SummaryThe St. Joseph Mercy Hospital emergency department operates the Next Step Program, which supports patients and family members after an unexpected death or other unexpected, negative event. A team offers to meet with affected patients or family members on one or more occasions as necessary. Team members listen to their concerns in an empathetic, compassionate manner, and, to the extent possible, address them and offer other support, including an apology and financial remuneration if the outcome was a result of a medical error. Without increasing the hospital's legal risks, the program has helped most patients and families better deal with the unexpected event and has contributed to improved physician communication skills and to the development of several patient safety initiatives.Suggestive: The evidence consists of feedback from program leaders and others involved in the face-to-face meetings, along with post-implementation data on the number of lawsuits and out-of-court settlements involving participants.
Developing OrganizationsSt. Joseph Mercy Hospital
Ann Arbor, MI
Use By Other Organizations
- As noted, several other Michigan hospitals have similar (though not identical) programs in place, and program leaders are working to promote adoption in other hospital departments and throughout the region.
Date First Implemented2006
Problem AddressedMany patients and family members who experience an unexpected death or an unexpected clinical event have tremendous difficulties understanding and coping with the event. For various reasons, the traditional approach of American health care—to deny and defend and limit communications—alienates patients and family members; it leaves many of them feeling tremendous anger and guilt, while looking to place blame, even without justification for doing so.
- Many unexpected deaths and events: Hospitalized patients and family members often experience unexpected deaths or other unexpected clinical events. In most cases, these tragedies represent the natural progression of disease or result from traumatic events. In some cases, they may result from medical errors, which still occur frequently in the health care setting.1-3
- Barriers to full disclosure and support: The vast majority of providers offer little or no support to those experiencing negative events4; cultural and legal barriers underlie providers' failure to do so. These barriers include lack of comfort in talking about the event; concerns that frank communication may imply guilt even when standards of care have been followed; and fear that apologies will lead to lawsuits, higher compensation awards and insurance premiums, and/or loss of malpractice insurance coverage.4
- Path to guilt and blame: Without support from the hospital, many patients and family members feel tremendous anger and guilt and look to place blame, even without justification for doing so. In some cases, they may turn to lawsuits to understand what happened and why and to fulfill a desire to be heard and to influence the safety of care in the future.5
- Unrealized potential of transparency and support: Patient–provider communication after a negative event, including empathetic listening, compassion, and an apology when appropriate, has the potential to help patients in their recovery, thus reducing feelings of guilt and the desire to blame someone for something that likely could not have been prevented.5
Description of the Innovative ActivityThe Next Step Program supports emergency department (ED) patients and family members after an unexpected death or other type of unexpected negative event. A team offers to meet with affected patients and family members on one or more occasions as necessary. Team members listen to their concerns and, to the extent possible, address them and offer other compassionate support, including an apology and financial remuneration if the outcome was a result of a medical error. Key program elements are outlined below:
- Initial and ongoing marketing: ED leaders introduced Next Step through a broad awareness campaign that included posting of flyers throughout the facility, media campaigns, and dissemination of information through the hospital Web site, relevant committees, bulletin boards, and other internal communication mechanisms. While the program is generally well known at this point, limited marketing efforts continue on an ongoing basis.
- Identifying patients and families: Each month, roughly 8 to 10 patients (from the roughly 7,500 ED patients treated) and families who might benefit from Next Step come to the attention of the program administrator in one of two ways (outlined below). Program leaders review each of these cases to determine whether the patient or family member would likely benefit from the program.
- Clinician or staff referral: Any hospital-based clinician or staff member (e.g., patient relations staff) can refer a patient or family by contacting the administrative point person for Next Step. Sometimes, individuals call the administrator directly the number is listed on the marketing materials, but, more often, referrals come through the hospital's anonymous, confidential reporting system. For example, a nurse might observe a patient or family member who seems quite upset about something that has occurred and report that observation anonymously through the system.
- Proactive medical record search: Every month, program staff search the in-hospital mortality report to identify patients who came through the ED and subsequently died in the hospital. The leadership team reviews each case to determine whether the death was unexpected and, if so, flags that individual or his or her family as someone to be considered for the program.
