DISCLOSURE€¦ · 1 Doctor Patient Communication Improving patient and physician satisfaction Ron...
Transcript of DISCLOSURE€¦ · 1 Doctor Patient Communication Improving patient and physician satisfaction Ron...
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Doctor Patient CommunicationImproving patient and physician satisfaction
Ron Hofeldt MDMedical Director
Wellness Develop Groupwww.WellnessDevelopmentGroup.com
855-205-4932
Ron Hofeldt MD
DISCLOSUREDISCLOSUREWe would like to disclose that
have no financial interests in any organizations that have a direct interest in the subject matter
of this CME presentation.
Objectives• Identify communication issues within the doctor-patient
relationship contributing to malpractice litigation• Discuss mutual value of improving doctor patient
relationship/communication• Describe common barriers to effective communication
following an adverse clinical eventfollowing an adverse clinical event• Highlight important considerations to preserving or restoring
the doctor-patient relationship when discussing adverse events or delivering bad news to patients or families
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Agenda• Discuss the impact and frequency of adverse events• Present factors contributing to lawsuits• Describe the value of effective physician patient
communication• Discuss apology and disclosure: types, style and content
MedicineA combination of complex science and intricate art
• Made in real time• No do overs
Decisions in medicine
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Modern Medicine• Characterized by:
– High volume– High acuity– High level of technology – High demandsHigh demands– High pressure– Lack of professional support– High complexity
Bad things happen
Survey results for Serious AEs•66% increase in anxiety re future errors•51% loss of confidence•48% decreased job satisfaction•48% sleep difficulties•15% harm to their reputation
Near misses56%36%34%
33%9%
Minor51%31%32%34%10%
Impact of adverse events
81% reported at least one of the above
Second victim
Gallagher, T. The Emotional Impact of Medical Errors on Practicing Physicians in the US and Canada, Joint Commission Journal on Quality and Patient Safety, August 2007
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• The Organization is deeply impacted, too- Excessive demands on staff: time and emotions
• Claims and Risk Management Departments • Administration and leaders
- Toll of responding to patients’ needs
Impact of adverse events
- Public relations issues
Third Victim
Impact of adverse events on clinicians
Relive the event
Anxiety
Guilt
Fear of litigation
Depression
Sleeplessness
Fear of judgment by colleagues
Emotional impact of adverse events
0 20 40 60 80
Anger
Professional self-doubt
Defensiveness
Loss of reputation
Consider career change
Use of substance
Percent of respondents who experienced symptomSymptom
The Impact of Perioperative Catastrophes on Anesthesiologists: Results of a National Survey/Adverse Anesthesia Events F. Gazoni, Intern. Research Soc. Mar 2012. V 114. No 3
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• Avoidance/Withdrawal• Guilt• Anger• Fear • Overcompensate
Emotional impact of adverse events
• Overcompensate• Shame
• 92% of the physicians had been involved with a near miss, minor or serious error
Frequency of adverse events
Gallagher, T. The Emotional Impact of Medical Errors on Practicing Physicians in the US and Canada, Joint Commission Journal on Quality and Patient Safety, August 2007
Adverse events are common• 2010 Inspector General study of hospitalized Medicare pts.
– Hospital Medicare beneficiaries: • 13.5% experienced an adverse event resulting in Temporary
Harm• 1.5% had an event that contributed to their deaths
– ~15,000 patients/month• 44% of in-patient adverse events were preventable
Tax Relief and Health Care Act
Levinson D, et al. Adverse Events in Hospitals Among Medicare Beneficiaries.OIG for DHHS Nov. 2010
• 44% of in-patient adverse events were preventable
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When an adverse event occurs, how is it viewed?
