>>KOPELOW: I’m Murray Kopelow the CEO for the Accreditation Council for Continuing Medical Education.
>>HOLDER: I’m Tim Holder, I’m a family physician from Muskogee, Oklahoma. I’m also on the CME planning committee at Oklahoma State Medical Association, and also, Chair of the Accreditation Review Committee.
>>KOPELOW: Tim, the thing we’re here to talk about is an interesting area of interest of yours that you’ve transformed into continuing education and into practice improvement: "Sorry Works," tell us a little bit about it. So, se can understand what the projects were about.
>>HOLDER: "Sorry Works" is a brand new way to do risk management for physician liability companies. This is a joint sponsorship for the Oklahoma State Medical Association with our liability carrier, Physician Liability Insurance Company, which insures most physicians in Oklahoma. Traditionally, risk management and liability insurance companies take a deny and defend approach to malpractice or to when an adverse outcome has occurred. And this is really the antithesis of what it means to be a physician and to have a relationship with patients. And our medical training there’s almost an unspoken rule that if something has happened, a patient has had an adverse outcome or a potentially harm, patient harm, that we should distance ourselves from that patient. And it really gets away from our training. Our training is to be there for the patient, to be communicating with the patient.
>>KOPELOW: So, this being defensive
>>KOPELOW: is not parallel with what we’re trained to be.
>>KOPELOW: So, this
>>HOLDER: So, the "Sorry Works" coalition has emphasized a more relational approach to risk management. It also emphasizes communication, it emphasizes empathy, and also, emphasizes apology if that’s the appropriate response. And so, this is a brand new way of looking at risk management. Our liability carrier had heard about this "Sorry Works" coalition and really got excited about it. They thought this was a really good project to bring to Oklahoma and to bring to our insured physicians across the state. Before they did that they wanted to make sure it was OK with our defense attorneys, for example. So, they actually went to the principles of the insurance company to make sure it was OK with them. They went to the defense attorneys to make sure this project was OK with them as well. And once they were all onboard
>>KOPELOW: did they go to the patients and ask?
>>HOLDER: no, not to the patients. But, actually to the Oklahoma Hospital Association. And the Oklahoma Hospital Association jumped onboard as well. And so, the CME activity, the continuing medical education activity that we had surrounding this was to present this very novel approach to physicians in Oklahoma. It was a CME activity that was about four hours in length, but not only did we have live didactic lectures about the approach, but we also had a chance to role play as well.
>>KOPELOW: So, they, the professional practice gap that you’re talking about is: What to do when something bad has happened. I mean that’s the professional practice gap that you’re talking about for a physician. It’s to try to prime him up how to handle it, instead of the denial to intervene in a different way.
>>KOPELOW: And do you think that they weren’t doing this because they didn’t know such an approach existed? They didn’t have the strategies in place?
>>KOPELOW: is that a fair description?
>>HOLDER: Yeah, because, again, you know, our training tells us to deny and to really distance ourselves from our patients.
>>KOPELOW: So, when you put together an educational activity what was the content of the activity that
>>HOLDER: Well, the content of the activity was to present this novel way, to present a method of showing empathy that whether if an adverse reaction, or adverse event, or an adverse outcome has occurred it’s always 100% appropriate for the physician to show empathy. To say: I’m sorry this happened to you. I’m sorry this happened to your family and, you know, we’re going to look into this situation; we’re going to try and figure out why this happened and we will get back to you. And down the road if through fact finding you find out this was a medical error that occurred that led to this adverse outcome or adverse event. Then, it’s appropriate, at that time, to apologize, and to talk about appropriate compensation for the patient, as well as, their family. Something
>>KOPELOW: So, did you do this in a didactic format as well as hands on or role playing?
>>HOLDER: Right. The didactic portion of it was actually to introduce the whole concept of empathy, being present to the patient, being present to the family, trying to make amends as available at that appropriate time. But, also be apart of a team that would actually look into the adverse outcome and try to figure out through root cause analysis what happened. And if maybe either a commission or omission if it was a cause for the adverse outcome or the adverse event. So, that was the basic of the didactic program but, them we also had a chance to role play.
>>KOPELOW: How did you run that? How did you organize it?
>>HOLDER: Well, the speakers actually call them volunteers or picked people to start volunteering if they were not raising their hands. And we actually had a person that read the scenario. And then, we had a patient person and we actually had a physician playing the patient, we had a physician playing the physician role and it was a model of first of all, sometimes, very poor communication styles and how to make an expression of empathy in that situation.
