Transparency programs in light of medical errors

The practice of medicine is not exact. Although medical professionals pledge and intend to do no harm, errors do occur occasionally. Sometimes these errors can be the cause of permanent injury to or even death of a patient.

In these instances, most patients or their families will seek litigation to be compensated for the injury. These suits affect the provider’s malpractice rate, his or her reputation and the overall cost of healthcare. Typically, a healthcare organization (HCO) will cease any communications regarding the incident and refer all conversation to a corporate attorney.

Despite the lack of tort reform requiring transparency programs, the tide is turning on this approach, and an increasing number of HCOs are implementing their own internal programs. In many transparency programs, it is not uncommon for medical professionals to not only apologize for the error, but also to publicize the adverse event. The question remains: Should HCOs implement internal transparency programs?

The adoption of transparency programs within HCOs can serve several functions: promote accountability, actuate improved quality and safety, encourage ethical behavior and trust and promote patient choice. Implementation of a transparency program requires a change in organizational culture that aims to improve outcomes by assuring physician protection, demonstrating consistent commitment toward program improvement and encouraging teamwork toward the final goal — optimal patient outcomes.

The malpractice factor

Medical malpractice and the resulting financial implications are at the heart of the issue of medical error transparency. Medical malpractice cases weren’t commonly seen in the United States until the 1800s, when malpractice suits were filed with increasing regularity. Historically, physicians would not testify against one another or would not even publicize the fact that a medical error occurred. Jumping forward to the 1960s the frequency of suits increased, and today they are relatively common.

During the 1960s, physicians began to testify regarding the standard of care in malpractice cases.¹ While it may have been disadvantageous for the defendant practitioner, this altered the mindset of damage control to one of sharing outcomes, even when it was an adverse outcome. This marked the beginning of transparency in revealing medical errors.

Most HCOs have experienced some sort of malpractice claim and most have implemented internal protocols for handling such suits. Due to fear of being sued, staff are often advised to remain silent and refer inquiries to the legal department in any case of error or possible malpractice, which can result in staff feeling frustrated or afraid.

Staff and clinicians usually understand what went wrong in the cases but are not free to openly discuss them. However, fear of retribution and being deemed an outsider are prevalent themes with clinical staff.

A resulting tendency to maintain silence about incidents can exacerbate them. By not receiving relevant information pertaining to an adverse event, a patient will often seek legal remedies for basic information about the incident. Almost half of respondents in a 2010 survey on patient litigation motivators indicated that they sued to get more information about what happened or reported that the physician was not honest or intentionally misled the patient.

Barriers to error reporting

Medical errors can occur for a variety of reasons, but incidents due to the malicious or egregious negligence of a healthcare professional are infrequent. The root cause of most medical errors can be traced to a systems error. For example, in 2004 a patient died due to injection of the incorrect medication. The error was quickly discovered, but even life-saving efforts to reverse the damage proved unsuccessful. This tragic error was not hidden, but rather it was thoroughly investigated and once the systems error was identified, the remedy was openly shared with other HCOs. The result allowed other HCOs to revise their systems to prevent such an error from occurring.

Disclosure of errors and near misses (incidents in which protocol/best practice wasn’t followed but no injury occurred) result in improved patient safety, as identified in the previous example. Dissection of the disclosure focuses more on what and why rather than who. Additionally, it details the aftereffects of errors and provides for process improvement to prevent repeat errors. Ideally, this information is shared interdepartmentally within the HCO and others within the field to improve patient safety.

Sample program infrastructure

Error reporting can improve the quality and safety of patient care. According to the National Patient Safety Foundation, a transparency program requires infrastructure to focus on four key domains of communication: clinician to patient, clinician to clinician, organization to organization and organization to public.

• Clinician-to-patient transparency: If a clinician is free to openly communicate his or her opinions with the patient, the relationship will be based on honesty and transparency. Further, it will serve to support non-adversarial interactions, encourage shared decision-making, reduce litigation and support an improved experience for the patient.
• Clinician-to-clinician transparency improves communication between those involved in direct patient care. This type of transparency encourages sharing of best practices and will serve to support accurate patient records.
• Organization-to-organization transparency improves communication at the level of organizational structure and policy. It will serve to share best practices observed in the organization, provide benchmarking data, share patient data that serves to reduce redundant testing and will aid in education toward preventing similar errors from occurring in other organizations.
• Organization-to-public transparency: This transparency will provide the public with the ability to critically compare organizations that support informed decision-making, motivate physicians toward improved quality and provide an opportunity for increased patient trust.

