Not All VA Hospitals Disclosing Errors...Surprised?
An article was recently published in the Tampa Bay Times saying - in short - that despite a national reputation as being a leader in disclosure of medical errors, not all VA Hospitals are following the VA's national policy of disclosing medical errors. In fact, the Times article implied very few patients/families are receiving disclosure and apology from VA facilities.
My response: I am not surprised, and, within the disclosure world, I'm not sure this is earth shattering news.
Look, to be absolutely candid, you could write almost the same article about any hospital in the United States, because around 2001 JCAHO told hospitals they needed disclosure policies, and most complied. Again, so what? Sometimes when I speak at a hospital I will hold up a copy of the JCAHO-inspired disclosure policy and ask how many doctors & nurses know the policy even exists? Usually only a few hands go up. I will then ask those with their hands up to continue to keep their hands up if they have actually read their hospital's disclosure policy. Almost always all the hands go down. When I read these disclosure policies, they appear to be written by lawyers for the benefit of lawyers. Absolutely worthless. No wonder we have so many doctors and nurses not knowing what to say post-event, no idea who to call for help, etc, etc.
Dr. Steve Kraman and Ginny Hamm, JD did an awesome job at the VA Hospital in Lexington, KY several years ago. They had a good disclosure program, and their work became the template/model for disclosure programs at many other hospitals and insurers. Kraman and Hamm received much well-deserved praise as did the VA System for giving them the ability to do this work. I believe Kraman and Hamm's work also was the reason for the disclosure policies within the VA and by JCAHO....but there is a world of difference between a policy and a program. Not enough private hospitals and VA hospitals have disclosure programs. We have a lot of work to do.
You need to have a program...a program that raises awareness within the institution from c-suite to front-line staff, provides the necessary training for all staff, and the institutional follow-through when adverse events happen. If all you have is a policy the Tampa Bay Times could write the very same article about your hospital (or insurer). You need a program, and the best part is the cost of developing a program will be recouped by stopping just one lawsuit.
To help train your front-line staff, be sure to get some copies of the newly released "Pocket Notes." Adapted from the successful Little Book of Empathy, Pocket Notes will in a few minutes teach the basics of empathizing and staying post-event without prematurely admitting fault. To order,click on this link.