Sorry Works! at ASHRM — Booth #507 & Industry Spotlight Presentation

Sorry Works! Founder Doug Wojcieszak will be at next week’s ASHRM meeting in Anaheim, CA (October 26th-29th).  Wojcieszak will be at the booth of our partner The Sullivan Group – Booth #507 — Sunday evening and Monday & Tuesday.  Sorry Works! has developed two on-line disclosure training courses with The Sullivan Group.   We have an Introductory/Just-in-Time disclosure training video and a CME-accredited Disclosure Fundamentals course.   Please stop by Booth #507 to learn more about these great courses which teach disclosure to your front-line staff and also new hires down the road in an economical and scalable fashion.

As part of ASHRM, The Sullivan Group and Sorry Works! will be providing an Industry Spotlight presentation on Monday, October 27th from 12:40 to 1pm in Exhibit Hall C.  The title of the presentation is “Empowering Clinicians with Risk, Safety, Quality Solutions,” and the speakers are Brant Roth, Doug Wojcieszak, and Arnie Mackles, MD, MBA, LHRM.  Please be sure to put our presentation on your schedule.

We look forward to seeing many of you in Anaheim next week!

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Baystate Health Story: Disclosure/Apology Programs & the Media

Below is a story about disclosure at Boston-area hospitals. The reporter interviewed Dr. Evan Benjamin who is the leader of the Baystate Health disclosure program. It’s a pretty good article….Dr. Benjamin said his disclosure program had reviewed 100 cases and decided six cases warranted a full apology. However, unfortunately, Dr. Benjamin was not ready to answer certain questions about his disclosure program. Consider the following section from the article:

“Benjamin, though, was not prepared to be completely transparent in our interview. He would not say how many resolutions included money, nor the amounts, which are paid by the hospital’s insurance — a Baystate-owned company. The hospital also declined to give out contact information for any patients or doctors involved in an error. And Benjamin said he couldn’t remember any case details.

I’d have to pull up my data,’ he said during the interview. ‘I’m not prepared to do that…. I’d have to get my staff to pull those particular cases.’”

Ouch!

First rule of dealing with the media is they like stories. Reporters are basically story tellers, and they often want more than facts, figures, and charts. Don’t tell us about how you operate a dog rescue agency that saved 1,000 dogs over the last five years, no, show us Lassie who you found covered on the side of road with three broken legs, covered with dirt, flees, and ticks, nursed him back to health, and then you found a really nice family to adopt Lassie, etc, etc, then tell us about the 1,000 dogs you saved over the last five years and other great facts and figures about your organization. Understand how the game plays? You give something then you get something.

Second, I understand how 100 cases of care that went wrong might translate into only six cases of apology, meaning a compensable error occurred. Personal injury lawyers will understand this batting average too, as most PI lawyers only accept one case out of 100 that walks in the door. However, the public might not understand, and my gut reaction is the average person who reads this article may be thinking those other 94 cases were just covered up. This needed to be wordsmithed and, yes, spun differently. Consider the following:

“During the life of our disclosure program, we have reviewed 100 different cases where the care did not go as planned. In each of those 100 cases we shared the results of the review with the patient or family. Six of the cases actually involved a medical error, we apologized to the patient or family, and worked to resolve these cases in a fair and just manner.”

Here’s another a rough area in the news article:

“Benjamin said during our interview he did not know whether families accepting the hospital’s resolution must agree not to sue, but a Baystate spokesperson later confirmed that is a condition.”

Another rule in dealing with the media is know your facts cold. Be the expert, and part of being the expert is anticipating the questions that will be presented to you and have your answers prepared ahead of time. Otherwise, reporters can become skeptical and think you are not being straight with them.

We have always encouraged you to think of the media (along with regulatory people, PI lawyers, and politicians) as one of the stakeholders in your disclosure program. Don’t be afraid to discuss your disclosure program with reporters and also editorial boards. In fact, talking with reporters is one of the ways we educate our patient/family population about our disclosure programs. However, be prepared for interviews and editorial board meetings. Have stories to share and know your facts cold. Don’t fly by the seat of your pants.

