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Rethinking How Health Care Responds to Adverse Events | Quality Time with Dr. Schaal

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Nearly one in four patients admitted to a U.S. hospital suffers from an adverse event. Of those events, about one in four are thought to be preventable and are usually the result of a system failure.

On this episode of Quality Time, Dr. Evan Benjamin, director of Community Innovation and former chief medical officer at Ariadne Labs, explores how health care organizations can respond to patient harm with accountability, compassion and transparency. He discusses communication and resolution programs, the importance of a strong culture of safety and why open, honest conversations help organizations learn from adverse events, support clinicians and patients and build trust while advancing high reliability in health care.

Guest: Dr. Evan Benjamin, director of Community Innovation and former chief medical officer at Ariadne Labs; associate professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health.

Notable topics covered:

  • Patient safety and preventable harm
  • Communication and Resolution Programs (CRPs)
  • PACT (Pathway to Accountability, Compassion and Transparency)
  • High Reliability Organizations (HROs)
DR. SHLOMIT SCHAAL:

Welcome to Quality Time, a Houston Methodist leading medicine podcast. I'm your host, Dr. Shlomit Schaal, a clinician scientist and a retina specialist, and I serve as the Chief Physician Executive of Houston Methodist. Join us each month as my guests and I discuss the many ways that quality impacts care delivery. Today, I'm pleased to welcome Dr. Evan Benjamin. Dr. Benjamin is the Director of Community Innovation and former Chief Medical Officer at Ariadne Labs, a joint center for health care innovation founded by Dr. Atul Gawande at the Harvard School of Public Health and Brigham and Women's Hospital. He is also Associate Professor of Medicine at Harvard Medical School and of Health Policy and Management at the Harvard Chan School of Public Health. Disclosure, Dr. Benjamin was my professor and I was his student and once a student, always his student. Dr. Benjamin is active in scholarly research in patient safety and health care delivery and consults nationally on issues related to improving health care delivery. And that's why he is my guest today. Welcome, Dr. Benjamin.

DR. EVAN BENJAMIN:

It's wonderful to be here, Dr. Schaal. And I will say that I know I was your professor, but you were an excellent student. So it is a wonderful, wonderful honor to be here now that you're in your role at Houston Methodist.

DR. SCHAAL:

Thank you. And I'm always learning, so I consider myself a forever student and I'm hoping to learn together with our listeners today. So, tell us a little bit about your background and how did you get to focus on patient safety?

DR. BENJAMIN:

So, yeah, I've been on a very interesting career path. My career started, I trained as -- in internal medicine and practiced mostly primary care and telemedicine throughout my career. I actually started working for the Indian Health Service, part of the U.S. Public Health Service, many years ago, really before health care quality and patient safety were really a focus. And I was working there as an epidemiologist, looking at public health, looking at diabetes care. And we had to figure out -- we had two problems. One, we had an epidemic of type 2 diabetes among Native Americans and we had to figure out ways to treat many, many patients with diabetes with very limited resources. And so this was, I'll age myself here, this was the early 1990s. And as a group, we came together in the Indian Health Service to define what is good diabetes care? What does it look like? And how can you measure what good care is? It was really the early quality improvement work. When I left the Indian Health Service, I continued my research, thinking about defining good care. And I came to Massachusetts, worked at a large health system where I became ultimately the chief quality officer, where I was focusing in on systems of care, understanding the care that we're delivering, and trying to identify the gaps that exist between what the care should be and what care do we actually have. And about that time in the late 90s, in 1999, the first Institute of Medicine report came out. It was sort of a shot over the bow that said to us,"Wow, there are significant medical errors that occur in the health care system. And actually, we harm many patients." At the time, we estimated between 50 and 100,000 deaths per year. We now think that is a significant underestimate. But I got very interested at the time. I was the chief quality officer doing the systems improvement work. And safety really became something I became very interested in. I left there, and I joined Ariadne Labs about eight years ago, came as chief medical officer. And I brought with me an interest in improving patient safety, but more importantly, in improving the transparency and accountability for how we respond when patients are harmed. And that's really been a big focus of mine over the past eight years, is focusing on improving the response when we harm patients.

DR. SCHAAL:

So, you talk about patient harms and really the idea that we're harming patients. This came to mind in 1999, which is not too long ago. How big is the problem today? What are the numbers? What is the magnitude? What is this, you know, what are we really facing?

