Read the following real stories from Beth Israel Deaconess Medical Center in Boston, Massachusetts, and ask yourself, “Did the patient and/or family experience harm?”
- A patient in a semi-private room overhears a conversation during which doctors inform her roommate about a terminal diagnosis. In the following months, the patient experienced recurring nightmares resulting from this experience.
- A son receives a 3:00 a.m. phone call from an orthopedic surgery resident seeking operative consent for his mother, who fell in the hospital and fractured her hip after being admitted for other reasons. This call is the first notification to the family of an adverse event.
- A patient is taken to surgery wearing her wedding ring, but when she awakens postoperatively, the ring is missing and is never found.
- A transgender woman patient is addressed as “Mr.” at the reception desk. When she corrects the staff, she witnesses them giggle and roll their eyes.
- A post on the hospital’s Facebook page reads, “Ok…I have surgery scheduled today and the paperwork says check in @ 5 a.m. I wake at 3:30 to make the 1 hr. drive from [far away] only to learn that no one can ever check in B4 6 a.m.?? The staff here states it is a little trick they do?? Hope my surgery doesn’t have any little tricks or surprises!”
We believe that these patient experiences meet the definition of harm as “physical or mental damage,” yet hospitals usually do not manage these events with the same formality that they do physical harm events. At Beth Israel Deaconess Medical Center (BIDMC), we called out this problem in 2015 and are now practicing a different approach by considering these patient experiences as examples of emotional harm resulting from disrespect. We have extended the processes that have been used to prevent physical harms to these important, but traditionally neglected, emotional harms. Our work shows that severe preventable emotional harms are common, that they are widely recognized as important, and that they can be addressed with use of a formalized approach utilizing an institution’s existing quality and safety systems.
Recognizing Emotional Harms
BIDMC is a 700-bed teaching hospital within a busy academic community in Boston. In 2007, in order to drive institutional improvement, the hospital set the goal of eliminating preventable harm. BIDMC classified harm as “preventable” if reasonable improvements in care would help to decrease the likelihood of similar events occurring in the future. Although it may not be possible to eliminate all preventable harm, setting this audacious goal enabled us to build broad consensus around our aim by holding ourselves accountable to an aspirational standard of care.
After developing systems for defining, detecting, reviewing, categorizing, reporting, and preventing harm events, we started to share instructive cases within our internal community as well as on our external website. This approach to improving patient experience has resulted in increased reporting, a more rigorous methodology for improvement and innovation across the hospital, and decreased overall harms. Although we have not yet eliminated all preventable harms, we have observed transformative changes. For instance, BIDMC has now adopted a standardized approach toward Communication, Apology, and Resolution after adverse events as well as a culture of fair and just treatment of the health professionals involved in such events.
As our approach to harm evolved, we gradually realized that we were focusing solely on physical harms and did not have a systematic approach to emotional harms to patients. Therefore, in 2014, we created a Respect and Dignity Workgroup consisting of representatives from hospital governance, social work, nursing, physicians, and our Patient Family Advisory Council to explore the idea of leveraging our existing approach to address emotional harms.
We began by establishing the principle that patients and families should always be treated with respect. Broad consensus was quickly and easily achieved with regard to this principle and the associated definition of respect as “the actions taken towards others that protect, preserve, and enhance their dignity.”
To begin detecting and capturing events, our Patient Relations representatives began flagging complaints and grievances from patients and families that seemed to describe a disrespectful experience. We also created a mechanism for staff reporting by reconfiguring our online safety-reporting tool to include a category for episodes of disrespect. Given that health care systems have not traditionally recognized emotional harms resulting from disrespect, we expected that, at least in the initial stages of our work, the majority of events would be reported by patients and families. Indeed, to date, staff reports have represented only 19% of the total number of cases (Figure 1).