Lastly, when looking at the article below see at the very end of the piece where the reporter asked two other hospitals how they handle medical errors. One hospital would not discuss their approach, and the other hospital said they wanted to do disclosure & apology but the insurance company said no.

Geez….we have so much work to do! In this vein, Sorry Works! is hosting a “train the “trainer” webinar on November 13th at 1pm ET/10am PT. To learn more and register, click here.

Sincerely,

- Doug

Doug Wojcieszak, Founder

Sorry Works!, 618-559-8168

 

*****************************

 

Hospitals Step Up Apology Process Around Medical Errors

by: Karen Brown, NEPR, October 2, 2014

Massachusetts’ Department of Public Health reported 753 cases of serious medical errors at hospitals last year. Patient safety advocates say the best way to reduce medical errors is for hospitals to openly acknowledge mistakes and learn from them. But the fear of malpractice lawsuits has gotten in the way of that. A couple years ago, Massachusetts passed a law that supports a more open apology process. Now, two hospital systems, Baystate Health and Beth Israel Deaconess, are taking that process one step further.

Historically, if a patient was given the wrong medication, or had the wrong leg operated on, or suffered from some other medical misstep, most hospitals would kick into a mode known as ‘deny and defend.’

“There was really quiet about what happened,” says Dr. Evan Benjamin, who oversees patient safety at Baystate Medical Center in Springfield. “And the only way for patients to get attention around what they believe was a medical error was to sue the organization.”

Benjamin says ‘deny and defend’ rarely gets patients or doctors any closure, and it doesn’t make hospitals safer. So he and his colleagues wanted a better approach — one that addresses what he says patients and their families really want after a medical error.

“They want the truth,” he says. “They want to know what happened, and how they’re going to be care for. They want an apology,……They want to know what’s been learned so it won’t happen again. And finally, …they’d like to understand about compensation for experiencing a medical error.”

In 2013, Baystate and Beth Israel launched an effort that Benjamin says offers all those components. The CARe program — which stands for communication, apology, and resolution — was modeled after an approach pioneered at the University of Michigan. Over the past 14 months, Benjamin says, Baystate administrators reviewed 100 cases where the care did not go as planned, and decided that 6 of them warranted an apology and resolution. Benjamin says this came after a decade of encouraging doctors and nurses to report their mistakes or near-misses within the hospital.

“Once you have a culture where you’re asking people to report errors and being transparent,” Benjamin says, “being transparent to patients is the next logical step.”

Benjamin, though, was not prepared to be completely transparent in our interview. He would not say how many resolutions included money, nor the amounts, which are paid by the hospital’s insurance — a Baystate-owned company. The hospital also declined to give out contact information for any patients or doctors involved in an error. And Benjamin said he couldn’t remember any case details.

“I’d have to pull up my data,” he said during the interview. “I’m not prepared to do that…. I’d have to get my staff to pull those particular cases.”

But later in the interview, Benjamin did recall one of those cases — in which an elderly woman’s medication was mismanaged after she was transferred to a nursing home. He says, in that case, the family accepted a resolution — without money.

“It was really about how that family wanted to make sure they were involved in the improvement of when patients are transferred. how can that be improved,” he says. “They wanted others to hear what happened. and then we talked about how we could have improved her management as a result of it.”

Benjamin said during our interview he did not know whether families accepting the hospital’s resolution must agree not to sue, but a Baystate spokesperson later confirmed that is a condition. Some malpractice attorneys have suggested this could put patients in a vulnerable position, but Charlotte Glinka, executive director of the Massachusetts Academy of Trial Attorneys, says she wishes more hospitals had similar apology programs.

“We are obviously very much in favor of doctors being forthcoming with their patients about errors or things that are unexpected,” Glinka says.