Patient autonomy is a critical aspect of the ethical consideration to a transparency program. The implication of beneficence and non-maleficence are addressed in a transparency program. Physicians are encouraged and supported to report errors or near-misses without fear of punishment or malpractice. An HCO’s core mission is to provide safe, quality care and it has an ethical obligation to reveal errors. This contributes to the patient relationship built on trust and supports collaboration. The clinician-to-patient transparency domain acts as the foundation for the remainder of the domains — transparency begins at this primary level.

A transparency program also requires infrastructure focusing on targeting strategic priorities within the HCO. The focus must be a change in the internal culture to promote acceptance versus penalty and being proactive rather than reactive. This will enhance the ability to sustain a culture of safety and accountability.


The executive team for the transparency program, typically composed of compliance, legal, quality and safety teams and the chief medical officer, will need to serve as ambassadors of change. These ambassadors support the culture change to overcome the fear of disclosure and potential negative effects on reputation and effectiveness. Implementation of a transparency program will require cooperation from all departments: the program’s executive team to create organizational culture that supports the campaign; clinicians to collaboratively involve patients before, during and after care; and leadership to thoroughly report on quality measures.

Understandably, implementing such a program requires buy-in from the HCO leadership/major stakeholders and preparation for dealing with those who prefer to maintain current programs. Transparency will involve educating/training staff and providing support at all levels. Fears about admission of error and the perceived harm to reputations must be acknowledged and addressed. The key issues are that the program will create positive change to improve the quality of care and relationships with the public.

Summary of findings

Despite the initial fear of worsening malpractice claims due to admitting errors, historical trends suggest that implementing a transparency program does not significantly increase total malpractice claims and liability costs. An academic HCO located in the Midwest has effectively demonstrated this – since 2001, the HCO has successfully managed a transparency program that offers full disclosure and a settlement offer after an adverse event. Since inception, the HCO has experienced a reduction in the average rate of new claims (7.03 per 100,000 patient encounters to 4.52), a reduction in the average monthly rate of lawsuits (2.13 per 100,000 patient encounters to 0.75) and a reduction in the median time until settlement (1.36 years to 0.95 years).

Another HCO has successfully implemented an organization-to-organization transparency program. This healthcare system, also located in the Midwest, achieved a 40% decrease in the rate of serious harm over a 20-month period, simply by encouraging and supporting transparency within its member organizations.

Legislative efforts that have encouraged and financially rewarded adoption of EHR systems have spurred efforts toward systemwide transparency. When EHRs can communicate interorganizationally, the interchange of relevant health data will support transparency. If HCOs can communicate effectively and collaboratively, patient care becomes more efficient and therefore less costly. Improved communication begins at the core of the healthcare relationship: between clinician and patient.

HCOs will need to accept the responsibility for errors on an organizational level to protect the provider’s reputation. Organizational culture must embrace accountability while remaining open and receptive when errors occur. This is a change from the current practice in most HCOs and will take effort to realize.² Leadership must remain cohesive and committed to change to convince all stakeholders of the benefits of program implementation.

Transformation to a culture of transparency will not happen overnight, but continuous commitment through incremental steps will eventually improve outcomes. Organizational leadership must demonstrate commitment toward improvement, assure physician protection and encourage teamwork. HCOs will need to actively review performance data, incorporate best practices and share lessons learned with others.

It is important to remember that the cornerstone of error prevention is that of error acknowledgment and reporting. This includes a system that supports identification and reporting of near-miss errors. Success of any transparency program will require a shift in the organization’s culture from that of blame to one that encourages patient safety. The Joint Commission, the accreditation organization that promotes patient safety standards for HCOs, supports the ideal that once errors are dissected and root causes are identified, reoccurrences can be prevented.

As administrators evaluate past failures and successes it’s in their best interest to focus on nationwide healthcare. Transparency programs can help promote accountability from all stakeholders, from the patient to a hospital system executive. Implementing treatment transparency actuates improved quality and patient safety and ultimately provides a more stable healthcare environment. Transparency removes the punitive blame that often is found with a treatment error, allows for open communication between clinicians and will encourage ethical behavior and trust among healthcare professionals.

Healthcare managers must strive for constant program improvement to meet the goal of providing quality care to all patients. Implementing a transparency program at an organization will demonstrate commitment to this goal. 

Editor’s note

This article was edited from a Fellow paper submitted toward fulfillment of ACMPE Fellow accreditation requirements. Learn more about ACMPE certification and accreditation at mgma.com/acmpe.

Notes:

1. “Medical malpractice.” West’s Encyclopedia of America Law, edition 2. 2008.
2. Kachalia A. “Improving patient safety through transparency.” The New England Journal of Medicine, October 2013; 369; 18.