Kenneth Sands, Alan Woodward, and Melinda Van Niel
Research in patient safety and medical liability in recent years has widened our definition of these terms. Patient Safety improvement is no longer a preventive strategy to protect medical facilities from lawsuits—it is a serious and wide-reaching effort to measurably improve the safety culture among staff in medical institutions, to find lasting and systemic prevention strategies for adverse events, and to work with patients—and with their families and caregivers—as equals to both address their care needs and to earnestly reconcile when their care does not go as planned. Working with patients as partners has become increasingly important in our rapidly changing medical landscape. Patients are experts in their own care and their own needs. Too often, we medical professionals ignore their expertise and opinion. In addition, caregivers and family members have knowledge and perspectives about the patient and his or her condition that can contribute to better care and improved patient safety. Transparency between and among medical colleagues and a supportive just culture1 are also central aspects to improving safety and creating a climate less prone to medical liability in health care facilities.
The articles included in this publication demonstrate a wide variety of studies that investigate the importance of openness and collaboration with medical colleagues and patients before, during, and after patient care. Many of the papers reveal the merits of involving patients as team members from the planning stages for their care, with programs like shared decision-making and team building. Several authors also demonstrate the need for internal transparency with regard to near-miss reporting and medication discrepancies during transfers to improve safety. And finally, there are several illuminating studies on working with patients when things go wrong, including communication and resolution programs (CRPs) and other disclosure strategies.
Patient safety, as a field, has come a long way in a short time, but there is still significant progress to be made. The National Patient Safety Foundation was formed fewer than 20 years ago, and in many places in the country, patient safety is not a central component of health care operations, but instead it is a patch to reflexively plug problematic holes in a system. Likewise, initiatives to address medical liability have only taken the progressive turn noted by our fellow authors in this publication in the last 20 years, and programs that embrace transparency and prevention of adverse event recurrence like CRPs are still few and far between. In order to create true progress in patient safety and medical liability and spread adoption of these successful programs, committed stakeholders must join together to press these programs forward. Our experience in Massachusetts has demonstrated that understanding the barriers and concerns of the stakeholders involved and working with those stakeholders to remove those barriers and collaboratively move toward safer, more transparent care together represent the best way to achieve lasting success.2 Engaging traditionally opposing sides and finding common ground and a higher purpose are strong drivers toward change, and the absence of this buy-in from all constituents—patients, physicians, insurers, attorneys, and others—stops rapid progress and adoption of programs that are demonstrated to show significant benefit for all stakeholders.
Likewise, additional research in patient safety and medical liability is crucial to overcome barriers and demonstrate value. The studies described herein are at the forefront of their field; this research is important pioneering work that must be continued to remove roadblocks such that prevent widespread adoption of these progressive patient safety and medical liability improvement measures.
Studying patient safety and medical liability takes diligence and patience, as the challenges of researching lawsuits, claims, and other patient harm include long resolution time (for example, the average medical malpractice lawsuit that goes to trial in the United States takes about 3.5 years to resolve),3 different insurance models (i.e., captive vs. commercial) that have the loci of control outside or inside the medical facility itself, and the common fear that engaging patients in dialogue around harm, safety, or even fallibility will create increased legal activity from patients. We must continue our research efforts to address these concerns and demonstrate that for each of the variables listed above, time and again, engaging with patients for safety in their care only improves their care and increases the quality of service that we, as health care professionals provide.
Additional research in patient safety and medical liability will also continue to emphasize the value in creating a culture of safety and in engaging with patients to improve quality of care. Using measures of patient experience such as the Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS),4 and patient-reported outcomes will assist health care facilities in composing a complete picture of patient safety by better understanding how patients feel physically and emotionally after the care they receive. In addition, using tools to measure staff and clinician experience through culture of safety surveys,5 and human resources (HR) metrics such as staff turnover and retention, will give health care facilities a 360-degree view of where their patient safety culture stands and areas in which they can improve.
Fortunately, over the past several years, many valuable tools have been built to help support positive changes in patient safety and medical liability through low- or no-cost measures. Organizations on both a national and local scale have created toolkits to help facilities implement programs like CRPs (see the AHRQ CANDOR Toolkit6 and the Massachusetts Alliance for Communication and Resolution following Medical Injury Implementation Guide7) and shared decision-making (see the AHRQ SHARE Program toolkit8) and have also built communities of stakeholders already doing the work who can provide support and encouragement to those who are at the beginning of their journey. These toolkits and communities were built with the express purpose of helping these concepts spread quickly, without reinventing the wheel and with low barriers to entry. We encourage you to take advantage of these valuable resources.
Patient safety and medical liability is a dynamic field, and we hope that in the next several years the concepts presented in these articles will be rapidly adopted to help ensure that we take the best care of our patients that we can. This, in turn, will enable staff and clinicians to feel secure and supported and our systems to be as close to error-free as possible. We must continue to build on those concepts tested here and help make the case for more honest, transparent partnership with patients before, during, and after their care and more open engagement with our staff around problems and solutions. This way forward will lead to delivering care and handling unexpected outcomes in a way that supports iterative improvement, so that all of the care delivered in the future is care of which we can be proud.
Author Affiliations
Kenneth E.F. Sands, MD, MPH, Chief Patient Safety Officer, Healthcare Corporation of America; Alan Woodward, MD, Chair, Committee on Professional Liability, Massachusetts Medical Society; Melinda B. Van Niel, MBA, CPHRM, Project Manager, Health Care Quality, Beth Israel Deaconess Medical Center.
Address correspondence to: Melinda B. Van Niel, 20 Overland Street, Beth Israel Deaconess Health Care Quality, 5th Floor, Boston, MA 02215; email mvanniel@bidmc.harvard.edu.
References
1. Introduction to the Just Culture. What is just culture? Outcome Engenuity Web site. Available at https://www.outcome-eng.com/david-marx-introduces-just-culture/. Accessed March 15, 2017.
2. Bell SK, Smulowitz PB, Woodward AC, et al. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q 2012; 90(4):682-705.
3. Norton A. Docs win most malpractice suits, but road is long. Reuters Health, May 23, 2012. Available at http://www.reuters.com/article/us-docs-win-most-idUSBRE84M11N20120523. Accessed March 15, 2017.
4. Agency for Healthcare Research and Quality. Consumer Assessment of Healthcare Providers and Systems Adult Hospital Survey. Available at
https://www.ahrq.gov/cahps/surveys-guidance/hospital/about/adult_hp_survey.html. Accessed March 15, 2017.
5. See for example the Survey on Patient Safety Culture Database. Available at
https://www.ahrq.gov/topics/topic-survey-on-patient-safety-culture-database.html. Accessed March 15, 2017.
6. Agency for Healthcare Research and Quality. Communication and Optimal Resolution Toolkit. Accessed March 15, 2017.
7. Massachusetts Alliance for Communication and Resolution following Medical Injury. Accessed March 15, 2017;
8. Agency for Healthcare Research and Quality. The SHARE Approach. Tools and curriculum. Accessed March 15, 2017.
