Honesty and Transparency, Indispensable to the Clinical Mission-Part I: How Tiered Professionalism Interventions Support Teamwork and Prevent Adverse Events.

At the foundation of clinical medicine is the relationship among patients, families, and health care professionals. Implicit to that social contract, professionals pledge to bring clinical excellence to advance their patients' wellness and healing-and to prevent harm. Patients trust that those privileged to deliver care will do so unwaveringly in service of patients' best interests; however, the incentives and infrastructure surrounding health care delivery can promote or undermine individual performance, teamwork, and patient safety. Modeling professionalism and identifying slips and lapses supports pursuit of high reliability. Part 1, Promoting Professionalism, introduces the first of 3 pillars of advancing the clinical mission.

Honesty and Transparency, Indispensable to the Clinical Mission-Part II: How Communication and Resolution Programs Promote Patient Safety and Trust.

When patients are harmed by health care, concerns fan out in all directions. Patients and families confront a sea of uncertainty, contending with injuries that drain them physically, emotionally, and financially. Health care professionals experience a powerful mix of emotions, but are seldom afforded the time to process what happened or the resources to relieve suffering and prevent harm. Honesty, transparency, and empathy are indispensable to a comprehensive approach that prioritizes patient and family-centered response to unintended harm, clinical improvement, and redemptive peer review. Part 2 introduces the second of three pillars for advancing the clinical mission: communication and transparency.

Honesty and Transparency, Indispensable to the Clinical Mission-Part III: How Leaders Can Prevent Burnout, Foster Wellness and Recovery, and Instill Resilience.

The hidden epidemic of burnout exacts a staggering toll on professionals and patients, reflected in increased risk of medical errors, complications, and staff turnover. For surgeons, nurses, and other team members working at the sharp end of care, adverse events can amplify work exhaustion, interpersonal disengagement, and risk of moral adversity. Visionary leaders are not content to mitigate burnout and moral injury; they elevate the human experience throughout health care by modeling wellness, fostering moral courage, promoting safety of professionals, and restoring joy in work. Part 3, Health Professional Wellness and Resilience, introduces the final pillar for advancing the clinical mission.

An Operational Framework to Study Diagnostic Errors in Emergency Departments: Findings From A Consensus Panel.

OBJECTIVE: To create an operational definition and framework to study diagnostic error in the emergency department setting. METHODS: We convened a 17-member multidisciplinary panel with expertise in general and pediatric emergency medicine, nursing, patient safety, informatics, cognitive psychology, social sciences, human factors, and risk management and a patient/caregiver advocate. We used a modified nominal group technique to develop a shared understanding to operationally define diagnostic errors in emergency care and modify the National Academies of Sciences, Engineering, and Medicine's conceptual process framework to this setting. RESULTS: The expert panel defined diagnostic errors as "a divergence from evidence-based processes that increases the risk of poor outcomes despite the availability of sufficient information to provide a timely and accurate explanation of the patient's health problem(s)." Diagnostic processes include tasks related to (a) acuity recognition, information and synthesis, evaluation coordination, and (b) communication with patients/caregivers and other diagnostic team members. The expert panel also modified the National Academies of Sciences, Engineering, and Medicine's diagnostic process framework to incorporate influence of mode of arrival, triage level, and interventions during emergency care and underscored the importance of outcome feedback to emergency department providers to promote learning and improvement related to diagnosis. CONCLUSIONS: The proposed operational definition and modified diagnostic process framework can potentially inform the development of measurement tools and strategies to study the epidemiology and interventions to improve emergency care diagnosis.

Medical error professionals' perspectives on Inter-system Medical Error Discovery (IMED): Consensus, divergence, and uncertainty.

