This paper was contracted by the Robert Wood Johnson Foundation. Preliminary interviews were
conducted in support of the workshop entitled, “Disclosure: What’s Morally Right Is Organizationally
Right,” at the 18th Annual IHI National Forum on Quality Improvement in Health Care, December 10-13,
2006, Orlando, Florida, USA. For more information, contact Eve Shapiro, Medical Writer, at
eveshapiro@aol.com.
Disclosing Medical Errors: Best Practices from the “Leading Edge”
By Eve Shapiro
Introduction
Mary McClinton went into Virginia Mason Medical Center for a relatively routine
procedure in 2004. While there she died after receiving an injection of chlorhexidine, a
caustic cleaning solution, instead of normal saline. Both were clear liquids and had been
placed side by side in unlabelled cups in the operating room.
A 9-year-old girl who had just undergone surgery at the University of Michigan Health
System in 2001 gave herself a lethal dose of dilaudid because she was given a
miscalibrated PCA pump.
Betsey Lehman, a Boston Globe reporter, and Maureen Bateman were being treated for
breast cancer at the Dana-Farber Cancer Institute in late November 1994. Lehman died
on December 3 and Bateman suffered permanent heart damage because, in one day, they
received four times the daily dose of the anticancer drug cyclophosphamide.
In 1999, the Institute of Medicine shocked the nation by reporting that between 44,000
and 98,000 people die in hospitals each year as a result of medical errors. That report, To
Err Is Human,1 raised awareness about the prevalence of medical errors in our nation’s
hospitals. Six years later, in 2006, the Institute of Medicine released the report,
Preventing Medication Errors,2 which revealed that a hospitalized patient can expect to
experience, on average, one medication error per day.
Dr. Donald Berwick, president of the Institute for Healthcare Improvement, experienced
such errors himself when his wife was a patient in a well-known Boston hospital. “It was
not just how she was treated,” Berwick told Time magazine,3 “it was that so little of what
happened to her was unusual.” Despite Berwick’s best efforts on his wife’s behalf, he
says, “tests were repeated unnecessarily, data were misread, information was misplaced.
Things weren’t just slipping through the cracks; the cracks were so big there was no solid
ground.”
1
Institute of Medicine. To Err Is Human: Building a Safer Health Care System. Washington, DC: National
Academies Press; 1999.
2
Institute of Medicine. Preventing Medication Errors. Washington, DC: National Academies Press, 2006.
3
Gibbs N, Bower A. Q: What Scares Doctors? A: Being the Patient. Time, April 23, 2006.
Shapiro: Disclosing Medical Errors (2008)
1
The prevalence of medical errors and their impact on the lives of patients and their
families is profound. Why, eight years after the IOM issued its indictment of the health
care system challenging it to reduce medical errors, are errors still a common fact of life
in our nation’s hospitals? What is being done to turn the tide?
The answer to the question “why” medical errors are still taking place may lie in the
IOM’s recognition that medical errors are not usually the fault of a single person
delivering health care. The problem, the report pointed out, instead has more to do with
flawed systems. So, for example, if a hospital’s practice is to pour solutions that look
alike into clear cups before an operation without clearly distinguishing one from another,
an error is almost inevitable. It would be easy for someone to reach for the wrong cup
without realizing it. Preventing such an error would require not punishing the person who
reached for the wrong cup, but changing the way the hospital prepares liquids before
surgery. Doing so would be considered a systems change.
Changing systems is more complex than punishing a person who makes an error. But,
ultimately, fixing flaws in the system is the only way to prevent the same errors from
happening over and over again. Medical institutions have been slow to change their
systems because doing so requires at least three things: first, admitting that errors are
made; second, communicating the errors to patients and families, throughout the
institution and, often, to the media; and third, suffering the uncertain consequences of an
error’s disclosure, which are commonly thought to include malpractice lawsuits.
The answer to the question, “What is being done to turn the tide?” is, at least, twofold:
first, patients and family members who have been harmed through medical errors are
demanding to be told the truth when something goes wrong in their care; and second,
some medical institutions, such as the Harvard Hospitals, are promoting open
communication, full disclosure of medical errors, and apologies to patients and their
families when something goes wrong.4
Patients and families have banded together to push for full disclosure of medical errors,
along with apologies, by establishing patient advocacy groups. Grass-roots organizations
such as Sorry Works! (sorryworks.net), Patients United Limiting Substandards and Errors
in Healthcare (PULSE), Medically Induced Trauma Support Services (MITTS),
Consumers Advancing Patient Safety (CAPS), and others are raising the awareness of
political leaders, legislators, and the medical community about the urgent need for
change.
Some medical institutions are seeking to turn the tide of medical errors by doing what
medical institutions have been historically afraid to do: that is, to confront and openly
admit their mistakes, to disclose them to patients and families and throughout their
institutions, to investigate their causes, and to use what they learn to improve their
processes and their systems so these errors do not recur. The seven organizations
4
Harvard Hospitals. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of
the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical
Error; March 2006.
Shapiro: Disclosing Medical Errors (2008)
2
highlighted here have begun this journey. What they’re doing, how they’re doing it, and
what they’re learning in the process is the subject of this white paper.
Shapiro: Disclosing Medical Errors (2008)
3
University of Illinois Medical Center
Nikki Centomani, R.N., Director, Department of Safety and Risk Management at the
University of Illinois Medical Center, has long believed that confronting and openly
disclosing medical errors as soon as they are discovered is the right thing to do for several
reasons. First, open disclosure is the most effective way to reduce errors because it begins
the process of learning. Second, open disclosure begins the process of healing for all
involved: for patients, families, and health care providers. Third, she intuited, open
disclosure would lead to fewer, rather than more, lawsuits. Bolstered by these beliefs,
Centomani began in 2002 what would be a four-year campaign to convince hospital
administrators and leaders to adopt a policy of full disclosure.
What made this a four-year effort instead of something much shorter was fear, according
to Timothy McDonald, M.D., J.D., Associate Professor in the Department of
Anesthesiology. “The hospital’s defense bar and claims management lawyers resisted for
years,” McDonald says, “advising the hospital and its physicians to ‘deny, deny, deny,’
even in such cases as wrong-site surgery.” As McDonald describes it, their own defense
lawyers were the biggest barriers of all. “We had one horrendous sentinel event and I
pushed for full disclosure,” McDonald recalls. “We’d done a wrong site surgery in a
neurosurgery case. Nikki and the physician said, ‘Isn’t this a case where we should just
tell the family we made a mistake and settle it instead of it letting it become a lawsuit?’”
The answer was “No,” McDonald relates, because there was no institution-wide process
in place to disclose an error.
What finally convinced the leadership at the University of Illinois Medical Center to
adopt a policy of full disclosure in 2006? As McDonald explains, it was a combination of
Centomani’s persistence and a little luck.
First, an Attitude Shift
The luck came in the form of shifting personnel. New people came in on the business
side who had heard about the positive outcomes of the full disclosure policies at the
University of Michigan and the Lexington, Kentucky, Veterans Administration. The new
staff members took those results seriously and, McDonald recalls, thought it would be
worth considering a process for full disclosure.
“When we decided to establish a policy and process for disclosure, we interviewed 16
law firms,” says McDonald. “Twelve of the 16 told us that medical errors should not be
disclosed and advised us to continue denying errors when they occurred. Four of the
firms approved of full disclosure. These are the four we chose to represent us,” he says.
Then, in 2005, McDonald and colleagues spent two and a half days in Ann Arbor with
Rick Boothman, learning about the University of Michigan policy, process, and
experience in fully disclosing medical errors to patients and families. When they returned
to Illinois, McDonald says, they set out to develop their own process.
Shapiro: Disclosing Medical Errors (2008)
4
The Process
McDonald and colleagues developed a process for disclosing medical errors to be
followed by everyone within the University of Illinois Medical Center every time an error
occurs. The process begins at the point an error is discovered and ends at the point,
McDonald says, “the organization has assured itself that the likelihood of it occurring
again is nil. From top to bottom,” he says, “that is what we did.”
According to the process, an investigation begins to determine whether a further
investigation is warranted as soon as an error is discovered. If it is, the process follows
steps outlined by McDonald:






If it’s a probable error, a rapid investigation team determines whether it’s a clear
error.
If it’s a clear error, the case meets our criteria for an apology with full disclosure.
If an apology is delivered with full disclosure, the remedy (that is, compensation)
is considered.
If a remedy is offered, a liaison is created between the patient and family and the
claims department, since physicians and nurses shouldn’t manage the process of
financial compensation for medical errors.
If a claim is large, the organization must decide how the claim will travel through
the administrative approval process.
Contemporaneous with the steps involving remedy, the organization must decide
how to put process improvements in place to prevent future error.
Developing the process was only the beginning. Next, McDonald and colleagues would
have to convince others that disclosing medical errors using this process was the right
thing to do, both ethically and financially.
The Right Thing to Do
“Slowly but surely, we started meeting with all the stakeholders whose buy-in we
needed,” McDonald says. “These were everyone in the organization from top to bottom:
the president of the university, then the chancellor, the provost, the dean of the college of
medicine, the chief executive officer of the health care system, the chief medical officer,
and the chief nursing officer. We then vetted the process through the board of trustees.
We drilled down to the grass roots,” he says. Next, McDonald and his colleagues held
small group meetings throughout the medical center to explain the process and to
highlight the positive experiences of the University of Michigan Health System and the
Lexington, Kentucky, VA in disclosing medical errors.
“Then,” McDonald says, “we pushed for transparency by stating the following concepts:

