Dr. Robert Wachter, Editor, AHRQ WebM&M: What are the advantages of someone coming to risk management with your background?
Dr. Geri Amori: What I might do differently than some of our colleagues is that I approach every issue first from the human interaction aspect of how the system may have fallen down from a psychological or sociological perspective, as opposed to from the purely clinical or purely legal perspective. It's a matter of where you focus initially, and then integrating the clinical and legal implications. For example, I've been called on to deal with what was perceived by nursing or physicians as a risk management problem, but I quickly perceived it was a communication breakdown or an ethics issue instead of a risk management issue. Although they're related, there are often subtleties that are very different, and if you address one, the other often resolves itself.
RW: What was risk management like prior to the patient safety movement beginning?
GA: It was very, very different. When I started in risk management, I was told very directly that I didn't know what my job was—my job was to protect the doctors from the patient—and that I did not have a good grasp on risk management because I wasn'’t doing that. I was listening to the patient, and I was listening to the doctors and nurses. Since we have moved into the patient safety realm, the notion of transparency has become more acceptable. The idea that we can and should listen to patients who know their bodies and know their personal histories has become more evident, and the whole notion of how we work together and communicate has become more important. So that is one way in which it is very different now, and I'm really pleased.
RW: Prior to 10 years ago or so, in most health care organizations the risk manager was really the only person there charged with doing anything that we would today call patient safety. Was that your perception as well?
GA: Yes, absolutely. We couldn't get money for it back then either. We would say this is an issue that we could fix if we have a way to get supplies or a way to vet where we're going to buy our supplies. There was no financial support for it. So it was a very different environment.
RW: Why wasn't it possible to get financial support then? After all, the risk manager was the gatekeeper around settlements that might be in the hundreds of thousands or millions of dollars. You would think there would have been some business case to prevent the next transgression that might have led to another malpractice case.
GA: What I remember most vividly was that the focus of people in the C-suite was very much on lawsuits: lawsuit prevention and winning and losing lawsuits. The focus was more on whether we won or lost the lawsuit and not on the contributing factors that led to the problems. They were more individually focused; they weren't systems focused.
RW: What are the forces that you see that have led to this major change in the way the C-suite, for example, sees a lawsuit or a patient safety problem?
GA: Well, some of it is that now the focus is on patient safety and what is being done proactively. Although many of us always asserted that risk management was intended to be proactive, our activities and priorities were valued and reinforced by those above us to shift the focus onto the reactive. With the emergence of a focus on patient safety, everyone knows we need to be proactive. There is also the shift to systems thinking, and away from individual blame for everything. The whole notion of systems thinking and safety science are huge shifts. We didn't talk about those things—we just didn't have those tools in our quiver.
RW: Did risk managers know those things? Is that the way they thought and no one else did, or did risk managers not think that way either?
GA: I think many of us thought that way but didn't have the same terminology. Many of us were looking at, how can we improve things? How can we keep this from happening again? I think we hadn't reached the tipping point where enough people were talking about safety science and were talking about systems thinking that we could get the attention of people in the C-suite. These things take a while to get into the mainstream of our vernacular and our consciousness. When the C-suite, administrators, and people who finance health care began to think this way, then people began to listen.
RW: You've highlighted the education that was necessary in the C-suite and the change in focus and mental model. How about among caregivers, particularly doctors and nurses?
GA: My husband is 71 and he's a retired physician. He tells a story about his first day of medical school. Picture an amphitheater full of first-day medical students. This obviously wizened, experienced physician stands in front of them and tells them that their job as physicians will be to know everything; to assume the patients knew nothing; to assume the rest of the staff knew nothing; and to always look like they were right even if they didn't know whether they were right. It was a whole image, and that was the image of leadership that was being taught to them in the early 1960s. I think we have a whole group of physicians who grew up with that belief system and who trained the next generation in that belief system. Now with the younger physicians growing up in an environment where it's okay to admit that we're human—that we need to look at the entire system not just what one person did—that generation of physicians and the ones that they will train, I think will have a better handle on and an acceptance of the notion of safety science, patient safety, and proactive safety.
I think nurses adapt more quickly because they hear lectures and webinars about these aspects of care earlier, and perhaps more often, than our physicians do.
RW: As you think about the hospitals that you've worked with now, 10 or 15 years ago, the risk manager or maybe the infection control person would have been the only two people who had preventing adverse events anywhere on their radar screen. Now you go into a big hospital and there's a cast of thousands. There's the compliance and accreditation person, there might be a physician safety officer, there might be a staff safety officer, and there might be a quality person. How has the role of the risk manager evolved vis-à-vis all these other players that didn't exist previously?