• Was the incident a–Wrongdoing, a blameworthy event, or a mistake
vs.–Unfortunate incident, unexpected event, unanticipated
outcome
The outcome of an adverse event• Strongly influenced by perception
–Perception of the event–Perception of the care providers, team, clinic and
facility• Therefore, perception is crucial
• Communication breakdown- 82%– 35%
Factors contributing to lawsuits
Provider attitude
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Provider attitude• Following an adverse event, patients perception
of their physician–32% of patients felt deserted–29% of patients felt devalued–26% thought the information was presented poorly–13% of patients felt their perspective was devalued
Beckman, et al. Arch. Int. Med. June 27, 1994
• Communication breakdown–Provider attitude 35%– 35%
Factors contributing to lawsuits
Communication failure
Communication failure• Root cause in
- 66% of all sentinel events* - 85% of maternal deaths and injuries*
• Considered the single largest source of patient *Communication Strategies for Patient Handoffs. ACOG, no. 367, June 2007
g g psafety threat**
**Communication in the Grey Zone- Perceptions about Emergency Physician-Hospitalist Handoffs and Patient Safety. Apkey, J. Soc. Acad.Emerg. Med. Oct 2007, vol. 14, no 10
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Root cause of sentinel events
The Science & economics of improving communication William T. ’Byrne, III, MD, LizaWeavind, MBBCh, John Selby, MD, JD Anesthesiology Clin 26 (2008) 729–744 doi:10.1016/j.anclin.2008.07.010 anesthesiology.theclinics.com
Percent of events
Percent of 3548 events
Hickson Study• Involved Individuals who filed birth injury claims n=127
–48% believed the physician was not honest or mislead the family–20% saw litigation as the only way to get information
Common causes of failure• Heuristics: mental short-cuts lead to solutions that are not optimal
• Errors in Perception• Confirmation bias
• Errors in Assumption• Errors in Communication
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Ineffective team communication• Most common cause cited for adverse events––Critical data is too often “lost”; hence, available Critical data is too often “lost”; hence, available information isn’t consideredinformation isn’t considered
–Missing vital information: the fumble/handnformation: the fumble/hand‐‐off error off error •• Lost in translationLost in translation‐‐ differing perceptiondiffering perception
Clinicians have a different “picture”Clinicians have a different “picture”–– Clinicians have a different pictureClinicians have a different picture
•• Lost in transition of careLost in transition of care–– When there’s a transfer of care When there’s a transfer of care
Translation error• Classic translational hand-off error
–Recovery nurse remembers telling the podiatrist that s/he was concerned and the situation was urgent
–Yet, the podiatrist recalls the communication as routine
To avoid hand-off errors• Use closed-loop communication
–Use clear, concise and “standard” language–Verify that the sent message is both
• Received by the intended party and• Interpreted by the receiver correctly
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Transition handoff errors• Occurs across
–Disciplines–Shifts–Call coverage–Location
• Results in–Lost information–Breakdown in situational awareness
• Communication breakdown 82%–Provider attitude 35%–Communication failure 35%–Unrealistic pt expectations 5%
Factors contributing to lawsuits
Set realistic expectations• Value of the informed consent
–Establishes realistic expectations–Coupled with appropriate documentation
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• Communication breakdown 82%–Provider attitude 35%–Communication failure 35%–Unrealistic pt expectations 5%–Jousting 7%
Factors contributing to lawsuits
Jousting• Avoid off-handed comments regarding other
clinicians–Verbal–Non-verbal –Written
When medical errors occur• Do not
–Point fingers, blame, scapegoat or criticize–Speculate or guess as to who or what
• If you don't know, say it–Make off the cuff statements–Withdraw from the patient–Hide information
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• Influences the patient–Patients use the quality of communication to judge
competency–Enhances compliance–Promotes patient satisfaction
Value of effective communication
• Influences the patient• Influences the physician
–Creates a stronger physician-patient relationship–Promotes physician joy of medicine/satisfaction
• Less patient conflict
Value of effective communication
• Greater patient satisfaction• More fulfillment in medicine
• Influences the patient• Influences the physician • Promotes teamwork
–High functioning teams communicate more openly–Promotes collegiality
Value of effective communication
Promotes collegiality–Promotes situational awareness and error reduction
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Teamwork• Requires leaders to develop team building skills
–Empower team members–Encourage speak up and step up behavior
Key to a safe practice • Accept vulnerability• Everyone makes mistakes• All humans are fallible• Encourage speak up and step up behavior
Promote backup behaviorAnticipate the needs of team members
Error reduction
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Watch out for your teammate’s back
Situational awarenessCountermeasure to errors
•Workplacefactors- Interruptions, distractions, noise, chaos…- Human factors - Incomplete / inaccurate information- New and changing team membersAccelerated pace/time pressures
Threats to situational awareness
- Accelerated pace/time pressures- Rapid switching/fluctuations- Work overload and under-load- Compromised/disrespectful communication
Stress-Performance Correlation
Image
Optimal
PERFO
RM
AN
CE
STRESS The Yerkes-Dobson Curve
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• Influences the patient• Influences the physician • Influences teamwork• Reduces the risk of litigation
Value of effective communication
Medical error• Leaves patients confused• Disrupts the patient’s trust with the physician
When the trust is broken When the trust is broken the relationship must be rebuiltthe relationship must be rebuilt
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Trust is reestablished withTrust is reestablished with
an honest, an honest, and heartfelt and heartfelt disclosure and apologydisclosure and apologytransparent transparent
Rebuilding trust promotes forgivenessRebuilding trust promotes forgiveness
Truth Empathy+ + Forgiveness =Forgiveness formula: + SincerityApology
“Full disclosure is the right thing to do.