DR. BENJAMIN:

Yeah, you know, in spite of our best efforts throughout the delivery of care, we harm patients. And when we talk about harm, there's really a couple Venn diagrams that are a good way to think about this. There are adverse events which occur. Then there's medical error. Not all adverse events happen because of error or anything that's preventable, but they're adverse events. They were unexpected in the care. That is still considered harm. We believe that probably about 200,000 people die each year as a result of unexpected adverse events. And a paper about a year ago, David Bates actually at Harvard and the Brigham published a paper that found that really nearly one in four patients admitted to a U.S. hospital suffers from an adverse event. And of those, about one in four were actually thought to be preventable. So, it is a very significant problem any way we slice it.

DR. SCHAAL:

Interesting. And this, you never talked about, you never mentioned misdiagnosis. Is misdiagnosis part of it or it's a different thing?

DR. BENJAMIN:

Yeah. So the typical studies that have been done, the initial Harvard Medical Practice study and David Bates' study looking at inpatient, really don't focus on the diagnostic error. Diagnostic error really adds to that. And it's harder to see it when you're just doing chart reviews, which was the methodology done in that New England Journal paper a year ago.

DR. SCHAAL:

So really, we're talking about patients who have the correct diagnosis, the correct maybe treatment orders, everything is correct, but still we harm them because something goes wrong. Can you really explain what is that something? I mean, if we have the diagnosis correct, if the orders are correct, if we ordered the right treatment, how come patients are still harmed? DR. BENJAMIN: Yeah. You know, to me, this is not about individual blame. In fact, when we look at most errors that occur, they're usually the result of system failures. The system really has allowed an error to occur or an adverse event. So as you said, you have the proper diagnosis, you write for a medication in the electronic medical record, and yet somehow in carrying out that order, the wrong medication gets delivered to a patient. When we analyze an event like that, we see a number of system failures that actually contribute to that. We've put in many safeguards in our systems. In that situation, you know, we have pharmacy checks, we have electronic medical order checking, we have nurse checking, and yet what happens is that the adverse event sort of falls through the medical error. We sometimes refer to this as the Swiss cheese phenomenon, where we have these systems to actually prevent errors, but still an error can pass through these systems that actually were designed to prevent it, and we end up with patient harm. So most of the time, these are system errors. They're often communication errors, failure to communicate, failure to hand over. It's very, very common we see at points of hand over. And certainly, you know, adverse events that result that were preventable in terms of failure to provide the proper care. So we, you know, I'm as a physician, and everybody in health care went into this profession in order to help people, to care for people, to make their lives better. But when we discover that we harmed somebody, how do we respond as providers or as systems?

DR. BENJAMIN:

Yeah, and unfortunately, this is often what the problem that we're seeing nowadays is that providers and health systems often respond with silence. You know, these are very difficult conversations to have, and what patients want to hear, they know something was awry. They understand that there was an adverse event, and they want someone to acknowledge it. More than anything, just to say, "Hey, we recognize that this was an unexpected event, and we recognize this happened on our watch." That is a huge step forward that, unfortunately, most health systems and providers don't do. And I think there are many reasons we can get into those reasons of why we fall back onto, I think, some very human reflexes to avoid difficult conversations, just a lot of fear, which we can get into, fear of litigation. But the issue is, most of the time, providers and health systems are, one, told, perhaps by the legal arm of an institution, or are really just hoping for the best, that the patient will recover, or it won't be too bad. They may not know what happened. If they do know, you know, they may think it's just part of the normal processes of care, and I'm not going to have a difficult conversation. And the problem here is that, you know, the first event, the first harm, if you will, is unintentional. It really happens and we can't anticipate it. The second harm, that silence, that's really intentional. And that's when patients really, they get angry. They get angry, and then they actually feel like they have to file a suit or file a claim because no one even recognized or acknowledged what happened. And so, you know, we've done a lot of research in this field to understand why do patients sue, you know, and it actually is such that, you know, patients sue because they don't feel that they never heard what happened.

DR. SCHAAL:

So very interesting, really kind of a different mindset that now you're alerting us to. We spend a lot of resources, a lot of time to prevent errors. We spend time to make sure that these don't happen. And certainly, if something happens, we spend a lot of time investigating what happened and making sure that we don't do it again or the system doesn't fail again. But what you are really alluding to is something new that I haven't heard before, which is the harm, the second harm is when you don't say anything. So, what have you and your colleagues developed as a kind of a countermeasure for that? How might we get better to prevent this second harm?

