Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Linking Transparency, Patient Safety, and Quality of Care (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Richard C. Boothman, Thomas H. Gallagher, Timothy B. McDonald, and Eric J. Thomas made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (5.2 MB).

Slide 1

Linking Transparency, Patient Safety, and Quality of Care
Innovative Institutional Programs and Future Directions

Richard C. Boothman, JD
Thomas H. Gallagher, MD
Timothy B. McDonald, MD, JD
Eric J. Thomas, MD, MPH

Slide 2

Session Objectives

  • Describe innovative institutional transparency efforts, including programs to promote reporting of adverse events and errors to institutions and disclosing these events to patients.
  • Describe the conceptual and practical linkages between event reporting, safety culture, and quality improvement.
  • Highlight future developments that could strengthen transparency and the link between transparency and quality at the institutional and national level. 

Slide 3


Topic Speaker Time
  • Introduction, session overview
  • Transparency, safety, and quality: conceptual considerations
Gallagher 15 min
  • Transparency and safety culture
Thomas 15 min
  • Promoting transparency at the institutional level
McDonald 15 min
  • What now?  Innovations to promote transparency at the institutional and national level
Boothman 15 min
  • Discussion
All 30 min


Slide 4


  • 29 year-old healthy male cared for by PCP and local hospital for recurring epistaxis
  • After several months, referred to academic medical center ED—presented ill, with SOB, epistaxis, hemopytsis, low platelets.
  • CT scan shows large lung mass, thought to be tumor (less likely blood clot).
  • Bronchoscopy attempted, finds free blood in lungs. 
  • Continued deterioration, recommendation for interventional radiology to embolize bleeding source 

Slide 5

(Case continued)

  • IR attempts biopsy, retrieves only clot.  Neoplasm still highest on differential.
  • While healthcare team is meeting, patient arrests and dies.  Autopsy finds large PE with pulmonary hemorrhage.
  • Communication with family immediately after death is challenging-cultural barriers, uncertainty about what happened, sudden and unexpected demise of young patient.
  • Security called to remove distraught family—first time risk management becomes aware of event. 

Slide 6

Follow-up disclosure meeting

  • One week later meeting held with 10 family members, unannounced trial lawyer, 5 physicians, 2 risk managers.
  • Clinical care thought to be reasonable; MD thought process shared with family.
  • Family perceptions addressed, misconceptions corrected.
  • Family could see shared grief.
  • Family's anger heard, appropriate apologies made, lessons taken back to management for follow-up.

Slide 7

Transparency, safety, and quality

  • Transparency long recognized as key to safety culture and healthcare quality
  • Yet a decade after To Err Is Human, major gaps in transparency persist
  • Healthcare workers experience multiple mixed messages about transparency
  • No accountability around transparency
  • Limited transparency becomes path of least resistance
  • Missed opportunities to promote greater synergy among transparency practices 

Slide 8

Practices in transparent healthcare organizations

  • Discuss events with colleagues, other team members
  • Formal event reporting
  • Disclose event to patient
  • Share lessons learned back with clinicians
  • Required external reporting
  • Optional external reporting
    • Standard quality measures
  • Extreme transparency
    • CEO blog
  • Other aspects of transparency
    • Clinical information (shared decision-making)
    • Price 

Slide 9

How transparent are we?

  • Event reporting:
    • 2009 AHRQ Patient Safety Culture survey-52% of staff reported no errors in the last 12 months 2005 Physician survey (n>2000)-65% unaware their hospital had an error reporting system. 
    • Disclosure to patient: Only 1/3 of harmful errors disclosed to patients 
    • Those disclosures that do occur often go poorly.
  • Feedback of lessons learned to clinicians:
    • 2005 Physician survey-18% of physicians agreed that current mechanisms to inform them about safety problems were adequate.
  • Suggests shortcomings in our current approach to promoting transparency.;

Slide 10

Comparing Patient and Physician Ratings of Disclosure Quality

Image of a bar chart.

