How policy makers can smooth the way for communication-and-resolution programs

Health Affairs

Volumn 33, Issue 1, 2014, Pages 11-19

  Sage, William M ^a   Gallagher, Thomas H ^b   Armstrong, Sarah ^c   Cohn, Janet S ^d   McDonald, Timothy ^e   Gale, Jane ^f   Woodward, Alan C ^g   Mello, Michelle M ^h  

^a UNIVERSITY OF TEXAS AT AUSTIN   (United States)

^b UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE   (United States)

^c UNIVERSITY OF WASHINGTON   (United States)

^d New York Stem Cell Science Program NYSTEM Department of Health   (United States)

^e UNIVERSITY OF ILLINOIS AT CHICAGO   (United States)

^f ASCENSION HEALTH   (United States)

^g Medicine physician Massachusetts Medical Society   (United States)

^h HARVARD SCHOOL OF PUBLIC HEALTH   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BILLING AND CLAIMS; CONFIDENTIALITY; DOCTOR PATIENT RELATION; HEALTH CARE ORGANIZATION; HEALTH CARE PERSONNEL; HEALTH CARE PLANNING; HEALTH CARE POLICY; HEALTH PROGRAM; HEALTH SERVICE; HUMAN; INTERPERSONAL COMMUNICATION; LAW SUIT; MALPRACTICE; MANDATORY PROGRAM; MANDATORY REPORTING; MEDICAL ERROR; MEDICAL LIABILITY; NATIONAL PRACTITIONER DATA BANK; PATIENT CARE; PATIENT EDUCATION; PATIENT PARTICIPATION; PATIENT SAFETY; PEER REVIEW; TOTAL QUALITY MANAGEMENT; ADMINISTRATIVE PERSONNEL; COMPENSATION; GOVERNMENT; HEALTH CARE COST; HEALTH CARE QUALITY; HEALTH SERVICES RESEARCH; LEGAL LIABILITY; LEGISLATION AND JURISPRUDENCE; MANAGEMENT; PATIENT ADVOCACY; UNITED STATES;

ADMINISTRATIVE PERSONNEL; COMMUNICATION; COMPENSATION AND REDRESS; GOVERNMENT AGENCIES; HEALTH CARE SECTOR; HEALTH POLICY; HEALTH SERVICES RESEARCH; HUMANS; LIABILITY, LEGAL; MALPRACTICE; NATIONAL PRACTITIONER DATA BANK; NEGOTIATING; PATIENT ADVOCACY; POLICY MAKING; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 84891757923     PISSN: 02782715     EISSN: 15445208     Source Type: Journal    
DOI: 10.1377/hlthaff.2013.0930     Document Type: Article

References (45)