We then retrospectively reviewed 2 years of patient complaints and comments on our HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys in order to identify a short list of common themes, which we currently use to categorize events. We also developed a simple severity scoring system (Table 1). Severity scores are assigned on the basis of the harm experienced by the patient and/or family as well as the risk of future harm as perceived by the institution. This approach acknowledges that sometimes a patient or family rates an event as having been of mild severity but we, as an institution, feel that a similar event would represent a significant risk of severe harm to a future patient or family. Conversely, sometimes a patient or family rates an experience as severe but we, as an institution, feel that such an event would not represent a significant risk of severe harm for the majority of future patients and families. By considering the severity scores from these two perspectives, we are able to focus on events for which there is broad consensus that the prevention of future harm is particularly important.
We currently focus our analyses on preventable episodes of disrespect that led to severe emotional harm, which represent approximately 20% of all reported events. We then use cause mapping to evaluate this subset of events and discuss them at the same peer review committee meetings at which physical harm events are discussed. Next, we share the numbers and types of preventable emotional harm events on a quarterly dashboard with the organization, the hospital governance, and the public via the aforementioned external website (Figure 2).
We have observed two notable reactions to these data. The first reaction is surprise that we have not traditionally tracked these kinds of harms and curiosity about why it has taken so long for us to do so. The second reaction is interest in what we are learning from these data and how we are applying this knowledge. Predictably, we have found that many of the events relate to problems with communication and the environment of care, but we also have discovered an unexpected theme related to care after death, including management of the body and other post-death processes, such as the communication of autopsy results. We incorporate what we have learned from each event into existing improvement initiatives, or, if a relevant initiative does not yet exist, we launch a new initiative designed to prevent future harm.
What Are We Learning?
Emotional harm resulting from disrespect is common and important. In our first year of tracking these harms, we have found that severe emotional harm events are identified more commonly than physical harm events. Given that the work is still gaining awareness in our organization, we believe that we are capturing only a fraction of the actual patient experiences. In part because we are focusing on the most severe harm events, we also have discovered widespread agreement that these harms matter and are deserving of the increased attention that they are now receiving.
Institutional management of emotional harms can fit seamlessly within existing patient-safety operations. At our institution, we have operationalized our program to address disrespect within our existing framework for addressing preventable harm by using the same principles and tools for assessment, analysis, reporting, and corrective actions. This approach has allowed us to quickly and effectively begin to systematically address a much broader range of preventable harms. Just as with physical harm events, we are finding that sharing stories of individual events can be a powerful way to promote positive change in our organization.
The reliable practice of patient respect depends both on individuals and on the system of care. As with physical harms, the behavior of the individual health care professionals involved in emotional harm events is evaluated according to “just culture” principles. In parallel with what we learned about preventable physical harm events, the vast majority of these events are not the result of negligence or nefarious behavior by individual staff. Typically, poorly designed systems are the underlying cause of situations in which, despite the best efforts of our staff, we fail to meet expectations for respectful treatment. As a result, individual staff typically are coached on how to prevent future harms rather than being disciplined for their actions.
Consider the case described above about the patient who was told to come to the hospital for surgery an hour before the check-in desk opened. The staff who developed those instructions knew that the hospital tracked “on-time OR case starts” as a measurement of efficiency. They also knew that delays due to traffic — particularly during the early morning commute to the medical center — typically are underestimated by patients, who tend to arrive late. Understanding these causal factors led to a more effective set of corrective actions than if we had simply disciplined the involved staff.
This work is raising important conversations about the overall culture of respect at our institution. We are recognizing that reliably treating our patients and their families with respect requires an overall culture of respect. Episodes of disrespect between staff, or of disrespectful treatment of staff by patients or families, pose challenges to the culture of respect. Such episodes are increasingly being shared and discussed as we work to better support staff who find themselves in such situations. For example, an interdisciplinary workgroup has begun to address patient and family actions that harm staff and is developing an internal dashboard to track and learn from such events.
Engaging in the “Practice of Respect”
We see our approach as a strategic initiative not only to eliminate preventable harm and improve our culture of respect but also to drive improvement in the patient experience. Individual stories of disrespect are powerful motivators of change and help to identify actionable priorities. As we explore this uncharted territory in our quest to improve, we encourage others to join us in the “practice of respect.”