Positive results coming from apology followed by quick settlements

‘Seven Pillars’ and similar approaches advocate disclosure, apology, and offer

The idea of full disclosure of adverse events was proposed to the risk management community years ago. Remember how controversial that idea was? Then the next suggestion was that providers should apologize for their errors. More debate ensued.

The next logical idea was to disclose, apologize and then make an offer of compensation without delay. This strategy, proponents said, was not only the right thing to do from an ethical standpoint, but also reduced the amount of money hospitals spend on malpractice litigation.

So how’s that working out for you?

The recent data suggests it’s working pretty well. The approach has developed many names and slight variations as it was adopted by healthcare systems, hospitals and insurance companies across the country, but the original and best known incarnation is the “Seven Pillars,” created by the University of Illinois hospital system in 2006. The Chicago system’s way consists of these steps:

  • Report incidents that could harm patients.
  • Investigate those cases, and fix problems before an error happens.
  • Communicate when an error occurs, even if no harm was done.
  • Apologize and “make it right” by waiving hospital and doctors’ fees.
  • Fix gaps in the system that can cause things to go wrong.
  • Track data from patient safety reports, and see if changes make care safer.
  • Educate and train staff how to make care safer.

Only two years after it started, the process led to more than 100 investigations and nearly 200 specific improvements, according to the Agency for Healthcare Research and Quality (AHRQ), which promotes the Seven Pillars program. In those two years, the policy also was the basis for 20 full disclosures of inappropriate care that caused patient harm.

AHRQ is funding a three-year project in 10 Chicago-area hospitals. The entire process is being tested at five hospitals; the other five will report data only and compare their results to the hospitals using Seven Pillars. Other hospitals and health systems have independently adopted Seven Pillars or variations to the approach, and the initial reports on effectiveness are all universally positive, says James B. Battles, PhD, senior service fellow for patient safety and medical errors, AHRQ Center for Quality Improvement and Patient Safety, Rockville, MD.

“We are excited by the results we are seeing so far from not only the Seven Pillars program, but also other programs that use some of the same principles,” Battles says. “There seems to be a consensus growing that this is a reasonable, productive way to approach medical errors. When you have the medical society and the trial lawyers association in Massachusetts agreeing on something, that’s pretty monumental.”

Battles notes that the Seven Pillars approach can be adopted in almost all states without special legislation, unlike some malpractice reform proposals. AHRQ is putting together more resources for healthcare providers interested in adopting the approach, Battle says. Information is available on the AHRQ site at http://tinyurl.com/sevenpillars.

“We are finding that, particularly for hospitals and hospital systems with enterprise liability, meaning they are self-insured, this program really offers benefits,” Battles says. “One of the things that is really important is to promote communication among all the parties on the defense side. This whole approach depends on good communication and having all the parties understand that this is an approach that makes sense for everyone.”

Disclosure programs of this sort are gaining great admirers among insurers who otherwise would have to pay out larger sums, says Frank A. Jones, an 18-year veteran of the insurance industry and partner with Mints Insurance, based in Millville, NJ. “This is the only formidable way for us to see drastic changes in the medical malpractice system,” Jones says. “In the University of Illinois system, the claims dropped about 70% and malpractice premiums dropped by several million over a few years. There is a huge, huge positive impact from a disclosure program that you cannot get from any type of reform.”

Nothing else achieves the same results as a disclosure program, Jones says. Everybody wins when you disclose and apologize quickly, and the settlement offer is almost always less than what it might have been later or what a trial jury would have awarded, he says. “Even with premiums declining, the insurance company wins because the payouts are declining,” he says.

A key component for success is to obtain complete buy-in from physicians, Jones says. That buy-in can be challenging because older physicians were taught to deny and defend, and they may steadfastly insist that approach is the right path. “The only way to educate them and get full buy-in is to use hard data that shows disclosure, apology, and offer works every single time it’s tried. I have not seen a single bit of evidence that this approach does not work to everybody’s best interest,” Jones says. “I’ve never seen an instance where this model failed. But I’ve seen plenty of other promises for tort reform and the like that amounted to nothing.”

Jones notes that the approach is becoming so well accepted and the beneficial effects so obvious that insurers are starting to consider it the gold standard for healthcare providers.

“We have made a 100% commitment to the disclosure model, as an agency,” Jones says. “We decided to only write policies with a carrier that practices this model fully, as we believe it will be the catalyst to changing this industry.”


  • James B. Battles, PhD, Senior Service Fellow for Patient Safety and Medical Errors, Agency for Healthcare Research and Quality Center for Quality Improvement, Rockville, MD. Telephone: (301) 427-1332. Email: James.Battles@ahrq.hhs.gov.
  • Frank A. Jones, Partner, Mints Insurance, Millville, NJ. Telephone: (856) 825-2880. Email: frank@mintsinsurance.com.