“We are not just providing full disclosure and rapid settlement; we’re taking each
of these cases and learning from it.
Shapiro: Disclosing Medical Errors (2008)
5



“The way we’re going to successfully manage the medical malpractice crisis is
through safer care, not tort reform.
“The best risk management strategy is patient safety.
“One important way to improve patient safety is to not make the same mistakes
over and over again.”
“At the end of one of our presentations on patient safety and full disclosure,” McDonald
recalls, “the president of the university, B. Joseph White, looked at us and said, ‘At the
end of the day, isn’t it just the right thing to do?’”
McDonald and his colleagues adopted the president’s words and combined them with the
principles Rick Boothman followed at the University of Michigan Health System:



When we hurt someone through unreasonable medical care, we need to make it
right.
When the care our staff provides is reasonable, we need to support them even
when something goes wrong.
We need to learn something from medical errors that will help us to improve our
care.
Their next step, McDonald says, would be to help their physicians put the policy and
process into practice.
Training and Consultation
McDonald and his colleagues knew that disclosing medical errors doesn’t come easily to
all clinicians. Some are better natural communicators than others, but training for
everyone would be essential. The type of training they decided to provide was twofold:
first, classroom training given by Gerald Hickson, M.D., associate dean for Clinical
Affairs and director of the Center for Patient and Professional Advocacy, Vanderbilt
University Medical Center; and then, on-the-spot training available whenever something
goes wrong. They called this on-the-spot training their Patient Communication Consult
Service.
The telephone number for the Patient Communication Consult Service hotline is posted
all over the organization and it works this way, as McDonald explains: “Anytime there’s
an adverse event of any kind, clinicians can call a hotline 24 hours a day, seven days a
week. Whoever is carrying a pager in the office of safety and risk management will get
an immediate page and be notified that someone in the organization has been involved in
an adverse event and needs help talking to patients and families. It may or may not
involve a clear error. If it appears to be a clear error, we prepare the possibility of a
remedy. If the case does not involve a medical error, we give the clinician advice, based
on our level of experience and training, on communicating with patients.”
“To create the communication consult service we hand-picked people we wanted to train
in all our departments, including medicine, nursing, pharmacy, guest services,
Shapiro: Disclosing Medical Errors (2008)
6
administration, legal, and so on,” McDonald continues. “This was a ‘train the trainer’
process, whereby the people we trained went back and trained other personnel in their
departments.”
Remedies
“We meet with patients, apologize, and provide a remedy whether patients want to file
a claim or not,” says McDonald. “The first important case in which we put our policy
and process into practice involved the unfortunate death of a young patient,”
McDonald recalls. “Within 90 days,” he says, “we settled the case for a large amount.
We’ve had many other, smaller cases in which remedies ranged from waiving a small
hospital fee, to $75,000. We have waived fees for professional services, hospital and
other medical services, drug costs, and more. These are real remedies and they impact
the lives of our patients.” McDonald explains their centralized hospital and
professional billing offices have the ability to put a hold on billing of the patient in
case of an error or a potential error.
Spreading the Word
Putting a process in place to disclose medical errors would be effective only if everyone
in the organization were familiar with the process and would follow it. “We held a huge
symposium on the full disclosure process that was open to the entire hospital,” McDonald
recalls, “which 110 people attended.” But staff awareness requires more; it requires
continual reinforcement. “We have monthly symposia where issues related to full
disclosure and communication come up, where we can talk about big wins and losses,
what went well and what didn’t. We created a form on which the staff can evaluate the
effectiveness of full disclosure with patients and families, and we discuss these at the
monthly group meetings,” McDonald says.
“We also hold seminars with the ethics department on the second victim,” McDonald
continues, “the person who has made the error, to discuss how badly they feel and what
the impact the error may be. Putting in a system where there’s employee assistance for
everyone is important.”
Outcomes
What outcomes has the University of Illinois Medical Center experienced since
implementing their full disclosure process? The results have been positive:


Families who have experienced an error or an adverse outcome at the University
of Illinois Medical Center continue to seek care there. That includes the case they
settled for a large amount.
Patient safety has improved. As McDonald says, “Each and every one of our
cases has its own associated process improvements and we’re tracking them all.
Shapiro: Disclosing Medical Errors (2008)
7


We have been able to show through root cause analysis, for example, that the
failure to supervise residents led to many medical errors. With our new process
there has been greater engagement by attending physicians with resident
physicians, and education and supervision on patient safety-related issues.”
The time it takes for clinicians to receive critical test results and to communicate
those results to patients has been reduced.
Employee attitudes have improved. “People are glad to finally be in an
organization in which clinicians can openly disclose errors in an organized way
and offer remedies to patients and families when appropriate,” says McDonald.
Lessons Learned
McDonald shares the following lessons learned:



Persuade your lawyers that disclosing medical errors is the right thing to do
ethically, legally, and financially, despite their fears related to admitting liability.
Recognize that shifting the culture of an organization is not easy and takes time.
Get buy-in from all the stakeholders once you decide on a process.
University of Michigan Health System
The University of Michigan always considered itself ethical and open with its patients
about mistakes and patient injuries, but in 2001 it systematically began to initiate
conversations with patients who complained and threatened to sue. To Rick Boothman,
Chief Risk Officer, open disclosure first made common sense as a way to save money: if
you knew you made an error and would have to settle anyway, wouldn’t it make more
sense simply to admit the error and compensate patients, saving hundreds of thousands of
dollars in court costs and attorneys’ fees?
But for Boothman and his colleagues, what started out as a pragmatic approach to
managing claims soon became much more. “There is no question in my mind that the
culture of open disclosure paves the way for clinical improvement in ways that we have
never seen before,” Boothman explains. “The culture of deny-and-defend prevents us
from improving. Being open with patients starts with being honest with ourselves about
our failings—that is a necessary prerequisite to any real improvement. That is where the
real gold lies,” he says.
Guiding Principles
There are three principles that guide the University of Michigan Health System’s
approach to a claim of medical error:


They compensate patients and families when they’ve made an error.
They fight to defend themselves when their care was reasonable.
Shapiro: Disclosing Medical Errors (2008)
8

