Disclosure and Resolution Programs Exciting Developments, Challenging Barriers

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Slide 1

Disclosure and Resolution Programs
Exciting Developments, Challenging Barriers

Thomas H. Gallagher, MD
Professor of Medicine, Bioethics & Humanities
University of Washington
On behalf of IL, WA, TX, NY, and Ascension AHRQ PSLR
Demonstration Projects and MA planning grant

Slide 2

Background

• Major focus in last decade on disclosing unanticipated outcomes to patients.
• Following unanticipated outcomes, organizations still struggle to:
  • Communicate effectively with the patient.
  • Learn from what happened.
  • Provide fast, fair financial and non-financial resolution for patients.

Slide 3

Image: A cartoon shows a doctor in medical scrubs with a guitar singing to a group of people in a waiting room. The caption reads, "Listen up, my fine people, and I'll sing you a song 'bout a brave neurosurgeon who done something wrong."

Slide 4

Quality of Actual Disclosures

• COPIC-large Colorado malpractice insurer.
• 3Rs (Recognize, Respond, Resolve) program for disclosure and compensation, 2007-2009:
  • 837 Events.
  • 445 patient surveys (55% response rate).
  • 705 physician surveys (84% response rate).

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What is the DRP?

• Be candid and transparent about unanticipated care outcomes.
• Conduct a rapid investigation, offer a full explanation, and apologize as appropriate.
• Where appropriate, provide for the family's financial needs without requiring recourse to litigation.
• Build systematic patient safety analysis and improvement into risk management.

Slide 6

AHRQ Grants with DRP Component

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DRP Goals

• Facilitate communication about unanticipated care outcomes (disclosure and reporting).
• Attend to the emotional needs of patients, families, and providers.
• Create mechanisms for providers, insurers, and others to collaborate around communication, event analysis, and resolution.

Slide 8

DRP Process

• Care team responds to immediate patient needs and provides information then known.
• Involved staff reports SE to Risk Manager.

• Initiates QI investigation using Just Culture approach.
• Initiates support services for patient/family.
• Initiates disclosure coaching and other support services for health care team.
• Contacts other Partners to explain SE and steps taken and initiate collaboration.

Partners collaborate on approach to evaluation and resolution.

Partners agree on approach to resolution:

• What are the patient's/family's needs?
• Will monetary compensation or other remedies be offered?
• What will be disclosed to patient/family?
• How will identified system improvements be pursued?

Patient/family is notified of findings and approach to resolution:

• Full explanation of what happened.
• Apology as appropriate.
• Offer of compensation and/or other remedies, or explanation of why no offer is being made.
• Information about any safety improvements.

Image: A chart shows the DRP process:

• Study Event (SE) →
• Action by Facility Risk Managers →
  • Physicians Insurance.
  • Other Insurer.
  • Facility Insurer →
• Expedited Care Assessment and Review of Event (CARE) →
• Joint Approach to Resolution →
• Patient/Family Communication.

Slide 9

The DRP is not:

• A rush to judgment.
• A rush to settlement.
• Mandatory.
• Telling the patient absolutely everything known about an adverse event.
• Paying patients when care was reasonable.
• Business as usual.

Slide 10

Potential DRP metrics

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Exciting Developments

• IRB approvals secured.
• Successful collaborations among diverse stakeholders:
  • DRP as mechanism to improve response to injury that triggers less concern about "tort reform."
• Growing interest in expanding DRP model at state, institutional level.
• Recognition of DRPs potential for significant cost savings for payers.
• Rising awareness of need for reform at NPDB, state medical board level:
  • Broader implementation of Just Culture concepts.

Slide 12

Policy/Legal Barriers

• NPDB.
• State medical boards.
• QI protection.

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Implementation Barriers

• Reaching consensus on what events qualify for DRP.
• Overcoming mistrust
  • Within healthcare stakeholders:
    • MD: Is DRP in my best interest? Why be proactive if claim may never materialize?
    • Malpractice insurers: What cases benefit most from DRP?
    • Healthcare institutions: Is DRP "inviting claims"?
  • Outside healthcare: "fox guarding the hen house."
• Bandwidth challenges for front-line personnel tasked with DRP implementation.

Slide 14

Scientific Barriers

• Time horizon problems.
• Small numbers problem.
• Uneven implementation across sites.

Slide 15

Next steps

• Exploring options for extending data collection.
• Ongoing work disseminating DRP models to additional states, institutions.
• Continued work on related areas in demonstration projects:
  • Judge-directed negotiation.
  • Patient compensation cards.
  • Expanding patient engagement in response to injury.