Best practices for how to respond are unclear when a medical error is discovered in a different system (inter-system medical error discovery or IMED). This qualitative study explored medical error professionals' views on disclosure, feedback, and reporting in these scenarios.We conducted semi-structured telephone interviews from January to September 2018 with 15 medical error professionals from 5 regions of the United States. Interview guides addressed perspectives on best practice, minimum obligations, and mediating factors with respect to IMED. Each transcript was coded independently by two investigators. Analysis followed the inductive approach of interpretive description.Medical error professionals expressed diverse views about minimum obligations and best practices for physicians when responding to IMED events. All cited practical barriers to disclosure, feedback, and reporting in these scenarios. There was general consensus that clear-cut, harmful errors should be disclosed to patients, and most advised investigation and feedback prior to disclosure. Respondents diverged in recommended best practices and thresholds for taking action. All noted the lack of guidance specific to IMED scenarios but differed in how they would extrapolate from more general guidance.While medical error professionals expressed consensus regarding obligations to disclose obvious errors, they differed on particulars. Guidelines or an algorithm could be very useful. Efforts to develop clear guidelines for IMED must take into account these factors, as well as practical and political challenges to communication about errors discovered across systems.

A Modified Communication and Optimal Resolution Program for Intersystem Medical Error Discovery: Protocol for an Implementation Study.

BACKGROUND: Preventable medical errors represent a major public health problem. To prevent future errors, improve disclosure, and mitigate malpractice risks, organizations have adopted strategies for transparent communication and emphasized quality improvement through peer review. These principles are incorporated into the Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR) Toolkit, which facilitates (1) transparent communication, (2) error prevention, and (3) achieving optimal resolution with patients and families; however, how medical errors should be addressed when they are discovered between systems-intersystem medical error discovery (IMED)-remains unclear. Without mechanisms for disclosure and feedback on the part of the discovering provider, uncertainty remains as to the extent to which IMED is communicated with patients or responsible providers. Furthermore, known barriers to disclosure and reporting one's own error may not be relevant or may be replaced by other unknown barriers when considering scenarios of IMED. OBJECTIVE: This study aims to develop and test implementation of a modified CANDOR process for application to IMED scenarios. METHODS: We plan a series of studies following an implementation framework. First, we plan a participatory, consensus-building stakeholder panel process to develop the modified CANDOR process. We will then conduct a robust preimplementation analysis to identify determinants of implementation of the modified process. Using the Consolidated Framework for Implementation Research as a theoretical framework, we will assess organizational readiness by key informant interviews and individual-level behaviors by a survey. Findings from this analysis will inform the implementation toolkit that will be developed and pilot-tested at 2 cancer centers, sites where IMED is hypothesized to occur more frequently than other settings. We will measure 5 implementation outcomes (acceptability, appropriateness, reach, adoption, and feasibility) using a combination of key informant interviews and surveys over the pre- and postimplementation phases. RESULTS: This protocol was funded in August 2018 with support from the AHRQ. The University of Michigan Medical School Institutional Review Board has reviewed and approved the scope of activities described. As of April 2019, step 1 of aim 1 is underway, and aim 1 is projected to be completed by April 2020. Data collection is projected to begin in January 2020 for aim 2 and in August 2020 for aim 3. CONCLUSIONS: Providing a communication and resolution strategy applicable to IMED scenarios will help address the current blind spot in the patient safety movement. This work will provide important insights into the potential utility of an implementation toolkit to improve transparent communication and optimal resolution of IMED scenarios. The natural progression of this work will be to test the toolkit more broadly, understand the feasibility and barriers of implementation on a broader scale, and pilot the implementation in new organizations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13396.

Communication-and-resolution programs: the challenges and lessons learned from six early adopters.

In communication-and-resolution programs (CRPs), health systems and liability insurers encourage the disclosure of unanticipated care outcomes to affected patients and proactively seek resolutions, including offering an apology, an explanation, and, where appropriate, reimbursement or compensation. Anecdotal reports from the University of Michigan Health System and other early adopters of CRPs suggest that these programs can substantially reduce liability costs and improve patient safety. But little is known about how these early programs achieved success. We studied six CRPs to identify the major challenges in and lessons learned from implementing these initiatives. The CRP participants we interviewed identified several factors that contributed to their programs' success, including the presence of a strong institutional champion, investing in building and marketing the program to skeptical clinicians, and making it clear that the results of such transformative change will take time. Many of the early CRP adopters we interviewed expressed support for broader experimentation with these programs even in settings that differ from their own, such as systems that do not own and control their liability insurer, and in states without strong tort reforms.

