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The philosophy behind Michigan's 'I'm Sorry' program

February 4th, 2010

by Emily Paulsen

Part I of a two-part series

Since taking over as chief risk officer at the University of Michigan in 2002, Richard Boothman has gained national recognition for transforming how the institution responds to medical errors and malpractice claims. Two simple words are at the heart of the shift: "I'm sorry."

By apologizing to patients when a medical error takes place, the organization has cut its malpractice insurance cash reserves by a whopping 81 percent--down to $13 million from more than $70 million. Now, instead of engaging in a courtroom battle, physicians and hospital leaders discuss errors promptly after they occur, engaging in a constructive conversation with patients that identifies and compensates errors and ultimately leads to improvements in patient care, he says.

"If we make a mistake, we'll move quickly to apologize and compensate that patient," Boothman recently told CNN. "But if we didn't make a mistake, we talk to the patient and explain."

Of course, the hospital's physicians are well-insured.

"I've the luxury of saying to our physicians, no matter how big a case is, how bad a case is, 'You're completely insured and your personal assets are not at stake,'" he told CNN. You can't ask them to be totally honest when they have such things at stake."

Hospital Impact recently talked with Boothman about his program. Here's an excerpt of our conversation:

[More:]

What is the philosophy behind the University of Michigan program?

RB: It started with a change in mindset that said we own these issues, we will control the flow, and it is really our choice whether we end up in a courtroom. What an irony it is that the healthcare community can castigate the legal community but then turn entirely to the legal community for direction on whether or not they made a medical mistake.

The truth is, [health professionals] know the difference between a medical mistake and reasonable care with a bad outcome. We don't need lawyers and a court room to tell us when we made a mistake. The University of Michigan program is based on three principles, which are pretty simple:

* If we have injured somebody through unreasonable medical care, we owe them quick and fair compensation.

* If the care was reasonable or did not adversely affect the outcome, we owe our staff full support. That may mean doing our best to avoid litigation by reasoning with the patient and the lawyer. It may mean a vigorous defense.

* The last, but the most important of the three, is that we need to hard-wire quality improvement immediately, strike while the iron is hot, and not wait until litigation was over in a given case.

That last principle was in some ways the hardest. The healthcare community has been hearing from lawyers for decades not to talk about things, and the reason a lawyer is trained to defend a case. The last thing a lawyer wants is for a stray comment to hurt his or her case. But on the grand landscape of things by not talking about what happened we're stunting quality improvement activities right and left for fear of hurting one case.

The bigger issue is being safe and having higher quality patient care.

How does your process work?

RB: It's fairly simple. We start with a catchment device. We've sold the institution on the value of early reporting by whatever method it comes to us--whether it's a phone call or peer review and evidence-based screening of performance or patient complaints.

All of these flow to the second component which is an assessment component. Physicians and nurses work in an inherently dangerous world where there are no guarantees even if they do everything reasonably. So that's a real challenge, and that's one of the reasons why we got to the point where we're at with deny and defend being the most prevalent response to patient injury.

Next, you need a protection component for your staff. It's not fair to ask surgeons and other healthcare providers to do the things we ask them to do, but hold total personal financial ruin over their heads if things go badly.

Then you need a communications component. It's human nature to run from uncomfortable situations and that tendency is even more prevalent in healthcare providers. As a group these are people who have been self-selected for finding meaning in helping other people. So when things go badly it's my belief that they feel it even more profoundly than the general public. Fear is also an enormous inhibitor. So I believe that any successful system is going to have some mechanism, some resource to help with that communication to overcome the natural inhibition to talk with angry people or hurt people.

You also need a measurement component so you have to have a way of knowing where the problems are and if they are a trend or represent a system-wide problem. [You also need] a way of knowing if you're making any difference afterward.

And lastly, you need accountability . The institution needs to say we own this problem, we will compensate when we've made a mistake, and we'll see to it that we'll fix it if something goes bad.

So those are really the pieces of what we've put in place here, but it all started with that mindset change. Instead of seeing ourselves as the victim of lawyers and the legal system, we saw ourselves as complicit in the problem and yet holding--at least in most cases--the fix in our hands.

How did you put the system in place?

RB: One of the very first things that I did after I got the agreement on the three principles was to alter the existing claims management architecture.

When I came here we had a medical committee involved, but the medical committee got the case literally on the eve of trial. We moved that up in time as early as we could. Our goal now is to get events through that medical committee after a full investigation no more than 3 months after the event. Most of them are getting there within a month or two.

We changed the makeup and nature of the committee too. It had been comprised of 6 members who saw themselves as part of a litigation team. It is now comprised of 22 health caregivers, including nursing and administration, and it is now my touchstone that gives me direction. I ask two questions of them: Was the care reasonable and did it adversely affect the outcome?

So we've basically fast-forwarded that whole process and taken control over the collection of information and assessment of whether we made a mistake. So now when we've had a bad outcome--either we picked up on it ourselves or the patient has made a complaint or in a very minority of cases now lawyers have come to us--the difference is now that we feel we can control what happens after that.