>>KOPELOW: Did they get feedback from the observers?
>>HOLDER: got feedback from the observers, as well, so, it was a very interactive session, where I got to be one of the participants in the hot seat up on the stage. So, it was really interesting just to, go through it and you really start figuring out how you would react in that situation, if it was an adverse reaction on your part.
>>KOPELOW: Did you see people change while they were
>>KOPELOW: doing it?
>>HOLDER: Yeah. And people also started to realize that maybe the communication styles that they had employed probably weren’t the best communication styles.
>>KOPELOW: How did you, what did you capture about impact, like what did you measure or
>>HOLDER: Well, what we measured here so far is just the physician’s initial reactions to the entire new concept. We also asked them, what they would take away from this learning. What would they implement right away? And most of it was communication and better communication styles. Also, we started identifying some barriers that might prevent them from instituting this in their hospital or in their private practice.
>>KOPELOW: So, that’s interesting that they probably could learn it to do it, but to go and do it needs permission?
>>KOPELOW: Needs predisposing conditions and facilitating conditions that’s what you’re talking about
>>KOPELOW: is the barriers to implement it. Let’s go back to the role playing session because
>>KOPELOW: there is opportunity to evaluate your impact at a sort of a competency or performance based way right then. Did you do any of the sort of recording or measuring or reporting of your direct observations?
>>HOLDER: No, we just got feedback from the audience. They were very good about telling us what we could have done better or maybe some of the perceived shortcomings of the communication style. So, we did get immediate feedback in the role playing scenario.
>>HOLDER: Very live real time feedback from the audience.
>>KOPELOW: And then you had a, when you say ‘we’ you mean you as a student?
>>KOPELOW: as a student and then did you get a chance to do it again?
>>HOLDER: No, we went on to the next scenario at that point.
>>KOPELOW: went onto the next
>>HOLDER: We actually had three scenarios. There was a team of about, three physician teams that went up there for the scenarios.
>>KOPELOW: So, what, what did the learners report to you about the impact?
>>HOLDER: Well, the learners I think really caught on to the whole concept very quickly. They thought it was something that they would really want to incorporate into their practices. That they learned from it. That risk management CME in general has always been sort of not the greatest thing. People don’t really want to attend but they have to because of their insurance company requiring it. And this particular CME was very exciting; people left talking about it. People are talking about it back in their own institutions. So, they’re encouraging their physicians to be sure to go to the next offering. So, that’s something that’s very unusual for risk management education.
>>KOPELOW: I wonder
>>HOLDER: So, it really brought excitement
>>KOPELOW: I wonder if
>>HOLDER: to educational experience.
>>KOPELOW: I wonder if how much that has to do with the extent what you started talking about that it’s aligned with what the docs do, what they want to do?
>>HOLDER: I think that’s a big part of it. You know, it really puts you back into a communication style with your patient. If an adverse event has occurred our inclination as a physician is to be there for them to be present for them and that’s the way we’re trained. We’re trained to be caring professionals and so the previous deny and defend mentality of risk management is antithesis to that. It really cuts to the core of who we are as physicians. So, this approach, I think, is just a very novel way and it really brings back physician back to why they’re doing medicine in the first place with their patients.
>>KOPELOW: I agree with you 100% and I think it has a number of other important sort of features to it. It’s an area that people haven’t really gone into. It’s sort of a, in this kind of way, it’s sort of one of those important areas, but, but not often dealt with. The other is that, that you used role playing; its simulations, which is not that common in continuing education, but surely the appropriate method for this. Because you didn’t just want them to walk out knowing there were things that they could do. You wanted them to walk out saying I’ve tried the things that you can do and I now know what I can do better. So, it’s the perfect, it’s the perfect method and it’s so much part of systems based practice and practice based learning and improvement that, that it’s so striking.
>>HOLDER: You’re right. It is really a systems approach. You know, one of the things that was really emphasized in the training was to be aware of the system in which you work and to be part of the team. So, if a adverse outcome or event has occurred as physician you’re going to be leading that team through trying to figure out why the adverse event occurred. You’re going to have people from your insurance company there walking you through the process. So, hopefully, what you’re doing it’s a real time learning laboratory. You’re in the laboratory. You’re learning through what the systems have allowed to happen, if indeed it was a system failure, you also, are putting systems into place that hopefully, will prevent another accident, another adverse event from occurring. You also, are sharing that with a patient and their family. Because if a patient and their family has had an adverse event occur to them, the first thing they want to know is: how will this to not occur again in the future? And that’s what you’re communicating to them. You’re communication that their suffering, their experience, will not be for naught. That they will know that some people have learned from it that systems will now be in place to prevent that from occurring so another patient, another patient’s family won’t have to go through the same experience.