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation.

CONTEXT: The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. METHODS: Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. FINDINGS: We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. CONCLUSIONS: Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.

Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions.

In mid-2001 and early 2002, the University of Michigan Health System systematically changed the way it responded to patient injuries and medical malpractice claims. Michigan adopted a proactive, principle-based approach, described as an "open disclosure with offer" model, built on a commitment to honesty and transparency. Implementation was followed by steady reduction in the number of claims and various other metrics, such as elapsed time for processing claims, defense costs, and average settlement amounts. Though the model continues to evolve, it has retained its core components and the culture it nurtured while spurring other initiatives such as a unique approach to peer review. In this article we review our experience, identify the essential practical components of our model, offer suggestions for tailoring the approach to other settings, and present some thoughts as to the future of this approach.

Trainees' perceptions of patient safety practices: recounting failures of supervision.

BACKGROUND: Ensuring that trainees receive appropriate clinical supervision is one proven method for improving patient safety outcomes. Yet, supervision is difficult to monitor, even more so during advanced levels of training. The manner in which trainees' perceived failures of supervision influenced patient safety practices across disciplines and various levels of training was investigated. METHODS: A brief, open-ended questionnaire, administered to 334 newly hired interns, residents, and fellows, asked for descriptions of situations in which they witnessed a failure of supervision and their corresponding response. RESULTS: Of the 265 trainees completing the survey, 73 (27.5%) indicated having witnessed a failure of supervision. The analysis of these responses revealed three types of supervision failures-monitoring, guidance, and feedback. The necessity of adequate supervision and its accompanying consequences were also highlighted in the participants responses. CONCLUSIONS: The findings of this study identify two primary sources of failures of supervision: supervisors' failure to respond to trainees' seeking of guidance or clinical support and trainees' failure to seek such support. The findings suggest that the learning environment's influence was sufficient to cause trainees to value their appearance to superiors more than safe patient care, suggesting that trainees' feelings may supersede patients' needs and jeopardize optimal treatment. The literature on the impact of disruptive behavior on patient care may also improve understanding of how intimidating and abusive behavior stifles effective communication and trainees' ability to provide optimal patient care. Improved supervision and communication within the medical hierarchy should not only create more productive learning environments but also improve patient safety.

Mainstreaming risk management education into new resident and fellow orientation.

INTRODUCTION: Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety. METHODS: DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey. RESULTS: Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution. CONCLUSION: Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.

Integrating risk management activities into a patient safety program.

A departmental culture that encourages continuous quality care and honest, critical introspection is pivotal to patient safety. Risk management enriches departmental quality efforts, providing evidence-based direction and flag vulnerabilities. Quality leaders should establish a close relationship with risk management, be aware of the risk management resources available, and communicate clear expectations for staff and risk management personnel for the collection and use of information acquired by risk management relating to near misses, unexpected outcomes, and medical errors. Integrating risk management resources into department-wide patient safety program can result in higher quality patient care, safer departmental staff, and lower risk.

A better approach to medical malpractice claims? The University of Michigan experience.

The root causes of medical malpractice claims are deeper and closer to home than most in the medical community care to admit. The University of Michigan Health System's experience suggests that a response by the medical community more directly aimed at what drives patients to call lawyers would more effectively reduce claims, without compromising meritorious defenses. More importantly, honest assessments of medical care give rise to clinical improvements that reduce patient injuries. Using a true case example, this article compares the traditional approach to claims with what is being done at the University of Michigan. The case example illustrates how an honest, principle-driven approach to claims is better for all those involved-the patient, the healthcare providers, the institution, future patients, and even the lawyers.