Slide 11

Transparency, accountability, and quality

  • Current paradigm
    • Culture of blame, shame, fear inhibit openness
    • Errors mostly represent system breakdowns
    • Greater openness promotes quality through event analysis, implementing prevention plans
  • Reality check
    • Errors mixture of individual and system breakdown
    • Transparency also promotes quality by encouraging low performers to improve and by deterrent effect
      • Performing poorly on report cards a potent stimulus
      • Accountability for transparency required
  • Current approaches to transparency not integrated

Slide 12

Are current approaches to transparency integrated?

  • Key transparency practices largely segregated by specialty
    • Nurses report events to institution
    • Physicians disclose events to patients
  • Most safety culture surveys measure event reporting but not disclosure attitudes or practices
  • Risk management and quality/safety programs often separated
  • Training usually addresses one transparency practice in isolation
    • Disclosure training rarely addresses event reporting to institution or communicating about events with colleagues

Slide 13

Are different transparency attitudes correlated?

  • 2005 Physician survey
    • Physicians who strongly agreed that serious errors should be disclosed to patients twice as likely to strongly agree that serious errors should be reported to hospital
    • Similar relationship between MD support for disclosing minor errors to patients and reporting minor errors to hospital
  • Considerable anecdotal experience supports hypothesis that different transparency practices may be related

Slide 14

Implications of an integrated approach to transparency

  • What our are goals for transparency?
    • Are transparency's deterrent, embarrassment effects good or bad?
  • Transparency is a skill, not just an attitude
    • Should training address reporting, communicating with colleagues, and disclosure in tandem?
    • Interprofessional implications
      • What are the real barriers to “speaking up?”
  • Will organizations adopt processes to ensure accountability around transparency?
    • Which of these will be publicly reported?
  • Will organizations compete on transparency?

Slide 15

Enhancing transparency, improving quality

  • Transparency and safety culture: Eric Thomas
  • Innovative institutional transparency programs: Tim McDonald
  • Future developments in transparency: Rick Boothman

Slide 16

Transparency and Safety Culture

Image of a butterfly on a flower.

Slide 17

Safety Climate

The culture in this ICU makes it easy to learn from the errors of others.

Medical errors are handled appropriately in this ICU.

I know the proper channels to direct questions regarding patient safety in this ICU.

I am encouraged by my colleagues to report any patient safety concerns I may have.

I receive appropriate feedback about my performance.

I would feel safe being treated here as a patient.

Sexton et al. BMC Health Services Research 2006;6:44.

Slide 18

Safety Climate

  • Improve safety climate by:
    • Improving incident report systems
    • Executive walkrounds or safety rounds
    • Increasing staff participation in RCAs and other efforts to learn from errors

Hudson et al. Contemporary Critical Care 2009;7:

Slide 19

Safety Climate

  • Executive Walkrounds Study:
    • Randomized 24 clinical units to receive EWRs or usual patient safety activities and measured safety climate of nurses before and after the walkrounds
    • At baseline the experimental and control groups had similar safety climate scores
    • After the intervention, 72.9% of nurses in the walkrounds group reported a positive safety climate versus only 52.5% in the control group

Thomas et al. BMC Health Services Research 2005;5:28. For other data on walkrounds also see Frankel et al. Health Serv Res 2008; Jul 20:2.

Slide 20

Teamwork Climate

It is easy for personnel in this ICU to ask questions when there is something that they do not understand.

I have the support I need from other personnel to care for patients.

Nurse input is well received in this ICU.

In this ICU, it is difficult to speak up if I perceive a problem with patient care.

Disagreements in this ICU are resolved appropriately (i.e., not who is right, but what is best for the patient).

The physicians and nurses here work together as a well-coordinated team.

Sexton et al. BMC Health Services Research 2006;6:44.

Slide 21

Teamwork Climate and BSIs Across Michigan ICUs: “No BSI” is > 5 consecutive months without BSI.

Bar graph depicting % of respondents within an ICU reporting good teamwork climate by 3 categories

  1. No BSI 21%
  2. No BSI 44%
  3. No BSI 31%

Strongest item level predictor: caregivers feel comfortable speaking up if they perceive a problem with patient care.

