From the Disputing Blog of Karl Bayer, Victoria VanBuren, and Holly Hayes.
The May/June edition of the Physician Executive Journal (PEJ) provides a
step-by-step approach for reporting adverse events to patients. The seven-step
approach is based on principles used in the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health.
A summary of each of the seven steps recommended include:
Step 1: Information gathering
Prior to any meeting with the patient or family, it’s critical to gather as much information about the serious event as possible. A thorough investigation and review of the incident should be conducted in collaboration with risk management.
Step 2: Identify stakeholders
The next step is to identify those individuals who will participate in the meeting. We want to get the right people to the table. It is likely that there will be two or three members of the family present at the meeting, including the patient.
The number of hospital representatives at the meeting should not significantly exceed the patient and his/her family. This may create the perception of a power differential and possibly be perceived as “bully” tactics.
The meeting should generally not include legal representation from the patient and his/her family because the discussion is designed to be informational in nature. In addition, cases that meet the definition of a serious event do not necessarily meet the legal definition of malpractice.
Step 3: Communicating the goal
The meeting should start with introductions by all of the participants and the role and responsibilities of the staff… (and) should state the purpose of the meeting:
“Our mission is to provide the highest quality of care to all of our patients. We take this very seriously. If we have an outcome that is not optimal, then we look very carefully at the care that we provided, and ask ourselves if we could have done better. In this case, there was a complication during the hospitalization. We looked into our processes with a multidisciplinary team. We believe that there may have been measures we could have taken to maximize the chances of success. When we believe this may be the case, we report these events to the state and meet with the family to discuss any mutual concerns.”
Step 4: Active listening
After the problem has been identified, the next step is to ascertain the self-interests or concerns of the patient and/or family. The Chief Medical Officer/Vice President of Medical Affairs (CMO/VPMA) should express a sincere interest in wanting to hear about their perceptions of the care rendered. This will require active listening.
The family may be angry, confused, or sad. This is the opportunity for them to express their concerns and vent some of their frustrations. This may be difficult for the physician to hear, but all of the staff must be active listeners and demonstrate empathy and concern for the patient’s self-interests. The initial goal is for the family to build confidence in those around the table. The CMO/VPMA must create a “safe zone” for the family that allows them to express themselves without reprisal.
Step 5: Seeking agreement
At this stage, the CMO/VPMA should start to elicit areas of agreement. The family should be asked if there were positive experiences about the care rendered. Were there individuals who gave them confidence and helped anchor them during a difficult time?
Agreements about the positive aspects of care should be reviewed and reinforced. The family should be asked if there were aspects about the care that they disagreed with, or found less than optimal.
Concerns about the quality of care may be categorized into several areas based on agreements and disagreements.
Step 6: Finding solutions
The CMO/VPMA should ask the family how the care team could have done this better. Having the patient participate in the corrective action plan will add value and generate buy-in to any solutions formed. Of course, the solutions must be feasible.
Step 7: Giving and getting
The parties should reach agreement on the proposed corrective action items. In many ways, this is a “give” and “get” process.
For the family, there was communication of information, the commitment by the hospital and staff to improve their performance, and an apology that the care delivered did not meet their expectations.
For the hospital, the hospital is able to “get” conflict resolution, reduce risk for litigation, and restore trust in their partnership with the community and the families. Seeking out these mutual gain options is important in order to redefine success.
The interests and motives should not only be aligned, but the family’s participation in the process will add value to the solutions proposed. If the patient and family view the process positively, then they will tend to embrace new achievements favorably and, most importantly, as fair.
The process by which a solution is found is important for both the family and the CMO/VPMA. Each will have to justify any alignment in self-interest and “give-and-take” with their respective constituencies.
For more information on the Harvard Program for Health Care Negotiation and Conflict Resolution, see here. We welcome your comments on this approach to communicating with patients about adverse events.