Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation

Abstract

Context:The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. Methods:Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. Findings:We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles.

How Policy Makers Can Smooth The Way For Communication-And- Resolution Programs

“…6 None protects the full scope of information that patients report needing when an unexpected outcome arises: a preliminary explanation of what happened; an expression of sympathy; an admission of responsibility; and a final analysis of the causes and consequences of the event, with information about remedial actions taken to prevent such incidents in the future. 6,29,30 In project team discussions and interviews, 19 AHRQ project participants in both New York and Massachusetts cited the absence of apology protections as a potential barrier to adopting CRPs. Although Massachusetts had protected statements of regret since the 1980s, it enacted a stronger law in 2012 after the state's CRP planning project found that stakeholders perceived this degree of protection to be insufficient.…”

“…25 In interviews that a group of researchers 19 conducted with stakeholders before the increase, the state's near-total charitable immunity was the most frequently mentioned barrier to the widespread adoption of CRPs.…”

“…18,19 Legal changes have been less of a focus for CRPs than for prior malpractice reforms because disclosing errors and offering early compensation are strategies that health care providers can pursue to improve the liability environment on their own, without intervention from legislatures, regulatory agencies, or courts. Indeed, the AHRQ projects were explicitly designed to test approaches that did not depend on altering existing law.…”

“…35 Staff at existing CRPs asserts that reporting payments to the NPDB makes physicians less willing to participate. For example, Massachusetts providers and insurers interviewed by AHRQ-funded researchers 19 in that state identified reporting as a barrier to statewide adoption of CRPs. Physicians worry that CRPs will offer compensation when the physician was not at fault, either as a compassionate gesture or because the hospital or insurer deems it prudent to settle, and that, as a result, physicians will be reported to the NPDB more often.…”

Effect of a Health System's Medical Error Disclosure Program on Gastroenterology-Related Claims Rates and Costs

“…Th ese included a compulsory 6-month pre-suit notice period requiring a plaintiff to provide written specifi cs of the intended claims before fi ling suit, which potentially served to facilitate collaborative claims investigation ( 6 ). A recent study examining stakeholders ' perceived barriers to implementation of DA & O programs categorized these barriers into four groups: cultural barriers such as physicians ' discomfort with disclosure and apology and fears about greater liability exposure, legal barriers such as physicians ' fears of name-based reporting of malpractice settlements and variability in governing state laws, logistical obstacles such as practice variability and complexities of inter-insurer coordination, and political barriers including ensuring favorable public policies / legislation and reassuring the public that such a system serves their best interests ( 7 ). Indeed, it is vital to recognize that a DA & O program is not, at its essence, a claims management strategy.…”