DR. BENJAMIN:

Yeah, I like the way you phrased that. So, you know, for the better part of the last 10 years, my colleagues and I and a number of people around the country have really been promoting what we've been calling generically a communication and resolution program. Sometimes you'll hear that as a CRP. I'll tell you about the work we're doing at Ariadne Labs, which we call PACT, which is the Pathway to Accountability, Compassion, and Transparency. So, when we talk about having a communication and resolution program, it really starts with the culture of an organization. It starts with leadership, really sharing through the organization that our culture is one of transparency and improvement. The only way for us to get better is to have open and honest conversations. So we talk about internal transparency among each other, and that is the sort of foundation of before we can be transparent with our patients, we have to first be transparent among ourselves. And that's what we refer to as a culture of safety as a foundation for this type of work.

DR. SCHAAL:

I think this is super important, the culture of safety and what it means, because as people in the C-suite, and we have leaders at the very top of health care systems, and also the board of many health care organizations, we are used to seeing data, and we're thinking that if we see less of it, it means that we're getting better. But actually, if we're seeing less adverse events or safety events, it might be that people are reporting less. So, this idea that we wanna see more of that, I think it's kind of counterintuitive to the way we are used to lead. Any suggestions from you of how to tackle that, how to change that mindset that actually more is better?

DR. BENJAMIN:

Yes. So, that's such an important point, and I'm so glad you mentioned it. To me, what this comes down to is the culture, as we said, and leadership talking about wanting to hear about the errors and the near misses, and that it's a big change from a punitive culture where leadership will say,"Oh my gosh, look at all these safety events. What is going on here?" As opposed to flipping that and saying,"We recognize that every report that we get, every near miss is a jewel, because that's how we learn to be able to prevent this again." So, event reporting is also a critical component of any type of patient safety initiative, and particularly this idea of communication and resolution programs.

DR. SCHAAL:

So the CRP, the C is the culture, R is the event reporting, really encouraging people to report an event, and what is the P?

DR. BENJAMIN:

So actually, the CRP, the generic term really stands for communication and resolution, and it's actually a terrible term, and I can explain why. But so, the components of a communication resolution program, though, include, first of all, the foundational culture that we've been talking about, two, a robust event reporting system, and a culture which supports more reports and rewards more reporting so we can learn. The third component is the communication, which means transparent communication to patients and families after a harm event, acknowledging the event, communication skills to do that is something that we actually have been working on to train people. The fourth component is then how do you do an event analysis? How do you take the event and learn from it? We keep evolving and improving the ways we do event analysis. The next component is patient support. So, once you tell the patient what happened, what are we going to do for this patient? How are we going to care for them clinically? How do we support them emotionally? And the final component is really physician and provider support. And I think that is something that probably is one of the most important things that often goes unrecognized, that providers who have been involved with one of their patients is harmed, having an adverse event, or suffered a medical error, they are suffering too. As you said, we were trained to get people better, and we know that because of systems, the patient may have suffered a harm event. And that's really difficult, when especially in the past, when the hospital says to the provider,"Don't talk to the patient because we're worried about a lawsuit or legal," then they're really holding that themselves. And that really leads to frustration and anxiety and even burnout among providers. So, a good communication resolution program has all these components, including the last one, which is a peer support program to help the providers manage what happened after a harm event.

DR. SCHAAL:

Yes, I love that. Because as you know, I'm a surgeon, and surgeries, the majority are going very well. But sometimes if just a little thing didn't go as well as you want it to, I can attest personally, you suffer, I suffer for days and sometimes for years, even if the patient did not get really harmed. But we as physicians, we take pride in our skills, and it haunts you. So this peer support, I love that. So, I wanted to ask you, where is the CRP today? I mean, this is the first time that I've heard about this. Where is it nationally?