1. Mello MM, Gallagher TH. Malpractice reform-opportunities for leadership by health care institutions and liability insurers. N Engl J Med. 2010;362(15):1353-6.
2. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12(12): 770-5.
3. Calman NS. No one needs to know. Health Aff (Millwood). 2001;20(2): 243-9.
4. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academies Press; 2000.
5. Agency for Healthcare Research and Quality. Patient safety primers: error disclosure [Internet]. Rockville (MD): AHRQ; [last updated 2012 Oct; cited 2013 Dec 4]. Available from: http://psnet.ahrq.gov/ primer.aspx?primerID=2
6. Mastroianni AC, Mello MM, Sommer S, Hardy M, Gallagher TH. The flaws in state "apology" and "disclosure" laws dilute their intended impact on malpractice suits. Health Aff (Millwood). 2010;29(9): 1611-9.
7. Truog RD, Browning DM, Johnson JA, Gallagher TH. Talking with patients and families about medical error: a guide for education and practice. Baltimore (MD): Johns Hopkins University Press; 2011.
8. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-7.
9. Kachalia A, Kaufman S, Boothman R, Anderson S, Welch K, Saint S, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-21.
10. Conway J, Federico F, Stewart K, Campbell MJ. Respectful management of serious clinical adverse events [Internet]. Cambridge (MA): Institute for Healthcare Improvement; 2010 [cited 2013 Dec 9]. (IHI Innovation Series White Paper). Available from: http://transplant pro.org/wp-content/uploads/ IHIManagementofClinicalAdverse EventsSep10.pdf
11. McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, et al. Responding to patient safety incidents: the "seven pillars." Qual Saf Health Care. 2010;19(6):e11.
12. Clinton HR, Obama B. Making patient safety the centerpiece of medical liability reform. N Engl J Med. 2006;354(21):2205-8.
13. Corrigan JM, Greiner A, Erickson SM, editors. Fostering rapid advances in health care: learning from system demonstrations. Washington (DC): National Academies Press; 2002.
14. Agency for Healthcare Research and Quality. Medical Liability Reform and Patient Safety Initiative [Internet]. Rockville (MD): AHRQ; 2012 Feb [cited 2013 Dec 9]. Available from: http://www.ahrq.gov/ professionals/quality-patient-safety/ patient-safety-resources/liability/ index.html
15. Agency for Healthcare Research and Quality. Demonstration grants [Internet]. Rockville (MD): AHRQ; 2010 Jun [cited 2013 Dec 4]. Available from: http://www.ahrq.gov/ qual/liability/demogrants.htm
16. Massachusetts Alliance for Communication and Resolution Following Medical Injury. About MACRMI [Internet]. Boston (MA): MACRMI; [cited 2013 Dec 4]. Available from: http://www.macrmi.info/aboutmacrmi/
17. To access the Appendix, click on the Appendix link in the box to the right of the article online.
18. Teninbaum GH. How medical apol-ogy programs harm patients. Chapman Law Rev. 2011;15(2):307-42.
19. Bell SK, Smulowitz PB, Woodward AC, Mello MM, Duva AM, Boothman RC, et al. Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation. Milbank Q. 2012;90(4):682-705.
20. Mello MM, Boothman RC, McDonald T, Driver J, Lembitz A, Bouwmeester D, et al. Communication- and-resolution program pioneers offer advice for new adopters. Health Aff (Millwood). 2014;33 (1):20-29.
21. Mello MM, Senecal SK, Kuznetsov Y, Cohn JS. Implementing hospitalbased communication-and-resolution programs: lessons learned in New York City. Health Aff (Millwood). 2014;33(1):30-38.
22. Mass. Gen. Laws, chap. 231, sec. 60L.
23. Waples v. Yi, 234 P. 3d 187 (Wash. 2010).
24. McDevitt v. Harborview Medical Center, 2013 Wash. LEXIS 931, 2013 WL 6022156 (Nov. 14, 2013).
25. Mass. Gen. Laws, chap. 231, sec. 85K.
26. Tex. Civ. Prac. & Rem. Code Ann., sec. 101.021.
27. Tex. Civ. Prac. & Rem. Code Ann., sec. 101.106.
28. American Medical Association. Apology inadmissibility laws: summary of state legislation [Internet]. Chicago (IL): AMA; 2012 [cited 2013 Dec 4]. Available from: http:// 134.147.247.42/han/JAMA/ www.ama-assn.org/resources/doc/ arc/apology-inadmissibility-statelaws- charts.pdf
29. Full Disclosure Working Group. When things go wrong: responding to adverse events: a consensus statement of the Harvard hospitals [Internet]. Burlington (MA): Massachusetts Coalition for the Prevention of Medical Errors; 2006 Mar [cited 2013 Dec 4]. Available from: http://www.macoalition.org/ documents/respondingToAdverse Events.pdf
30. Lazare A. On apology. Oxford, UK: Oxford University Press; 2004.
31. Mass. Gen. Laws, chap. 233, sec. 79L.
32. Teninbaum G, Kraman S. Disclosure and offer at twenty-five: time to adopt policies to promote fairly negotiated compensation. Suffolk University Law Review [serial on the Internet]. 2013 Feb 25 [cited 2013 Dec 5]. Available from: http:// suffolklawreview.org/teninbaumkraman/
33. 45 CFR., sec. 60.3.
34. Thompson JN, Robin LA. State medical boards. Future challenges for regulation and quality enhancement of medical care. J Leg Med. 2012;33(1):93-114.
35. Medical Quality Assurance Commission. Preventing wrong site, wrong procedure, and wrong person surgery [Internet]. Olympia (WA): The Commission; 2011 Sep 30 [cited 2013 Dec 9]. Available from: http:// www.doh.wa.gov/Portals/1/ Documents/3000/MD2011-08 %20Preventing%20Wrong%20Site %20Surgery%20%28signed %29%20.pdf
36. 45 CFR, sec. 60.7.
37. 2013 Or. Laws Ch. 5 (S.B. 483). Approved March 18, 2013.
38. Health Resources and Services Administration. NPDB guidebook [Internet]. Rockville (MD): HRSA; 2001 Sep [cited 2013 Dec 5]. Available from: http://www.npdb-hipdb .hrsa.gov/resources/NPDBGuide book.pdf
39. Wojcieszak D. Reforming state licensure boards and the National Practitioner Data Bank [Internet]. Glen Carbon (IL): Sorry Works!; 2012 May [cited 2013 Dec 5]. Available from: http://sorryworkssite .bondwaresite.com/what-is-theproblem- cms-44
40. Tex. Occ. Code Ann., sec. 160.007.
41. 735 ILCS 5/8-2102.
42. 42 US Code, sec. 1395y(b)(2)(B)(ii).
43. Centers for Medicare and Medicaid Services. MMSEA section 111: Medicare secondary payer mandatory reporting: liability insurance (including self-insurance), no-fault insurance, and workers' compensation user guide [Internet]. Baltimore (MD): CMS; [revised 2013 May 6; cited 2013 Dec 5]. Chapter 5: appendices. Available from: http:// www.cms.gov/Medicare/ Coordination-of-Benefits-and- Recovery/Mandatory-Insurer- Reporting-For-Non-Group-Health- Plans/Downloads/New-Downloads/ NGHPUserGuideVer36Ch5 Appendices.pdf
44. McLaughlin v. Chicago, Milwaukee, St. Paul & Pacific Ry., 143 N.W.2d 32 (Wis. 1966).
45. Grayson v. Williams, 256 F. 2d 61 (10th Cir., 1958).