|
|
|
June 27, 2008 NEWSLETTER
Doug Wojcieszak, Founder & Spokesperson
Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net
THIS WEEK'S EDITION:
- Odds & Ends
- Summer Reading
- Major Progress in Illinois
- Florida Update: Sorry Works! on FL Patient Safety Corp. website
- Sorry Works! Presentations
- "Sorry" Started in the VA
Special note for our readers: Sorry Works! will be taking next week off for the 4th of July holiday. We wish all of our American readers and supporters a safe, happy holiday.
ODDS & ENDS:
In this section of this week's newsletter we will share several tidbits of enlightening information with you, our readers. Enjoy!
- Birthday calls: Sorry Works! Founder Doug Wojcieszak recently made a presentation to the Northern New England ASHRM chapter, and during Q&A one of the risk managers in the crowd shared a story of how one of her doctors had a tragic adverse event in which a young patient died. The doctor put the young patient's birthday on his calendar and called the family every birthday to let them know he was/is thinking of them and has not forgotten their child. The doctor has never been sued.
- Park Nicollet Hospital: Earlier this year we told you about Park Nicollet Hospital in Minnesota and how they publicly disclosed and apologized for a surgery in which the wrong kidney was removed from a patient - leaving the cancerous kidney inside the patient. The disclosure led to much news coverage. A risk manager at the Northern New England ASHRM meeting shared the story of how her brother was a cancer patient at Park Nicollet at the time of this event, and her brother said (to her) he was in the safest place in the world and he continued his care at the hospital!
- Follow up on "duped:" Earlier this week we asked and answered the question "Are families being 'duped' by Sorry Works?" In response, a Sorry Works! friend wrote the following:
"One of the catch 22's that patients find themselves in when the provider has an early apology and settlement offer is that you probably won't know the full extent of your permanent disability or rehab costs for several years. Need settlements that have ongoing cost/compensation structure."
Again, this is why it's important for a patient/family to be advised of their right to legal counsel and for legal counsel to be welcomed into the disclosure process. Medical errors are literally emotional train wrecks for patients/families...they're not thinking long-term. They're just trying to make it day to day. However, a good attorney who is emotionally detached from the situation can guide the patient/family and make sure that all needs are fairly met in the disclosure process, including long-term needs that might not be readily apparent.
- Punishment: Recently we reported about a Tampa, Florida hospital that publicly disclosed and apologized for a wrong-side surgery. The news article contained the following line that troubled many of our readers and supporters: "Those who made the mistake 'will be subject to the appropriate disciplinary actions,' the hospital said in a statement."
Indeed, if there is a possible criticism or critique of the hospital for this disclosure, this is the spot. Yes, all reporting requirements must be met and followed, but disclosure must not take on a punitive tone towards providers. Mistakes will happen and support and healing is needed for sides, especially the providers. Good disclosure programs include support services for providers. Very important!
SUMMER READING:
As you get ready to head to the beach this summer, be sure to take along your flip-flops, sun tanning lotion, and a great book to read: The Sorry Works! Book. At $21.95 per copy it's affordable for any budget, and the book is the "how-to" manual on disclosure and apology. Get your copy today by visiting this link: http://www.sorryworks.net/booksoon.phtml . For bulk discounts, call 618-559-8168 or e-mail doug@sorryworks.net
MAJOR PROGRESS IN ILLINOIS:
It was reported last week at a meeting held by CAPS and the Chicago Patient Safety Forum that the Illinois State Medical Society and their insurer, ISMIE, are developing a disclosure task force. This is a major shift in med-mal thinking in Illinois, and should be welcome news for the Illinois hospitals that are moving towards disclosure but wondering how to incorporate ISMIE-insured doctors into their disclosure programs. Stay tuned for more information.
FLORIDA UPDATE: SORRY WORKS! NOW ON FL. PATIENT SAFETY CORP WEBSITE
Recently we reported that the Florida Patient Safety Corporation (FPSC) formally endorsed Sorry Works! FPSC was created by the 2004 Florida Legislature and whose Board of Directors includes the Florida Hospital Association, the Florida Medical Association, insurers and other key medical organizations in the Sunshine State. Now, FPSC has included Sorry Works! on their website on the home page, bulletin board, and professional resources page. We appreciate this exposure to the medical, hospital, insurance, and legal community in Florida. To visit the FPSC website and see Sorry Works, visit this link: www.floridapatientsafetycorp.com.
SORRY WORKS! PRESENTATIONS/NORTHERN NEW ENGLAND ASHRM AND LOS ANGELES
Sorry Works! presentations for the spring wound down with two great presentations over the last week to the Northern New England Risk Managers (ASHMRM) chapter and a major hospital in Los Angles, California. Also, Northern New England ASHRM purchased a copy of the Sorry Works! Book for each of their members. Requests for fall and winter presentations are coming in fast, so don't delay - book your Sorry Works! presentation today! Call 618-559-8168 or e-mail doug@sorryworks.net.
"SORRY" STARTED IN THE VA
A great story ran recently on Dr. Steve Kraman and his team at the VA and how they truly were the genesis of the disclosure movement. Read below.
