by Emily Paulsen

Part II 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.

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Hospital Impact published the first part of our conversation with Boothman last week.

How can other healthcare organizations replicate the success you've seen at University of Michigan?

RB: You have to have a way of capturing the incidents, and you have to have a way of assessing the incidents. You also have to have a means to communicate both to the patient and your staff. Finally, you have to find a way to measure these things--you have to have accountability. There are different ways of providing each of those things, but if you satisfy each of those elements my belief is that our model is transportable anywhere.

Can a small hospital change its approach to claims?

RB: In many ways it's even more important for small hospitals. Large institutions can absorb the hits easier than a small hospital, so a proactive approach for a smaller hospital with fewer resources it is even more important and smarter.

If I were thinking about starting a program at a small hospital, I'd take those three principles [capturing, assessing and communicating] and I'd ask the board of trustees or the board of directors, "Can you argue with any of those three?" Because once you get agreement on any of those things, I think everything falls into place.

How could a private-practice physician put this into practice?

RB: That's a great question. If I were a doctor in group practice, one of the first things I would do before any crisis was confronting me is to sit down with a defense lawyer who is sophisticated in medical malpractice issues. I would say, "It's a new day, we're going to do things differently. Are you comfortable with this or not?"

I would say to them, "I take my relationships with my patients very seriously I need help in identifying ways that I can improve, and I need help if I do find myself in a crisis situation navigating the insurance waters, the relationship with the hospital and even just as a sounding board so I don't react one way or another irrationally."

Because no matter how socially mature physicians may be when they're involved in a malpractice claim, they may not always make the best choices. They may get defensive, they may do a mea culpa, and they have to make sure that that's the correct response.
I would arrange to have those [legal] support services just like you would an accountant.

Are there medical malpractice policies that would prevent this approach to claims?

RB: To be honest, I think that's an urban myth. I've reviewed hundreds of insurance policies in my career, and I've never seen [a policy that prevents this approach]. It is widely believed that if something bad happens and the doctor talks honestly to the patient, that that physician could endanger his or her insurance and yet I've never seen that in an insurance policy. I happen to think that would be against public policy and not even enforceable. But when the perception becomes reality and when the doctor believes they're going to get canceled from their insurance simply for talking to their patients within the scope of a physician-patient relationship, that's a pretty powerful fear that chills them and stops from doing the right thing.

What factors make this program most successful?

RB: I don't think they're ultimately necessary but there are two factors that definitely made it easier for me. At the University of Michigan Medical Center, we have a captive medical staff. At least 80 percent of our claims involve just University of Michigan. It's a lot easier with the alignment of the institution and the physicians financially and ethics-wise to be able to do this.

The second thing is by far the most important, and that's our captive insurance program. Our captive insurance program is very sound financially, and the state of Michigan stands behind the doctors and the institution. [Damage awards in a lawsuit are] never going to reach a doctor's personal finances.

[Because of the captive insurance program] I have the luxury of being able to say to our medical staff, "You may be and should be professionally accountable for what happened and we'll put you through peer review, but you don't have to worry about personal financial ruin just because you made a mistake."

I think it's unreasonable that we ask [healthcare professionals] to do such dangerous things all the time and then penalize them with total financial ruin--or at least the prospect of that--if they make a mistake. That's not fair. I think it's expecting too much, for instance, to expect an obstetrician who is looking at a neurologically devastated baby to walk into room and say, "I could have done better," knowing that by saying that he or she may be sealing his or her own financial fate.

So for all of our sakes, we need to find a way to make [healthcare professionals] reasonably safe--that's not to say unaccountable--to be able to do this.

What else should people know going into this?

RB: If you just sit down and figure this out intellectually, this makes a heck of a lot more sense than running away from these problems all the time. I think the only advice I would give is to swallow the fear, get past it, and do not only the right thing but the smart thing.