- Monthly case review by multidisciplinary task force: Each month, a multidisciplinary task force meets to review all new cases referred by the leadership team (usually 4 to 5 out of the initial group of 8 to 10). The task force includes ED physician and nurse leaders, along with representatives from social work, patient relations, behavioral health, pastoral care, and risk management/quality improvement. The committee confirms that the patient or family might benefit from the program and discusses the best approach to contact and follow up, including appropriate timing. In time-sensitive cases, the physician and nurse leaders might conduct the review and formulate the strategy outside of the monthly meeting.
- Proactive outreach to offer in-person session: The administrative point person typically contacts the patient or family by telephone, usually 3 weeks after the event in the case of a death so as to give the family time to grieve and avoid disrupting funeral arrangements. Contact may occur earlier or later depending on the specific circumstances. If the patient or family member is reached, the administrator acknowledges that he or she may have questions surrounding the negative event and offers the patient or family members the opportunity to meet with a team of individuals so they can learn about and address those concerns, including through a full review of the medical record and autopsy report if appropriate.
- Followup with those not reached: The point person leaves a message if the patient or family cannot be reached and calls back up to two additional times. If telephone contact is not made, the administrator sends a letter describing the program and inviting the patient and family to call. Over the course of a year, the administrator will typically reach out to roughly 50 to 70 patients or families (4 to 6 per month), making contact with about 40 of them. Approximately two-thirds of those reached accept the offer for an in-person meeting; the others are satisfied with the phone conversation.
- Pre-meeting rehearsal: Before the meeting, those scheduled to be involved hold a "rehearsal" to review relevant records and circumstances surrounding the case and discuss questions that the patient or family might have. The rehearsal includes role playing in which someone asks anticipated questions and another person attempts to answer them. Typically held the day before or the day of the actual meeting, the rehearsal generally involves a physician and nurse leader from the ED (in some cases two physicians and/or nurses may attend), along with a social worker, behavioral health specialist, or patient relations staff member. Those providers actually involved in the case typically do not attend, unless the patient or family specifically requests that they be a part of the face-to-face meeting and the circumstances make it appropriate (a relatively uncommon occurrence).
- Face-to-face meeting(s): During the session, the team listens to the patient/family perspective on the event, which can sometimes be quite different from that of the provider. The goal is to understand and address concerns openly and honestly. Despite the upfront preparation, providers will often not be able to anticipate all concerns. As appropriate, the team will acknowledge the role that any medical error(s) may have played, offer an apology, discuss actions being taken to prevent a future recurrence, and indicate the hospital's willingness to financially remunerate the patient or family. The meeting typically lasts an hour or less, although it can run longer, and in some cases multiple meetings may be necessary. What follows are brief summaries of meetings with several patients or family members served by the program:
- Inappropriate medication dose, contributing to death: A patient died after receiving an inappropriate medication dosage, although the dosage error likely did not directly relate to the death since the patient was very ill and faced a high risk of death from disease. However, the program team could not be sure of the role the dosage error played, and, as part of the organization's commitment to honest and open disclosure, met with the family, disclosed the error, and apologized for it. Over the course of several additional meetings, the team answered the family's questions about how and why the error occurred, described actions taken to prevent similar events in the future, and indicated a willingness to provide financial remuneration as a way to demonstrate compassion and support.
- Patient death after tube placement: A patient died of cardiac arrest shortly after a tube had been placed in his stomach. The family blamed the hospital and providers, believing the tube had caused his death. During the meeting, a provider (not involved in the patient's care) explained why the two events were not related and how the cardiac arrest likely resulted from other factors. During the session, it became clear that family members also blamed themselves, believing they somehow should have recognized the warning signs and called for help before their loved one's condition began to deteriorate. The meeting helped them to understand that little if anything could have been done differently and thus served to ease their intense feelings of guilt.
- Elderly patient who died after hemorrhage and stroke: The husband of an elderly woman died during transport from another hospital. The wife arrived at St. Joseph Mercy ahead of her husband and later learned that he had died in transit. She could not understand how this could have happened, given that her husband was alive and communicating when she last saw him at the other hospital. During the meeting, it became clear that this woman—in her eighties—had obtained all her husband's medical records and had pieced together the timeline of events, which did not make sense to her. She harbored resentment, anger, and guilt, feeling that someone was hiding something from her. When the team reviewed the records, they agreed that the stated timeline could not be correct and identified a mistake that had been made in a time notation at the other hospital. They explained the mistake and what actually happened to the wife, which largely resolved the issue and reduced her feelings of anger and resentment.