Glinka’s organization worked on the 2012 Massachusetts law that makes most medical apologies inadmissible in court. It also requires a 6 month cooling off period before a patient’s family can sue a hospital — time that can be used to work on a resolution.

“In some instances that’s going to make sense for the patient to have an early resolution, to not be involved in a lawsuit that could take 3, 4, 5 years,” Glinka says. “But there may be someone who’s very severely injured and what the hospital is offering just may not be adequate.”

Dr. Benjamin says Baystate patients are encouraged to have a lawyer present during the apology meetings. He says five of the six families approached accepted the hospital’s resolution — and one decided to sue instead. But he says the hospital is not just trying to avoid lawsuits.

“Honestly, the motivation has been to improve patient safety, to do the right thing, by our patients and families,” he says.

And to do right by doctors. Benjamin says he cannot point to any specific safety improvements that have come directly out of the CARe program. But he says doctors and administrators are learning how to conduct better apologies.

“A good apology is one from the heart,” Benjamin says. “It’s an apology for the experience — an apology that says, ‘I made a mistake. We made mistake. We are sorry for that.’ As opposed to an apology which is – ‘I’m sorry that happened to you.’”

Insurers have done studies that show effective apologies can reduce the number of lawsuits, although Stephanie Sheps of Coverys Insurance — which supports the CARe approach — says they still expect to pay the same amount in settlements.

“The real benefit financially comes to the efficiency, of being able to resolve claims more quickly,” Sheps says.

Sheps says insurers that used to be skittish about too much disclosure are now embracing apology and resolution programs. That’s good news to patient advocates. Paula Griswold of the Massachusetts Coalition for the Prevention of Medical Errors says she’s hoping more openness leads to safer hospital practices — though it may take a while.

“I think what everybody is aiming for is….more reporting of events,” Griswold says, “and a greater sense of safety among the clinicians that they won’t have their career destroyed.”

So far, apology and resolution is not yet standard practice. A Berkshire Medical Center spokesperson says he’s never heard of the CARe program, and was not willing to say what kind of approach the hospital takes with medical errors. The patient safety director at Cooley Dickinson Hospital in Northampton says they’ve moved towards a more open apology process, but as for resolutions offered by the hospital — he says their insurance company wouldn’t allow it.

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Risk Manager Remembered Through Donation to Sorry Works!

Sorry Works! was recently contacted by Illinois Risk Management Services (IRMS), which is part of the Illinois Hospital Association. IRMS’ long-time Director of Claims and Risk Management – Mr. Sydney Gross – had passed away, and IRMS wanted to find a way to remember him. Syd was an early supporter of disclosure and apology, so IRMS chose to give Sorry Works! a $1,000 donation in Syd’s memory. In appreciation, Sorry Works! provided to IRMS 100 copies of the Little Book of Empathy customized with a tribute to Syd along with his picture. IRMS distributed the customized books at their recent annual conference.

Donations to Sorry Works! provide the support we need to continue producing our e-newsletters and to keep our website current and useful to our readers. The Sorry Works! e-newsletters are distributed weekly to over 3,000 healthcare, insurance, and legal professionals, and the Sorry Works! website receives over 600 unique visits per day. We encourage you to provide a donation by clicking this LINK.

Below is the tribute to Sydney Gross – we all need to follow Syd’s example. We thank Illinois Risk Management Services for their generous donation in memory of their colleague and friend and we appreciate their continued support of disclosure and apology.

 

“Sydney A. Gross was a pioneer in the fields of risk management and patient safety. He helped to establish the Illinois Provider Trust in 1979 and served as the Director of Claims and Risk Management for the Illinois Provider Trust and Illinois Risk Management Services for 16 years. He advocated for early reporting of adverse events and embraced the philosophy of disclosure to patients long before it became the norm. He believed in early intervention to meet patients’ concerns and being fair but firm. When patients are harmed, they need an apology and Syd always said, ‘Don’t be afraid to say you are sorry.’

