A patient’s lung imaging showed a concerning spot, but the technician’s flag in the electronic health record didn’t register with the care team, which was busy treating his stroke in the Emergency Department. Two years passed before the patient received an overdue diagnosis of cancer.
This scenario, based on the experience of a Massachusetts man, was part of a presentation at the 10th annual CARe Forum in Boston last month demonstrating effective interactions with patients and families in the aftermath of adverse events using a CARe approach.
CARe, which stands for Communication, Apology and Resolution, is a model developed more than 10 years ago to respond to adverse medical events. Instead of using traditional “deny and defend” tactics, organizations with communication and resolution programs such as CARe proactively respond to unexpected outcomes with open communication, support (for clinicians as well as patients and families), investigation and system improvement. When warranted, patients and families receive financial compensation for medical harm without having to go to court.
The CARe model is gaining momentum in Massachusetts, with 15 programs in place at healthcare facilities by the end 2023, and two more expected in 2024. Barbara Fain, Executive Director of the Betsy Lehman Center for Patient Safety, which provides technical and other support to organizations building or sustaining CARe programs, spoke at the forum about the ways in which the principles of communication, apology and resolution contribute to larger goals in the state’s strategic plan, the Roadmap to Health Care Safety.
Fain also noted that the President’s Council of Advisors on Science and Technology endorses the use of programs like CARe in its report, A Transformational Effort on Patient Safety, released in September. Organizations across the country increasingly look to the Betsy Lehman Center for guidance and expert advice as they contemplate similar programs.
Doug Salvador, M.D., M.P.H., Chief Quality Officer at Baystate Health, who was involved in developing CARe and now oversees the project at five institutions at Baystate, reflected on the growth of CARe and the 10-year history of CARe Forums:
As in the past, the CARe forum offered simulated discussions with patients and families that model important components of a sample case, followed by a live panel discussion from CARe practitioners. This year’s simulations were based on the case of the man whose lung cancer diagnosis was delayed by two years and are available on YouTube. An archive of simulations based on other adverse events be found under the category “Simulations and case studies" in the CARe resource library or by browsing past CARe Forums.
Apply CARe in “every case, every time”
At the forum, CARe Program Director Melinda Van Niel explained that the model is comprehensive and includes a pathway for evaluating adverse events and guidance for how to approach communication, apology, investigation, healing and resolution. Van Niel urges organizations that commit to using CARe apply it to all adverse events: “every case, every time.”
Initial steps involve proactively disclosing the adverse event, responding to the patient’s immediate needs, keeping them informed, investigating the event, and determining whether the standard of care was met. CARe also includes taking action to help prevent similar events from happening again and, when appropriate, compensating patients for harm.
A three-year pilot study found that in 85% of CARe cases, the provider organization met the standard of care or the event resulted in low-level harm to the patients. Regardless, patients are informed about what happened, invited to participate in a structured conversation about the event with staff and clinicians and may receive support for immediate needs related to the event.
When the standard of care is not met or the event results in significant harm, the CARe pathway includes the organization’s malpractice insurer in next steps, as well as clinicians and the patient, family members and a patient’s attorney. Resolution of a CARe case may include financial compensation for the patient, which can be agreed upon without going to court.
In all cases, clear, empathic communication is a priority, and the effect of the event on clinicians is also addressed. Research has shown that:
- CARe does not increase claims and related costs.
- Clinicians support use of the program.
- Patients are often spared long-term negative psychological impacts from adverse events.
Karen Fiumara, PharmD, Vice President of Patient Safety at Mass General Brigham, also spoke to forum attendees about ways to create a framework for meeting the short-term needs of patients and families in the immediate aftermath of an adverse event, such as financial help with transportation, child care or other expenses related to follow-up care.
Clinicians can also benefit from the CARe approach
Jay Kilpatrick, D.O., Director of Psychiatry Consult Services at Baystate Medical Center in Springfield, shared that his recent, first-time experience in with CARe was positive.
Providers may feel anxious about having CARe conversations with patients and families, particularly if they are experiencing strong emotions, such as grief and anger. Dr. Kilpatrick encouraged providers to listen, engage and support patients and families despite the discomforting circumstances. “While your body may be saying to lean back, what you actually want to do in those moments is lean in,” said Dr. Kilpatrick. While the immediate experience of a patient’s emotions may be challenging, accepting them may help move the conversation toward healing, he said.
The CARe model includes support and coaching for providers and staff, who may be dealing with their own difficult emotions while trying to help patients and families. “We want to keep the families at the forefront of the discussion,” said Dr. Kilpatrick, “but I think what providers may not realize is that they may be suffering, too.”