It is not an option; it is an ethical imperative.”
Lucian Leape
t s a et ca pe at e
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How to mitigate the impact of adverse events
A timely disclosure and a genuine apology
The disclosure and apology gap
Num
ber
ExcellentPoor
Preliminary data from T. Gallagher, MD
ExcellentPoor
Num
ber
Style
The Disclosure and Apology The Disclosure and Apology •A learned skill•Elements:
-Empathy, compassion, sincerity & vulnerability-Components of disclosure and apology
•A learned skill•Elements:
-Empathy, compassion, sincerity & vulnerability-Components of disclosure and apology Content
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•Desirable qualities: -Transparent -Organized -Thoughtful-Forthright-RemorsefulE thi
•Desirable qualities: -Transparent -Organized -Thoughtful-Forthright-RemorsefulE thi
Style counts! Style counts!
-Empathic-Pace: set by patient
•Style -Leaves a lasting impression -Helps to repair the broken trust-Involves trainable skills
-Empathic-Pace: set by patient
•Style -Leaves a lasting impression -Helps to repair the broken trust-Involves trainable skills
Shows you care!Shows you care!
•Type of apology: determines the content •Components of an apology•Type of apology: determines the content •Components of an apology
Content Content
•Statement of sorrow•Offered from one person,organization or country to another•When heartfelt, provides a salve that heals wounded relationships
•Statement of sorrow•Offered from one person,organization or country to another•When heartfelt, provides a salve that heals wounded relationships
An apology- definition An apology- definition
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I.Expression (apology) of regret I.Expression (apology) of regret The Apology The Apology
II.Apology of remorse II.Apology of remorse
Commonly offered in our society Commonly offered in our society I.Expression (apology) of regret I.Expression (apology) of regret
•Expression of sympathy or consolation•Indicated when:
-Person was harmed, impacted or inconvenienced-The event not due to a wrongful act. “No fault”
•No system error or breakdown•Non-preventable adverse event
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•Expression of sympathy or consolation•Indicated when:
-Person was harmed, impacted or inconvenienced-The event not due to a wrongful act. “No fault”
•No system error or breakdown•Non-preventable adverse event
E l
I.Expression (apology) of regret I.Expression (apology) of regret
•Examples: -Patient experiences known side effect to medication-Caregiver is late for the appointment
•Examples: -Patient experiences known side effect to medication-Caregiver is late for the appointment
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Elements of an expression of regretElements of an expression of regret•Involves
-Expression of sorrow: •“I am sorry that you…”•“I am sorry you…”•“I am sorry it…”•“It must be difficult that…”“I t th t ( ) d ”
•Involves -Expression of sorrow:
•“I am sorry that you…”•“I am sorry you…”•“I am sorry it…”•“It must be difficult that…”“I t th t ( ) d ”
Apology Apology
N thN th •“I regret that (____) occurred.” -Name the wrong (if appropriate)
•“I regret that (____) occurred.” -Name the wrong (if appropriate)
Name theviolated
social norm
Name theviolated
social norm
“I’m sorry the door slammed on your foot. I didn’t catch it in time.
