Among those of us in the patient safety field, the story of Mary McClinton is achingly familiar. A devoted mother, a community activist, a dedicated teacher at a Baptist church, a beloved sister, Mrs. McClinton died in 2004 because of a medical error. In a mistake that was all too easy to make, an experienced technician filled a syringe with the wrong substance, which a radiologist injected into Mrs. McClinton. As her body reacted to the chemical in her blood, physicians scrambled to try to save her, but they were unable to do so.
As tragic as her story is, it could have been worse. It could have ended with the hospital and physicians not conducting a thorough investigation of why she died. It could have ended with the technician being punished or fired for what was, the subsequent analysis showed, a systems error. It could have ended with the hospital taking a defensive stance, going to court, settling the case with the McClinton family, and sealing the records. It could have ended with no changes in procedure — leaving the hospital and its patients vulnerable for a repeat of the same tragic cycle.
But that’s not how it ended. The clinical team who cared for Mrs. McClinton conducted a thorough investigation and explained the error to her bereaved family. The leaders of the organization revealed the error in an email to the entire staff, emphasizing the flawed system and vowing to learn from the event.
The press covered the story, and the medical community realized that the same conditions that led to Mrs. McClinton’s death existed at other health facilities, putting additional patients at risk. As a result of the public accounting of the case, other hospitals changed their procedures, even before The Joint Commission added a National Patient Safety Goal related to labeling of medications on and off the sterile field in perioperative and procedural settings.
Such is the power of transparency in health care. Unfortunately, the transparency demonstrated in this case is an exception; transparency has been mostly overlooked as an effective patient safety tool. As members of the National Patient Safety Foundation’s Lucian Leape Institute, we hope to promote the national discussion underway to change that fact.
In a 2009 paper, the Institute members called transparency “the most important single attribute of a culture of safety.” The latest report from the Institute, Shining a Light: Safer Health Care Through Transparency, defines transparency as “the free, uninhibited flow of information that is open to the scrutiny of others.” That is an expansive definition, and reaching such a state is an ambitious goal.
However, a consideration of the barriers and the benefits reveals that we have much to gain—particularly in the patient safety arena—and very little to lose by being more open. Real change will be realized only when clinicians are transparent with patients and with their peers, and when organizations are transparent with each other and with the public.
Evidence suggests, and we strongly believe, that greater transparency would boost patient safety in multiple ways:
- Promoting Accountability. Patients and policymakers deserve clear and complete information to ensure that clinicians and organizations are delivering safe and appropriate care.
- Driving Improvements In Patient Safety. We—and others—can learn from our mistakes only when we are truly honest about them, and we share the details.
- Promoting Trust. Transparency is at the heart of the doctor-patient relationship, and trust can develop only when both parties are open and honest.
- Facilitating Patient Choice. Without full, honest, open communication, patients cannot make informed decisions about their care or manage the emotional and physical challenges when things go wrong.
Assessing The Barriers To Change
Barriers to transparency are ingrained in health care culture. Among them are fears about conflict, disclosure, and potential negative effects on reputation and, subsequently, finances. Strong leadership is required to overcome these barriers and create a culture of safety.
Organizations need to implement systems and a structure to support open communication, and that can only come from the top — from the executive leadership and the board. Even leaders who value a culture of safety recognize that they need to develop the mechanisms to promote it; that can take time, and it is hard work.
When it comes to public reporting of errors and other quality measures, a significant obstacle is a lack of reliable definitions, data, and standards. Outcome measures can be difficult to interpret in the absence of robust case mix adjustment, and it can be difficult to separate an adverse event (a hospital readmission necessitated by less-than-optimal care) from a complication of disease (a hospital readmission due to expected worsening of chronic illness). Moreover, many of the existing publicly reported metrics, such as those reported by Hospital Compare, hold little value to patients and clinicians, given the limits of specialties, procedures, and populations represented.
Given all of these barriers, achieving transparency may seem too aspirational, partly because successfully overcoming these obstacles requires action by so many stakeholders outside of any individual organization’s control. Yet there are those who have long recognized the benefits of greater transparency and who have taken steps to achieve more openness.
The University of Michigan Health System has pioneered a program of disclosure of medical error and apology to patients and families. Fears that full disclosure would increase malpractice claims and result in larger settlements have proven to be unfounded, as both have in fact decreased. Beyond the financial rewards, the commitment to openness makes it more likely that staff will report errors or near misses –enabling the organization to proactively address potential safety issues.
Ohio Children’s Hospitals Solutions for Patient Safety offers an example of transparency among a group of organizations. With agreements to not compete on safety and with legal protection afforded to allow sharing of data and outcomes, a group of eight pediatric hospitals in Ohio (which has since grown to become a national collaborative) joined together to identify the most serious types of harm and to use high reliability methods and an emphasis on safety culture to drive improvement. Recently reported data from the collaborative show that between January 2011 and October 2012, events of serious harm in the member hospitals decreased by 40 percent.
Achieving Transparency: First Steps To Giant Leaps
So where to begin? Shining a Light: Safer Health Care Through Transparency offers more than three dozen recommendations for leaders of organizations, clinicians and patients, and regulatory and accrediting bodies. They address a broad range of issues, from improving the ways we collect and report safety data to creating and maintaining safety cultures in organizations and ensuring that patients have reliable, unbiased, understandable information by which to make choices regarding their care.
At the organizational level, there is much that leaders can do quickly and at low cost to begin moving toward greater transparency:
- Create organizational cultures that support transparency at all levels.
- Frequently and actively review comprehensive safety performance data.
- Provide patients and family members with reliable information in a form that is useful to them (including access to their medical records).
- Include patients in inter-professional and change-of-shift bedside rounds.
- Promptly provide patients and families with full information about harm resulting from treatment, followed by apology and fair resolution.
- Provide organized support to patients, families, and the clinical staff involved in a safety incident.
- Share lessons and adopt best practices from peer organizations.
The breadth and depth of the recommendations in the report reflect the fact that achieving true transparency in health care will require work on the part of just about everyone. Collaboration is essential. Will it be easy? No. Can it happen overnight? Certainly not. But as our examples demonstrate, we can begin. Transparency that permeates the health care system starts with one person in one organization believing in its importance and committing to making it a reality.
In a story about Mrs. McClinton’s death, The Seattle Times quoted Dr. Robert Caplan, then head of quality and safety at Virginia Mason Medical Center, where the error occurred.
“The only way to improve patient safety, he said, is to be ‘open and honest about our errors. . . . You can’t understand something you hide.’”
That was true in 2004, and it is true today.