In a joint initiative with the Massachusetts Medical Society (MMS), Beth Israel Deaconess Medical Center (BIDMC) received a planning grant from the Agency for Health Care Research and Quality to transform the medical liability system in Massachusetts by examining the potential for disclosure, apology and offer (DA&O) programs. The BIDMC/MMS initiative had four aims: 1) to identify the barriers to implementation of a DA&O model in Massachusetts, 2) to develop strategies for overcoming these barriers, 3) to design an in-state roadmap for DA&O program implementation, and 4) to assess applicability of the roadmap to other states. This document summarizes that Roadmap and the central messages from the study:
- Strong support for the DA&O approach—above any other model—among respondents
- Consistent view that such a model is the "right thing to do" ethically, with cost savings as an additional benefit
- Many proposed strategies can be pursued relatively quickly and easily
- The DA&O approach benefits patient safety by encouraging open discussion of error, leading to improved reporting and deeper understanding of safety risks.
Structured interviews were conducted with 27 key stakeholders holding leadership positions in organizations central to implementation of the DA&O approach: the Massachusetts legislature and administration, hospital systems (including academic health centers and community hospitals), practicing physicians, liability insurers, health insurers, medical professional associations, patient advocacy organizations, malpractice attorneys, patient safety experts, major physician practice groups, and a major business association.
The barriers and strategies collectively identified during the interviews were then shared with the project’s interviewees for individual feedback. The project team integrated stakeholder feedback into the Roadmap prior to presentation at a symposium entitled Roadmap for Transforming Medical Liability and Improving Patient Safety in Massachusetts held at MMS in March 2011. The roadmap was then further refined based on additional feedback from the approximately 150 symposium participants, primarily physicians but also representatives of each of the other stakeholder groups.
Barriers and strategies
The interviews revealed several barriers and potential solutions to implementation of a DA&O model. Below are the 12 most commonly cited barriers, each followed by proposed strategies for overcoming it.
- Fairness and accountability: education of the public and media; legal representation for patients/families; standardized root cause analysis processes; transparent compensation formulas; and mechanisms for sharing "lessons learned" to improve patient safety.
- Physician discomfort with disclosure: physician education and training including peer mentors; establishment of a "just culture"; support from hospital/health enterprise leadership.
- Concern about increased liability: data dissemination from sites having implemented the model.
- Physician name-based reporting: education; process change allowing institution-based reporting