CARe Approach Continues to Gain Ground

Vital Signs: November 2013

Communication, Apology, and Resolution for Adverse Medical Events

In the past 18 months, a new approach to handling adverse medical events has made strides in Massachusetts, with six pilot sites now participating in a program called Communication, Apology, and Resolution (CARe).

The program, based on an approach pioneered by the University of Michigan and formerly called Disclosure, Apology, and Offer (DA&O), continues to gain supporters, said Alan Woodward, M.D., past president of the MMS and chair of its Committee on Professional Liability.

The current system of handling medical malpractice cases ― which take on average more than five years if the case has to wind through the court system ― takes “a terrible toll” on both patients and providers, said Dr. Woodward.

The CARe approach involves four components: open and ongoing communication with the patient; investigation and safety system improvement; appropriate apology; and resolution, including offer of compensation, if warranted.

“All we are talking about is doing what is morally and ethically correct, and what you would want done if you or a family member was harmed,” Dr. Woodward said.

“A Culture of Secrecy”

Historically, Dr. Woodward said, physicians and health systems have worked under a system with “perverse incentives and forces, as well as a culture of secrecy and finger-pointing.” Change will take time.

“The current system created a culture of secrecy, so we failed to communicate and learn from our mistakes. That was counterproductive to our well-being as physicians,” Dr. Woodward said, pointing to escalated rates of divorce, depression, and suicide among physicians named in a malpractice lawsuit.

Using a 2010 grant from the Agency for Healthcare Research and Quality given to the MMS and Beth Israel Deaconess Medical Center (BIDMC), a wide variety of stakeholders ― including physicians, hospital administrators, malpractice attorneys, patient groups, and insurers ― were interviewed about barriers to implementing CARe statewide and strategies for facilitating adoption.

The program’s Roadmap to Reform was released in spring of 2012, and a few months later, the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) was formed. MACRMI’s CARe model is currently being piloted at BIDMC, Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Baystate Medical Center, Baystate Mary Lane Hospital, and Baystate Franklin Medical Center.

According to Kenneth Sands, M.D., senior vice president for health care quality at BIDMC, the pilot program is going well and about 90 cases have been assessed since December 2012.

In a small number of those cases, it was determined that there was significant harm to the patient and it was unclear whether reasonable care was provided. Those cases are currently undergoing a more complete evaluation and there has been full communication with the patient and/or family, said Dr. Sands.

“We have had a good response from physicians, administrators, and patients who have somehow been a part of the program, he said. “Clinicians, after some initial trepidation, find that it feels like the natural and ethical way to approach an adverse event.”

Other States Looking to Massachusetts

Hoped-for federal funding to support the pilot site implementation did not materialize, so MACRMI successfully solicited support from a broad coalition, including all of the state’s major health and liability insurers.

State legislation, which applies to all providers in the Commonwealth, cleared the way for CARe provisions that went into effect in November 2012. The legislation included a six-month prelitigation resolution period, sharing all pertinent medical records, strong apology protections, and guidelines for full disclosure of significant medical injury.

State reporting requirements to the Board of Registration in Medicine have been changed to clarify obligations under CARe and efforts are underway at the federal level to do the same.

In recent months, other states have sought advice from Massachusetts about starting similar programs.

“Based on our and others’ progress, many states are now interested in implementing this kind of approach,” said Dr. Woodward.

MACRMI members hope that doctors ― especially ones in training and new to the profession ― will begin to view adverse medical events through a new lens.

“We are optimistic and hopeful that this will become the standard way to approach patient harm,” said Dr. Sands. “If we are successful, it will indeed become the standard way that the next generation of clinicians approach patient safety and event resolution. It really is a much larger issue than medical liability that is at stake.”

― Erica Noonan

For more information on the CARe program and the MACRMI coalition, or to request a presentation at your institution, contact Melinda Van Niel at (617) 667-7155 or visit www.macrmi.info.

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