Even the best prevention can’t keep the unthinkable from happening.
Sometimes you can do everything right, and something still goes wrong. The variable of “human nature”, when added to any standard formula, can make for wonderful surprises or terrible tragedies. Ultimately the only elements we truly control are the values we choose that will guide us through these events, and their aftermath.
If your job involves caring for others, it’s a particularly daunting task to balance best practices with the awareness that things may not go according to plan. Sometimes there’s only one chance to bring all one’s training, experience, and muscle memory to bear in making the right call. Years of intensive training and study go in to making these decisions, and yet still—even when everything is done exactly right, things can still turn out far differently than what was anticipated.
When things go wrong, what you do next is all you can control, and your choices can make the difference in preventing an incident from repeating itself. This is especially true in medicine, a field where adverse events can result in extensive residual trauma, costly litigation, and organizational dysfunction—if they’re not constructively and transparently addressed.
In a 2015 Health Affairs blog post
about the importance of professional transparency in improving patient safety, the authors, a team of physicians and patient safety experts, pointed out that culture change is not a process without hurdles. “Barriers to transparency are ingrained in health care culture. Among them are fears about conflict, disclosure, and potential negative effects on reputation and, subsequently, finances. Strong leadership is required to overcome these barriers and create a culture of safety.”
Transparency is about more than just saying sorry—it’s about using constructive communication to reach real resolution after a crisis.
The push for a paradigm shift in medicine in coping with adverse patient events, medical mishaps, or near misses, originated out of a desire to address issues of litigation, including malpractice. The so-called “Michigan Model
” is probably the best-known example of a communication-and-resolution program (CRP). These are programs that encourage hospitals to move away from the traditional “defend and deny” approach to communicating with patients and their loved ones after an incident, and address situations in a more proactive and person-centered way.
The University of Michigan Health System is considered one of the first pioneers of an approach that strives to build transparency and trust between patients, staff, and organizations. “You may have heard something about our policy of ‘saying sorry’, or apologizing and having an open discussion, when clinical care does not go as planned. And while apologies are certainly part of our approach, there’s much more to it than that. Communication, full disclosure, and learning from our experiences are all vital,” they write in their summary
of best practices for addressing patient safety.
At CPI, we’re deeply invested in the work of enhancing cultures of safety in many fields, including medicine. With nearly 40 years of successful collaboration with health and human services organizations, we know that a critical component of crisis prevention involves helping staff improve communication skills to better advocate for the Care, Welfare, Safety, and Security
℠ of all
individuals involved in a critical incident.
You can proactively address risk and improve the quality of care for the long term with a person-centered approach.
Our emphasis on the relationship between prevention and positive outcomes supports the broader paradigm shifts that CRPs are attempting to drive, and the idea that the right approach can fulfill regulatory expectations along with measurably improving a culture of safety for staff and patients. The best practices within CRPs, particularly regarding candid and constructive communication with staff, patients, and loved ones, were created to address the issue of litigation. But the positive byproduct of their implementation is a significant improvement in the larger culture of care, which can serve to prevent patient crises in the future.
This perspective is shared by industry experts who are looking to proactively address risk and enhance a person-centered approach in medicine. Writing about the relationship between such culture change and positive outcomes, executive Dov Seidman noted
, “Much of the attention focused on the Michigan Model has centered on the fact that doctors’ apologies have lowered lawsuits and payouts, in contrast to the conventional wisdom that apologizing increases the risk of litigation. [The] University of Michigan Health System has certainly dislodged its doctors from the conventional approach to ‘defend and deny’ mistakes. But I am more interested in the transformative waves that have been unleashed throughout its wider ecosystem because of its commitment to the values of transparency and truth — defending themselves if they do their job and authentically apologizing when they do not.”
In a Health Affairs study
of the implementation of CRPs, researchers noted, “Administrators at all six programs believed that rates of adverse events had decreased because the programs fostered a culture of safety and of incident reporting, which in turn facilitated more event analyses and the identification of interventions to improve safety.” A paradigm shift fueled a change in staff behavior, which ultimately impacted the likelihood of adverse events and associated litigation.
This free session on debriefing will teach you strategies that support CRP best practices.
At CPI, we recommend debriefing
to help staff thoroughly and constructively follow up on a critical incident. In our training, we explore the communication skills involved in debriefing as a compliment to organizational policies and best practices. Check out this free, 15-minute session that dives into some of our best strategies for effectively following up, cultivating staff consistency, and establishing preventive and proactive solutions after a crisis.
- Basic debriefing techniques—why they matter, and how they can establish pathways to prevention.
- How these communication and debriefing techniques enhance staff consistency and drive better team performance.
- How CPI’s Crisis Development Model℠ helps you identify common behaviors and choose appropriately supportive responses during a crisis.
- How to use the CPI COPING Model℠ as a systematic framework for debriefing and prevention.
Sometimes you can do everything right, and something still goes wrong. Debriefing enhances a range of professional best practices by supporting a thorough documentation of a critical incident, providing space to process trauma, evaluate the effectiveness of an intervention, and plan successfully for future prevention—ultimately enriching organizational cultures with person-centered values.
As cultures of caring and safety continue to evolve, it’s important to remember that these person-centered best practices can help fulfill the expectations of regulations and policies in a way that protects the well-being of staff in a way that improves their ability to deliver quality care to patients. Breaking out of a paradigm of “defend and deny” empowers staff to improve collaboration and implement strategies for prevention by allowing them to openly address a problem and learn from what went wrong, evolving a more inclusive culture of safety.
Finally, bear in mind that culture change is an investment that takes time—but it does
deliver ROI. As early adopters of CRPs more consistently embraced a transparent approach, not only did they see a gradual reduction in costly litigation, but they were also able to build trust within their team and organization that early and honest incident reporting was a constructive process that could prevent future mishaps.