They systematically use mistakes as tools for learning and for making needed
changes to their system.
“When we make an error,” Boothman says, “we do not hesitate to accept responsibility,
apologize directly to the patient, and move quickly to compensate them without their
having to file a malpractice suit. But when we think our care was reasonable, we explain
to the patient and family, and their lawyers, why we don’t think they have a case,”
Boothman says.
Boothman spent much of his time that first year meeting with medical staff, faculty,
University of Michigan trial attorneys, the courts, and the plaintiff’s bar in Southeastern
Michigan to explain and gain acceptance for this approach. In his meetings with
plaintiff’s attorneys, Boothman presented the essence and significance of this new
approach: he explained the University of Michigan’s commitment to compensate quickly
and fairly when they felt the medical care was unreasonable, but he cautioned that they
would defend their staff and institution vigorously when they felt the care was
reasonable. He committed to working with plaintiff’s attorneys so they would understand
the difference between reasonable and unreasonable care before litigation was filed.
What enabled Boothman to take this unusual approach in response to medical errors?
“Leadership and faith that we were doing the right thing,” Boothman says. “There are
corporate cultures in every organization. Some cultures will make this easier to do than
others. For some, deny, defend, and scorched earth is the way they choose to do things.
It’s tougher to get those organizations to say, ‘Maybe we did make a mistake and maybe
we ought to be courageous enough to confront it and tell people that.’ I happen to be
blessed with an institution that has an historically open culture and medical leadership in
the form of Skip Campbell, chief of staff, who is unflinching about patient safety and
honesty,” Boothman says.
The Process
Michigan laws have created the ideal circumstances for Boothman’s approach. The
University of Michigan Health System takes advantage of the compulsory six-month presuit notice period the law allows (Michigan Compiled Law 600.2912). Before a
malpractice suit may be filed against any health care practitioner or facility in Michigan,
the patient or patient’s family is required, by law, to present details of their claims in
writing. Once this notice is served, a suit cannot be filed for 182 days. This pre-suit
notice period allows prospective defendants time to investigate the claim, gives them the
opportunity to meet with the patient or family, and offers patients and families time to
reconsider their decision to sue.
The University of Michigan Health System strives to thoroughly review the required
written claims within three months or less (see Figure 1). Every suspected injury and
claim is triaged and a focused investigation planned. Each case undergoes internal and,
often, external expert reviews. The patient care at issue is submitted to the Medical
Liability Review Committee, which reaches conclusions about the reasonableness of the
Shapiro: Disclosing Medical Errors (2008)
9
care delivered and its impact on the patient’s outcome. The committee also considers
every submitted case for peer review, clinical quality improvement, and educational
opportunities. The committee’s role is purposefully restricted to medical issues and
quality of care concerns. Its conclusions inform claims management, but this committee
does not oversee litigation or involve itself in the financial aspects of claims
management.
Figure 1.
Present UMHS Claims Management
Chief Risk Officer
Assess and
Plan Investigation
CRO/Risk Management
Investigation and
Analysis of Risk and Value
Medical Liability
Review Committee
(3 months)
← Before Suit →
Health System
Legal Office
(Assigns Trial
Counsel)
Agree to Disagree
Litigation
No Dialogue
Engage Patient,
Patient’s Lawyer
and
Share Information
nt
me Injury
e
l
t
/
t
Se istake
Claims Committee
Settle or Trial?
M
Agree no Claim
Once the issues have been clarified, the University of Michigan Health System openly
discusses them with the patient and his or her lawyer. Often, patients and lawyers are
invited to meet with the doctors or nurses they are threatening to sue, or with experts
whose opinions are pivotal to the assessment. Discussions usually occur between the
Chief Risk Officer or a Risk Management consultant and the patient and his or her
lawyer. This disclosure is vital to the success of the program: parties have a chance to
reconcile their recollections and analyses about the patient’s care and complaints.
Questions are answered. Factual information is supplied and misinformation corrected.
Other perspectives are communicated and explored. Expert reviews are shared.
Frequently, patients and their lawyers are satisfied with the explanations and neither suit
nor settlement follows.
If the Medical Liability Review Committee concludes the care was unreasonable and the
patient’s outcome suffered, and the patient is interested in compensation, there is an
Shapiro: Disclosing Medical Errors (2008)
10
attempt at resolution. In some cases, discussions are extended by agreement to offer the
parties more time to explore the issues. In one case, for example, a patient suffered an
errant nerve transection that was grafted. An interim payment was made to help the
patient with his immediate business needs, and the parties regrouped 14 months later to
evaluate the outcome of his nerve repair.
The University of Michigan Health System’s commitment to its principles opens the door
to immediate and decisive quality improvement measures and peer review opportunities.
Fear of adversely impacting subsequent litigation is virtually non-existent because the
University of Michigan Health System is committed to acting consistently with its own
conclusions about the reasonableness of care. Unfettered by fear of litigation, patients’
complaints travel through a process designed to prompt all involved to ask whether the
care could have been better, whether anything can be done to avoid such complaints in
the future, and whether there are lessons to be learned. (See Figure 2.)
Figure 2.
Pre Suit Investigation
Chief Risk Officer
Assessment
and Direction
CRO/Risk Management
Investigation and
Analysis of Risk and Value
Peer Review
Medical Liability
Review Committee
(3 months from notice or less)
Clinical Quality
Improvement
Educational
Opportunities
Barriers to Full Disclosure
The biggest barriers to implementing their full disclosure policy were, first, the
perception that openly disclosing medical errors would adversely impact the health
system’s ability to defend itself and, second, according to Boothman, those within the
university who still worry about adverse consequences of open disclosure. Fear of
lawsuits and fear of disclosing medical errors to irate patients and their families can be
powerful deterrents to doctors. Despite the logic and common sense of Boothman’s
Shapiro: Disclosing Medical Errors (2008)
11
approach—and despite the positive outcomes that have resulted—“lawyers who tell
clients to deny and defend find a willing audience because doctors’ emotions rather than
logic are guiding them,” Boothman says. “This is a battle we’re making progress on, case
by case, doctor by doctor. We’ve had to overcome the human impulse to avoid anything
we’re sure is going to be uncomfortable or distasteful,” he says.
Overcoming the Barriers
Boothman has found the most effective way to overcome the barrier of fear is to remind
doctors that full disclosure serves the best interests of the doctor and the institution.
“But,” he says, “this is an intellectual argument that has to overcome the emotional
reticence of doing this. You’ve got to be able to say to a doctor, ‘I serve you best by
helping you avoid litigation. And if we made a mistake, the best way to avoid litigation is
to make it right, right now.’”
The second argument that helps to overcome the barriers is to remind doctors that it is
only by confronting and thoroughly investigating an error that clinical improvement is
possible. “And the faster we do this while the lessons are still fresh, the better,”
Boothman says.
Reassuring Patients and Doctors
“There was a case in which a University of Michigan doctor had not made an error,
but there was a delay in diagnosing a woman’s breast cancer,” Rick Boothman says.
He continues, “I told the oncologist, whose care was not at issue, that we needed to
understand the implications of this delay: did it make a difference in her care, did it
make a difference in her prognosis, would she need to have surgery when she might
otherwise not have needed surgery? I explained that I wanted him to talk openly to the
patient and her lawyer and simply tell them what he’d already told me. Despite the
fact that his own care was not being questioned, his response was, ‘I’d rather eat
tacks.’ I finally asked him to trust me. That case settled two days after we had the
meeting. And to this day the patient will tell you that conversation made all the
difference for her. She found it reassuring, she found it honest.”
After this physician’s experience with open communication, Boothman says, “I think
he’s a convert. He understands. But he also appreciates the level of support and skill
we provide. We prepare people well. We don’t script it for them, but we help reassure
them and help them understand what the themes ought to be. They’re often worried a
patient will become very confrontational. One of the first things I tell them is, ‘If this
ever gets uncomfortable, it’s totally voluntary; we’ll just stop it.’ It’s never happened,
but that’s always a concern.”
Outcomes
Shapiro: Disclosing Medical Errors (2008)
12
Like the other organizations in the early stages of implementing processes for disclosing
medical errors, Boothman is reluctant to attribute their declines in malpractice suits since
2001 to their new policy; other factors are always in play. “The malpractice climate is
affected by so many things,” he says, “social forces, the political climate, statutory
changes. I have been told that patients and lawyers have walked away from suits they
otherwise would have brought, but I do not know whether this is directly attributable to
our policy.”
That being said, Boothman continues, “We’ve experienced a reduction in claims that has
exceeded anyone’s expectations.” “Certainly,” he adds, “our full disclosure policy hasn’t
been the catastrophe everyone predicted it would be.” The number of claims against the
health system has dropped steadily since 2001.
Of course, the number of malpractice suits is not the only measure of their policy’s
effectiveness. Another measure is physician satisfaction with the process and the
outcome. “I believe we’ve tapped into something physicians intrinsically want to do,
anyway,” Boothman says, “but have been afraid to do and have been told not to do for
their entire careers.” Doctors feel empowered by the policy because they finally have
permission to tell the truth.
Their full disclosure policy has also created a culture in which clinicians understand and
value the importance of communicating with patients, regardless of whether an error has
occurred. “Disclosure has to start from the very beginning of the patient’s care. If the
patient’s experience is close to what they’ve been led to expect it would be, then
everything, even after a complication occurs, is a heck of a lot easier to manage,”
Boothman says.
“Most importantly,” Boothman says, “our policy of disclosure has clearly energized the
patient safety efforts here because it’s not taboo to talk about errors openly and to openly
express opinions. We’re seeing a willingness to confront these issues on a departmental
and an institutional level. I think that would be impossible in a culture of deny-anddefend.”
Lessons Learned
Boothman shares the following lessons he and his colleagues have learned since
implementing their full disclosure policy:
 Don’t expect leadership to embrace this unquestioningly. Start with small
successes and publicize them widely to gain the confidence of leadership.
 Have courage. It is important to appreciate the significance of what you’re asking
people to do, especially because it runs contrary to human nature.
 Be willing to hold the line both ways. Sometimes you need to tell patients they
won’t be compensated because your care was reasonable; sometimes you need to
tell doctors they made an error and must communicate that to patients and their
families.
Shapiro: Disclosing Medical Errors (2008)
13
Virginia Mason Medical Center
Open communication, including timely and transparent communication about medical
errors to patients and families, has been part of Virginia Mason Medical Center’s culture
since its founding in 1920, according to Cathie Furman, R.N., M.H.A., Senior Vice
President of Quality and Compliance. Now, they wanted to do more than communicate
errors: they wanted to prevent them. They looked to the automobile manufacturing
industry for a model. Why cars? Because, Furman says, “Both automobile manufacturing
and health care must produce a safe product or people die.”
In 2001, Furman and her colleagues went to Japan to see what Toyota was doing to
prevent product errors. During what she calls a “life-changing” visit, they learned that
open communication throughout the organization is key to mitigating real and potential
errors. Toyota’s principles, they believed, could be applied just as effectively to health
care. Furman and her colleagues decided to put Toyota’s principles into practice at
Virginia Mason. “In Toyota’s pursuit of zero defects,” Furman explains, “we saw that
any worker at any time could stop this multi-million dollar line if they saw a quality
defect or error. We thought, ‘If they’re able to do this for cars, we should certainly be
able to do this for our patients.’” In 2002, they introduced the “Virginia Mason Patient
Safety Alert System,” the pursuit of zero medical errors. Adopting the Patient Safety
Alert System was an executive decision at the top level of the organization, according to
Furman. “The leadership of Virginia Mason declared, ‘This is how we’re going to do our
business,’” she says.
The Virginia Mason Patient Safety Alert System
“An ingredient of the Toyota production system is transparency and visibility,” Furman
explains. “We began to look at how transparent we were,” she says, “and realized we
weren’t as transparent as we could be.” Their solution to this problem was to develop
their Patient Safety Alert System, which declares the following principles:

Everyone is considered a safety inspector. Anyone from the housekeeping staff on
up can and should “stop the line” if they see a patient safety issue by reporting it,
according to Furman. “This is a big deal in health care because health care is very
hierarchical,” Furman admits. “For us or any health care organization to tell a
housekeeper or a patient care technician that we want them to tell us if they see an
unsafe situation—if a doctor or nurse is not following policy, for example—that’s a
big deal,” she explains.