DR. BENJAMIN:

One of the things that Ariadne Labs has been doing with the Collaborative for Accountability Improvement, which is an organization at the University of Washington, we came together to form a collaborative to help health systems actually implement these programs. It includes lots of tools, like, for instance, how do you have these conversations? So we do conversation guide and conversation communication training, tools in terms of how do you actually break down the silos. Many systems and hospitals have many different silos. They have patient safety departments and quality departments and risk and legal and patient relations all having a role to play in a harm event. But you actually have to break down those silos to create a hardwired process that happens consistently. Through your event reporting, every time there's a harm event, the process gets activated. Everybody knows what to do. Right now, we have about 50 health systems going through our collaborative work. But what we find is that many hospitals and health systems hear about this and they'll say,"Oh, yes, we do that." And when you really understand what this is about, it's not -- this isn't a risk management tool to get to an early settlement. That's often what people say."Oh, yes, we had this error. And so we came clean and we talked to the patient and then we offered a settlement." Those are for the most egregious cases. A real CRP, communication resolution program, is across the board looking at from very small adverse events, unexpected harms. It's -- it becomes part of the mission of the organization to do two things, to learn from every event so they don't happen again, and also to retain trust in patients who they know they have suffered. And by going through this process, they can retain trust in that very, very system.

DR. SCHAAL:

So, with these 50 health care systems that are already using it, what are some of the challenges that you've been hearing back when people start implementing this quite new mindset?

DR. BENJAMIN:

Yeah, so I would say our biggest challenge that we see and when folks are just joining us or when we're talking to them is they're applying these principles inconsistently. They're doing it for some patients or some events, but not all, or they're doing it for just a proportion of certain types of patients. And the risk there is there's a lot of cynics. And if, as physicians, for instance, we're trying to promote this culture of safety and transparency and learning, and if we see that this is being done inconsistently, the cynics will just say,"Oh, this is just -- this is a legal risk management tool to lower our costs," as opposed to, "This is actually mission critical. This is part of being a safe organization, a learning organization, and to do the right thing by our patients." I will say that I think over the years, as physicians, we have been very deferential to the legal fears of the health system. Those people who we work with in the legal departments and claims departments who've told us,"If you say more, the likelihood is you're going to be sued." And ironically, what our research has shown is that actually doesn't happen. The avalanche of the lawsuits that the fearmongers have said actually doesn't happen. And if anything, patients actually retain their trust in the system that actually acknowledged an error. They could actually come back and get their care. They wanna be part of learning to prevent this from happening again, and there's support for the doctors and for the patients. And so, I think we've been too deferential. And as physicians, what I tried to promote is we need to take this back. When we care for patients and something doesn't quite go right, we need to have a system in place to respond to that harm, to recognize it, tell patients what happened, what we're going to do to care for them, how we're going to change so this couldn't happen to somebody else.

DR. SCHAAL:

So, you know, you pointed out that this is really should be part of the culture, should be done consistently in every single case. And then the other part of it, we really need to learn from our mistakes. It's not enough to admit,"Yes, we made a mistake and we found out what went wrong." And, you know, how do systems correct these things? And then also a question of, you know, how do we learn before we make a mistake? How do we kind of learn from other systems?

DR. BENJAMIN:

Yeah, that's a great question. So, you know, the learning is such a big part of this program. And again, we're trying to break down these silos. So the quality department, the patient relations, the safety, the risk management are all working together to learn about what happened in a much more transparent, in a non-blame way, non-judgmental way. We are saying that this is a very complex world and health system that we work in. It's a very complex industry. We have to learn about what happened. And then many organizations have been on this path towards high reliability. We discussed this in our class, you know, high reliability.

DR. SCHAAL:

Tell our listeners, please, what is high reliability and what is a path to high reliability for those who might not know what it is.

DR. BENJAMIN:

That's right. So, you know, other industries that are very complex and deal with lots of risk have become what we refer to as an HRO, high reliability organization, where there is openness and communication and reporting where we, when there's an event that occurs, we don't simplify, oversimplify the explanation for it. And we have deference to the people who are close to the ground level taking care of that process. They understand it best. And so, we've learned from other high reliability industries, the aviation industry, the nuclear power industry, chemical industry, that these principles of high reliability can actually be applied to health care. And that is all part of the learning. When we do these event analyses and we understood what happened and what went wrong, we then apply the fixes using high reliability principles to prevent them from happening again.

DR. SCHAAL:

And the good news is that high reliability, since I was a student in your class several years ago, now it's more common and more health care systems are going through that path of high reliability. There's also a certification of high reliability. Any thoughts about that?

