Implementing Change within Health Systems: A Case Study
Change. It’s as inevitable as death and taxes—and often just as scary. There are many reasons for change. Some changes are capricious such as when a new department store manager seeks to make his presence palpable and initiates a change in décor. Often change is driven by necessity when you have to adapt to some different environmental influence. As a Risk Analyst for the UCLA Medical Center, Louise Underdahl, Ph.D. experienced the following change first-hand. In this case, a precedent of law changed that had a dramatic effect on how physicians obtained—and documented—informed consent from patients.
In 2001, a female patient succesfully sued her surgeon and the medical center where he worked, claiming malpractice. It wasn’t that the surgery had been botched or that she suffered medical harm. Rather she claimed she had not agreed to the size of her new “assets” prior to breast augmentation surgery. The medical center felt the claims were preposturous and appealed the case, which went all the way to the state’s Supreme Court. The court decided the case was so egregious they wanted to change the precedent for malpractice. The justices ruled that failure to adequately obtain informed consent was paramount to assault and battery, thus changing the charges from civil to criminal. This had the chilling effect of placing malpractice claims related to issues of informed consent outside of the Medical Injury Compensation Reform Act of 1975 limits of $250,000 for pain and suffering, available to plaintiffs in the State of California. It also made physicians personally liable for damages because most malpractice insurers do not cover “criminal deeds”.
Faced with a new climate of litigation, the medical center’s adminstration decided on a purposeful change. Says Dr. Underdahl, “We not only wanted to improve patient safety, but reduce risk exposure by improving the process of obtaining—and documenting—informed consent.”
Underdahl explains that the medical center decided to create pre-printed consent forms and make them available to physicians on their website. In theory, the physician would discuss the information with the patient and both physician and patient would sign the form which would become part of the medical record. It was a win-win proposition—physicians could save time and reduce their risk, and the medical center reduced its risk for lawsuits and improved patient safety.
After implementation, however, a review of medical charts clearly showed the forms were not being used.
To increase utilization, Underdahl and her risk management team went from department to department to garner participation, to no avail. In fact, one respected physician told everyone, “I don’t care what you do. It’s not that we can’t get to them. I’m just not going to use them. I’ve never done that before and I’m not going to change now,” recalls Underdahl.
The physician’s sentiments highlight one of the challenges of implenting change. Says Underdahl, “You will never be able to convince some people of the need to change. Many are slaves to the familiar and others are so scared of how the change will affect their livelihood that they cannot embrace the change, no matter how beneficial or necessary. However, you can’t abandon a good idea because you don’t get 100% compliance. As an agent of change, you must simply do the best you can and hope those resistant to change will get involved in time.”