“It takes many good deeds to build a good reputation, and only one bad one to lose it.” So said Benjamin Franklin and his words still ring true today. Can cardiologists and providers rebound after a slip? A health system administrator and two cath lab directors share tips on how to face negative events head on and apply key principles that will help preserve good will and restore a damaged reputation.
How do healthcare providers build and maintain a good reputation? And how do they repair their reputations after a damaging incident? According to the Public Relations Society of America, the three most important factors that contribute to regaining a good reputation after a damaging incident are transparency, responsibility and effective problem-solving.
Transparency & responsibilityBefore-after Claims & Costs
University of Michigan Health System in Ann Arbor, reported decreases in the number of claims, resolution time and costs when it changed its method for responding to patient injuries and malpractice claims in 2001. Between 1995 and 2007:
• 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;
• Median time from claim reporting to resolution decreased from 1.36 to 0.95 years; and
• Average monthly cost rates decreased for total liability, patient compensation and noncompensation-related legal costs.
Source: Ann Intern Med 2010;153(4):213-221
Typically when a cardiologist has a poor outcome and reports it to a medical liability insurer, the physician is instructed to limit discussion of the problem with the patient, and to be careful not to concede error. Doing so will encourage the patient to file suit and will weaken the physician’s defense, according to traditional thought.
The deny-and-defend tactic has ill-served healthcare providers, says Richard C. Boothman, JD, a trial lawyer who spent much of his career defending physicians in malpractice actions and who currently serves as executive director of clinical safety at the University of Michigan Health System in Ann Arbor. He asserts that an institution that supports a culture of hiding mistakes or wrongdoing cannot effectively monitor itself, and therefore cannot effectively address compliance, or most importantly, patient safety issues.
Srihari Naidu, MD, the director of the cardiac cath lab at Winthrop University Hospital in Mineola, N.Y., advocates for a proactive approach. He holds and documents a family meeting before all high-risk procedures. His purpose is to make sure that everyone who will be involved in the process understands the potential risks and benefits and has an opportunity to prepare for all possible outcomes.
Naidu will delay a procedure a day or two if necessary to ensure that all appropriate family members are in the room for the family meeting. During the meeting, he tries to convey that the patient’s treatment and recovery are a team effort that requires the cooperation and informed participation of everyone on the team—and that Naidu himself is a member of the team, not just the “procedure-doer.”
This approach benefits his reputation, he says, especially when the result is not as good as had been hoped. “If the patient has a complication, then I can go to the patient and the family and say, ‘You remember, this is one of the things I was concerned about,’ and it becomes a simple conversation, because I have already done the hard work at the family meeting,” Naidu explains.
Full disclosure is necessary to honor the trust that must guide an appropriate physician/patient relationship, Boothman adds. The University of Michigan’s experience shows that trust can be regained when a hospital creates a culture of acknowledging errors, he claims (ACHE Frontiers 2012; 28:13-28).
In an effort to settle claims in a speedier and more predictable fashion and to improve patient safety, Boothman and his colleagues in 2000 developed a process of responding to medical errors and patient complaints that utilized experienced nurses as risk managers to review and investigate all unanticipated outcomes. These risk managers discuss all such situations fully with patients and families, and provide explanations as far as they are known. In cases of true error, the patients receive an apology and compensation. When the situation reveals an opportunity for a change in systems or processes to prevent a recurrence, this change is shared with the patient and/or family. All information gathered in the process is used to enhance patient safety efforts, Boothman asserts.
In Naidu's cath lab, if a patient dies, he stays with the family “even as they’re hugging and crying. I just sit there and I am part of the initial reaction. I stay until it’s clear that they want their privacy. It makes a big difference to the family that I go through that with them, that I don’t run away,” he says.
As Naidu understands, when choosing transparency, especially when admitting an error or revealing a problem, it is essential that the right person deliver the news. At the University of Michigan Health System, after a physician has informed a patient or family of an unanticipated outcome, the risk manager/nurses often take over the discussions regarding causes and compensation.
“The risk managers know the clinical stuff, they know the realities of medical care delivery, but they can discuss these realities with the patients with less emotional charge,” Boothman says. “They can deliver the information without getting defensive.”
Another example of an institution mitigating damage by selecting the correct spokesperson occurred in 2011, when the Excela Health System learned that two of its interventional cardiologists at Westmoreland Hospital in Greensburg, Pa., may have placed unnecessary stents in more than 190 patients. The CEO of Excela made the initial announcement, and continued to be available as the public face of the institution until the investigation was complete. At the time of these announcements, Excela was praised for accepting responsibility and being responsive at the highest level.
After Excela acknowledged the stenting situation, it cooperated with investigators, began negotiations with affected patients and paid fines to settle claims of billing Medicare for unnecessary services. But to fully recover from the incident, Excela had to rebuild the reputation of its cardiac cath lab.
It began that process with a new director, Howard P. Grill, MD, who saw the situation as an opportunity for quality improvement. “My focus was not on restoring the reputation per se, it was on making sure that good quality assurance standards were in place. If we produce quality results, [then] the reputation will follow,” he remarks.
The hospital’s administration and Grill determined to rebuild the department from the ground up and do everything possible to ensure the development of a first-class facility. Grill first made sure that the cath lab was staffed with high-quality physicians, nurses and technical staff who were open to reflection, review and change.
Then Grill and his team analyzed how the stenting problem had developed, how it had gone undetected, and identified measures that would prevent a recurrence. Using the Society of Cardiovascular Angiography and Interventions (SCAI) Toolkit, which describes optimal care for every aspect of cath lab operations, Grill and his team were able to establish functional quality assurance processes that led to Accreditation for Cardiovascular Excellence certification in 2012.
“It’s great to be able to say we’ve looked at what was wrong, we’ve fixed it, and an uninterested third party, a certifying body, agrees that we’re doing quality work,” Grill says.Liability system erodes trust
Decades of deny-and-defend responses to medical errors have eroded patients' trust in physicians and hospitals. Researchers recently conducted a study of patients' responses to acknowledgment of medical errors and offers of compensation (Health Aff 2012;31:2681-2689). Individuals were asked to imagine that they were patients and to read hypothetical vignettes describing medical errors. The "patients" then were offered varying sums as compensation for the error.
Individuals who were offered low or moderate payouts were more likely to accept the offer than patients who were offered a very high payout. The authors of the study found that when individuals were offered high payouts they assumed that the hospital must be hiding something, and further assumed that the money the hospital was offering must be inadequate, even though the sum was equivalent to what the patient could reasonably expect to win in a successful malpractice action.
Physician distrust in the malpractice system adds to the dysfunction, but another recent study indicates that the distrust is warranted (Health Aff 2013;32:111-119). Researchers found that the average cardiologist spends a mean of 52.9 months of a 40-year career with an open malpractice claim pending. To make matters worse, 41.5 of those months are spent waiting for resolution of a claim that ultimately does not result in payment to the patient. Any open claim, meritorious or not, provokes stress, requires work to defend, and damages the physician's reputation.
The University of Michigan Health System has a policy of acknowledging errors and paying compensation when warranted, and an agreement on compensation is usually reached within three months, says Richard C. Boothman, JD. But the system mounts a vigorous defense to all claims as long as the care was reasonable. This policy reassures the physicians working in the system that frivolous claims will not be settled for convenience, and reassures patients that they will be fairly compensated for true errors (Milbank Q 2012;90:682-705).