Syd believed that a good risk management program does more than just minimize losses, but rather, it enhances quality patient care and safety. He was a leader and innovator in risk management and instilled in many of us a true appreciation of the value of proactive risk management.

He is greatly appreciated for his many years of service and contributions to the field of risk management, and will be greatly missed.

From his friends and former colleagues at Illinois Risk Management Services.”

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“Train the Trainer” Webinar on Disclosure – November 13th -

At Sorry Works, we continue to receive a lot of inquiries from hospitals and insurers that need disclosure training for their front-line docs and nurses, but, too often the conversation stops when we hear the following: “Our education budget has been cut this year” or “The CFO said ‘no’” or “I just can’t get the attention of the c-suite.”

We understand.

The healthcare industry is going through massive changes & challenges…reimbursements are down while providers adjust to getting paid for quality instead of quantity, and c-suite personnel are busy purchasing physician practices while contemplating mergers with other hospitals. Busy & challenging times.

But the need for disclosure training doesn’t go away during challenging times. We still need to teach risk, claims, legal, and physicians and nurses what to say and do following an adverse event. And while face-to-face training is always preferable, we can accomplish much via webinar and make it affordable so you don’t have to bother the CFO.

Sorry Works! will be offering a disclosure training webinar led by Doug Wojcieszak on Thursday, November 13th at 1pm EST/10am PST. The webinar will go for up to two hours….about 1 hour of presentation time and up to 1 hour of discussion and questions. You will see and hear the slide deck we use to teach front-line staff in the field, and be educated so you can do the same with your physicians, nurses, and other clinicians. This will basically be train-the-trainer, so it’s perfect for risk, claims, physician leaders, nursing managers, and attorneys.

The cost will be $249 per line, and include five (5) copies of the Little Book of Empathy. You can also receive a taped copy of the presentation for the same cost, or order a live line with a taped copy for $349.

Here is the LINK to register for the webinar. If you have questions, please call 618-559-8168 or e-mail doug@sorryworks.net.

 

 

Sincerely,

 

-Doug

Doug Wojcieszak
Founder Sorry Works!
PO Box 531
Glen Carbon, IL 62034
618-559-8168

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Question from Road: Power Dynamic & Measuring Fairness?

During a recent Sorry Works! presentation I received a very interesting question from an audience member:

“What about the power dynamic between the hospital and a patient and/or family? The hospital has more knowledge, experience, and resources handling adverse events…how do we keep the power dynamic from getting out of hand during the disclosure process? Also, what about fairness? How do we know we are being fair when we try to resolve an error? How do we know our early offer compensation is reasonable as opposed to taking advantage of vulnerable people who don’t know what to ask for or don’t know what they are entitled to? How do we measure fairness?”

Great questions. Important questions.

When a legitimate medical errors occurs, whereby it was proven by a credible and expedited review, many risk managers are disclosing the error, apologizing, and then turning the conversation back to the patient or family: “Mrs. Smith, again we are sorry for the harm we caused your husband and family…it was our mistake….how do we make this situation right by you? What do you need us to do?” This is a good approach…you can find out what is important to patients and families. It’s not always money, and if it is money it’s not always “jackpot justice.” Every case is different. Some families will focus on the emotional fixes such as remembering their loved one in a constructive manner, getting involved in patient safety at the hospital, etc. You never know until you ask. However, you have to be careful, because as suggested by the person who raised the question above, patients and families often don’t know their needs or what they can legitimately ask for. Patients and families often don’t think about their needs five or ten years down the road. Or, I once had an educated consumer express shock to me that hospitals have insurance to cover medical errors! She literally had no idea. Indeed, there is a large knowledge and experience gap between hospitals/insurers and consumers when it comes to addressing medical errors.

