Editor’s note: For more on Ascension Health’s initiative to disclose unexpected events to patients, see Ascension Health’s Demonstration Of Full Disclosure Protocol For Unexpected Events During Labor And Delivery Shows Promise, part of a cluster of articles on alternatives to medical malpractice litigation in the January issue of Health Affairs.
Over a decade has passed since the majority of health care and practitioner accreditation and certification groups mandated the full disclosure of unexpected events and medical errors to patients and their families. Yet full disclosure, an element of establishing a ‘just culture,’ is still not the norm for most providers. Disclosure is difficult and there are impediments at the systemic and practitioner levels.
We at Ascension Health used our core values of truth and justice and our identity as a healing ministry to transition to a just culture that puts the priorities of those we serve above our own. We believe that these core values and identity are not unique and that all providers have a moral compass. Thus, we put forth a call to action for all health care providers to achieve the goal of establishing a just culture with 100 percent full disclosure by 2018.
For over a decade, the Joint Commission has mandated that hospitals disclose adverse outcomes and medical errors regardless of health care providers’ liability concerns. Compliance with this standard has not been achieved in U.S. hospitals, even though disclosure of medical errors to patients has the potential to decrease malpractice claims and improve the level of trust between patients and their providers. Furthermore, while disclosure of medical errors by physicians to patients is unequivocally recommended by the American Medical Association Code of Medical Ethics, U.S. physicians’ disclosure practices continue to vary greatly. Studies have shown that more than half of physicians may mention an adverse event to a patient, but not an error.
Without transparency, patients can be deprived of a complete account of the event; an opportunity to heal from the loss; and, where appropriate, potentially necessary and vital compensation. Physicians and nurses also suffer distress when practicing without opportunities to fully discuss adverse events and errors; to actively engage in correction of those errors when they occur; or to express empathy through acknowledgment or apology to the patient and family. Practitioners and hospitals continue to work within a flawed malpractice system that works against the creation of highly reliable providers and open communications with patients and families.
Ascension Health, the nation’s largest Catholic and non-profit health care system, adheres to the Ethical and Religious Directives for Catholic Healthcare Services, 5th ed. which requires its health ministry to be guided by the moral tradition of the Church. As leaders in mission-driven health care, our purpose is to improve the health and lives of individuals and communities, especially those who are underprivileged and vulnerable.
This goal, shared with many secular health care organizations, compels us to work towards reforming medical liability as part of a larger transformation of the health care system. In this narrative, we outline our journey towards establishing a just culture that includes full disclosure.
Just Relationships and the Catholic View of Human Dignity
Within the Catholic theological framework, human dignity is understood as the intrinsic and inviolable value of all human life. This inherent dignity means that every person is deserving of reverence and moral protection due to the fact that humanity was created in the image and likeness of God. Therefore, we are called to deliver person-centered care with special attention to poor and vulnerable populations through relationships characterized by justice.
Failure to disclose medical error is contrary to engagement in just relationships in several fundamental ways. First, failure to disclose an error — whether driven by a fear of liability, by the discomfort of admitting imperfection, or by the emotional discomfort of confessing to those we have harmed — would be to invert the motivations that should drive every interaction between the care team and the patient. Second, central to just relationships is the same trust that is central to each provider-patient relationship. Patients are in their most vulnerable state when they approach providers anticipating that we will ‘do no harm.’ We have an obligation to strive to maintain and foster trust and faith to benefit the individual patient, as well as to bolster the confidence that society has placed in the healing profession.
Third, within the Catholic moral tradition, respect for human dignity establishes the basic human right of all individuals to participate in those decisions that directly affect them. In short, humans have been graced with the gift of reason, with an ability to act as designed co-creators for the sake of their own good and for the good of those with whom they live in community. The failure to disclose medical errors denies individuals their rights to participate in decisionmaking and to take appropriate subsequent action.
Moreover, justice requires that patients and their families be able to seek appropriate restitution when an error results in harm. Withholding information related to a medical error may result in spiritual, emotional, social, and financial marginalization, the very vulnerability to which we are called to respond with love and compassion.
These core values, combined with the principles surrounding the essence of our purpose and existence, compel us to ensure a just culture which includes full disclosure.
Establishing a Just Culture
Disclosure has been a crucial component of Ascension Health’s larger journey toward establishing consistent and highly reliable care over the last decade. Eliminating harm and capturing ‘near misses’ was central to establishing ‘highly reliable care’ in support of holistic, reverent care and treatment of those we serve. Five key concepts are the basis for becoming a high reliability organization: 1) preoccupation with failure; 2) sensitivity to operations; 3) reluctance to simplify; 4) deference to expertise; 5) and resilience. These principles serve as the foundation supporting a cultural shift from blame, shame, and remedial training to an open and just culture which embraces system learning. After each event, practitioners must understand ’what just happened here?’