It's up to us to analyze the situation, take a hard and honest look at the medicine. And if we feel that we were reasonable, and we feel that we didn't do something incorrectly in the patient's care, then we take as much time as we need to disclose and discuss that with the patient. But we pretty much hold the line.

I'm often saying to patients I don't think your problem is compensable and here's why, but I want to look at listen to them also because I'm not doing my staff any favors when I'm submitting them to litigation when it's a case we should resolve. So it's very interactive, it's not a one-shot conversation. The truth is it's continuation of what is a very interactive relationship before the medical care was rendered.

So it's an extension of the dialog that goes on between the patient and the healthcare system throughout the care process?

RB: Absolutely. In our experience in getting involved after the fact has only highlighted the absolute importance of informed consent and a good solid dialog before the medical care was rendered.

There's a whole category of people who accept bad results without feeling the need to go to a lawyer, and when you look at the difference between [those who go for litigation and those who don't] the one thing that you find most prevalent is the failure of communication before the mistake or before the bad outcome.

This has caused us to push our physicians and nurses on the value of getting on the same page with patients before anything bad happens. Because we know that the public is a lot more forgiving than we ever believed. And if you sat down and said to them, "You know what I'm going to do the best I can, but here are some of my concerns. It doesn't happen very often, but if it happens, I'll be with you to deal with the consequences." Most of the time the patients who are participants in that kind of relationship wouldn't even think to sue you. They see you as a partner in their care.

With the fragmentation of medicine and super specialization--when you go in for a colonoscopy you'll be lucky if you spend 5 minutes with the guy or the woman performs the procedure--the challenge of achieving that kind of relationship is even greater, but it's so important, perhaps more important than our response after a bad outcome.

What have been the benefits of your "I'm sorry" program?

RB: We do surveys on patient safety culture and we have seen a steady, steady rise in the acceptance in our healthcare community here of the notion that everyone is responsible for delivering safe care. I really believe that we have turned the conversation away from the fear of litigation to understanding that it's not about claims at all, it's about being the best caregiver you can be. I think that our institution now believes that we'll handle our claims in an ethical way, but more importantly we'll learn from it. I think the first and most important benefit is the change in mood here and I have seen a remarkable change in the 8 years we've done this.

We also have an arm's-length list of clinical improvements that find their genesis directly with claims. We've made some large organizational changes like rolling out pulse oximetry across all of our hospitals or developing a pulmonary embolism screening tool after we had a missed diagnosis. So we have a long list of clinical improvements directly related to our work up of claims.

We have also seen lots of savings financially in terms of our defense dollars. Some I can take credit for and some I can't. But I can say that we have had no catastrophes as a result of being open and honest, and that's almost as important as being able to attribute our drop in claims to this approach. Everybody is so fearful of talking to a patient when things go bad and it's great to be able to say this has been an incredibly rewarding experience for us.

Have there been unexpected consequences of this approach?

RB: I've seen some things I never thought I would see. Our institution has paid on three claims that were clearly barred by the statute of limitations. We felt that principles can't be bound by expedience, and these were clear errors that should not have happened. These patients missed an arbitrary legal cut off but that was not going to stop us from serious compensation. All three cases were brought to our attention by our staff members. It was important for us to demonstrate to our staff that when we said we were principled, we were principled all the time.

The other thing we've seen is natural manifestations of this approach that you would not see in a defend-and-deny environment. Because we're uninhibited about talking about these things here, we were able to create a video about a bad outcome that could have happened at any academic medical center in the country, but it shouldn't have happened.

The video tracks a pediatric trauma patient, a 15-year-old patient who had been involved in a rollover car accident. It tracks the course of his care here with commentary from our own healthcare staff pointing out how things were heading in the wrong direction for this or that reason. We even had the surgical intern commenting on how fearful he was of asking for help when he knew he needed help because he was afraid in a very hierarchal [residency] environment.

That video is such an agent for change you can't believe it. We've shown it over a hundred times. Mixed units of doctors and nurses are watching it together and the discussion and the action lists that come out of those discussions are just stunning. I never thought I'd see that. It's a tool that couldn't come out of a defensive environment.

What was the most difficult part of implementing this program?

RB: I don't mean to minimize it but none of this was that hard. The people who dedicate their lives to healthcare are by and large unbelievable people. I am humbled everyday by what they do and how they choose to spend their lives. Disclosure is about as natural as these healthcare providers as falling off a log.

When people talk about disclosure, the first disclosure that so important is not to the patient. It's to yourself. It's the realization that the medicine you just gave that child caused the injury or the little flip in surgery was a big deal or the little oversight made a difference. That's the hardest disclosure. Once they make that disclosure, it's the next one the one to the patient that we can help with. We need to make it safe for them to make that first disclosure, and we need to help them with some expertise to make the second one.

All it took really was two things. We just have to make it safe for them, and we have to give them permission.

(Part II of this interview will publish next week and will focus on how other healthcare organizations and physician practices can replicate the program.)

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