Lexington Herald-Leader
Sun, Jun. 22, 2008
'Sorry' started here: VA began error disclosure
MANY HOSPITALS HAVE ADOPTED POLICY
By Jim Warren
JWARREN@HERALD-LEADER.COM
It was an afternoon in 1987. The two grown children of a Kentucky woman who had died a few weeks earlier at Lexington's VA Medical Center arrived to hear details of their mother's death.
The children, who thought their mother had died of natural causes, had been asked to bring a lawyer.
When they sat down, Dr. Steve Kraman, then chief of staff at the VA hospital, made a startling admission: their mother had died because of a medication error made by a hospital staffer.
That meeting was the first major test of a pledge that Kraman and officials at the Lexington VA had adopted about a year earlier: the hospital would disclose all medical errors even if it meant the threat of a malpractice lawsuit.
Today, that seemingly simple concept has become a model for many hospitals, medical insurers and health facilities around the country, as well as in some foreign countries. Major university medical centers -- including Johns Hopkins, Stanford and the University of Michigan -- have adopted all or parts of the program that started here. It also is standard policy at VA medical centers across the country.
The American Medical Association and the Joint Commission, the agency that accredits hospitals, both encourage disclosure of medical mistakes, following the general outline of the Lexington VA policy. And stories about the policy that started in the Bluegrass have recently appeared in the New York Times and other major newspapers.
The idea of a hospital "doing the right thing" by voluntarily admitting devastating medical errors might sound like insanity in today's litigious medical landscape. But hospitals that have tried the idea say it actually saves money by heading off expensive malpractice lawsuits and fostering rapid settlements of claims, often at amounts far less than would have been paid in protracted court battles.
For example, the University of Michigan Health System's chief risk officer recently told the New York Times that existing claims and lawsuits in the system dropped from 262 in August 2001 to only 83 in August 2007 after the university adopted a policy of full disclosure.
But things looked much less clear cut when Lexington VA officials made their first major disclosure that day in 1987.
Kraman recalls that the woman's children at first were shocked, then tearful, when they heard the story of how their mother had died. But if they had not made the admission, he said, the two almost certainly would never have known how their mother's death actually occurred.
"It was a situation where, in the tumult of taking care of a lot of patients, something was overlooked by somebody who otherwise was quite competent, and no one caught it," he said. "Once we had the evidence in front of us ... we knew we couldn't just sit on it. Our responsibility to the family outweighed the potential financial concern for the hospital."
'That felt good'
Ginny Hamm, who attended the meeting as regional counsel for the VA, said the family members were so grateful to get the truth that they and their attorney rapidly agreed to a settlement that cost much less than a lengthy lawsuit would have.
"The family members naturally were tearful and we had some moments of our own," she said. "But we told ourselves, 'That felt good; that felt right; this is the way we're going to do it from now on.'"
Linda Cranfill, quality director at the VA, says the disclosure policy actually grew out of a very down-to-earth goal -- saving money.
The Lexington VA had been hit with some large malpractice judgments in the early 1980s, totalling almost $2 million. Prompted by that, officials for the first time had launched a risk management program. The admission of the woman's death was the program's first big test, Cranfill said.
"We had started looking for a better way of doing things," she said. "Initially, the focus really was on protecting the institution. But it quickly moved to the next level of putting the patient and the patient's family at the top of the equation."
The Lexington VA made no public announcement of the new policy. Word really didn't start to spread until December 1999, when Kraman and Hamm wrote a report on the program for the medical publication Annals of Internal Medicine. Its title was "Risk Management: Extreme Honesty May Be the Best Policy."
The article got lots of attention -- partly because it came out right after a stunning federal report showing that medical errors were causing up to 98,000 deaths annually.
'Sorry Works!'
Suddenly, lots of doctors, hospital managers and news reporters wanted to know more about what the Lexington VA hospital was doing. Kraman recalled that news crews from around the country came calling, as did numerous hospital representatives, some from as far away as Australia. Hamm was invited to speak before medical groups, hospital associations and insurance companies in 39 states over the next two years.
Kraman said that while some doctors, and lawyers representing doctors, initially were taken aback at the idea of admitting errors, it began to catch on and facilities started adopting the VA program, or similar policies.
The Lexington VA never gave its program a name. But an Illinois publicist, Doug Wojcieszak, launched a program called "Sorry Works!" in 2004 that incorporated some of the main features of the VA program and advocated that doctors and hospitals fully disclose and apologize for medical errors.
Kraman, who now practices at the University of Kentucky, says some medical officials resist the idea of admitting errors. He noted that it's unclear just how many hospitals and medical groups have adopted disclosure policies because those that do often don't announce the fact.
"Some just don't want to talk about medical errors happening in their hospitals, no matter how they're handling it," he said.
Nevertheless, Kraman thinks medical disclosure will continue to be adopted by many hospitals and medical organizations.
"To me, the proof of the pudding is, would you do this even if you knew you could absolutely get away without admitting anything," he said. "If you could lock the information in a cabinet and walk away, would you still disclose it, even if you knew if might cost you half a million dollars?
"That's the question that really goes to the morality of a company or organization."
|
|
|
|