Slide from Bryan Sexton

Slide 22

RN reports of Teamwork Climate and Subsequent RN Turnover

Bar graph depicting RN Turnover in that Quartile 3 years later.

Data from the University of Texas at Houston Memorial Hermann Center for Healthcare Quality and Safety

Slide 23

Teamwork climate

  • Improve teamwork climate by:
    • SBAR training
    • Briefings
    • Daily goals checklists
    • Shadowing other providers

Hudson et al. Contemporary Critical Care 2009;7:

Slide 24

Transparency and Safety Culture

Slide 25

Promoting Transparency at the Institutional Level

Slide 26

Condition Predicate to "Transparency"

Slide 27

Condition Predicate to "Transparency"

  • Courage.. and Leadership

Image of the Cowardly Lion from the 1939 "Wizard of Oz" film.

Slide 28

How can we "encourage" institutions and care givers to be transparent?

Slide 29

How can we "encourage" institutions and care givers to be transparent?

  • Deal with the drivers of human behavior

Slide 30

How can we "encourage" institutions and care givers to be transparent?

  • Deal with the drivers of human behavior
    • Fear
    • Greed
    • Ego - soul
    • One we can leave out

Slide 31

How can we "encourage" institutions and care givers to be transparent?

  • Deal with the drivers of human behavior
    • Fear
      • Support structure-patients, families and providers
      • Education
      • Attack "truth to power" problems head-on
    • Greed
      • Financial incentives, disincentives for reporting
      • Tie to employment, privileges - OPPE, credentialing
      • Show the ROI - process improvements, claims
    • Ego - soul
      • Adopt principles of "just culture"
      • Handle occurrence reports with discretion
      • Focus on systems unless reckless, repetitive behavior

Slide 32

On the educational front: ACGME program director survey data

  • Most believe being transparent and honest is important
  • Future depends on resident physicians
  • Few feel competent
    • Little training
    • Lack of infrastructure in "real life"
    • Mixed messages from institutional leadership, insurers, risk management
    • Desire for clear articulated and approved principles

Slide 33

ACGME core competencies

  • Patient Care
  • Medical Knowledge
  • Practice-Based Learning & Improvement
  • Interpersonal and Communication Skills
  • Professionalism
  • Systems-based Practices

Slide 34

Elements of a "Transparent" Response to Adverse Event Process

  • Reporting
  • Investigation
  • Communication
  • Apology with remediation
  • Process and performance improvement
  • Data tracking and analysis

Slide 35

Elements of a "Transparent" Response to Adverse Event Process

  • Within the context of the Core Competencies
    • Reporting - all six competencies involved
    • Investigation - SBP & PBL & I
    • Communication - Professionalism and com skills
    • Apology with remediation - Professionalism
    • Process and performance improvement
    • Data tracking and analysis - PBL & I
    • All done in the context of institutional oversight

Slide 36

Resident Reporting

  • Must report 5 unsafe conditions or "near misses per year"

Slide 37

After reporting

  • Degree of harm assessed
  • If harm, investigation ensues
  • Must engage the family
  • RCA depending on severity
  • Consideration of "care for the care giver"
    • Life After Death: The Aftermath of Perioperative Catastrophes, Gazoni et al. Anesth Analg.2008; 107: 591-600
  • Hold bills

Slide 38

Power of engaging families in the aftermath of a tragic event

Slide 39

Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study

  • West et al. JAMA. 2006 296(6): 1071-8. "Self-perceived medical errors are common among I.M. residents and are associated with substantial personal distress. Personal distress and decreased empathy are associated with increased odds of future errors... reciprocal cycle." Must consider "care for the care giver" and methods to maintain trust between provider and patient/family.

Slide 40

Future possibilities and opportunities

  • Deal with the drivers of human behavior
    • Fear
      • Federal & state legislative changes
      • NPDB & State licensing
    • Greed
      • Personal asset protection if transparent
    • Ego - soul
      • Expanded adoption of "just culture"
      • Screening prior to medical school
      • Emotional intelligence assessment tools
      • Values drive behaviors which drive performance

Slide 41


 In a time of universal deceit, telling the truth becomes a revolutionary act.

George Orwell

Slide 42

Habit #2: Begin with the End in Mind.