GA: That could be a mixed bag depending on the organization. In places where it works well, there is someone who oversees and coordinates and brings it all together. Every organization defines the role of their risk manager differently. Some organizations see them as primarily a claims person, but this is diminishing, in keeping with the American Society for Healthcare Risk Management's' recommendations. Some organizations now are expanding their roles to full enterprise risk management to look at where changes in one area affect change in another, and where exposure in one area shifts to create exposure in another. In some organizations, risk management is expanding to encompass compliance, infection control, and more. In other organizations, the individual given the title of patient safety officer is considered more important than the risk manager. I actually think we're missing the boat in both of these models. There needs to be an understanding of the unique things that a risk manager brings to the table, such as risk financing, risk control, and proactive risk management. I worry that systems are becoming more compartmentalized, and people are becoming hungry to justify their positions. I don't like to see us creating new silos, and I fear in some places we might be doing that.
RW: Talk a little bit about what the field used to think about disclosure, apologies, and openness, and how it has evolved over the last 10 years?
GA: I remember when we would have [adverse] events and were told, "Don't say anything. They may not find out." On one occasion, I was talking to our attorney saying, "We really should be open and honest about this." His response was, "Why do you care? It's not your money." I remember that day very clearly because I was taken quite aback. Now trustworthy communication is being seen to be in the best interests of everyone. Even when there is a lawsuit, honesty changes the color of the lawsuit. Where there has been no communication, the money gets made by the lawyers through time spent in discovery, motions to quash, and back and forth. Those billable hours and the drive to contingency add up. When there has been honest communication, the suit becomes one of "Let's talk about what this is worth, if it's worth anything." If the organization has been honest, less time needs to be spent on "did you, or didn't you." There are those who fear that, if we were totally truthful, the whole system would collapse upon itself by costing us much more money. But what I find personally is that when I talk to patients or families, most of them say, "If I only felt like somebody cared about what happened to me I wouldn't have sued."
RW: Why is this so difficult? How much of this is shame? How much of this is fear that, in fact, it will encourage lawsuits? How much of this is because people don't know how to have these conversations?
GA: I think it's all of the above. John Banja talks about professional narcissism, the good kind, where we go into this work because we want to do the right thing. When we don't live up to our own expectations for ourselves as professionals, it is painful. It hurts. So there's the shame aspect. Fear of litigation is a huge piece of it. If I admit to you that I don't know if I did wrong, or I did do wrong, or we don't know what's going on, we have a belief system that people are going to sue us. We've seen that historically. We also know that if you go through a lawsuit, it's not easy—it's hugely painful. We know the effects of being sued on the physical and mental health of providers.
Not knowing how to have these types of tough conversations, I think, is a piece of it, too. We have taken "disclosure" and turned it into a unique animal. We say this is "disclosure" and "this is how to do it." In fact, disclosure is, at its base, nothing more or less than a difficult conversation where you're admitting that you may have played a part in something that hurt another person. Now I know that we don't have those conversations every day. Nothing in life prepares us for them. However, if we can look at these conversations for what they really are and work on the skills that it takes to be humble and human with people and yet not to capitulate, not to admit guilt when we don't have it or fault when we don't have it—if we can learn that human skill, disclosure is not a totally unique animal. Disclosure is also a skill for life, not a skill just for work. This is a skill for when you crash the car, you overdraw the checking account. You went and you impulse-bought a boat. This is a skill for all of those things, not just when you've made a medical error. So, although the ramifications may be different, let's talk about the basic, human components.
RW: Are you convinced by the emerging literature around disclosure and apologies that it does not increase your liability and may even decrease it?
GA: It's been 10 years but we've not been on the road long enough yet. The tail for medical malpractice is very long and we're still wrestling with how to be honest. The next 10 years will be where we will really see the results of our efforts. We have seen some trends. Some people say we have successes, but it depends upon how you define success. Success doesn't mean that patients don't sue. Success means that if you get sued, it's a different lawsuit. There are legitimate financial needs, and sometimes you cannot come to a settlement agreement. Sometimes there's unresolved familial guilt on the part of the plaintiff, or unresolved grief underlying the need to lash out. And even if it's not medically justified, when we've been a mensch and done all the right things, if we go to court, the lawsuit will have a different tone.
RW: You've talked about transparency and openness vis-à-vis the relationship between the providers and the individual patient. But what about when we've harmed or killed someone in one clinical unit and we were open and discussed it with the patient. Now the question is, are we transparent in our own organization? Do we talk about this error in a way that might help others in the building learn from it? But we're worried that the error might be disseminated more broadly, outside the walls of the institution, and we may not want that. What is your thought about this issue?
