Healthcare System Transparency and Patient Safety

When a few cautious experiments in the direction of greater health care provider transparency were proposed, some were alarmed. The worry was that so-called "Disclosure, Apology & Offer" (DA&O) practices would lead to increased litigation costs.

In a Perspective post in the NEJM, A. Kachalia discusses the immediate benefits for transparency, but also cites systemic obstacles to broader adoption of the practice.  (Kachalia is likely aware of the issues, guessing from the symbols listed after his name.) Citing the few known DA&O studies, he writes that:
. . . data from two pioneering programs have revealed improved liability outcomes, including a 60% decrease in legal and compensation costs in one program. Proponents of DA&O programs also tout downstream safety benefits from greater transparency. Early program successes have fueled extensive interest and a push for broader implementation, but there has not been immediate widespread adoption, so transparency is far from ubiquitous.
That's the promising news. Less hopeful: a complex mix of obstacles. Many of the impediments would be concerns in any setting, not only health care. They include:
  • A real or perceived tendency to single out a single provider's error rather than pursue a systemic solution
  • Unclear path to clear communication between providers, patients, family and public reportage
  • Even if organizations accept responsibility for "systems-level errors" (and if those can be defined), providers are singled out in reporting to state boards and quality monitoring data bases like the National Practitioner Data Bank. Worse, physicians may worry that, if caught up in systems-level errors, they could be "associated" with compensation to patients.
Kachalia also argues for legal reforms, such as greater use of "enterprise liability" instead of the current method which holds individual practitioners responsible. Another idea would be to have "administrative health courts."


The practice of medicine will become increasingly a systems-level enterprise. Transparency must become an integral part of those enterprises. The legal framework in which failures occur should take into account systems processes. Transparency should be fully integrated into the workflow -- both human and automated -- inside those enterprises, and nurtured by professional standards within health care related disciplines.

According to a 2012 DHS report, most medical errors are not reported, and even when they are, corrective actions are often not taken.

Increased transparency should be part of health reform. As more of the practice of medicine becomes software-assisted, e.g., through clinical decision support and workflow automation, initiatives such as those proposed by Kachalia will become increasingly important. Accountability in health care -- as with quality and cost containment --  must be seen as the corporate, enterprise effort that it has become.

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