[A little girl's laughter] Carole Hemmelgarn: I have a beautiful
A little girl's laughter Carole Hemmelgarn: I have a beautiful
blond haired, blue eyed nine year old daughter, who is a quirky little girl,
contagious laugh, funny, avid reader. And she was a blooming artist,
and an athlete. And she is no longer with me anymore.
She died of medical errors. She got a hospital-acquired infection.
She was a classic case of failure to rescue where all the signs were
there that she was deteriorating and no one did anything.
Narrator: At any one time, one in 25 hospitalized patients has a
healthcare-associated infection, or H-A-I. About 75,000 hospital patients with
HAI's die during their hospitalization. In the case of Carole's daughter,
Alyssa, the hospital's response was less than optimal.
Carole Hemmelgarn: She was in a teaching institution where the fear of
hierarchy was there, and the resident didn't go up the chain of command.
The organization where she died shut down on me. They wouldn't talk about
what happened. They would not give me her medical records.
It took the organization where she died three years, seven months and 28 days
to have a conversation with me. Richard Kronick, Ph.D.: The current
system doesn't work well for patients or providers or hospitals. When harm
occurs, the strong tendency for hospitals is to disclose as little as possible
about what's happened. Narrator: For Dr. Heather Farley, being
forced into silence in another case made her question her ability as a health
care provider and nearly ended her career as an emergency room physician.
Heather Farley, M.D., FACEP: I remember the day really clearly, even though it's
several years ago now. I remember what she looked like. I remember the sound
of her voice. She came in saying that she was having some palpitations.
That's a very frequent complaint that we see in the emergency department.
We did a full physical exam and we put her on the monitor and we did a whole bunch
of blood work on her, an EKG, X-ray, pretty thorough workup, and by the time
I saw her she wasn't having any symptoms at the time. I discharged her, and
I didn't think anything more about it until the next day.
Narrator: The patient went into cardiac arrest on the drive home from the hospital.
She was resuscitated and admitted to the intensive care unit.
Heather Farley, M.D., FACEP: I was sitting in my office checking my email, and my
administrative assistant called across the hall and said, Hey, did you know
that patient that you saw yesterday she ended up coming back in." And my heart sank.
Narrator: Dr. Farley's first instinct was to visit the patient in the ICU and talk
with her family. Heather Farley, M.D., FACEP: And everybody
that I talked to said, you know, "I don't think it's a good idea if you talk
to the family." And I just wanted to tell them what I knew and... because I
knew that they were suffering, and I knew that they had questions, and I just wanted
to reach out to them, but I never got the opportunity to talk to them, which is
something that I regret to this day. Narrator: The patient later died
in the hospital. Heather Farley, M.D., FACEP: Several months
later, I was notified that I was being sued, Which was the first time that that had
happened in my career. I know that I'm a good person, and I care about my patients,
and I work hard and to have someone there accusing you of not caring, of being a
bad physician, of being incompetent, it just strikes so deeply. Most emergency
physicians... there's a high percentage that are sued at some point in their
career; I knew it was probably inevitable, but it doesn't make it any easier.
Narrator: Traditionally when harm has occurred, the first reaction is to deny
responsibility and defend vigorously. Richard Boothman, J.D., A.B.:
When we talk about deny and defend, we talk about a whole paradigm of responding
to patient injuries or unanticipated clinical outcomes that has historically, and literally
for decades now, been given over to the legal profession.
William Sage, M.D., J.D.: Culturally, we have several generations of physicians now
who believe in patient autonomy and who believe in things like informed consent.
If one should and under law must tell a patient about the risks of what might
happen to them, don't you think we should tell patients about what actually
did happen to them? Richard Boothman, J.D., A.B.: I had been
22 years in the trenches knowing that I had fought battles that I didn't need
to be fighting. I was running up defense costs. I was dragging it out for a couple
of years, and then we were settling cases on the courthouse steps.
Richard Kronick, Ph.D.: Research funded by the Agency for Healthcare Research and Quality
have shown that communication resolution programs had achieved some pretty remarkable
results. An AHRQ-funded grantee saw about a 50% reduction in claims and lawsuits
and big increases in satisfaction from both patients and providers.
