Let’s imagine a woman brings her elderly father to a primary care appointment. They’re checked in. They’re put into an exam room and, 35 minutes later, the doctor still hasn’t come in to see the patient.
The daughter goes out to the reception desk to find out what’s going on. Someone tells her, “Oh, the doctor isn’t scheduled to be in the clinic today.” The daughter asks, “How could this happen?” The person at the desk says, “It’s not my job to schedule appointments.”
The patient and his daughter are so upset that they leave. They never return to that clinic or to that health system.
While no one was subjected to physical harm in this situation, clearly this family suffered other important consequences. They might even feel as though they had been treated with disrespect.
The Lasting Effects of Disrespect
As a physician, and in my health care quality and safety role, I often hear about situations like the one described above. The patient isn’t losing the function of a limb or experiencing organ failure from an incorrect dose of medication, but they are suffering other kinds of injury.
Recognizing the importance of these injuries, my colleagues and I have been working to call them out, develop a terminology to describe them, and explore the mechanisms that lead to them. We call these injuries “non-physical harms” and, in our experience, they matter greatly to patients and families.
Such harms include the emotional and psychological impacts that can occur after adverse events or suboptimal medical care. These often result in mistrust, an unwillingness to return to or recommend the professional or organization, and the weakening of their therapeutic relationships. Problems with interactions between patients/families and health care professionals/organizations may also contribute to non-physical harms. Patients and families often describe these issues as disrespect.
Disrespect is a powerful word, and one that must be wielded carefully. While few health care professionals intend to be disrespectful, we have found that patients and families often use the term to describe their experiences and to explain why they matter so much to them.
Disrespect can mean many different things to different people, so some definitions are important. Disrespect can be conceptualized as a failure to honor or acknowledge a patient’s dignity. Dignity can be conceptualized as each person’s intrinsic, unconditional value as a human. This framing can help us see why patients and families might use terms like disrespect, undignified, or indignity to describe situations where they felt their humanity or value were ignored.
In addition to the scenario described above, here are a few common examples:
A family member shares a concern that their loved one seems confused after surgery and their worry is disregarded, dismissed, or not acknowledged by anyone in the health care system.
A patient feels his privacy has been violated when he overhears a clinician speaking flippantly about information the patient thought he had shared in confidence and has no relevance to his medical care.
A clinical team doesn’t have any disease-specific treatment options left for a seriously ill patient, but they don’t share this information with the patient, leaving that patient and their family unaware of what the future might hold.
A Tool for Taking Action
When harm occurs, many organizations do a deep dive. We spend hours investigating what took place and all the contributing factors because we want to prevent the harm from happening again. This approach is often described as Root Cause Analysis or RCA.
Despite the widespread use of RCA, patients continue to experience harm, and the same types of harm continue to recur. We need to more reliably turn what we learn from our RCAs into stronger corrective actions.
This is where RCA2 can be helpful. RCA2 stands for Root Cause Analyses and Actions (RCA “squared”) to emphasize the importance of turning lessons learned into steps to prevent future errors.
In addition to physical harm events, my organization, Beth Israel Deaconess Medical Center (BIDMC), has extended our use of RCA2 to non-physical harm events. When a patient or a family member experiences disrespect in our health care system, and it leads to harm, we treat the incident very similarly to physical harm events.
First, we do a deep dive and try to understand what happened. With a situation like the first scenario I described, BIDMC would review the case and ask many questions: How were any patients scheduled if the doctor wasn’t going to be there? Why did we respond defensively when the daughter pointed out the problem? Did anyone follow-up with the patient?
Then, we discuss our findings at a series of meetings, focus on the contributing factors, and talk about what we can do to prevent it from happening again. In a case like the first scenario, we would think about what system level changes we could put in place to prevent that kind of scheduling error and disrespectful response from happening again.
While this work is complex, and continues to evolve, it has not only led to improvements that we hope will reduce to risk of future harm, but it has deepened our understanding of the patient/family experience. Furthermore, recent evidence suggests there may be important connections between experiences of disrespect and physical harm: disrespect has been identified as an important contributing factor to diagnostic error — if a health care professional disregards a patient’s concern, they may miss out on important data that might have led to a more accurate or timely diagnosis
We also believe extending the RCA2 process to non-physical harms has driven a cultural shift at our organization. By regularly discussing these kinds of cases, the concept of building a more reliable “practice of respect” is taking hold. We’re increasingly appreciating the ways in which we need to improve our interactions with patients and families and we’re grappling with how much practice it will take to get better. We encourage you to join us in this work!
Dr. Sokol-Hessner will share more details on the work he describes above at the IHI National Forum during session SH13: Practice of Respect: Find Out What It Means to You on Sunday, December 8 from 1:00 - 4:30 PM.
Patient Safety sessions are a part of IHI’s National Forum this December.