Gut Check: University of Michigan's Medical Error Disclosure Program

We're all familiar with the story of George Washington and the cherry tree that gave rise to the famous line, "I cannot tell a lie, father, you know I cannot tell a lie!"

What motivated him to tell the truth? Was it some sort of rumbling gut feeling that told him that it was the right thing to do? Probably the same motivating forces that led the University of Michigan Health System (UMHS) to transition to a medical error disclosure program that is fully integrated with the hospital's quality improvement and patient safety efforts in 2001.

Unfortunately, our health care world today is one in which we don't follow George Washington's leadership. Medical malpractice is guided by a "deny and defend" approach. Insurers and counsels often urge secrecy, dispute fault, deflect responsibility, and make it as slow and expensive as possible for patients to continue the already unfavorable process. As a result of this approach, it's not uncommon for medical lawsuits to take five or more years to resolve. Information about the cause of injuries is also denied to patients and families for long periods of time; and compensation is unavailable to those who most need it. Worst of all, there is little meaningful quality feedback for providers. Patients and providers are placed in adversarial positions, allowing fear to fester in between.

Turning the current, "deny and defend" approach to medical liability on its head, the current system at UMHS emphasizes full honesty and transparency between staff and patients and encourages the participation of risk management, regardless if a medical error is involved. At UMHS medical errors are identified and collected by all staff, patients, and family members. Experienced risk managers with a clinical background investigate the claims, and care quality is evaluated. The system's three guiding principles are:

1. Compensate quickly and fairly when unreasonable medical care causes injury.

2. Defend medically reasonable care vigorously.

3. Reduce patient injuries (and therefore claims) by learning from patient's experiences

Most importantly, conclusions of the investigation are shared.



We were fortunate to have Rick Boothman, UMHS Chief Risk Officer, join the University of Michigan's IHI Open School for our first Monthly Speaker Series event of the year to discuss UMHS's medical error disclosure program. Boothman's presentation was focused on the underlying principles of quality improvement that help inform the disclosure program.

Boothman's extensive experience as a trial lawyer has given him a strong and intuitive sense about cases that he can almost accurately predict if he can win a case. But, he does what he refers to as a "gut check." Would he accept this kind of care for his own mother?

The undercurrent of quality improvement has led to some great results. As reported in the Annals of Internal Medicine in a paper written by Allen Kachalia et. al., with implementation of UMHS's disclosure-with-offer program, the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. The average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters. The median time from claim reporting to resolution decreased from 1.36 to 0.95 years. Average monthly cost rates decreased for total liability, patient compensation, and non-compensation-related legal costs.

A system that makes patients and physicians happier...and saves money at the same time? My gut is telling me that this is a system that we should take a look at.

Being Honest: Ducking Out from Under the Table

My adorable dog, May, has her flaws. Her bark and temper are infamous in our neighborhood. If the toy is not made of rubber, it will become an unrecognizable ball of mush within days. However, when it comes to going out to do her business, May almost never has accidents. On those rare occasions she makes a mistake, she slowly greets us with her head ducked down rather than her normal energy-filled charge when we arrive home.

We understand why these accidents happen. Most medical errors, as discussed in the IOM report, To Err is Human, are a result of poorly designed systems that do not give providers the best chance possible to care for patients in the way that they would like. May's accidents are also systems error. We only find a pool of pee in the house when we leave for a long period of time without allowing her to go out before we leave. May was not being negligent or purposefully filthy; the system she lives in simply does not allow her to successfully avoid these accidents. With these system constraints in mind, we do not blame her, but continue to work on scheduling improvements to prevent future occurrences.



Clinicians never want to intentionally harm their patients and are often emotionally impacted by a mistake. Similarly, as far as we can tell, May deeply regrets her accidents. Since she cannot use words to express her regret, she hides under the dining table and avoids eye contact as we clean up the mess until we say, "It's okay, May." Sometimes, she will even circle the "biohazard" zone slowly, as if admonishing herself. May's actions demonstrate her acknowledgment of the accident and we accept her apology--a courteous exchange that occurs between people all the time.

Medical malpractice is one of the few bipartisan goals of the current health reform battle. However, how to reform this messy process that is hard on all participants (physicians, hospitals, patients and families, and insurers) emotionally and financially is not as clear. Focusing on how to minimize costly lawsuits through caps on financial damages awarded to patients further complicates the fundamental courtesies that should occur when a mistake happens: acknowledgment, understanding, acceptance, and forgiveness.

In a paper published in the NEJM in 2006, then Senators Hilary Clinton and Barack Obama discuss how to improve patient safety and the medical liability climate through open communication between physicians and patients. The paper cites that the most important factor in people's decisions to file lawsuits is not negligence, but ineffective communication between patients and providers: lawsuits occur when "unexpected adverse outcomes are met with a lack of empathy from physicians and a perceived or actual withholding of essential information."



For those of you who are Grey's Anatomy fans (click here to read a Grey's Anatomy Obsession confessional), episode 13 of season 6 titled, "State of Love and Trust," touches specifically on medical liability reform and being honest with patients. A patient, later discovered to have a form of cytochrome P450 that unexpectedly allows her to metabolize anesthesia faster than normal, wakes up from anesthesiology in the middle of her bowel surgery and is traumatized by the violence of surgery and the panicked yelling from the surgical team. Emotionally disturbed by the experience, the patient wishes to press charges against the hospital. Dr. Shepherd, interim Chief of Surgery, is deep in thought about the threat of a lawsuit on his first day as Chief, when Dr. Miranda Bailey talks to him about open communication between physicians and patients in situations of medical error (see clip above). By apologizing to the patient, Dr. Shepherd is acknowledging the mistake and the patient's concerns, is providing the patient with the opportunity to understand and accept the mistake, and is working with the patient to reach an agreement that allows both sides to accept the mistake and attempt to reach forgiveness.

As then Senators Clinton and Obama explain in the paper, open communication allows for improvements in patient safety. The proposed National Medical Error Disclosure and Compensation (MEDiC) Bill was based on model disclosure programs such as those in place at the University of Michigan Health System (Go Blue!) and the Veterans Affairs system. These programs have given both patients and physicians protection while successfully reducing administrative and legal costs for providers, insurers, and hospitals. Surveys from these successful programs have also showed greater trust in and satisfaction with health care providers. On the cost side, the disclosure programs have resulted in the filing of fewer malpractice suits, a reduction in litigation costs, accelerated provision of compensation to patients, and increases in the numbers of patients who are compensated.

It is a remarkable feat that the University of Michigan Health System has reduced litigation costs from $3 million to $1 million in four years with its disclosure program. Though isn't it ironic that at the heart of the solution to such a complex problem are the basic principles of being honest and communicating openly with patients?

Telling patients the truth at times may be harder, but it is the most respectful thing to do. My dog, May, would bark in agreement.