This program resulted in a 22% decline in malpractice premiums for the hospital and
saved Medicare and Medicaid $3 million annually. It's very important both to try to figure
out how to improve the process of what happens after harm occurs, and even more important,
to try to figure out how to reduce harm to begin with. And it is clear from the
evidence that we have generated that the implementation of communication resolution
programs can be successful in achieving both of these goals.
Text on Screen: Communication and Optimal Resolution Process or (CANDOR)
Richard UmbdenStock, MHSA: The CANDOR process is a simple plan and hospitals
should have it ready to go whenever a patient is harmed during a stay. First, provide
emotional first aid immediately to the patient, the family, and the caregiver, and maintain
communications with them as your understanding of the cause of that harm event grows.
Learn to prevent similar events from happening in the future.
And finally, make things right with the patient and explain what you're doing
to ensure that care will be safer for future patients as a result of this experience.
Richard Boothman, J.D., A.B.: The topic of Resolution is integral to the entire idea
of this model. Resolution is a proxy, and it's not always money.
It sometimes speaks to our credibility. It sometimes speaks to how earnest we are
in terms of an apology. It tends to help people
find justice in the whole approach. One of the misconceptions about the
CANDOR process is that it's just a big mea culpa every time something goes wrong.
The real truth of this approach has little to do with the malpractice part of it.
It has everything to do with reconnecting a sense of accountability for the clinical
outcomes that we have. At its core, it is literally as simple as saying, We're
not going to push things to lawyers when we haven't exhausted the notion that maybe
there's a clinical explanation. Maybe this is way more important to the
key mission of health care in general. Richard UmbdenStock, MHSA: When patients
have been harmed during a hospital stay, we can't always undo the harm that's occurred,
but we can change the way we respond. CANDOR urges transparency from the beginning,
teaching providers to be honest to rebuild trust.
Richard Boothman, J.D., A.B.: In every hospital system, there's at least three different parts
to the equation of resolution. There's the folks in the trenches who have
to deal on a very personal level with patients, patients' expectations both for the sharing
of information, and at some point, for compensation.
But there's typically an insurance office or
sometimes a commercial insurer, and then there's the legal office, the folks who have to pick
up the pieces if the effort at pre-suit litigation doesn't work.
In order to employ this model in a sensible way,
and in its most effective way, there must be
trust between all three components. Brian Atchinson, J.D.: I think our healthcare
system is largely designed now, rightfully so,
to continuously improve. And prompt and early communication certainly helps to do
that. It reduces the worry. It reduces the concern
of the patients and their family. We anticipate that this learning will continue
and the program will evolve and will benefit from the experiences of certainly the medical
professional liability community and all of those they insure.
William Sage, M.D., J.D.: I think it is transformative for health care organizations.
It engages the patient and the family early on.
It doesn't regard error disclosure as a single event. But instead it opens a conversation.
Carole Hemmelgarn: The only way for an organization to learn is to show the failures
and say, We are fallible. But we're going to
learn about this, we're going to tell you about it so that all of us together can make
the system better. Richard Boothman, J.D., A.B.: The CANDOR
process is a wonderful entrée to meaningful quality improvement, to healing the
caregivers when bad things happen. Richard Umbdenstock, MHSA: One error is too
many. And its impact on the patient and loved ones
can be devastating. Health professionals involved
in an event that harms a patient often
experience many emotions. Heather Farley, M.D., FACEP: I was just so
ashamed of what happened and how I was feeling. One of the main pieces of CANDOR is
Care for the Caregiver. When I did finally tell my boss what I was
dealing with, it was a very cathartic experience, and he was very, very supportive.
Richard Kronick, Ph.D.: The implementation of
these programs requires culture change. It requires a change in how people within
the hospital identify errors... communicate errors.
AHRQ's goal in this project is to create the tools and the infrastructure to allow a broad
array of hospitals to be successful in implementing communication resolution programs.
Richard Boothman, J.D., A.B.: I think the most
simple but powerful thing that I can say to people who are entertaining this idea but
are afraid, Don't be afraid.
Don't forget why you came into healthcare, whether you're a lawyer or whether you're
a doctor or a nurse in the trenches.
Move forward in this approach with the confidence that the greater rewards will more
than offset any fear that you have in trying it.
Start small. Build confidence and build expertise in this
space. The real truth is that this approach taps such basic human needs that it works
in Tokyo, it works in London, it works in Stockholm, and it will work
everywhere in this country. Just don't be afraid.