Hospitals Accept Responsibility for Patient Harm and How to Resolve It

Much of the time, when a patient experiences medical harm, the ensuing conversation and activity is focused on malpractice liability. But, finally, a common-sense ethical notion seems to be taking hold: patients who suffer harm deserve to be informed promptly, and measures need to be taken to prevent that harm from being repeated.

We’ve previously addressed the fact that mistakes happen, and that acknowledgment and accountability go a long way toward repairing the harm. A program at the University of Illinois Hospital and Health Sciences System (UIHHSS) that relies on communication, disclosure and financial remediation has been doing just that.

A commentary by Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality (AHRQ) was posted recently by the Institute of Medicine. It describes “Seven Pillars,” the model embraced by the UIHHSS.

A full-disclosure policy adopted by the University of Michigan Health System in 2001, Clancy writes, is credited with reducing costs for each claim by half, and 98 in 100 of the system’s faculty physicians approved of it. The Seven Pillars process was adopted five years later by the UIHHSS, but still is considered unusual because it doesn’t rely as heavily on the medical liability system to resolve patient harm as other institutions.

Seven Pillars focuses on transparency to eliminate patient harm and learn from patient safety events. The pillars are:

1. patient safety incident reporting;
2. investigation;
3. communication and disclosure;
4. apology and remediation, including waivers of hospital and professional fees;
5. system process and performance improvement;
6. data tracking and performance evaluation; and
7. education and training.

In two years at the UIHHSS, the process generated more than 2,000 incident reports, prompted more than 100 investigations and claimed nearly 200 specific improvements. It has served as the basis for more than 100 disclosure conversations and 20 full disclosures of inappropriate or unreasonable care that caused patient harm.

To find out if similar programs would work outside of the contained environment of an academic medical center, the AHRQ is funding a three-year demonstration project in 10 diverse, private, insured Chicago-area hospitals. Five are implementing Seven Pillars and five serve as a control group.

Preliminary data from the intervention hospitals show an increase in incident reporting and disclosures from physicians and residents, even in early settlement offers. One hospital reported a significant decrease in serious safety events and open claims within 18 months. When hospitals identify incidents of inappropriate care, hospital and physician fees are waived.

Final results won’t be available for a year, but the progress so far is notable. Even better, several other states are pondering how to implement elements of the Seven Pillars process.

“From AHRQ’s perspective,” Clancy writes, “Seven Pillars incorporates much of what we believe is paramount to lasting gains in patient safety and quality improvement. First and foremost, it seeks to prevent patient harm by reporting-and correcting-flaws in processes that can undercut the work of the most dedicated clinicians. Second, the environment fostered by communication and disclosure builds respect and trust, which figure prominently in the well-being of patients and physicians. That trust is enhanced by substantial involvement of patient advocates in designing the study. Third, the Seven Pillars process establishes and reinforces a culture of learning, especially among medical residents who previously have had few opportunities to identify and learn from patient safety events.”

Slowly but surely medical providers are starting to understand and accept that patient safety is paramount and that the best practice in resolving adverse events in patient care is not avoidance and silence, but, in fact, the opposite.

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