What are the advantages of CARe? What is the evidence that it works?
The increased transparency that comes hand in hand with CARe leads to improved patient safety as well as an improved rapport with patients, and better public relations. (Visit the About CARe page for details.) The culture is one which has been shown, in particular at the University of Michigan Health Systems, to lead to greater satisfaction among clinicians, and to enhance recruitment and retention.
An approach such as CARe provides an opportunity to address and heal the emotional impact of errors on health care providers. Click here to download a 2007 article in the Joint Commission Journal on Quality and Patient Safety on this topic. Click here to download "Guilty, Afraid and Alone--Struggling with Medical Error," an article in the New England Journal of Medicine on how patients, families and clinicians can move beyond feelings of guilt, fear and isolation.
There is also clear evidence of reduced malpractice claims. For insight into the experience at the University of Michigan Health Systems, click here to download "Liabilty Claims and Costs Before and After Implementation of a Medical Error Disclosure Program in the Annals of Internal Medicine, August 2010.
What hospitals or health care organizations have experience with CARe?
Several hospitals around the nation have implemented programs with the elements outlined in CARe. The reports from these institutions are very positive in terms of financial impact, patient satisfaction, and staff satisfaction. Additionally, reporting of patient safety risks goes up.
- Baystate Health, a participant in the CARe pilot program, has been implementing the CARe principles and elements for several years. Click here to download an article in the Joint Commission Journal on Quality and Patient Safety on Baystate Health's journey in this area.
- Beth Israel Deaconess Medical Center
- Southcoast Health Systems
- Lahey Clinic
- Reliant Medical Group
In other states:
Click here to download an article in the Journal of Health and Life Sciences Law, 2009, about the University of Michigan experience.
Download "Nurturing a Culture of Patient Safety and Achieving Lower Malpractice Risk Through Disclosure: Lessons Learned and Future Directions" about the University of Michigan Health Systems' experience.
Download the Stanford PEARL program brochure.
- University of Illinois
Dowload a presentation by Timothy B. McDonald, MD, JD, on setting up a successful patient disclosure program.
View "Disclosing Medical Errors: Best Practices from the Leading Edge," Robert Wood Johnson Foundation.
- University of Washington
View a University of Washington teaching module on talking about medical error with patients.
Download a presentation by Thomas H. Gallagher, MD, of the University of Washington School of Medicine on recent developments and future directions in disclosure.
What steps should an institution be taking if it wants to explore the potential implementation of a CARe model?
The following are the basic requirements for implementation of CARe:
1. A baseline just culture to enhance trust and safety: Establish a baseline culture of safety focused on continuous patient safety improvement and error prevention. Encourage open communication, a just and blame-free culture, near miss (incident) reporting and a rigorous root cause analysis system with loop closure/system improvement to prevent recurrences of any miss/near miss. The model should be discussed with your liability insurer in order to ensure a common vision for moving forward.
- Download a workbook for Implementing Your Version of the Michigan Model.
- Download "Patient Safety and the Just Culture: A Primer for Health Care Executives" by David Marx Consulting, in support of Columbia University, 2001
- Downoad "Balancing No Blame with Accountability in Patient Safety" in the New England Journal of Medicine, October 2009.
2. The practice of full disclosure in the case of an adverse event:
Setting up such a practice requires that these elements be in place:
- Institutional ability to capture adverse events promptly and reliably
- Disclosure training for clinicians
- Peer support
- Mentoring (including just-in-time coaching)
- Enabling legislation at the state level
Download a discussion in the New England Journal of Medicine on disclosure in the case of large scale adverse events.
3. Apology in the case of avoidable harm.
As in the case of disclosure and explanation, this requires:
- Training and mentoring.
- A state apology law prohibiting the introduction into evidence of a provider's expression of apology or regret. (See Massachusetts Legislation here.)
See also On Apology by Aaron Lazare, MD, chancellor, dean and professor of psychiatry at the University of Massachusetts Medical School.
4. Offer: a consistent and thorough policy on compensation.
- Patients should be offered legal representation.
5. Ongoing support services
- For the patient and family
- For the providers.
Medically Induced Trauma Support Systems (MITSS) offers a toolkit for building a physician and staff support program, an organizational assessment tool for clinician support, and a wealth of other resources for health care organizations wishing to improve support systems for caregivers along with patients and families after unexpected outcomes.
Download Implementing Your Own Michigan Model, by Richard Boothman, Executive Director of Clinical Safety at the University of Michigan Health Services.
If we are to resolve cases early, won't there be more cases and greater expense?
This has not been the experience of other hospitals to date. The number of “claims” (meaning any offer of compensation, whether initiated by the patient or the institution) has tended to remain constant or decrease. Overall costs have tended to go down as well, but with a greater percentage of that compensation going to the patient as opposed to legal costs. For additional information, download “Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program” in the Annals of Internal Medicine, 2010.
What legal basis is there for the CARe approach?
Massachusetts has enacted a new law, Chapter 224 of the Acts of 2012, aimed at controlling rising health care costs and increasing transparency, efficiency and innovation in the Massachusetts healthcare system. Chapter 224 includes several provisions to facilitate implementation of the CARe model which took effect in November 2012.
These provisions include a 6 month pre-litigation period, disclosure protections, the sharing of all pertinent medical records, and strong apology protections.
Key liability provisions found in the 2012 Massachusetts Payment Reform Legislation are available for download here.
Is there someone who can come present this program at my institution?
Yes. If you or your colleagues are interested in learning more about CARe and current activities in the Commonwealth and would like to have Alan Woodward, MD, past Massachusetts Medical Society president and chair of the Committee on Professional Liability, present to you and your colleagues please contact Charles Alagero at 781-434-7001 or firstname.lastname@example.org.