To effect this transition, it was first necessary to change the perceptions that events are indicative of weakness and inattention, or that a single individual causes an error, and to instead instill the notion that ‘human factors’ must be examined after every unexpected event. As James Reason has outlined, “fallibility is part of the human condition and it is only when we swim upstream to understand the ‘true’ causal nature of events [that we] can we learn how to prevent them consistently.”
For Ascension Health, this premise entailed training all providers and associates in high reliability attributes and in the importance of learning from each event. In our diverse system, a reported event of patient harm in one hospital or setting offered the opportunity to prevent a similar event from occurring elsewhere. This necessitated the encouragement of reporting unexpected events by leaders at all levels. Over a one-year period we trained more than 100,000 leaders, physicians, care providers, and associates on high reliability and the value of serious safety event reporting.
In addition, under the Patient Safety and Quality Improvement Act of 2005, we initiated a Patent Safety Organization that establishes a framework for the collection and analysis of patient safety events. This has enabled us to mine and analyze unexpected and serious events data, to disseminate reports and guidance, and to work with providers on prevention policies and processes. Hence, fully disclosing errors and unexpected events, as well as following a causal analysis with standardized terms and approaches, became organizational commitments regardless of the type of harm.
Due to these efforts, Ascension Health was already exploring new models of full disclosure and early resolution when the Agency for Healthcare Research and Quality issued its 2010 Call for Proposals to test new models of early resolution, with a stated goal of reforming medical liability. Since we had already achieved a collaborative partnership among our leaders in risk management, safety, and quality, the AHRQ request provided a strong internal Call to Action for the acceleration of work through a demonstration project in one of our highest-risk areas: obstetrics.
The goal of this accelerated effort was to address the impediments to establishing a just culture with full disclosure of all unexpected events to mothers and their families. Ascension Health’s core value of ensuring just relationships evolved into an expectation for all demonstration-site hospitals and practitioners to ‘Communicate Openly and Resolve Early.’ The three-year evaluation has shown promise with respect to one of the most vulnerable, high-liability risk populations, and has provided us with the expertise to spread the disclosure protocol to forty-two more sites.
The Disclosure Imperative in Secular Ethics
As noted above, the obligation to disclose is not limited to Catholic health care, or even faith-based health care. To the contrary, the norms of secular medical ethics, professionalism, public policy, and law provide a firm foundation for practitioners’ obligation to disclose within any health care institution. Principle-based secular ethics start from the standards of non-maleficence, beneficence, autonomy, and justice. The principle of respect for autonomy requires not only that we avoid interfering with an individual’s decision-making, which advances his or her own physical and spiritual well-being, but also that we provide the necessary information for an individual to make a true decision. Likewise, notions of justice, such as fairness and equity, require that patients, when harmed, be able to seek recompense.
Thus, we believe Ascension Health’s core values and identity are not unique, and that all providers can use their own approaches to reverence, truth, and justice as the catalysts for establishing a just culture with full disclosure.
Call to Action
Operationalizing the obligation to disclose unexpected events and medical errors to patients and families is consistent with both Catholic as well as secular ethics. We have learned from our associates, physicians, and nurses, and from mothers who experienced an unexpected event, that disclosure is a healing process for each individual involved as well as a courageous journey for any organization.
Based upon our demonstration study results, we put forth a Call to Action for our colleagues and other health care systems. The Call advocates that we commit to the following initial actions: accept our human duty as health care providers and healers; utilize our core values and identity to secure a sustainable shift to a just culture; develop broad-scale, interdisciplinary, and informed approaches to full disclosure; and utilize principles of high reliability so knowledgeable disclosures may occur and sensitivity to human factors may be incorporated into the evaluation of each event to deepen the understanding and context of causation.
From a foundation of high reliability, we must all take the next step to full disclosure. This requires an investment in learning and in tools which facilitate discussions between our care providers and patients so that they become accustomed to ‘sharing the truth’ in a structured way that seeks to inform and heal those involved at the ‘sharp end of care.’ Disclosure standards must require that an event be explained whether or not the patient involved requests an explanation. This path is not always apparent, due to inabilities to determine the causation of certain events, but disclosure must be considered fundamental if the patient or family members are to be safeguarded from misconceptions.
Timeliness is also imperative to reducing human suffering once the circumstances of an event have been assessed by the provider organization. Disclosure is a process rather than a single interaction with the patient and care providers. Iterative conversations may need to occur to give a patient opportunities to absorb information and to formulate questions or ask for clarification. Practitioners must be supported by an interdisciplinary team including the provider, risk managers, and others to assure information is shared as it is confirmed.
Through its core values and identity, Ascension Health is on a path to establishing a just culture which totally embraces full disclosure. In the Call for Action, we invite all health care providers to achieve a 100-percent full disclosure rate by 2018. As health care providers, and more importantly as healers with moral compasses, we can achieve this goal and correct persistent and intolerable injustice.