When anyone reports a patient safety concern, the process stops immediately.
“When the incident is reported, we determine whether we should pull the process and
provider off-line during our investigation. We don’t want even one more patient to be
exposed to whatever that process error might be and we’ve completed an
improvement plan,” Furman says.
Shapiro: Disclosing Medical Errors (2008)
14

“Poka-yoke,” the Japanese term for mistake-proofing. “Before any ‘red’ patient
safety alert can be closed—and they all go to the board for closure—we need to
demonstrate that we’ve done something to ensure that the error never happens again,”
says Furman.
Virginia Mason’s patient safety alerts are color-coded, the colors reflecting whether there
was actual harm or potential harm. “We’re required to complete an investigation of actual
harm to a patient involving permanent or close to permanent damage within 24 hours. If
it’s a near-miss, our investigation will take longer, perhaps a week,” Furman says.
Patient safety alerts can be reported anywhere, by anyone in the organization, by
telephone or through the Internet. “A scrub technician can ‘stop the line’ in the operating
room when a surgeon doesn’t take the procedural pause. We’ve also had reports about
elevators malfunctioning and outdated tuna sandwiches,” she says.
When Mary McClinton died in November 2004 after receiving an injection of
chlorhexidine instead of normal saline, Virginia Mason communicated the error
throughout the entire organization as well as to the family. “Because our culture had
gotten to the point where we were very transparent—and because we knew this caustic
solution was present in the organization, but we didn’t know who was using it and to
what degree—we sent an e-mail out to all 5,000 of our employees telling them what
happened. An investigation started and we changed our policy about the use of these
solutions that day,” Furman relates. “We felt we owed it to our patients.” The hospital
also provided information about this medical error to the media and in this way other
hospitals were able to learn from their mistake. “Other hospitals were able to correct their
processes for the use of this solution as a result of our disclosure,” she says.
The Importance of Training
Virginia Mason’s focus on error prevention runs parallel to their focus on the need to
provide continual training for physicians in how to effectively communicate errors to
patients and families.
Virginia Mason offers two-and-a-half-hour workshops each year to teach physicians how
to communicate medical errors and unanticipated events to patients and families.
Training is not mandatory, Furman says, but word of mouth has spread and physicians
want to attend. “We send invitations to physicians telling them they’ve been selected as
someone who could really use this training. First, we invite the high-risk physicians for
training: the intensivists, the hospitalists, and the surgeons, since they’re the ones who are
most likely to need this service, as opposed to primary care physicians,” she says.
In addition to training individual clinicians, Virginia Mason has developed the role of the
‘situation facilitator,’ according to Furman, “12 people who have a deep knowledge about
how to communicate errors.” Situation facilitators undergo two full days of training.
Once they are trained, physicians must consult them whenever an error needs to be
disclosed.
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15
“One hundred percent of Virginia Mason’s physicians know they must call the Patient
Safety Alert System to report an error or a potential error,” Furman says. Situation
facilitators take physicians’ calls, ask them how they plan to communicate the problem to
the patient or family, and then advise them about the need to have a situation facilitator
present when this discussion takes place.
Challenges
Virginia Mason still faces challenges in their pursuit of open, transparent communication
of medical errors. As Furman says, these challenges include the following:


Lack of clarity in some situations about what constitutes an error and what is an
event that can be considered normal during the course of care. “For example,
infections,” she says. “Is this an infection we gave to the patient, or is this an
infection caused by the patient’s compromised immune state? Is it an error or a
natural outcome of a person’s disease? When the answer is unclear, we tell the
patient, ‘This is what’s going on, but we’re not certain what the cause is.’” As
soon as their investigation reveals the cause of the adverse outcome, they
communicate their findings to the patient.
Virginia Mason now receives so many reports through their Patient Safety Alert
System that they need to channel their resources and prioritize their handling of
cases. “For example,” says Furman, “our Chief Nursing Officer can have five
patient safety alerts actively open. She needs to decide which ones to manage at
any particular moment.” Circumstances that result in patient harm are always
handled first.
Outcomes
Virginia Mason’s Patient Safety Alert System has led to increased reporting of actual as
well as potential errors, according to Furman.


When Virginia Mason introduced their Patient Safety Alert System in 2002, they
averaged three patient safety alerts a month; they now average well over 300
reports a month.
Since their Patient Safety Alert System began, Virginia Mason has had more than
6,000 reports.
“Because people are reporting more freely,” Furman continues, “we’re able to learn what
the problems are.” Learning what the problems are allows Virginia Mason to
communicate them to patients and families quickly and accurately, to fix them, and to
take steps to ensure they never happen again.
Virginia Mason has also tracked malpractice claims, Furman says. “It looks as though we
have had fewer claims over last few years,” she says, but cautions they cannot make
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16
simple comparisons of the dollar amounts paid to plaintiffs or attribute the cause to their
Patient Safety Alert System.
Lessons Learned
Furman shares the following lessons with organizations based on the Virginia Mason
experience:

“Prime your nonclinical staff about the nature and number of medical errors that
can and do occur. The staff should know what to expect. If I were to do it over
again, I would put more effort into raising everyone’s awareness,” she says.

“Tell stories and overcome fear by being transparent. For example, we’d tell
stories at our monthly meetings about how we pulled doctors off the line and they
couldn’t work because they shouted at a nurse. This was important to nurses who
were afraid to challenge certain doctors. These stories helped them overcome their
fear.”

“You just have to do it. Too many physicians and other staff are afraid and have
excuses. Our patients and their families want to know what we’re doing to correct
errors and make sure they don’t happen again.”
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17
Kaiser Permanente
KAISER PERMANENTE STATEMENT OF PRINCIPLE
Patient safety is every patient's right and every leader’s, employee’s, and clinician’s
responsibility. Patient care should be reliable, effective, and safe. Kaiser Permanente is committed
to an ongoing and relentless effort to build safer systems. Yet, despite constant and committed efforts
to provide safe health care, from time to time patients experience unanticipated outcomes that are
adverse.
To fulfill our commitment to our patients, “Quality You Can Trust,” we embrace our
responsibility and acknowledge our ethical obligation to communicate with our patients when an
unanticipated adverse outcome has occurred. When such an outcome occurs, the patient, or the
patient’s health care representative, has a right to an explanation of the outcome and its effects,
provided in a timely, truthful, and compassionate manner.
Human error and systems conditions periodically align and combine to contribute to
unanticipated adverse outcomes for patients. What is most important is the manner in which we
handle these circumstances. Patient safety and clinician welfare will be best served if we are honest
about unanticipated adverse outcomes with our patients, open with our colleagues and ourselves, and
able to handle such occurrences with sympathy and empathy for our patients and our colleagues.
Kaiser Permanente is a pre-paid, group practice, nonprofit integrated health care delivery
system with facilities concentrated in northern and southern California, the mid-Atlantic
and Northwest regions of the United States, Georgia, Ohio, Colorado, and Hawaii.
The 1999 Institute of Medicine (IOM) report, To Err Is Human,5 caused Kaiser to reexamine how it was communicating with patients and families when something went
wrong in their care, according to Doug Bonacum, Vice President for Safety Management,
the Kaiser Foundation. “The IOM report said that health care needs to hold itself
accountable and be transparent and sympathetic with patients and their families in the
wake of unanticipated adverse outcomes,” says Bonacum. The IOM report prompted
senior management at Kaiser to ask, ‘How well are we doing that? What could we be
doing better?’”
“Kaiser felt an ethical obligation to have open discussions with patients and families
when we contribute to patient harm because it is aligned with our values,” says Bonacum.
Once they recognized the need for such discussions, Kaiser developed and disseminated a
policy statement about what Kaiser expects its physicians to do in the wake of a patient
injury. They trained physicians to have open disclosure conversations with patients and
families, established peer support groups, and developed ways to foster continuing
dialogue until the patient and family feel their needs have been met.
5
Institute of Medicine. To Err Is Human: Building a Safer Health Care System. Washington, DC: National
Academies Press, 1999.
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18
Guiding Physicians
The first thing Kaiser did, according to Bonacum, was to develop and disseminate a sixstep statement of principle to guide physicians in communicating with patients and their
families in the aftermath of an adverse outcome or medical error:

Step 1: Care for the Patient. The first priority in responding to an unanticipated
adverse outcome is to address the current health care needs of the patient by
assessing the patient’s condition and determining what, if anything, needs to be
done immediately.

Step 2: Communicate about the Unanticipated Adverse Outcome. After
caring for the patient’s immediate clinical needs, preparation for the initial
communication session with the patient and/or the patient’s representative must
begin. This session should address the “who, what, when, where, and why”
surrounding the unanticipated adverse outcome. A lead coordinator should be
designated to manage the communications.

Step 3. Report to Appropriate Parties. Various people, departments, entities, or
agencies may need to be notified that there has been an unanticipated adverse
outcome. Internal notification and reporting should be conducted in accordance
with a facility-specific Situation Management Plan.

Step 4. Check the Medical Record. The medical record should contain a
complete, accurate record of clinical information pertaining to the unanticipated
adverse outcome. As applicable, this should include:
o Objective details of the situation, written in neutral, non-judgmental
language;
o The patient's condition immediately prior to the event;
o The intervention and patient response;
o Notification of the primary care physician and attending physician; and
o Information shared with the patient and/or patient’s representative
following the event.