“I’m sorry the door slammed on your foot. I didn’t catch it in time.
“I’m sorry.”“I’m sorry.”vs.vs.
Expression (apology) of regret Expression (apology) of regret
I am very sorry.”I am very sorry.”
•Indicated when-An injury/harm that is clearly caused by an error or system failure
•Delivered by-The individual directly responsible
•If capable!
•Indicated when-An injury/harm that is clearly caused by an error or system failure
•Delivered by-The individual directly responsible
•If capable!
II. Apology of remorse
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II. Apology of remorse•Following an error, patients want:
-What happened. The KNOWN FACTS•The facts told succinctly
-An apology -Clear explanation of the impact of error on health-Why it happened-How injury will be treated/corrected-Prevention of future similar errors
•Not every apology requires a full apology•Every apology is unique•Not every apology requires a full apology•Every apology is unique
•Illinois Public Act 094-0677 Sec. 8-1901, 735 ILL. Comp. Stat. 5/8-1901 (2005)
•Arizona A.R.S. 12-2605 (2005)
•Montana Code Ann.26-1-814 (Mont. 2005)
•Louisiana R.S. 13:3715.5 (2005)
•Missouri Mo. Ann. Stat. 538.229 (2005)
•New Hampshire RSA 507-E:4 (2005)
•Virginia Code of Virginia 8.01-52.1 (2005)
•Vermont S 198 Sec. 1. 12 V.S.A. 1912 (2006)
States with apology laws•Revised Statute 13-25-135 (2003)
•Oregon Rev. Stat. 677.082 (2003)
•Massachusetts ALM GL ch.233, 23D (1986)
•Texas Civil Prac and Rem Code 18.061(1999)
•California Evidence Code 1160 (2000)
•Florida Stat 90.4026 (2001)
•Washington Rev Code Wash 5.66.010 (2002)
•Tennessee Evid Rule 409.1(2003)
•Ohio ORC Ann 2317.43 (2004)•Connecticut Public Act No. 05-275 Sec.9(2005) amended (2006) Conn. Gen. Stat. Ann. 52-184d
•South Carolina Ch.1, Title19 Code of Laws 1976, 19-1-190 (2006)
•Delaware Del. Code Ann. Tit. 10, 4318 (2006)
•Indiana Ind. Code Ann. 34-43.5-1-1 to 34-43.5-1-5
•Idaho Title 9 Evidence Code Chapter 2 .9-207
•Iowa HF 2716 (2006)
•Utah Code Ann. 78-14-18 (2006)
•Nebraska Neb. Laws L.B. 373 (2007)
•North Dakota ND H.B. 1333 (2007)
( )
•Georgia Title 24 Code GA Annotated 24-3-3.1(2005)
•Wyoming Wyo. Stat. Ann. 1-1-130
•Oklahoma 63 OKL. St. 1-1708.1H (2004)
•Maryland MD Court & Judicial Proceedings Code Ann. 10-920 (2004)
•North Carolina General Stat. 8C-1, Rule 413
•Hawaii HRS Sec.626-1 (2006)
•Maine MRSA tit. 2908 (2005)
•South Dakota Codified Laws 19-12-14 (2005)
•West Virginia 55-7-11a (2005)
35 states and the District of Columbia
Call to action!• Transformation of medicine is occurring
–Clinicians are losing autonomy–Administrators are “telling” clinicians how to practice–Clinicians are becoming dissatisfied and disillusioned
• Further contributing to burnout and medical errors
•Yet clinicians must play step up and engage•Yet, clinicians must play step up and engage
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Physicians must• Become leaders
–If not, no one will follow–Help to create teams with situational awareness
• Address the impact of stress in our lives & practices• Maintain life-work balance
A leader is one who knows the way, goes the way and shows the way
Questionsand
Comments
Doctor Patient CommunicationImproving patient and physician satisfaction
Ron Hofeldt MDMedical Director
Wellness Develop Groupwww.WellnessDevelopmentGroup.com
855-205-4932