The Internal Neutral: Why Doesn’t Your Hospital Have One?

The National Naval Medical Center (NNMC) in Bethesda, Maryland is the first acute health care institution in the nation to offer a full-time internal neutral for the resolution of health care issues.

Through the use of a well-trained and experienced organizational ombudsman/mediator, who is also an experienced clinician, NNMC has improved patient safety, reduced medical malpractice costs, enhanced both staff and patient satisfaction and created an informal feedback loop that identifies and fosters systemic improvements within the hospital.

The data obtained thus far indicates that the presence of a well-trained and properly positioned internal neutral can be a highly cost-effective and efficient resource for resolving patient-provider conflicts.

The organizational ombudsman/mediator at NNMC is uniquely poised to achieve resolutions concerning patient-provider issues at the earliest possible opportunity and at the lowest possible level, well before they are elevated to legal claims. Typical interventions may involve medical errors, sentinel events, near-miss occurrences, patient-provider interactions which are a “poor fit”, dissatisfaction with treatment outcome or quality of care, expected or unexpected patient deaths, or potential claims against the institution.

A significant focus of the program is to assist in the enforcement of the accrediting organization, JCAHO regulation RI.1.2.2, which deals with the mandate for disclosing medical errors: “Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.”

Related programs at other hospitals offer mediation, generally by attorney-mediators, for medical malpractice claims already in the litigation pipeline rather than the early resolution options offered at NNMC. Unlike the medical malpractice mediation model in place at other hospitals, the NNMC ombuds program has centered around creative options for resolution rather than the payment of funds.

The ombudsman/mediator serves as an impartial third party who facilitates discussions between patients and providers, focuses upon underlying issues, needs and interests, clarifies perceptions, frames issues, helps to create options and assists in developing terms of a settlement agreement that assists parties in reaching sustainable and mutually-satisfactory solutions to patient care disputes.

Techniques include listening, coaching, shuttling between patients and providers, or conducting a face-to-face mediation session. Patients are advised that they may not be provided with results of formal investigations or information regarding any action taken against providers by the hospital.

Both patients and physicians provide critical input into achieving meaningful resolutions. The Ombudsman/Mediator conforms to the Code of Ethics and Standards of Practice of The Ombudsman Association: confidentiality, neutrality, independence, and informality.


Program results are very encouraging, suggesting increased patient and family satisfaction. Of the 82 plus cases handled in the first eighteen months of operation, a 100% resolution rate was achieved, and 77% were resolved within 10 hours. To date, no claims have been filed on cases resolved.

Universally, patients seek an explanation of unexpected occurrences, an apology if warranted, and an assurance that processes or policies are being implemented to ensure that the adverse event does not recur with another patient.

Results reflect a reduction in legal costs, claims against the hospital, and negative publicity, with a concomitant increase in quality of care and system effectiveness. Lessons learned from cases are analyzed and translated into recommendations to facilitate a reduction in medical errors. Recommended policy or protocol changes are submitted via Patient Safety/Risk Management or individual service lines. Upward feedback is provided to senior management by tracking and analyzing the types of concerns brought forward.


Carole Houk

Carole Houk is a conflict management consultant and attorney specializing in the design of integrated conflict management systems for businesses and government, with a particular focus on the healthcare industry.  Ms. Houk works with organizations to develop their capacity to become conflict competent. Her client-focused firm provides consulting and strategies… MORE >

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