Step 5. Follow Up and Provide Closure. The ongoing goal in the aftermath of an
adverse event is to meet the patient’s health care needs and concerns and to help
manage and address the patient’s and/or patient representative's emotional needs.
It is critical to assume the burden of maintaining open communication. After the
initial discussion and throughout the event analysis, it may be necessary and
appropriate to conduct follow-up discussions to:
o Convey new information discovered and corrective action taken;
o Maintain an ongoing dialogue regarding patient care issues; and
o Identify and address new concerns of the patient and/or patient’s
representative.
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
Step 6. Support the Patient Care Team. Physicians and other health care personnel
generally need some form of emotional support in the aftermath of an unanticipated
adverse outcome. The Situation Management Plan should identify specific individuals
or departments that can provide needed support to the staff members involved.
Training and Supporting Physicians
To support physicians before and during disclosure conversations, Bonacum says, “We
created situation management teams with trusted people within the medical center. These
might include the director of hospital operations, a medical group leader, or the director
of quality or risk management. A physician can call any of these people for immediate
counseling and support, advice about how to handle particular situations, even roleplaying of a discussion with the patient and family.” The situation management team
allows physicians to quickly get a respected outside opinion about the situation and a
thoughtful reaction to what the physician plans to say to the patient and family.
Kaiser has developed a four-hour training program to help physicians have these difficult
conversations with patients and patient representatives. It includes a videotaped series of
difficult cases to help model effective, empathetic conversations. Kaiser is planning to
develop a shorter, more streamlined version of this training as a refresher for physicians
who have taken the four-hour training in the past.
The Healthcare Ombudsman / Mediator
Training physicians to have these conversations is usually not enough, according to
Bonacum. The physician may initiate the disclosure conversation, “but it’s not over until
the patient or family says it’s over,” Bonacum observes. “This could take a day, a week, a
month, a year, or it might never be over,” he adds. To ensure the patient and family have
open and continued dialogue with the health care system until they feel their needs have
been met, Kaiser created the role of health care ombudsman/mediator in June 2003,
modeled on the health care ombudsman program of the National Naval Medical Center in
Bethesda, Maryland.
The health care ombudsman/mediator, who has 40 hours of special training and is a
certified health care mediator, is an internal, neutral, and confidential link between the
patient and family and the health care system “for as long as it takes,” says Bonacum.
“The health care ombudsman/mediator maintains an open line of communication to
arrive at a satisfactory outcome for both the patient and the involved practitioner,”
Bonacum explains. “In June 2003 we piloted this program in six different locations. Now
we have 29, one in each of our main hospitals,” he adds.
What enables Kaiser to have open, transparent communication with patients and their
families isn’t any of these things alone, Bonacum asserts, but “it’s the bundle that makes
it possible. We have policy, we have training, we have situation-management teams, and
we have the health care ombudsman/mediator that define what our program is and make
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20
it a complete package. I’m not convinced that just saying ‘I’m sorry’ works. This is about
more than individual conversations between practitioners and patients.”
Kaiser’s Biggest Challenges
Overcoming physicians’ fear is probably the biggest challenge to open communication
when something goes wrong. “One hundred percent of our physicians are not yet on
board. Even with training and statements of principle, it’s very hard to have these
conversations. These are events physicians will never forget,” Bonacum says.
It’s impossible to know how a patient or family will react to being told about an adverse
outcome or medical error. They can either be grateful the physician was open and honest,
or, Bonacum says, “They may say ‘Aha! I knew something was wrong! I’m going to get
my attorney!’ Every conversation with a patient should be based on what is the right
thing to do, not on what the outcome might be. Because we never know how someone
will react, every conversation is a risk; but you have to do what’s right.”
The challenges Kaiser faces, like those of other health care organizations, are ongoing.
Bonacum stresses that their program and support systems didn’t spring up all at once or
overnight. Rather, Kaiser has developed these systems over the last seven years and
gradually created a multipronged approach to help physicians talk openly with patients
and their families about negative outcomes.
Outcomes
Kaiser decided to implement a policy of open disclosure of medical errors, adverse
outcomes, and patient injury “because it’s the right thing to do, not because we thought it
would reduce the number of medical malpractice suits,” Bonacum says. “Driving down
medical malpractice is part of but is not the whole story,” he observes.
Kaiser measures outcomes one interaction at a time. “If, at the end of our interaction with
the patient and family, they are satisfied with the way we’ve responded to them and met
their needs in terms of honest answers, an apology, and communication about what will
happen next, we’ve done our job,” Bonacum explains.
Early patient and physician satisfaction surveys reveal positive reactions to the health
care ombudsman program and its outcomes, according to Bonacum. In a sample of
practitioners who have used the program:


Ninety-six percent rated their experience with the health care ombudsman
program as “excellent” or “very good.”
More than 75 percent of the respondents “strongly agreed” that access to the
health care ombudsman program was easy, their cases were kept confidential,
they would use the program again, and they would recommend the program to
others.
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Results of patient satisfaction surveys indicate that the health care ombudsman program
helps patients understand the issues and resolve their concerns.
Lessons Learned
Bonacum shares the following lessons learned at Kaiser:



“Treat staff as respectfully as you strive to treat your patients. It’s hard to treat
your customers any better than you treat each other.
“Engage respected and trusted thought leaders in the process. Physicians need to
hear from other physicians whom they respect and trust about why this is the right
thing to do, and how to do it right.
“Teach others who may have been involved in a medical error how to respond as
part of the team. People other than the physicians often are involved in a medical
error.”
Geisinger Health System
Geisinger Health System, founded in 1915, is a physician-led integrated health system in
central Pennsylvania. It is the largest single rural health care system in the country,
covering 41 counties.
In 2002, the Pennsylvania state legislature passed Act 13, the Medical Care Availability
and Reduction of Error (MCARE) Act. Among other stipulations, the Act states:


“A person who has sustained injury or death as a result of medical negligence by
a health care provider must be afforded a prompt determination and fair
compensation.
“Every effort must be made to reduce and eliminate medical errors by identifying
problems and implementing solutions that promote patient safety.”
Geisinger Health System began to communicate errors and adverse outcomes to patients
and families in January 2003 because it was the law. “Act 13 provided a framework to
make disclosure routine,” says Albert Bothe Jr., M.D., Chief Quality Officer, “and to help
move along those who needed encouragement.” For those who had always wanted to
disclose errors, Act 13 simply made it easier for them to follow their ethical instincts.
Because disclosure was now the law in Pennsylvania, Geisinger developed a process that
would make such disclosure routine throughout the health system. Their process includes
the following steps:
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22





Tell patients and families about serious or sentinel events6 as soon as they are
discovered and follow up in writing within seven days.
Explain the circumstances under which these events occurred and their
consequences, to the extent known.
Assure patients and families of a complete investigation.
Identify systems issues that contributed to the adverse outcome.
Provide the patient or family with the names of those who will manage
communication between them and the hospital over the long term.
“We jumped on the bandwagon a little uncertainly in the beginning,” admits Karen
McKinley, Vice President, Clinical Effectiveness. “It was uncomfortable for lots of
people to have these conversations,” she says, “but we’ve learned to do it fairly well.”
“We expect our leadership to model that communicating medical errors and adverse
outcomes is the right thing to do,” says McKinley. “Our leadership talks about this and
the subject is incorporated into Grand Rounds and Quality Rounds,” she says. “Our
leadership supported this and the law gave us some structure. Whether we wanted it or
not, the law did provide the structure to make sure this happens each and every time,”
McKinley adds.
Taking the Law One Step Further
Geisinger began by following the letter of the law, according to McKinley, but “it has
now gone way beyond that,” she says. “It has become a personal commitment at
Geisinger to involve patients and families in all elements of their care, including when
things go wrong, because it’s the right thing to do,” she says. According to McKinley,
Geisinger also encourages physicians to report near-misses.
McKinley has found that conversations informing patients about the causes of a serious
or sentinel event, if done in the right way, help not only patients and families but also
help providers. “Initially, physicians felt they had to do this because it was the law,”
McKinley says, “but over time their thinking has evolved. Physicians and other providers
gradually discovered that this policy actually helps them,” McKinley continues.
When they began communicating serious and sentinel events to patients and families,
Geisinger created a core team of people specially trained to have these difficult
conversations and to mentor others through the process. “These team members observed
the conversations, helped the physicians through them, and helped physicians to improve
their skills in having such discussions,” McKinley says.
6
A serious event is defined by Act 13 as an event that causes death or compromises patient safety and
results in an unanticipated injury that requires the delivery of additional health care services to the patient.
A sentinel event is defined by The Joint Commission as an unexpected occurrence involving death or
serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb
or function. Such events are called “sentinel” because they require immediate investigation and response.
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Now, McKinley says, Geisinger is trying to help physicians understand how important an
apology is when something goes wrong, and to give them the skills to apologize
appropriately.
The Geisinger Process
When something goes wrong in a patient’s care at Geisinger, the information can be
reported to the department of quality in multiple ways by either the patient or the
provider. “We use an on-line, Web-based, self-reporting system that can be used
anonymously,” says McKinley. “All employees are trained to use it and any employee
can access it. We also tell people our door is always open and they can call us at any
time,” she says. “Sometimes,” she adds, “someone in the facilities department will report
about equipment failure or infrastructure failure that leads to something deeper.”
Geisinger also has a hotline for patients to report concerns or problems. “We give
patients information about the hotline in writing when they are admitted and it is repeated
in almost all of the written communications that go to patients,” McKinley says.
Reports can also come through their patient representatives. Patient representatives have
a process, according to McKinley, that is organized around the regulations of the Center
for Medicare & Medicaid Services (CMS). This process involves the following:




Tracking complaints;
Interviewing the patient, family, and provider;
Investigating the complaint; and
Responding verbally and in writing.
“When a patient representative thinks an event warrants elevation to a higher level,”
McKinley says, “it is reported to Dr. Bothe, to me, and to leadership in the organization
or facility where it occurred. We discuss the event, apply the Act 13, CMS, and Joint
Commission rules to it, and decide whether it needs to be categorized as either serious or
sentinel.”
If an event meets the criteria for being either serious or sentinel, Geisinger conducts a
root cause analysis to thoroughly investigate the event and to determine what they will
change to make sure the error doesn’t happen again. “One of the organizing principles for
those conducting these investigations,” Bothe says, “is, could this happen again?” Our
goal is always to answer, “No,” by taking the appropriate steps.
“Once the root cause analysis team completes its work,” McKinley says, “it reports to the
performance improvement committee of that facility as well as to the patient safety
committee. Any change is then directed or led through the leadership of that facility,” she
says.
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Barriers
Fear of legal repercussions is the biggest barrier to the full disclosure movement and can
lead to a defensive posture, according to Bothe. “To its credit,” he says, “the state spread
an umbrella over disclosure that provided some protection, or at least peer review
coverage, so we could do the right thing while minimizing the effect of lawsuits.”
Training Is Essential
Despite the fact that communicating serious or sentinel events became law in
Pennsylvania in 2002, many physicians lacked training in how to have such
conversations. “We did a lot of education and skill-building to bring front-line staff
along,” says McKinley.
“We provided training to teams from each of the hospitals in our patient safety
collaborative with the Institute for Healthcare Improvement,” McKinley says. Geisinger
used story-telling and videotaped interviews to help clinicians understand what, in the
wake of a negative outcome, patients want and deserve.
Geisinger doesn’t have a formal program to train staff in disclosing medical errors or
serious adverse outcomes, according to McKinley, but they make training opportunities
available through a number of different forums throughout the year, including the
following:






Incorporating training into the Geisinger Quality Institute;
Providing ad hoc training;
Training through electronic education programs;
Facilitating physicians’ ability to take annual courses that are mandated by CMS
or the Department of Health;
Offering training during morbidity and mortality rounds throughout the
organization; and
Participating in multiple and diverse educational opportunities through the
Institute for Healthcare Improvement’s 5 Million Lives Campaign.
Training during staff orientation and ongoing annual training in “service dialogue”—that
is, how to interact with patients, families, and other customers—is required at Geisinger.
This training does not include discussion of errors or apology, but “training in service
dialogue certainly enhances physicians’ ability to have these difficult discussions,”
McKinley says.
“One hundred percent of our physicians go through training of one kind or another in
how to disclose medical errors and adverse events,” says McKinley. “That is our
expectation.”
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Outcomes
Since they began to implement Act 13 in 2003, according to McKinley and Bothe,
Geisinger has experienced positive outcomes. They are quick to point out, however, that
these outcomes cannot be directly attributed to the policy of full disclosure:

Geisinger has experienced a significant increase in the reporting of serious events,
sentinel events and near misses, and an increase in the number of conversations
physicians have had with patients about these events.

Geisinger has had fewer claims filed than the national average. When they
observe the trends in their own data, the number of claims has decreased.
McKinley believes a case is less likely to become a lawsuit because they’ve had early
discussions with the patient or family. “Patients and families get a full explanation, a
commitment from us that we’re going to correct the problem, and feedback after the root
cause analysis to let them know what we’ve done,” she says.
Lessons Learned
McKinley and Bothe share three of the lessons learned at Geisinger:

Adopt a patient-centered, rather than a legalistic, philosophy toward disclosure.
This will allow physicians to follow their ethical instincts, rather than being
constrained by fear of lawsuits.

Use patient stories to help clinicians understand the importance of open, honest
communication. “It is easy to respond empathetically when patients share their
stories,” McKinley says.

Eight times, eight ways. Repeat the same message and the same set of principles
repeatedly, using different methods, to drive change in your organization.
Catholic Health Initiatives
Catholic Health Initiatives, headquartered in Denver with offices in the Cincinnati area
and Minneapolis, is a religious-lay partnership and the product of four Catholic health
systems that merged in the mid-1990s. Its core values are reverence, integrity,
compassion, and excellence. “We attempt, and are expected, to live out these core values
in our everyday work life,” says Mitch Melfi, Esq., Senior Vice President and Chief Risk
Officer, and President and Chief Executive Officer of First Initiatives Insurance Ltd.
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“Compassionate Disclosure”
The concept of compassionate disclosure has been ingrained into their organization,
according to Melfi. Catholic Health Initiatives gradually codified their long-held beliefs
and unveiled, in 2006, their compassionate disclosure policy, a “how to” document for
their clinicians in the wake of an error or an adverse outcome. Their compassionate
disclosure policy addresses all aspects of what should be disclosed to patients and
families, according to Melfi, from the perspectives of culture, ethics, clinical care, law,
and risk.
Their compassionate disclosure policy, Melfi says, offers some guidance to staff about
how to disclose, who should disclose, and more, since this is “obviously not an easy thing
for people to do. It’s not so much around the ‘what,’” he says. “It’s really more about the
‘how.’” With a policy to guide them, he says, everyone knows what’s expected.
“The reason we decided to create this compassionate disclosure policy,” Melfi says, “was
to give people permission to do what they should have been doing all along, and what in
most cases they were doing all along.” In their culture, Melfi explains, compassionate
disclosure is, and feels like, the right thing to do.
It’s the right thing to do for two reasons, Melfi says. One is that it’s what patients and
families want and deserve. The other is that admitting and confronting errors is the only
way to improve care. “We took a more aggressive position about opening up the black
box and openly sharing information with our patients and with each other when an error
or adverse outcome occurs so we can learn from it,” says Melfi.
“We recognize that lawyers want to zealously represent what they believe to be in their
client’s best interest. That representation may well include advice to not share
information with a potential adversary, namely the patient, when that information could
compromise the hospital’s or the doctor’s interests in subsequent litigation.” That,
according to Melfi, has a chilling effect on disclosing medical errors to patients and
families. This approach can prevent information about adverse events and patient injuries
from being reported, thereby diminishing the chance to learn and improve. “How are we
going to get better if we don’t know what we have to do to get better?” he asks. “We have
to admit that we made a mistake, we have a problem, and we have to fix it,” he adds.
Catholic Health Initiatives’ staff is available to assist facilities in managing the process of
compassionate disclosure in the wake of a medical error. “Individuals with training in
disciplines such as ethics, law, risk management, and clinical care have been providing
guidance during national system meetings and at local facilities, such as during Grand
Rounds,” Melfi says.
Whenever there is an adverse event, according to Melfi, there is a system in place that
provides for the rapid reporting and dissemination of critical information. “It is our
expectation,” Melfi says, “that all adverse events will be reported to my risk team within
48 hours of the event’s occurrence.” Melfi’s team then “makes this information available
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to key individuals within the organization, those in a position to do something about it,
those who can help us learn and improve our care.” Meeting this expectation was
incorporated into the annual incentive compensation program for the organization’s
leadership, including the hospital CEOs.
Catholic Health Initiatives’ policy of compassionate disclosure isn’t, however,
mandatory, Melfi notes. “We developed a model policy around compassionate disclosure
that each of our facilities can adopt as their own as they feel they need to. We want to
emphasize the compassionate part of the disclosure and specifically incorporate the
concept of an apology. We want to allow flexibility for our facilities that are in states
with existing disclosure and reporting laws,” he says.
Compassionate Disclosure and Risk
“It’s a legal myth that if you say you’re sorry you’re admitting fault or that you’re going
to get sued,” Melfi says. “We absolutely are sorry when someone is injured in one of our
facilities. It’s not what we intend to happen when patients are in our facilities. We need
to empower and give permission to caregivers to behave in a just and compassionate way,
which is how most caregivers otherwise behave absent legal obstacles,” he says. “Our
position is that we want to fully disclose what happens, when it happens. If we get sued,
that’s just the way it has to be. We deal with that if we have to. We must do what is right,
not what we think we can get away with,” Melfi explains.
Every facility in the Catholic Health Initiatives system participates in their risk program.
“It’s not optional within the various hospitals. We manage centrally all of the litigation
when a hospital gets sued for malpractice, as well as the reporting of those events,” Melfi
says.
Whenever an error or adverse event occurs and is reported, Melfi’s advice is to manage
the event, not necessarily to manage the claim. “And part of managing the event has
always been to be very up front with the families or the patients about what happened,”
he says. “It’s about doing what’s best for the patient rather than doing what’s best for the
bottom line,” he adds.
Barriers
The biggest barriers to openly disclosing medical errors and adverse outcomes, Melfi
says, “can be lawyers and the fear of being sued, the fear of negative publicity, and the
threat of financial losses. Hospitals are competitive as well as compassionate entities.
We don’t want the good work we do to be overshadowed in the media by stories of
injured patients suing us.”
Addressing the financial barriers to disclosing errors, Melfi says, “Our legal system is not
perfect. When medical errors are litigated, the outcome can often be an unreasonable and
unrealistic economic award for the loss. We support reasonable and fair compensation
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for injuries that are the result of our medical errors, but the potential for unreasonable and
highly inflated jury awards is an economic reality that we must also deal with.”
“To get staff buy-in,” Melfi says, “we tell our staff, ‘these barriers do exist. There is a
potential down side to full disclosure and information sharing. But there is also an up
side: that is, we learn from our mistakes, we get better, we manage expectations better.
Even if you are sued, your outcomes will be better because people typically aren’t out to
damage people they like and who they think are being honest with them.’” The up side
far outweighs the down side, Melfi believes, and their experience with compassionate
disclosure has borne this out.
Mitch Melfi recalls a talk he gave at a national Risk Management meeting:
“I said that in health care, we’re human and we do make mistakes. A man in the
audience was clearly bothered by my comments and he offered, ‘We don’t make
mistakes. We get sued for bad outcomes.’ My response was that we have to be able to
admit we make mistakes and do everything we can to learn from them and not make
those mistakes again. Part of that includes working with the family. You’ve got to be
able to admit to them you made a mistake and to say, ‘We’re very sorry we made a
mistake; it certainly wasn’t our intention.’ My experience has been that, for the most
part, patients can accept that we make mistakes.” Melfi says, “What they can’t accept
is that we don’t accept that we make mistakes or that we try to hide the fact that we
do.”
Overcoming Barriers
To get the word out to everyone in their health system about their intention to implement
their compassionate disclosure policy, Melfi says, they have addressed the issue at
various system meetings and conferences, including their annual Risk Management
conference. “We knew we needed to get buy-in from the litigators we retain to represent
our facilities,” he says. At their annual defense counsel meeting, Melfi addressed the
topic of disclosure with the attorneys, telling them, “This isn’t going to feel right to you
because it’s not the way lawyers are trained.” He went on to tell them, “Don’t advise the
facilities you represent to not disclose information out of fear of having it used against
them in litigation. We fully recognize that it could be used against them, but we think
that the benefit of disclosure and information sharing outweighs the risk.” Melfi
continues, “We told our lawyers, ‘This is what we’re doing, this is why we’re doing it,
and if you can’t get comfortable with it, then we’ll need to retain someone else to
represent these facilities in litigation.’ I’ve actually had litigators call me after the fact
and say, ‘You know what? You really get it. It really does work. Outcomes are better.’”
Melfi says they offer guidance to caregivers in how to disclose medical errors. For
example, “When you sit down with a patient and talk about what happened, you don’t
want to engage in speculation such as, ‘Well, I think the reason this happened was that
the nurse was incompetent.’ No…you deal factually in a compassionate way: ‘This is
what we know….,’” he says.
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Outcomes
“Although it’s only one part of the picture, there is a business case for disclosing errors,
too,” Melfi says. “Our losses when somebody sues us are coming down. We still make
mistakes, we still get sued, but the outcomes are better,” he says. “When you clearly
made a mistake and you’re either pointing fingers or denying you did it, you inflame the
situation. That causes plaintiffs to demand more money, it inflames juries, it just doesn’t
get better,” Melfi adds.
Instead, Melfi continues, “Our policy and our practice is that, if we made a mistake for
which we think we have liability, the objective is not to fight that. What’s important to
ask is, ‘How best can we compensate the patient?’ We sit down and say, ‘We know this
happened. We’re sorry that it happened. If money can make this right, how can we do
that? What is reasonable and fair compensation?’”
Melfi recalls this discussion and its outcome:
“I recently dealt with a case involving the death of a newborn. In the course of the
delivery, the expectant father, a physician, thought something was wrong and he said
something to the obstetrician. The obstetrician told him, ‘I don’t tell you how to practice,
don’t you tell me how to practice obstetrics.’
“That was the wrong thing to say in that situation. The outcome was devastating. The
cord was wrapped around the baby’s neck and the baby was stillborn. Now, there were
things that showed up on the monitor that our nurses should have picked up. Had they
picked up these things, the outcome might have been different.
“In addition to all this, we’re dealing with two physicians who apparently disliked each
other. We believed that the obstetrician, other than perhaps saying the wrong thing, didn’t
do anything wrong medically. If anything, it was our nurse, and we recognized that. The
case went to mediation because both sides were polarized and we felt this was a case that
needed to be settled.
“How do you compensate someone for the death of a newborn? Somehow, you’ve got to
put a value on it. At this mediation, the first thing our claims person did was to approach
the mother and say, ‘I just want you to know we’re sorry this happened.’ According to
our defense counsel who was there, her apology immediately broke down the barriers.
Melfi explains the way they resolved the case. Money wasn’t necessarily the issue, but
they offered to provide the family with a sum of money for the loss of their child. In
addition, Melfi recalls, “We offered to endow a fund at the hospital that guarantees, on an
annual basis, the ongoing training of nurses in how to read fetal monitoring strips. We
invited the parents to participate in the process, and we proposed to make the endowment
in the name of the deceased child. With that, we settled the case.”
“In doing this, we took a catastrophe and at least made it manageable,” Melfi concludes.
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Lessons Learned
Melfi shares the following lessons learned at Catholic Health Initiatives:

Identify the obstacles at the outset and strategize about how to overcome them.
Because they knew the lawyers would be the biggest barriers, “we told them what
we were doing, why we were doing it, and invited them to work with us to
accomplish our objectives,” says Melfi.

Tie the organization’s disclosure policy back to its mission, core values, and
vision. Whatever an organization’s mission, Melfi notes, a policy of open,
compassionate disclosure is embodied in it. “Staff will be able to say, ‘This isn’t
just something I’m being told we have to do…this is why we’re here,’” Melfi
says.

Be as quick to explain the “how” as the “what.” They were a little slow to define
the “how” of disclosure, Melfi admits. Clinicians, he says, need the tools to do it.
COPIC Insurance Company
COPIC, a Colorado-based, primarily physician-led malpractice carrier, began to openly
communicate medical errors in October 2000. They were disillusioned with the
inefficient, slow, adversarial tort system that, according to Richert Quinn, M.D.,
Physician Risk Manager, “destroys relationships between physicians and patients. We
were looking for an alternative that would result in a higher degree of satisfaction from
physicians and patients after an adverse outcome occurs,” he says.
The COPIC philosophy is to aggressively defend care they believe meets the standard of
care but to compensate negligently injured patients in an adequate and timely way. “Our
experience with the traditional tort system,” says Quinn, “led us to believe it was largely
not achieving these goals.”
The COPIC Alternative
The COPIC alternative to the tort system is their no-fault, early intervention “3Rs”
program, which stands for:



Recognize an unanticipated event.
Respond soon after the event.
Resolve related issues.
The COPIC 3Rs intervention begins with a telephone call by a physician to the COPIC
risk management department to report a patient’s adverse outcome, injury, or anger about
some aspect of the care they’ve received. “Cases involving, for example, wrong-site
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surgery, patient death, or obvious negligence are ineligible for the 3Rs program,” Quinn
explains, “and are instead handled by the COPIC claims department.”
But if a patient has been injured during the course of his or her care, has made no written
demand for compensation, has not issued a complaint to the licensing board, and has not
involved an attorney, the COPIC risk management staff encourages, trains, and supports
physicians to:





Communicate with their patients, addressing their needs for information,
emotional support, financial assistance, and more.
Openly disclose what is known about how an injury occurred.
Apologize when appropriate.
Explain what they will do to prevent the error from happening again.
Offer to cover expenses not covered by the patient’s insurance and time lost from
work because of the injury.
“If a case lends itself to this intervention, the physician approaches the patient to discuss
the program. As of March 31, 2007, more than 4,100 occurrences have met our criteria,”
Quinn says. “Of these, just over 875 have resulted in payment.”
Under the 3Rs program, Quinn notes, patients can be reimbursed for expenses up to
$30,000: $25,000 for expenses not covered by insurance and $5,000 for loss of time on a
per diem basis of $100.
COPIC does not ask patients to sign a release or waiver in return for accepting
reimbursement. Patients are free to file a lawsuit after accepting payment if they choose
to do so. So far, Quinn says, eight have done so.
How COPIC Was Able to Develop This Alternative
COPIC was able to introduce and sustain their early intervention program because,
according to Quinn, the following situations had developed over time, in addition to their
history of early reporting:





Colorado has had historically good tort reform with a cap on non-economic and
global damages.
COPIC has had open and collaborative relationships with the state legislature,
state Department of Insurance, and Board of Medical Examiners, and support
from senior management and the board of directors.
Colorado has a strong “I’m sorry” statute, which Quinn believes has given
physicians greater confidence to participate in their 3Rs program.
Physicians are given incentives to attend training workshops.
The COPIC risk management department has historically had close, collaborative
relationships with their physicians, which has created “a level of trust that is quite
remarkable,” Quinn says.
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
COPIC conducts communication training seminars all over the state, regularly
and often, attended by several hundred physicians a year.
“You need all these things in place to do what we did,” says Quinn. “We didn’t think of
all the different barriers beforehand. We started small with a few cases early on, and we
just moved forward,” he says.
Challenges
COPIC’s biggest challenge was, and still is, the reticence among many physicians to have
candid and open discussions with their patients, according to Jeffrey Varnell, M.D.,
because mentors and malpractice carriers have discouraged them from being open in the
past.
“About half of our Colorado-insured physicians—3,210 out of about 6,000—participate
in our program,” says Quinn. “Half don’t participate, sometimes because they’re
skeptical about open disclosure and feel as though they’re admitting guilt. Then
something happens and they say, ‘How about putting me in that program?’” The COPIC
program is voluntary. The number of physicians who participate, Quinn says, climbs
steadily each quarter.
“Word of mouth” has proven to be the most powerful tool for overcoming physicians’
reticence, Quinn has found. “Once someone goes through a case, they’re pleased,” Quinn
says, “and they’re happy they’ve been able to help their patients.”
COPIC’s Outcomes
What has been the impact of the 3Rs program on claims and premiums? “We have
compared the physicians who participate in the 3Rs program with those who don’t.
Although the data is immature, our preliminary view is that those who participate have
had fewer claims filed against them,” says Quinn.
He continues, “We did this in the first place because it’s the right thing to do. I think
that’s a compelling enough argument. It doesn’t seem to have had a negative fiscal effect
on our operations. Our alternative to the tort system appears to be associated with a high
degree of satisfaction on the part of the consumer and provider and it does seem to save
relationships.” More than 95 percent of COPIC patients and physicians surveyed when
the files are closed, Quinn says, have rated their satisfaction with the program as 4 or 5
on a scale of 1-5.
Lessons Learned
Quinn and Varnell share their lessons learned:

Developing and nurturing good relationships with patients is essential. If patients
feel they have a good relationship with their physician, then if something goes
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

wrong the patient is more likely to say, “That’s a mistake; everyone makes
mistakes and can be forgiven.”
Strong backing from senior management is key. The organization’s leadership
must be supportive of such efforts for physicians to feel comfortable participating.
Have faith in patients’ ability to forgive their physicians. When COPIC started
this program, they were taking a risk that patients would use the money COPIC
paid them to finance a lawsuit. To a large extent, this has not occurred.
Brigham and Women’s Hospital
Brigham and Women’s Hospital, a 747-bed teaching affiliate of Harvard Medical School,
adopted a policy and a process for routinely disclosing adverse outcomes and medical
errors to patients and families when The Joint Commission released National Patient
Safety Standard RI.2.90 in 2001, which states, “Patients and, when appropriate, their
families are informed about the outcomes of care, treatment, and services that have been
provided, including unanticipated outcomes.”
“Initially we adopted our policy in 2002 because it is what The Joint Commission
expected,” says Janet Barnes, Executive Director, Risk Management, Brigham and
Women’s Hospital. “But over time we realized communicating adverse outcomes and
medical errors is the right thing to do,” she says.
The risk managers at the Brigham and Women’s Hospital wanted to draft a policy and an
institutional process for disclosing medical errors, and to involve their Chief Counsel and
members of other departments in doing so. “Before we put a written policy and process in
place,” Barnes says, “lots of people were hearing they needed to disclose medical errors
but not everyone was doing it.” And not everyone had the same understanding about
when to communicate, what to communicate, and how to communicate with patients and
families when something went wrong.
Getting the Staff on Board
To get staff support for their open disclosure policy, Barnes and her colleagues met
weekly with groups throughout the hospital, emphasizing that disclosing medical errors
to patients and families was the right thing to do. “We told our health care providers to
think of themselves as patients and to put themselves in the patient’s shoes. Then we
asked them what they would want to know if they were the patient,” says Barnes.
Support from leadership is essential to elicit the support of staff and to be able to
implement a policy throughout the hospital, according to Barnes. “Our Chief Medical
Officer sits with the physician and has that difficult conversation with the patient and
family,” she says.
The real push was within the first year, according to Barnes, but the staff of Brigham and
Women’s Hospital continues to talk about the policy and process. “Before this policy, we
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were concerned about telling patients and families too much; now, we tend to be
concerned about telling them too little. There’s been a huge sea change. There’s no such
thing as too much information,” she says.
Barriers
Physicians’ fear of lawsuits was a formidable barrier to Brigham and Women’s ability to
openly and transparently communicate adverse outcomes and medical errors, Barnes
believes. “But,” she says, “the common theme that runs through patient-family
depositions has been that patients and families didn’t think they were given complete
information. Or they had questions that were never answered. Once something bad
happened, they never saw the doctor again.” Barnes tries to help physicians understand
that if they don’t communicate openly about an adverse outcome, they are more likely,
not less likely, to be sued.
Another barrier to physicians’ willingness to communicate adverse outcomes and medical
errors is their lack of training in having these conversations. Although it may be easier for
some, everyone would benefit from such training, Barnes believes. Brigham and
Women’s Hospital does not have a formal training program, although Barnes says their
insurance carrier is developing one. In the absence of formal training, Barnes says, their
communications policy provides some very basic guidelines about what to say.
“Our advice to the medical staff is, ‘If an error or adverse outcome is obvious to the
patient or family member, you should tell them, whether there is a bad outcome or not,”
Barnes continues. “If a nurse makes a medication error, the nurse must tell the patient. If
it reached the patient, that is all it takes to trigger disclosure. Our risk management
department offers support for these conversations to help nurses feel more comfortable,”
she says.
Barnes suggests clinicians might find it reassuring to have a tip sheet handy before
walking into a room to have a disclosure conversation with a patient and family. For
example, she says, a tip sheet could have prompts to guide discussion, such as, “Thank
you all for being here. This is the patient’s current condition. I’ve asked you here because
it’s important for me to tell you something that involves the care of your husband. I’m
really sorry that I have to tell you this right now but I’m going to explain what happened,
what we know thus far, and I will give you an opportunity to ask questions. I want to
assure you that we’re taking care of your husband at the moment, but this is what
happened….”
“We recognize that patients and families can become extremely angry” after such
conversations, according to Barnes. “We need to help physicians deal with that emotional
fallout,” she says.
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Facilitating Communication
Close contact between physicians and their risk management department facilitates
physician-patient communication at Brigham and Women’s. “Physicians tend to call risk
management before the patient knows about a problem,” Barnes continues. “I’ve gotten
calls in the middle of the night, with physicians saying, ‘This just happened. I need to talk
with the spouse. This is what I plan on saying to the patient and family. Do you think that
sounds right?’
“Disclosure conversations happen every day,” Barnes continues. “Some are more
complicated and require more support than others,” she says. “Those that are most
difficult revolve around a medical error. In such cases, we want to hear about it either
right before or right after the patient and family are told,” she says.
The Brigham and Women’s Hospital risk management department involves their patientfamily relations department in setting up meetings with the patient and family. “The
patient-family relations department staff circles back to the physician about what the
patient or family wants to know or have clarified,” Barnes explains.
“Our investigations and follow-up are very detailed in response to serious complaints,”
Barnes says. “Our disclosure is not only verbal, but it can also be written. The president
may be the one to extend an apology to the patient, or it may be the provider or the
director of patient-family relations who communicates the results of our investigation,”
she says.
Outcomes
More physicians are communicating adverse outcomes and medical errors because they
know it’s the hospital’s policy, according to Barnes. “We’ve seen a decline in lawsuits
since we implemented this policy, but I’d be the last person to say it’s because of this
process. Many other factors could influence this reduction. But there definitely hasn’t
been an increase in the claims as a result. I think we’ve been able to resolve some cases
more quickly because we’ve taken on the problems at the very beginning,” she says.
Brigham and Women’s goal in openly communicating with patients and their families “is
not to decrease lawsuits but, rather, to save the relationship” with patients and families.
“We want patients to continue to come to us rather than go elsewhere to seek care,”
Barnes says.
Discussion
Fear can be a powerful deterrent to doing the right thing. Openly disclosing medical
errors or adverse outcomes to patients and their families as soon as they are discovered is,
inarguably, the right thing to do. When a physician’s instinct to do the right thing is
subverted by the fear of legal repercussions for doing so, the resulting tension can
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engender anxiety and guilt on the part of the doctor that is often difficult to live with and
often impossible to overcome. For patients and families who have experienced a medical
error or adverse outcome that may be life-altering, not being told the truth engenders
anger, frustration, and distrust.
A mother never gets over the grief caused by her child’s death. But when her child dies in
the hospital and she is never told—openly, honestly, and completely—why her child
died, profound and life-long anger is added to her grief. And, as a large and growing
body of evidence shows, anger at not being told the truth about an error, rather than the
error itself, is why people sue physicians and hospitals for malpractice.
Yet, as the leaders of the organizations highlighted in this white paper explain, this
evidence-based advice is not what lawyers tend to give to the physicians and hospitals
they represent. Instead, they give advice based on fear: “Deny, deny, deny.” Such advice
ensures that physicians’ relationships with patients will be frayed or worse, that patients
will go elsewhere to seek future care, and that nothing will change to improve the system
and prevent such mistakes from happening again. Such misguided advice also may cause
physicians to carry an emotional burden that can last a lifetime.
No one can predict with certainty what will happen when a physician tells a mother her
child died because of an error that occurred in her care. But based on evidence and
experience, we can predict that not telling a mother why her child died is more likely to
lead to a malpractice suit, more likely to ensure that a similar error will happen again, and
more likely to cause the physician added grief and anxiety.
The experiences of organizations that have rejected fear and embraced open disclosure
indicate that openness and transparency do not lead to increased lawsuits. All have, in
fact, experienced a decline in lawsuits, although these organizations will not directly link
their new policies to the decline. They have also reported increased clinician and patient
satisfaction, the preservation of physician-patient relationships, and more.
Physicians fear not only lawsuits, as the representatives of these organizations explain,
but they fear having what can be emotionally charged conversations with patients and
families in the wake of a medical error. Not all clinicians communicate effectively with
patients under ordinary circumstances. But when a clinician contemplates telling a
mother her child has just died, and what is known about the reasons for his death, it is no
wonder that the “fight-or-flight” mechanism is apt to take over. To overcome the impulse
to flee, clinicians must be trained to have such highly specialized and sensitive
conversations and must have the support of their hospital’s leaders and colleagues. The
organizations highlighted in this white paper understand the importance of such training
and provide it in a variety of ways.
The biggest challenge organizations may face in developing a process by which errors
will be disclosed routinely may be getting physicians on board. Story-telling about
patients’ and families’ experiences is essential for creating empathy and understanding.
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And story-telling for staff about positive changes resulting from open disclosure is key to
gaining acceptance and increasing the commitment to and momentum for change.
Despite their having embraced a policy of open disclosure and all such disclosure entails,
the organizations highlighted here still face challenges, physician resistance being but
one. Nonetheless, their experiences, though still formative, can inspire others who are
ready to develop similar policies and processes. In the words of Eleanor Roosevelt, “You
gain courage and confidence by every experience in which you must stop and look fear in
the face. You must do the thing you think you cannot do.”
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