Have to be careful not to take advantage of people! It can be tempting to get out of a $200K case for trinkets because you said “sorry” and family is no longer angry at you, but you have to assume that the patient or family will go back to their family members, friends, neighbors, co-workers, etc and share how the hospital handled the situation and more than one person will say some version of the following: “That’s all they gave you?! You got ripped off!! Should have talked with my attorney!” You don’t want to develop the reputation of ripping off vulnerable people or your disclosure program will eventually fail because patients and families will know not to talk with you post-event. Remember to keep your eye on the big picture…disclosure is not about getting out of one or two cases on the cheap.

So, how do you be fair? Tell patients and families they have right to legal counsel upfront. Better yet, educate local PI attorneys about your disclosure program and how you want to be pro-active and collaborative post-event with patients and families. I know this will feel awkward, like you are inviting the enemy in, etc, but this bold move will build the credibility and success of your disclosure program. Some hospitals even recommend to patients/families the names of local PI lawyers who will be receptive (not the patient or family will always listen to the advice). If the family does not want to be represented, that is fine, that is their right….so you have to work harder. Again, remember, this family sitting across the table from you will re-tell the story multiple times of how you treated them during the worst moments of their lives. So, again, it is OK to turn the conversation back to the patient or family, but if they don’t know what to ask for or seriously undervalue their case, you may need to push back: “Mrs. Jones, we are happy to provide what you asked for, but we owe you more…your case, your situation, is worth more. We suggest XX.” OR “You seem to be struggling what to ask for….may we suggest the following…”

If the family pushes back and says,The money is not important….we are more interested in making the hospital safer, etc, go with it. At least you’ve tried and no one can say you took advantage of vulnerable people.

But, what if the family goes in the other direction…they think a $100K case is worth $1 million, for example? Keep talking…try to learn why they think the case is worth $1M. Maybe there are some things about their situation you don’t know about that truly does raise the value, or maybe they are just angry. If the family is represented by counsel, the attorney may step in and help the client understand the true value of their case. If they are not represented and the case is only worth $100K, be polite but firm, “I am sorry, Mrs. Jones, this is what is fair for your situation…we encourage you to review this offer with an attorney of your choosing, and please get back to us.” This is why we share the details our disclosure program will local PI attorneys because they may help guide families.

Hey, remember, Thursday, November 13th, 1pm ET/10am PT is the “train the trainer” webinar being given by Sorry Works! Great chance for c-suite, risk, claims, legal, and medical leaders in your organization to learn about disclosure and apology. Click on thisLINK to learn more.

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Sorry Works! to have booth at PA Risk Managers Meeting this Friday

Sorry Work! will have a booth at the Pennsylvania Risk Managers annual meeting tomorrow and Friday in Harrisburg, PA….Sorry Works! is also sponsoring the meeting.  Very excited about this meeting, as Pennsylvania just recently passed an apology law.  I think a lot of people in the Keystone state are anxious to get disclosure started, and Sorry Works! will be there to help!

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Mom Shares Daughter’s Death & Need for Disclosure

Late last year I did a disclosure presentation for an insurer, and immediately before my speech they shared a video with the audience entitled “Jess’ Story.” The video was the tragic story of a young woman – Jessica Barnett, or Jess – who died because her doctors did not listen, and then litigation – not disclosure – followed. The video was narrated from the perspective of the now-deceased Jess and it was incredibly powerful.  It’s one of those videos that just makes you stop and watch.  Over 40,000 people have viewed this video on YouTube, and it has become a teaching tool for medical and nursing students.

Well, this summer I met Jess’ Mom, Tanya, via Facebook, and I invited her to share her story with the Sorry Works! audience.  Below is the text given to us by Tanya last week. Included in the text is the link to the same video I saw before my speech for the insurer.

Chasing Safe — Honoring a daughter taken by medical harm by Tanya Rempel Barnett

I am here, and she is there. And there are times when sharing her story, the weight of it all, pulls me down, even under. Only sometimes, but it does. Her goneness has left a void that grows with each passing year. Sometimes its silence is deafening, and sometimes it speaks to me softly. Sometimes it roars, guttural in sound. And this void, and my pain, are entwined in the push-pull of its continual movement.