Stephen R. Covey

Slide 43

What do patients want?

What do patients deserve?

Slide 44


Truthful Explanation

Slide 45


Slide 46

Apology and Compensation when warranted

Slide 47

What do caregivers want?

What do caregivers deserve?

Slide 48

Truthful Explanation

Slide 49

Reasonable Benchmark against which you judge their actions

Slide 50


Slide 51

What do hospitals want?

What do hospitals deserve?

Slide 52



Truthful Explanation

Slide 53

Opportunity to be Accountable

Slide 54

 Opportunity to Improve

Slide 55

The very best risk management is to make no medical mistakes

The next best is not to make the same mistake again

“Deny and defend” and learning from mistakes are mutually exclusive

Slide 56

Institutional Patient Safety Concept



Intervention, Investigation, Stabilization

Referral for Action

Measurement to Gauge Improvement

Educate with Lessons Learned, Facilitate Improvements in Patient Safety, QI

Slide 57

Define "Disclosure"

  • Communicating with patients/families/caregivers
  • Following unanticipated medical outcome
  • And telling them the truth (or as close to it as we can come after the fact)

Slide 58

When an apology is truly owed, every day that passes results in a new injury

When an explanation is needed, every day that passes further cements mistaken beliefs

Slide 59

University of Michigan's Claims Management Principles

We will compensate quickly and fairly when inappropriate medical care causes injury.

We will defend appropriate care vigorously.

We will reduce patient injuries (and claims) by learning from mistakes.

Slide 60

Key Questions:

  • Was the care at issue "reasonable"?
  • Did the care adversely impact the patient's outcome?

Slide 61

U of M Claims Management Model

  1. Assessment and Direction
  2. Investigation and Analysis of Risk and Value
  3. Medical Committee (3 months after notice)
  4. Engage Patient and hare Information
    • Litigation - Agree to Disagree, No Dialogue
    • Legal Office Assign to Counsel Litigate
    • Claims Committee Settle or Trial?
    • Settlement - Mistake/Injury
    • Claims Committee Settle or Trial?
  5. Agree no Claim

Slide 62

Pre Suit Investigation

  1. Assessment and Direction
  2. Investigation and Analysis of Risk and Value
  3. Medical Committee (3 months after notice)
    • Peer Review
    • Clinical Quality Improvement
    • Educational Opportunities

Slide 63

Biggest Barrier: Fear

Slide 64

The University of Michigan has two important advantages:

  • Caregivers are employees of health system/medical school
    • Alignment of culture, ethics, financial consequences
  • Caregivers are insulated from personal financial ruin
    • Still accountable, but freedom from imminent, catastrophic financial consequences enables transparency, adherence to principles, wider and longer view of patient safety imperatives

Slide 65

Fear leads to:

  • Provider/hospital's abdication of responsibility to ask threshold question: what should my/our response be to this patient's unanticipated outcome?
  • Fight or flight rules, cedes control over this critical issue to lawyers/courtroom
  • And freezes efforts to improve in deference to the legal system

Slide 66

Ten years from now . . .

  • Information and honesty prevail
  • Incentives and penalties aligned to favor just response to patient and improve patient safety
  • Social safety net for patients so financial ruin is not main impetus for litigation
  • Protection for caregivers so financial ruin is not reason for deny and defend
  • Accountability (peer review), reasonable consequences based on "just culture" algorithm
  • Robust, widespread, compulsory data collection, sharing best practices, lessons learned and measurement of improvement

Slide 67

  • Litigation must change
    • Last resort (cooling off period, mediation, other ADR)
    • Elimination of opportunistic exploitation of weaknesses (runaway verdicts/caps, early evaluation of merit, affidavits of merit, junk science limits)
    • Favor full disclosure (federal civil procedure trend)
    • Experts are key (Australia's "hot tubbing", use of "masters", elimination of charlatans)
    • Consideration of "health courts"

Slide 68

The truth will set you free. But first, it will piss you off.

Gloria Steinem

Current as of December 2009
Internet Citation: Linking Transparency, Patient Safety, and Quality of Care (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care