innovative changes in corporate structure, all toward serving a greater sense of accountability at every level.

 

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Disclosure with Patients: A Case Vignette

Boothman describes a particular anecdote to illustrate the process of disclosure with patients at UMHS.

The patient, JW, was a 36-year-old school teacher, a wife, and the mother of two young children. She initially approached her primary care physician with concern about a breast lump. Her physician discounted its importance and failed to pursue the problem with appropriate testing. When breast cancer was eventually diagnosed, the mass was removed with clear margins, but there had been a two-and-a-half-year delay in treatment.

JW underwent surgery and chemotherapy. She became depressed and felt unable to return to work, despite being deemed physically capable by her oncologist. Boothman invited JW, her attorney, and the clinicians involved to a meeting to discuss openly the details of the case, including a fair means for compensating JW for the delay in diagnosis. Among the topics discussed was the risk of recurrence.

JW had previously believed her risk was relatively high, a belief based on clinical trial statistics from the existing literature base and exaggerated by experts hired by her attorney. Hearing her concerns, a medical oncologist was able to reassure her that the often quoted statistics were primarily based on studies conducted before the current treatments were available, and that JW’s prognosis was better than she had believed. The oncologist also encouraged her to return to work, pointing out that JW had no need to avoid working and was an invaluable asset to her children and the students in her classroom.

The atmosphere in the meeting shifted with this exchange. JW shared that she regretted that she had not pressed more firmly for diagnostic testing when she first discovered the lump. According to Boothman, at that moment the breast surgeon reached out, touched her hand, and said, “Stop blaming yourself. This is on us.”

In the end, the parties agreed to a settlement chosen because it would provide for college and graduate schooling for JW’s children. The hospital also videotaped an interview with JW and promised to use it for educational purposes.

According to Boothman, what JW wanted most was not financial; it was an open conversation about her care and its flaws, a chance to ask questions and to share her own feelings of regret, and an honest apology from her clinicians. As she described her feelings about the meeting in the video recording, “I felt like I had been heard, they listened. . . . If that had been the end of the legal pursuit, that would have been fine with me. I was perfectly satisfied after that night.”44 The videotape of her story has been used within UMHS to educate clinicians, residents, and students. JW returned to work and remains a UMHS patient.

Lessons Learned:
Small Steps and Growing Comfort with Transparency

In the course of implementing the disclosure program, UMHS learned two key lessons about transparency. First, it was important for the organization to take small steps when initially moving into full disclosure. Creating a protected space within the organization to discuss errors was essential for crossing the emotional hurdle to disclosure outside the organization. Gaining confidence and experience only emboldened expansion of disclosure, which, with time, has led to true culture change.

Second, UMHS learned that the historic concerns about transparency were exaggerated. As the organization made the transition to full disclosure and open conversations with patients, clinicians and leaders found that the previously feared horrific outcomes did not materialize. “We made the difficult disclosure to ourselves when we hurt patients in preventable ways—and we discovered that it wasn’t so bad,” Boothman says. With growing comfort with disclosure, clinicians and leaders began to appreciate the benefits of transparency and were increasingly less concerned about possible negative consequences resulting from being fully honest with patients and families about errors.

 

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References

Kachalia A, Kaufman SR, Boothman R, Anderson S, Welch K, Saint S, Rogers MA. 2010. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 153(4):213–21.

Studdert DM, Mello MM, Gawande AA, Brennan TA, Wang YC. 2007. Disclosure of medical injury to patients: an improbable risk management strategy. Health Aff (Millwood). 26(1):215–26.

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