Massachusetts Medical Society: Carving a Collaborative Path through Medical Injury Disputes

Carving a Collaborative Path through Medical Injury Disputes

By Kate Connors, MA, MMS Director of Communications

In a medical environment in which administrative burdens seem to chip away at the patient-physician relationship, some relief may come from an unlikely place: a communication-based approach to resolving medical injury cases.

The new model seeks to address medical injury disputes via communication, apology, and resolution. It was urgently needed, advocates say. The traditional deny-and-defend approach “is a stressful, adversarial model that isolates both patients and providers and thwarts patient safety improvement efforts,” says Alan C. Woodward, MD, co-chair of the Massachusetts Alliance for Communication and Resolution following Medical Injury ( MACRMI), a coalition of health and medical groups in the Commonwealth. The new approach, he says, is “about taking responsibility for, and control of, adverse outcomes, and doing what is morally and ethically right.”

The liability reform provisions of Chapter 224, initiated by the Medical Society and signed into law in 2012, made it possible for MACRMI to establish a pilot program — the Communication, Apology, and Resolution (CARe) model — in Massachusetts and nationally. Following positive results from a program at eight institutions, MACRMI is bringing the model to additional hospitals and physician practices across the country.

The older, tort-based means of addressing disputes restricts interaction between physicians and patients, sometimes for years, fracturing those relationships. The CARe model reverses this trend. “For physicians, it’s a huge benefit to be able to communicate openly with a patient and say, ‘I’m sorry,’” says Dr. Woodward, who is a past president of the Massachusetts Medical Society and past chair of the MMS Committee on Professional Liability. “It helps defuse patient anger and provider grief while maintaining trust and focusing on the patient’s medical and psychosocial needs and prevention of recurrences.”

Alan Woodward at microphone
Alan C. Woodward, MD, past president of the Society, advocates for a collaborative approach to resolving disputes.

The CARe model is based on rapidly initiating communication following a patient injury. The physician, or an appointed hospital or facility representative, meets with the patient (and/or their family) to explain what happened, express regret, and discuss the next steps for patient care and support. A subsequent investigation leads to a determination about whether the patient’s injury was caused by medical mismanagement. If so, the CARe team, including facility and insurance company representatives, moves into the resolution phase, which may include discussions about compensation.

The CARe model functions whether or not there is a determination of medical mismanagement because of its emphasis on regular communication and on improving patient safety.

In a paper published in Health Affairs in 2017, the authors report that in a large majority of cases reviewed, the standard of care was met. The CARe model seeks to provide the information and empathy that patients need to process the event and understand that it does not merit legal redress.

In the cases in which the standard of care was not met, or the care was determined to have been unreasonable, the patients received an apology. Resolution efforts were initiated, including compensation when appropriate. The median compensation payment was $75,000; only 5 percent of care events led to malpractice cases or lawsuits.

The CARe model can dramatically slash the time required to achieve resolution, compared with the “deny and defend” model — down from multiple years to roughly nine months, says Dr. Woodward. “The experience of going through litigation for many years is horrific for physicians, and even if they win, the toll is the self-doubt, persistent stress, and sleepless nights.”

According to the Health Affairs paper, 7 out of 10 clinicians who self-reported as knowing enough about the CARe system to answer questions on it gave strongly positive reviews. One finding of the survey was simply that more clinicians should know about the model.

Working through the CARe process can also lead to patient safety improvements. In an early analysis of preliminary data reported in Health Affairs, more than 40 percent of cases gave rise to a safety improvement action.

Newton-Wellesley Hospital, which adopted the CARe model in mid-2017, has already experienced positive outcomes. Jodi Larson, MD, chief quality and experience officer, described a situation in which patient care had suffered due to communication failures. Improved communication, she says, turned the experience around. “The patient was grateful that we were transparent with her. The caregivers were grateful that they could tell her what had happened and apologize for it. The providers were able to talk about it with each other rather than worry in isolation.”

Regarding another, yet-unresolved situation, Dr. Larson observes that without the CARe model, which has supported both the physician and the patient, “the attending would have been left to his own to deal with the emotional burden of the case.”

A team-driven, communication-based approach to resolution, she says, keeps the attention on patient outcomes, rather than on litigation or reputation management. “Involving the patient in the discussion and keeping the focus on the patient, who is a real-life person that we all have connected with and formed a meaningful relationship with, has been so powerful,” says Dr. Larson.

“It reminds us of the importance of our job and connects us back to why we decided to work in health care.”

MACRMI’s 6th Annual Forum will take place on May 15, 2018, from 10:00 a.m. to 2:30 p.m. at MMS Headquarters, Waltham. Learn more.

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