DR. BENJAMIN:

Yeah, you know, I think this is a wonderful time in health care to see so many health systems and physicians take on high reliability. I think the certification programs are great. You know, they're not for everyone, but they actually give you a framework to work with and actually an education to think about how to apply these principles to complex health care. And, you know, in spite of what sometimes people say when they first hear, "Well, you know, aviation is so different than health care," the principles are not. They really apply to what we do every day as physicians in high risk situations. So, I think there's a lot to be said for high reliability and it fits right into this work of how do we respond to harm? How do we learn from these events? And how do we have the right culture? It's the same culture we talked about earlier. That is the culture that needs to be created to be a high reliability organization as well.

DR. SCHAAL:

So, tell me a little bit about PACT and what it is.

DR. BENJAMIN:

So PACT, as I mentioned, stands for the Pathway to Accountability, Compassion and Transparency. And I just wanna pause on those words because I just love those words. They actually came from, we have a group of patient and family advisors, many of which have actually been harmed by health care. Some actually have lost loved ones to medical error. And when we talked about our support of health systems to change the way we respond to harm and we asked them,"What does this mean to you?" They came up with these words and they said,"You know, one, this is about accountability. We want people to acknowledge what happened." That feels probably more important than anything. Just to acknowledge it, say it. You know, it's sort of like, say the name, the error happened. Two, "Help me, deal with me compassionately and tell me now how I'm going to be cared for because things may change because of this adverse event, this medical error. I may need a different care plan. I wanna know that. I wanna hear how this has affected me. So, deal with me compassionately." And then finally,"Have transparency, not only to me, but transparency among yourselves." In other words, "Go learn about what just happened in a nonjudgmental way. Do the event analysis. I'll contribute to it. I'll tell you my perspective of what went wrong. Include me as well." They actually came up with these words, accountability, compassion, and transparency. We added the pathway because we realized this is a journey. And so what PACT is, it's a learning collaborative. We bring together health systems and over a one-year period of time, they go through a learning collaborative where we have learning sessions. They're usually virtual for two days. We have all the leaders who come from the health system. And we teach step-by-step the processes of how to lay out an effective communication and resolution program with communication training. Every health system is assigned a coach. Some of these coaches go to those sites to actually do on-site physician leadership, education, and communication training. And then we work with the quality and the risk and the claims departments to create a hardwired process. And after a year of doing this together where they're implementing new things, they come back together in these learning sessions. They go back and they implement new things. They learn from others. We've had some of the largest health systems in the country go through this. So, they're learning from each other. They're discussing cases saying,"Oh, how would you have handled this case?" And then another health system will talk about their cases. After about a year, they begin to have things hardwired and established. So, that's what PACT is. It's run through Ariadne Labs and the University of Washington. And we'll be recruiting new systems for our launch in the fall. And I'm excited because I hope Houston Methodist could join us.

DR. SCHAAL:

Well, I can tell you that these words resonate very well with Houston Methodist because these are -- really are -- Part of these words are actually part of our I CARE values. I CARE value stands for integrity, compassion, accountability, respect, and excellence. So, you know, the A and the C are there and they resonate very well with us. Well, Dr. Benjamin, thank you so much. Before we go, I just wanna ask you one last question that I ask all my guests. Is really what does quality mean to you?

DR. BENJAMIN:

Ah, that's fantastic. So, you know, I've spent most of my career thinking about this. And while I do a lot of policy work, do a lot of quality measurements, I could throw out the various measures that are out there from mortality and safety. But ultimately, it comes down to when I think about quality, it's quality from the patient's perspective. Right? And recently, I had a family member who was going through some health issues. And they know that I've been focusing on quality and safety throughout my career. And I said to them,"You know, you're going to have this surgery. What do you want from this?" And they said,"Well, first of all, I wanna make sure I have -- And you've told me about patient safety, I wanna make sure I'm not harmed, you know, that I don't get an infection I didn't have. I wanna make sure, you know, it's going to be safe. Second is I just wanna be cured, you know. I want the right care and I want it be effective. And the third is I want people to be nice to me, you know, respect me and be nice to me." And I was like, that to me summed up everything. Like, make it -- Do no harm, cure me, and be nice to me. Sort of in that order as well, that's how they said it. And I think that almost is a good priority.

DR. SCHAAL:

Fantastic. I love it. And, you know, I could talk to you probably for hours. And I really enjoyed our conversation. Thank you very much for being our guest today.

DR. BENJAMIN:

It's my pleasure.

DR. SCHAAL:

And thank you for listening. So that you never miss an episode, subscribe to Quality Time. New episodes will download to your podcast device. I appreciate your support. Thank you. And until next time, I am always listening.