>>KOPELOW: And that’s so empowering for the physician and for the physician/patient relationship. At a time when you don’t need silence and you need good communication that the physician is empowered with something to do, something concrete. And it’s a wonderful example of what people call, just in case, continuing medical education. It’s not something that you do every day. But, you need, just in case it happens; you need a set of tools. But also, there’d be a bit of a network that if it comes up and you can’t remember what to do and you’re not sure what to do there’s colleagues that around you who could remind you about what it is.
>>HOLDER: Right. Right.
>>KOPELOW: Now, you’re a physician and you practice, have you, what did you take away from it? How do you feel in sort of a better prepared kind of way? What are you going to do, do you think?
>>HOLDER: I think that the major thing is the communication that is key to this whole process, you know, what they emphasize on, is the idea of empathy. You always show empathy to the patient, and to their family; you also, disclose what happened. And then, through fact finding if there is a causation for what happened and there is or was a medical error and then, offering an apology. You know, which most patients, that have had adverse outcomes or an adverse event, never hear. And that’s what really leads to the malpractice suit, because they get angry that nobody cares about what they’ve gone through. And so, their lack of apology really translates into legal action.
>>KOPELOW: You know, it strikes me that we are so often compared to the aviation industry and people talk about the aviation industry with respect to our quality and safety issues, but there’s another parallel here that, that I’ve never really thought of before was that several years ago, here in Chicago, an airplane went off the runway. And standing in front of that airplane several hours later was the CEO of that airline saying I’m sorry, I’m responsible for this. And we’re going to do what we can for the people that this affected and to ensure that it never happens again. And really that’s what you’re talking about.
>>KOPELOW: Is being able to have the skills and the ability in a difficult situation to get a new clinical skill to stand there and say, I’m responsible and I’m sorry and we’re going to do something about it. And I know that if I was a patient I would sure appreciate you, Time Holder, saying that to me.
>>HOLDER: One of the things, they emphasize too, is that sometimes adverse events occur there’s no harm to the patient. We have mechanisms in place to, hopefully, you know, if it’s the wrong unit of blood being hung, you know, through double checking you know it’s the wrong unit of blood and you alert whoever to that potential adverse event. You take the blood away and then bring in the right blood. What they emphasize is that if a adverse event like that occurred you should still disclose to the patient, even though the patient was not harmed. You know, in that event they know that systems are in place and the systems work. But, they still have to know that something almost occurred, because it could have been a disaster in that situation. But, you know, down the road, oh, by the way, you know, Dr X comes in and says, Did you know you almost got the wrong blood last night? You know, they shouldn’t be surprised. You know, if a near miss occurs they should know and they should hear it from their physician.
>>KOPELOW: Comprehensive and complete communication.
>>KOPELOW: Regardless of what the occurrence is and this gives you the tools to do it.
>>HOLDER: And what I like about this process is that the Hospital Association is really onboard and the hospitals are really encouraging their physicians, their medical staff to be onboard with it as well. So, the new Criteria really gets at collaboration and this is one of the things that we can do as physicians and as educators as we try to collaborate with hospitals around the state of Oklahoma.
>>KOPELOW: Maybe one of the non-educational strategies as a final word we could say is to recruit someone like the hospital association to the workplace to create this as proper behavior and expected behavior and rewarded behavior so that people do it. So, that to remove barriers.
>>HOLDER: One other thing, you were talking about systems approaches and systems being in place, what was really interesting is one hospital talked about real life example of how this works. And if a patient has gone or had an adverse event occur you know, with their care the hospital brings in a very nice vase of plastic roses, they look very nice they’re on their bedside and anyone who comes in contact with that patient knows an adverse has occurred. Even if it’s the housekeeper, even if it’s the nurse, even if it’s the radiology tech coming to get the patient to take them to radiology. They automatically see that vase of flowers and they’re giving them tender loving care the entire time they’re in the hospital. So, they know that they are validated; they know that they are people that are being respected and treated with affection. And they, it’s just a very powerful way for a system to realize that we all can be doing better in our customer approach to patients.
>>KOPELOW: I think this whole thing is a wonderful example of how people who care for people can do things in order to make that care better. So, thanks very much for this.
>>HOLDER: You’re sure welcome.
This is a transcript of "Sorry Works" - Risk Management CME.
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