 

Although the part of her dying, what lead to it and how it was handled, is a fixed point in time that separated our lives into before and into after. And my journey, like anyone’s, is ever evolving. Pieces are added as they are lived, experiences processed and learned from (when courage can be found), and thoughts of all those yet-to-be moments imagined, some not. A reach/pull-back existence is one that I’ve been left with; I reach out to others, live and love, press for changes, then retreat to heal and recharge. It’s cyclical in nature, this reaching and pulling back. And it needs to be for me to honour her in this way.

 

I’m a visual person, and that’s why chose to create a video of Jess’ ill-fated journey through healthcare. Although I’ve done extensive writings around her death and the needed changes to save lives, I love the deeper connection made through these images between my daughter and the viewer. The video brings everything together in one place; the how, what and why, all wrapped up in the power an emotional connection. So, click on the link below to view her story, but before you do, there are a couple of things you need to know about my daughter.

 

  • Her name is Jess, and it always will be
  • There would have been 18 candles on her cake later that week
  • She hated salmon, but loved jujubes, and really loved cheesecake!
  • Her parents will always have 3 children
  • Just cause you can’t see her, doesn’t mean she isn’t still here
  • Although they don’t show it, at times her brother and sister still struggle
  • She loved children, and she was the best kind of friend
  • She could be loud, really loud!
  • People always say she was kind and loving (sometimes annoying too…)
  • She is honoured each time her story is viewed, each time a doc thinks twice
  • Jess is like an echo; still here long after the source is gone

https://www.youtube.com/watch?v=t6mr3gxXx64

 

You’re back. Catch your breath, and then we’ll go on.

 

So, it’s sad, and needless, isn’t it? And sometimes, even now, I wonder how I got to this place, how my life came to be resting on the edge of this challenge. Looking at my patient safety contributions over the past seven years since her death, it just makes my head hurt… and my heart weeps for her and all that’s been lost. At times, my spirit is tired, so tired of dealing with it all. But part of me is also proud of what I’ve done, and I’m hoping Jess sees it that way too.

 

So, here’s what I’ve done so far:

 

I launched email-writing campaigns (some even replied), had meetings (and more meetings) with patient safety folks, government officials, physicians, hospital CEOs, other families who had been harmed, anyone who showed an interest. I raised awareness as I talked with people in waiting rooms, and online, in planes and at bus stops. I even continued a conversation with a woman in the restroom, slipping my ‘I am Jessica’ card under the stall. Anyone, I spoke with anyone who’d listen, anyone who didn’t walk away. I joined Facebook groups, asked questions, and researched late into the night. I created a set of recommendations relating to her care, which have been accepted by many I’m told, but not by her docs. I cried a lot too through these times, for my girl, and for the frustration of it all; why was I having to do this work in the midst of my grief? I stood, fist at my sides, but soon realized, who better to do this than the mamma bears of this world. And my resolve would be strengthened.

 

I spoke at conferences, gave media interviews (eventually becoming a go-to person in our province for comments about safer care), encouraging those who’d also been harmed to share stories and strategies, helping them feel supported, and heard (which often doesn’t happen in healthcare). I worked independently and with patient safety groups; Patients For Patient Safety Canada and the Canadian Patient Safety Institute (CPSI ), and The Empowered Patient Coalition. Many articles and letters, and the beginning chapters of a book, were written and re-written. Word followed word until the screen became blurred (at times, I’ll admit it, balance was fucked ). Art installations were imagined and dreamed into life. I built bridges between patient and provider (no torching by design). In the early years of my grief, I lead a bereavement group called , helping not only myself, but others to heal. I became a WHO patient safety champion. And wrote poetry, lots of poetry. And all the while, was supported by family, and special friends. And it takes a special kind of friend who’s able to read the autopsy report of a child… it does, it really does.