GA: I would really go head on with this one. If it's appropriate and you have a good enough relationship with this family after being open and honest, I'd ask them if you could use it within the organization to help ensure this doesn't happen to somebody else.
RW: You're a fan of transparency, not only with the individual patients or families around the error, but as an organizational strategy to be very open about bad things that have happened so that people will learn from them. And recognizing that probably engenders some risk as well in terms of the organization's standing with the local community in the media.
GA: It has to be handled well. I'm not advocating letting it all hang out. You have to communicate strategically. Hopefully by now you've already identified who in the local media you could turn to, to give you a fair shake. You don't want to leave your media coverage to chance. Somebody's going to find out and want the story. One of your employees is going to call somebody at the paper or television station. Certainly it happened to me multiple times as a risk manager. Once we had a fellow from the rehab unit jump out of a third story window. How he got the safety bars out I don't know to this day. But he did. Before he landed the press was on the sidewalk. I don't know how they managed it. It was totally amazing. They knew before I got the call! People call the press. So you may as well manage your risk as opposed to react to your risk. I follow [health care reporter] Larry Tye's recommendation: know who your local media are and let them know that you're going to deal straight with them if they'll deal straight with you.
The other thing healthcare organizations don't do well enough is tell our community what we're doing right. We wait for something to go wrong. If we told them, "We're constantly looking for ways to make our care safer. Even when nothing is going on, we're looking for how to make sure we're always giving the right medications. We work at reducing our infection rates so you don't have to worry." Because believe me the community knows all the dirt, but they don't know all the good stuff we do. Consequently, why would they believe we're doing anything good. I'm an advocate for regularly telling people what we do right. And if something goes wrong, then say, "Well, we're going to work on that, too."
RW: What do you think of the role of patients in protecting their own safety?
GA: Oh, it's huge. The challenge is that when you're sick, you're scared, and when you're the family you may be too scared. The other part of the challenge is that staff members are exhausted and overworked. Our exhausted response often squelches the patient and family comments. I had a very personal experience in 2008: in one year I was "family" to three friends in three hospitals in three parts of the country. One in the West, which was an emergency. My friend was in the intensive care unit. One in Florida, where my friend ultimately died. And one in Massachusetts. In all three places, I was present as family with HIPAA [Health Insurance Portability and Accountability Act] rights and Power of Attorney, so I was the "constant." The way that I was treated as family was totally different in each of those places. The quality of interaction I had with staff and the amount of participation I was allowed in the care was totally different dependent upon the attitude of nursing staff. How I was received when I would make an observation was totally different in each of those places. Consequently, my experience and my friends' experience were totally different in each of those places. Patient and family involvement in care has to be fostered, and not foisted.
RW: Did you have a sense of the places that did it really well, what made it that way?
GA: The hospital in Boston was the best. The nurses and staff there talked to me. They answered my questions. They taught me how to assist with various things. Remember I'm not a nurse, I'm a PhD counselor. They taught me how to do various maintenance kinds of help. As I was helping, they positively reinforced me. It was very welcoming. It was very different from where when I asked a question they were like, "we don't have time to answer you." And it would be a question such as, "A nurse came in asking for consent for a test, but nobody had talked to us about the test. Can you tell us how we can find out more?" I got the cold shoulder in another hospital. In fact, in one of the hospitals I said, "Your ice machine is right around the corner here. If you would allow me, I could make the ice pack." "No, we can't do that. Go away." I mean literally they said that. I don't think it had anything to do with the places as much as the individual cultures of those hospitals and how welcoming they were to families. So families have an important role, but if I can be intimidated with what I know and my beliefs about it, I can only imagine that many families would back down very quickly feeling intimidated by the organization.
RW: What do you see as the future for the interface between risk management and patient safety?
GA: I think they're two sides of the same coin. I think they should reside together. They're not really different. They have the same goals. Patient safety is the proactive aspect of risk management, and I would like to see all the divisiveness go away.
RW: You see real divisiveness as opposed to just silos and people in different camps? You actually see tension sometimes between these fields?
GA: I do. What I sometimes see is people grabbing turf that doesn't need to be turf. We do duplicative work sometimes. Even though, for example, an investigation for patient safety is different from an investigation for a risk management purpose. Too many investigations wear down staff and create potential for missing information. Let us combine and create a way of making risk management and patient safety part and parcel of the same thing—to improve care for patients.