- Sharing relevant stories and lessons throughout department: As appropriate after meetings, program leaders share relevant findings and lessons from the sessions with the entire ED staff, including any systems or cultural issues that might have contributed to unexpected negative events.
Context of the InnovationSaint Joseph Mercy Health System operates 7 hospitals (collectively licensed for 1,726 beds), 5 outpatient centers, 5 urgent care facilities, and more than 25 specialty centers. The system serves six counties in southeast Michigan. The system's largest facility, St. Joseph Mercy Hospital, is a 537-bed teaching hospital located in Ann Arbor. Doctors who are part of Emergency Physicians Medical Group staff the majority of the EDs of Saint Joseph Mercy Health System, along with EDs at 30 other hospitals in the region, including other Trinity Health facilities.
The impetus for the program came from the spouse of a patient who unexpectedly died after coming to Saint Joseph Mercy Hospital's ED. She sent Dr. Mikhail (then chair of emergency medicine at the hospital) a letter roughly 6 months after the event to discuss the pain, confusion, and anger she was experiencing related to her husband's death, along with frustration about not understanding exactly what had happened and why. Dr. Mikhail contacted the woman and offered to meet with her in person, which subsequently led to a meeting with the whole department. (See the Back Story section for more details.) After seeing how helpful the meeting was for the spouse, Dr. Mikhail realized that this program could be beneficial to many others. He wanted to make the service available to all those affected by an unexpected, negative event and to do so proactively so that such support could be provided closer to the event. Around the same time, several other hospitals in Michigan had either implemented or were contemplating similar initiatives designed to promote full disclosure and openness after negative events, including the University of Michigan, which implemented its Sorry Works program.
ResultsWithout increasing legal risks, the program has helped most patients and families better deal with negative events and has contributed to improved physician and staff communication skills and to the development of several patient safety initiatives.
Suggestive: The evidence consists of feedback from program leaders and others involved in the face-to-face meetings, along with post-implementation data on the number of lawsuits and out-of-court settlements involving participants.
- Positive response from participants: While the program does not lend itself to objective measurement through satisfaction surveys, program leaders report that the vast majority of meetings end with feelings of gratitude and appreciation—frequently with hugs and tears on both sides—and a general acknowledgement that everyone came out of the session with a much better understanding of and greater levels of comfort with the situation.
- Stimulating better communication and safety programs: ED-based physicians and staff have improved their communication and listening skills directly as a result of the stories and feedback that have come out of the meetings. The meetings have also helped to identify safety-related issues that have been subsequently addressed through specific programs. For example, in one meeting it became clear that some unit-based staff did not feel comfortable raising concerns when they observed an error or dangerous situation. In response to this and other similar feedback, the hospital created a program that empowers any staff member to "stop the line" at any time and call for a patient safety huddle.
- Little or no increase in legal risk: Since the program's implementation in 2006, only one participating patient or family member has brought legal action against the hospital or physicians. In several cases, the hospital or physician group acknowledged an error that contributed in some way to the negative outcome and opened the door to financial remuneration. In a couple of these cases, the hospital and patient or family came to an agreement. In other cases, the hospital's offer to discuss remuneration has not been taken up by the patient or family. Information provided in May 2013 indicated that the hospital was dealing with its first allegation of medical malpractice following a family meeting.
- Decrease in face-to-face meetings: Information provided in May 2013 indicated that the hospital team has seen a drop-off in the number of patients and families wanting to meet face to face in the previous year. The team hopes this decrease is the result of caregivers spending more time with families at the time of the event to address their concerns, thus lessening the need for formal followup.
Planning and Development ProcessKey steps included the following:
- Winning leadership support: After being contacted by the aforementioned spouse, Dr. Mikhail approached the hospital's legal counsel and risk management leaders to discuss the idea of meeting with her. They agreed to sit in on the meeting with the spouse, after which they strongly supported the idea of a broader, proactive program. The hospital's general counsel briefed the chief executives about the concept, earning their support as well.
- Initial planning, marketing, and launch: Dr. Mikhail, the hospital medical director (Dr. Robert McCurdy), and the nurse manager took charge of formalizing the program. They recruited an administrative staff person with strong communication skills to coordinate program operations, including reaching out to patients and families. They also developed marketing materials and executed the initial awareness campaign. Early on, these four individuals handled all aspects of the program.