 

I developed the website, and created a video of her story. And was one of many used by CPSI in helping to champion the patient’s voice. I created word and video that gave a voyeuristic look into the life of a family dealing with the fallout of medical harm, and how this system continues to harm us. I watched with amazement, as Jess’ video was viewed more than 40,000 times on YouTube! And even more so, when it became a teaching tool used in one country after another. It’s been used at patient safety conferences on two continents, and in lectures to encourage med students to understand the real cost of medical harm. I’ve encouraged healthcare to embrace their own humanness of making mistakes (it’s not if but when, and it’s what you do with those mistakes that’s important). And all the while my husband-slash-backer (emotional and financial), well, he had my back! Advocacy on this level, if we’re honest, takes an incredible amount of time and energy, and headspace. And money; let’s face it, someone had to work! He read every word that I wrote, listened to me anguish at the latest door closed, and cried with me over every photo used in her work. I offered forgiveness, first to myself, and then later to them. And like my husband says; it was much easier to forgive them for her death, than it was to forgive them for what happened after. As a counsellor I helped others to begin healing, and became a mediator in hopes of sparking a more healing process, an alternative to adversarial litigation for cases of malpractice. And one day we will, we really will. Deep breath…

 

I shake my head, and marvel at it all; where did the energy come from to advocate for those who could not? Where did the optimism, the perseverance, the glass-half-full mindset that continued to buoy me as door after door was slammed in my face, coupled with years of requests to meet with her doctors were denied, time and time and time again? And where did the strength come from that saw me climb out of the muck and the ooze of that dark hole of my grief? And where did I garner the strength to continue to live and love well, to remember I still had living children after all? And remember, I did this all while my grief sat heavy and sour with the weight of a stone rammed deep in my soul Where?

 

Where did it all come from?

 

Perhaps it was the unfairness of it all, the indifference we faced, and our real concern that more children would die if changes weren’t made. Maybe it was even the ‘don’t you dare walk away from us!’ indignity that kept me going back, and that smoldering desire to be heard was kindled into this raging bonfire called advocacy. And it’s reasonable to suspect that my naivety in thinking it would be easier than it was, pushed me forward, sent me on. For I’m guessing that if we really knew what we faced, most of us advocates would’ve stayed home on the day of the big race.

 

All of these reasons have merit, they do. But the one that made top of my list (I’m sure you can guess) as to why I became the ‘tortoise’ (not the hare) in this race, was to honour my girl, who’s loud I’ve now borrowed. And thanks to her, I’m no longer afraid, and I’m no longer quiet.

****************

Thank you for sharing, Tanya.

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Surgeon Admits Error; Insurer’s Attorneys Balk

 

Caroline Carcerano went to Tufts Medical Center last November (2013) for what she hoped would be a brief procedure to relieve back pain. She died instead. The surgical team inserted a dye into her spine that is not supposed to be injected in the spine, and Caroline died the following day.

Caroline’s surgeon was candid and apologetic, telling Caroline’s sons that “a mistake was made….we gave her the wrong dye,” according to the Boston Globe. But, then, eight months later — eight months! — Caroline’s sons received a letter from the attorneys representing Tufts’ insurer saying the surgeons and pharmacists were not negligent. The Boston Globe reported the following: “Her sons, Michael and Stephen Carcerano, found the letters baffling. ‘A mistake was admitted, and now they’re saying it’s not their fault,” Stephen Carcerano said. The brothers filed a lawsuit three weeks ago in Suffolk Superior Court against the hospital and 12 pharmacists, nurses, and surgeons. The insurer made a settlement offer soon after the Globe inquired about the case, said William Thompson of Lubin & Meyer in Boston, which is representing the family.”

The Boston Globe article is linked below, and it’s pretty clear that medical errors did indeed occur. The Globe article discusses numerous safety measures enacted by the hospital in the wake of this tragedy. But, it took eight months after the initial disclosure — eight months! — to contact the sons again, and the contact came in the form a letter from some attorneys saying, “Nah, we didn’t kill your Mom,” only to quickly settle the case after a newspaper starts poking around?

