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Hospitals Find a New Way to Say 'I'm Sorry'

The Wall Street Journal. logo The Wall Street Journal. 2/1/2016 Laura Landro


While operating on Gary Avila’s arm last year, a surgeon at Stanford Hospital accidentally nicked a nerve, causing an injury that affected the use of his hand.

Mr. Avila’s injury was resolved through a Stanford program known as Pearl, short for Process for Early Assessment, Resolution and Learning. In addition to an apology, an explanation of what had gone wrong, and a waiver of his medical bill, Mr. Avila received a monetary settlement that both sides agreed to keep confidential to compensate for his pain and suffering.

Stanford’s Pearl program is serving as a model for more so-called communication and resolution programs that hospitals are adopting to interact with patients when things go wrong and avoid costly litigation.

While Stanford in Palo Alto, Calif., and a handful of other large medical centers began adopting the practice more than a decade ago, the approach never caught on widely. Risk managers at hospitals have been leery of making financial offers unless they are sure a suit is about to be filed. And doctors and other medical staff are often reluctant to admit errors and apologize for fear of their own liability and disciplinary action, says Thomas Gallagher, a professor of medicine at the University of Washington, in Seattle.

Hospitals are more receptive to the idea now as they come under pressure from accrediting groups, patient safety organizations and lawmakers to be more transparent about errors and analyze them carefully to prevent them from happening again. Evidence has accumulated that the approach can improve patient safety and substantially reduce malpractice costs. At Stanford, for example, from 2009 to 2014, after Pearl was implemented, the frequency of lawsuits was 50% lower, and indemnity costs in paid cases were 40% lower compared with 2003 to 2008. (Last month, Stanford changed the name of the Pearl program, which had been called Process for Early Assessment and Resolution of Loss. It says “learning” better reflected the process, which includes learning from adverse events, than “loss.”)

More states are adopting laws that cap damages in malpractice cases, reducing incentives for plaintiff’s attorneys to file suit. And some state laws allow doctors to say they are sorry without the apology being used against them in court as evidence of wrongdoing.

The Collaborative for Accountability and Improvement, which is run by Dr. Gallagher, is based at the University of Washington and includes Stanford, Beth Israel Deaconess Medical Center in Boston and the University of Michigan, as well as malpractice insurance providers and patient safety organizations. It is working to spread communication and resolution programs through training seminars. The federal Agency for Healthcare Research and Quality has funded several communication and resolution demonstration programs in recent years and plans to offer a guide to help hospitals create their own.

The programs require a commitment from hospital administrators and physicians to be transparent about risks and adverse events. Patients can still seek legal representation at any time.

Hospital staff are trained to report problems as soon as they become aware of them, without fear of punishment. Hospitals are expected to use findings from investigations to put preventive measures in place. To encourage participation doctors may be offered a reduction in their malpractice premiums.

Communication and resolution programs can offer financial compensation to patients who experienced harm or distress, even if an investigation determines the standard of care was met. At Stanford, patients may receive up to $5,000 to cover out-of-pocket expenses.

“Sometimes we recognize that patients need to heal and need answers, and even if we aren’t obligated to provide compensation, it is still the right thing to do and we want to make them as whole as possible,” says Jeffrey Driver, chief executive of the Risk Authority Stanford, a subsidiary of Stanford Health Care and Stanford Children’s Health providing risk-management services to Stanford’s health-care institutions and other clients. The Pearl program, which he oversees, analyzes adverse events and classifies them on a severity scale to determine fair compensation if needed.

Emotional support for patients and families is a big component. Patients like Mr. Avila at Stanford often hear first from someone who has been in their shoes—Leilani Schweitzer, assistant vice president for communication and resolution.

Ms. Schweitzer’s 20-month-old son, Gabriel, died of complications from hydrocephalus, or water on the brain, at Stanford’s children’s hospital in 2005, when the Pearl program was just getting started.

An investigation found a nurse turned off an alarm, thinking it would be silenced only in his room so he and his mother could sleep. But because of a problem with the alarm-system programming, it was also turned off at the nurses’ station. As a result, no one came to Gabriel’s aid when a shunt in his brain failed, leading his heart to stop beating.

Despite her devastating grief, Ms. Schweitzer says she was struck that hospital administrators immediately admitted the error, apologized, answered her questions and promised they would make sure it never happened to another child. She used a financial settlement (its amount undisclosed under their agreement) to start a nonprofit to help families with hydrocephalus and became a vocal patient safety advocate.

After serving as a consultant to the Pearl team for three years, she joined the Risk Authority in her current role in 2015.

Ms. Schweitzer talks with patients by phone and meets with them in person, often accompanied by Abdul Hamamsy, interim vice president of claims and litigation operations at the Risk Authority Stanford.

Mr. Avila, a 64-year old pastor who lives in Palo Alto, Calif., says that he had suffered through several difficult surgeries in the past, and the new injury was “painful beyond words.” He says he hadn’t considered hiring a lawyer because friends warned him going up against Stanford would be tough, and he was initially skeptical when approached by Ms. Schweitzer.

But the sincerity of the apology she gave, expressing regret and acknowledging his suffering, “was the first time anyone ever said ‘I’m sorry’ ” after a difficult hospital experience, he says. He learned of Ms. Schweitzer’s own loss by looking her up online after their initial conversation. “I was overwhelmed that she had gone through this, and now she was so kind and compassionate and reaching out to a patient who had a difficult time,” he says.

Stanford’s investigation found the nerve injury was an “unanticipated outcome” of his surgery—one that isn’t intended but not necessarily the result of error or negligence—and classified the nerve injury as “permanent minor” on its severity scale.

Stanford waived Mr. Avila’s bills and offered compensation. The entire process took six months, as they discussed issues including his loss of income from being unable to work. Physical therapy has helped improve the use of his hand and he is back to work part-time.

“I’m not fully recovered, but well on the way and very happy with the outcome,” Mr. Avila says.


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