- Forming multidisciplinary task force: Over time, additional staff expressed interest in participating in the monthly case discussions, including representatives from social work, patient relations, behavioral health, pastoral care, risk management, and quality improvement. This multidisciplinary group ultimately became a formal task force that meets monthly to review referred cases (as described earlier).
- Training additional staff to meet with patients and families: Several task force members (including social workers, behavioral health specialists, and patient relations staff) and several other ED physician and nurse leaders expressed interest in being part of the meetings with patients and family members. In preparation, these staff first observed a few sessions (including the rehearsals) and then took the lead role in one or two sessions under the observation of a more experienced individual.
- Ongoing expansion to other departments, hospitals: Program leaders are trying to win leadership support for the program in other St. Joseph Mercy departments, including the intensive care unit, operating room, and labor and delivery. Some clinical leaders in these departments are already familiar with and supportive of the program. They are also promoting broader dissemination throughout St. Joseph Mercy Health System and to approximately 30 other hospitals in the region that operate EDs staffed by Emergency Physicians Medical Group.
- Endorsement by parent organization: Information provided in May 2013 indicated that the program has been embraced by Trinity Health, the parent organization of Saint Joseph Mercy Health System, as a model to replicate. Trinity Health executives have discussed expanding the program throughout its system.
- Launch of "care of the caregiver" program: Information provided in May 2013 indicated that St. Joseph Mercy Hospital's interdisciplinary team is now in the process of launching a parallel care of the caregiver program to address the issues that surround the caregiver when a tragic or negative occurs.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as all team members participate as part of their regular duties. As noted, one individual serves as "the face" of the program—answering the phone, sending out letters, and scheduling meetings. This individual needs to be a good communicator with excellent service skills, including the ability to be empathetic and supportive of patients and family members during a highly stressful time.
- Costs: The program requires no incremental expenditures and may have the potential to reduce liability-related costs.
Funding SourcesSt. Joseph Mercy Hospital
Getting Started with This Innovation
- Ensure appropriate culture, leadership support: This program cannot succeed unless the organization's culture actively promotes full disclosure and transparency, with support for such openness coming from the very top of the organization. Those organizations without such a culture should likely work on establishing one before launching this type of initiative. A starting point may be to formally acknowledge that an open, honest, and trusting environment will be best for patient care.
- Find right administrative point person: Those served by this program are going through very difficult, stressful times. Consequently, the person who contacts them must be an excellent communicator who is highly skilled in dealing with frustrated, confused, and often grieving patients and family members in a compassionate, empathetic manner.
- Consider companion program to support providers: Health care providers who care for patients who die unexpectedly or experience other negative events also may have great difficulty coping and, hence, need ongoing support to overcome their feelings of guilt and remorse. St. Joseph Mercy is developing a similar, companion program for these caregivers.
Sustaining This Innovation
- Emphasize listening and compassion: The program is not designed to defend provider actions, to give a detailed explanation of what went right or wrong from a clinical perspective, or to change the patient's or family members' minds about what happened. Rather, the point is to listen to and understand the patient and family member perspective; to address their concerns in an open, compassionate, and caring manner; and to maintain or restore their trust in the health care mission.
- Train and prepare those involved in meetings: Meeting with patients and family members can be quite stressful and anxiety producing. Those involved should receive adequate training and mentoring before taking a lead role. In addition, pre-meeting rehearsals provide valuable preparation, although they may not anticipate all patient and family concerns that surface during the session.
- Let patients and families participate on their own terms: Although program leaders encourage patients and family members not to record sessions or to bring along an attorney, some will insist on doing so.
- This program won the 2011 MITSS HOPE Award. MITSS (Medically Induced Trauma Support Services) is a nonprofit organization that works to support healing and restore hope to patients, families, and clinicians affected by an adverse medical event.
Contact the InnovatorMichael Mikhail, MD, FACEP
Regional Director of Emergency Medicine at St. Joseph Mercy Health System
Chairman of the Board of Emergency Physicians Medical Group
2000 Green Road
Ann Arbor, MI 48105
Innovator DisclosuresDr. Mikhail has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
Boothman RC, Blackwell AC, Campbell DA, et al. A better approach to medical malpractice claims? The University of Michigan experience. J Health Life Sci Law. 2009 Jan; 2(2):125-59. [PubMed]
5 Goodman DN. Apologizing for medical mistakes, saying 'sorry' is paying off for doctors at U. of Michigan. The Washington Examiner. July 20, 2009.
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Original publication: June 20, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 23, 2013.
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