Clearly, we need to do better.

This is the MAJOR break down area for many hospitals and insurers. The bedside and initial disclosure efforts are good and sincere, then everything gets gummed up. Things drag out, nobody stays in touch with the patient or family, the investigation or review takes forever and does not involve the family, and sometimes even clear cut cases of error are handled by defense attorneys or claims managers who were taught to never throw in the towel. Weeks and months pass, families become angry all over again, and they start plotting revenge in the form of lawsuits, complaints to regulatory authorities, and tips to reporters and bloggers.

Look, the time to talk about how events will be handled is long before any event happens. Talk with your insurer(s), defense counsel, and risk and claims managers. Get them all in the same room and discuss several different scenarios. The best disclosure training seminars have all of these people in the room. Get everyone on the same page, and, if someone refuses to join the party fire them. There are still many “old school” defense attorneys and claims managers who were literally taught to never throw in the towel, and they will kill your disclosure program. So, put them out of your misery and develop your disclosure program with the right people.

Caroline Carcerano’s case could have been resolved in a few weeks, but to do so requires a functioning disclosure program. To help develop your disclosure program, remember the Train the Trainer webinar being held at 1pm EST/10am PST on Thursday, November 13th. For more information, see this link.

And here is the link for the Boston Globe article.

 

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New NPDB Language Helps Disclosure & “Train the Trainer” Webinar

Shortly before Labor Day, we shared with our Sorry Works! readers an important announcement concerning new language from the National Practitioner Data Bank (NPDB) that will help and encourage disclosure.  Since many of you were still on summer schedule, we thought it best to repeat this information since it is so very important.  Here is the new language from NPDB: “HRSA would issue guidance explaining that when ‘the provider initiates the settlement and no written demand for payment is made,’ no NPDB report is necessary.”

And here is an entire blog post we wrote about the new NPDB language: http://sorryworksblog.net/?p=794.   Be sure to read this blog post to understand everything about this issue.

Also, Sorry Works! is holding a “train the trainer” webinar on Thursday, November 13th at 1pm EST/10am PST.  This two-hour webinar will cover everything disclosure, and include lots of open time for Q&A and discussion.  Absolutely great training for risk, legal, c-suite, and physician and nursing leaders.  Also, with times being tight financially for healthcare organizations, this webinar offers an economical way to train your leaders on disclosure.  Put as many people around the phone as you wish.  Taped copies also available.  To register, visit this link: http://www.sorryworks.net/webinar-disclosure-training-train-the-trainer-cms-256.

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The Cross Family Disclosure Story — Teachable Moments

I have a story to share…actually two stories.

About a year ago Sorry Works! partnered with The Sullivan Group (TSG), a leading provider of on-line learning courses for healthcare professionals   It’s been a great partnership…last Fall we developed two on-line courses, a Just-in-Time trainer for front-line staff and a more indepth Disclosure Fundamentals Course for physicians, nurses managers, c-suite, etc.  We just started marketing these courses earlier this year, and have had a great reception.  We look forward to showing off these courses at ASHRM this year.

Well, in the midst of marketing these disclosure courses, Dr. Dan Sullivan, President and CEO of The Sullivan Group (TSG), had his own disclosure story.  Friends of Dr. Sullivan – the Cross Family – had a bad experience at a local hospital and wanted disclosure.  Unfortunately, the disclosure did not go well, but, there are several teachable moments from this story that can benefit hospitals and insurers.  It’s a very compelling story.  Dr. Sullivan dedicated an entire TSG newsletter about the Cross Family story and what other hospitals and insurers can learn.  I urge you to click on this link to read the Cross family story: http://sorryworkssite.bondwaresite.com/photos/File143.pdf

Thanks to Dan and the entire TSG team for sharing this story and their commitment to the disclosure movement.

To learn more about the TSG/Sorry Works! on-line courses, e-mail doug@sorryworks.net or call 618-559-8168.

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