Baystate Health continues the conversation around its commitment to a Communication, Apology and Resolution (CARe) culture…
CARe: Apology, before and after an Investigation
About a year ago, Baystate Health posted a blog about the importance of COMMUNICATION in the CARe process and highlighted some Baystate Health initiatives for communication training. The next component—APOLOGY—is equally important, and not without its own challenges.
Apologies have the power to heal humiliations and grudges, remove the desire for vengeance, and generate forgiveness on the part of the offended parties. For the offender, they can diminish the fear of retaliation and relieve the guilt and shame that can grip the mind with persistence and tenacity that are hard to ignore. (“On Apology,” Aaron Lazare, 2004)
The act of apologizing is a critical element to the disclosure and resolution of unexpected adverse medical events. An apology should be an integral part of the communication: early on during the initial disclosure conversation, and may be repeated throughout the CARe process, specifically during any resolution conversations.
The initial disclosure apology is usually one of sympathy, “We are very sorry this happened to you, we care about you.” Any additional information conveyed must be limited to the facts known at the time. Usually, it is too soon to say, “This is what happened…” or “We take responsibility.” It’s important to avoid speculation of the facts as it can lead to confusion and an inaccurate understanding of the event. However, this perceived “lack of information” has the potential to breed significant distrust between the provider and patient or family. It is our goal to protect patients and families from this feeling of distrust.
Any apology acknowledging a complete understanding of the facts, or even what is thought at the time to be an appropriate acceptance of responsibility, should usually await a thorough investigation. However, at the time of the initial disclosure and apology of sympathy, the patient and family do need to be assured that the providers will investigate the event with the intent of sharing the information from the investigation with them. We also encourage the patient and family to ask questions and express concerns, as this can help inform our investigation. Patients and families become participants in the investigation, and this is how a foundation is created for maintaining a trusting relationship.
The next step in the process is determination of the facts, evaluation of the care provided, and identification of any breach of duty that may have caused harm to our patient. This investigation is an essential and meaningful element of any subsequent apology allowing us to inform our patients with transparent, accurate and honest information. Patients and families want an explanation. They need and are entitled to understand what happened and why. This part of the apology process is often referred to as acknowledging the offense and also includes validation or recognition of the impact on the patient and family regardless of responsibility.
The timing of this subsequent apology with factual information should be determined with care and attention to the patient’s or family’s individual needs. As the provider, we may want to move forward quickly and complete our apology process because we are ready, however sensitivity to the patient and family’s readiness is essential to allow for successful exchange of information. Sometimes multiple meetings or exchanges are necessary regardless of whether or not there is determined to be medical error causing harm.
The final step in our CARe process is to work with our patient or family to find a resolution that helps to repair any harm done. A promise to prevent the event from happening to others is often well received. Reparation or compensation may help to restore the loss. However, we have found that many times, promises and compensation by themselves fail to achieve genuine forgiveness. An honest, humble, one-on-one apology usually contributes significantly to restoring trust and respect between provider and patient or family, and sometimes that is all patients and families want or need.
On a final note, the apology frequently contributes to healing not only for patients and families but also for providers who have feelings of remorse and responsibility for any harm he or she may have caused. The offering of an apology helps to restore the provider’s sense of self-worth and confidence in their practice, and provides a small measure of courage to continue giving of him or herself to patients.
Apologizing for a medical error is always challenging but has great potential to heal and restore.
Heather Beattie, Director of Clinical Safety and Risk Management, Baystate Health, and Mary Ryan-Kusiak, Risk Manager, Baystate Health.