The Michigan Claims Management Model, or “disclosure, apology and offer,” is a shockingly honest approach in an environment better known for high-priced lawyers and expensive legal battles.
The system, to combat medical malpractice claims, has been a beneficial tool for both patients and medical staff since its inception in 2001. The University of Michigan Health System’s new response to medical errors and unintended, unanticipated outcomes was commended in the December issue of the Milbank Quarterly, a prestigious health care journal, for its emphasis on honesty and disclosure.
“The Michigan Model” was developed in a decade-long effort by Boothman and UMHS chief medical officer Darrell Campbell, based on three central principles: compensating patients quickly and fairly when unreasonable care caused injury, supporting clinical staff when the treatment was sensible or did not negatively impact the clinical outcome, and reducing patient injuries by learning from patients’ experiences.
Rick Boothman, executive director of clinical safety and co-author of “The Michigan Model,” observed issues with malpractice lawsuits as a trial lawyer for more than 20 years before developing the new approach.
“One, there was a lot of unnecessary litigation that occurred because people simply didn’t talk to each other,” Boothman said. “But more importantly, two, I felt that the process of litigation got in the way of patient safety improvements.”
The development of this new approach to malpractice dramatically changed the way suits are handled, according to Campbell.
“We were trying to improve the culture of the hospital by advocating for openness and honesty,” Campbell said. “Rick (Boothman) was able to put in place a mechanism that would take the big picture goals for this institution into a legal environment and it has worked beautifully.”
Although the approach was developed to decrease malpractice claims, the true efforts were aimed at medical care.
“But the real goal was not necessarily to lower our medical malpractice claims numbers, the real goal was to improve patient safety,” Boothman said.
The authors of the article in Milbank Quarterly, researchers from Harvard Medical School and the Massachusetts Medical Society, view the University’s strategy as promising and advantageous for the state. The article included 37 physician interviews, which unanimously said “The Michigan Model,” better known as the DA&O model, has a possibility of improving medical liability and patient safety.
Campbell added that he sees honesty as the underlying success of the strategy.
“Honesty and transparency — that is the main principle,” Campbell said. “If the people that you’re talking with think you’re being honest, you can solve a lot of problems.”
Basing the model around the principles of honesty has been a dramatic change in the culture of malpractice lawsuits.
“Honesty and transparency was revolutionary at the time because most lawyers, like me, were telling doctors ‘for God’s sakes, don’t talk about things’ for fear that a stray comment would somehow compromise our defense in court,” Boothman said.
Since changing from a deny-and-defend approach to the DA&O model, malpractice claims per month and total liability costs have decreased, claims are resolved faster and UMHS has made a habit of avoiding litigation.
Despite doubts and predictions of increased malpractice suits, “The Michigan Model” has silenced the nonbelievers.
“Everybody said when we started doing this, ‘Oh my god the floodgates are going to open up and you are going to be inundated with lawsuits,’ because we’re honest,” Campbell said. “That didn’t happen. In fact, it’s the opposite.”
The DA&O model not only avoids litigation and decreases the number of malpractice claims, but it is also a useful tool for identifying problems in patient care, according to Boothman.
“The transparency and honesty has opened the door and opened our eyes to pockets of problems,” Boothman said. “So right now we can target specific areas that are dangerous. For instance, we know that the culture in the operating room, which tends to be very hierarchical, is dangerous because nurses that do not feel comfortable speaking up to surgeons can lead to bad things.”
In 2010, after DA&O was fully implemented within UMHS, the average monthly rate of new claims decreased from 7.03 to 4.52 for every 100,000 patients seen, according to the Annals of Internal Medicine.
According to the Journal of Health and Life Sciences Law, the number of new claims in 1999 was 136 and the number of new claims decreased by 2006 to 61.
This model was also praised by the Annals of Internal Medicine in 2010 and the Journal of Health and Life Sciences Law in 2009. It was featured in the American College of Healthcare Executives’ publication, the Frontiers of Health Services Management, in 2012.
On Dec. 13, 2012, Campbell and Boothman presented DA&O to the University’s Board of Regents as a feasible option for hospitals throughout the country.
The full version of DA&O received additional research grants from the Agency of Healthcare Research and Quality to study the effect of the model as a principal response system for malpractice crises.
“We’ve been trying to understand whether it’s portable to other places or not,” Campbell said. “We have our own malpractice insurance and that makes it easier. People wonder if it’s only applicable to groups who have their own insurer, or is it just a function of Boothman’s success as a leader.”
Legislation and research efforts have also been launched in New York, Illinois, Washington, Massachusetts, Oregon and Florida based on “The Michigan Model.”
DA&O has shifted the focus of medicine from the physicians to patients, according to Boothman.
“We have recognized that medicine for generations has been physician-centric. Even though we are treating patients, the whole system is built around more the convenience of the physician than the interests of the patients,” Boothman said. “This experience has caused us, now going forward, to work hard on becoming patient-centered.”