Concerning the negative impacts of the medical errors, our research is among the first empirical study that utilized the GMB process to investigate the causal structure of why the public trust in healthcare services and the doctor-patient relationship have been weakening over time. Working with relevant stakeholders, we identified potential high-leverage points in health systems to reduce medical errors, improve public trust in healthcare services, and strengthen the doctor-patient relationship in Thailand. The implications of our research are two-fold: that the GMB methods can serve as a useful tool to elicit a common understanding that is usually lacking, and that multiple perspectives are needed to create a more sustainable solution.
The shared understanding is lacking
Our study demonstrates that the GMB methods can serve as a useful tool to elicit a common and in-depth understanding of complex problems of why the public trust in healthcare services and the doctor-patient relationship have been declining. Most workshop participants indicated that the GMB process encouraged them to learn and collaborate with people from various organizations in both the public and private sectors of Thailand. They primarily benefited from hearing the direct experiences of people who had been impacted by medical errors. This benefit has been well reflected by an in-depth understanding of the problem, as shown in the mutually-synthesized CLD.
Even though the GMB process is an effective method for participatory research that addresses cultural and ideological barriers to collaboration, there are many other reasons why partnerships were difficult . We also encountered several challenges during our GMB workshop. For instance, in the “hopes and fears” session designed to decrease the barriers among the workshop participants, participants were confused with the ideas of whose hopes and fears. Such confusion could also suggest a lack of shared understanding of this problem and a lack of common goals of problem-solving among the stakeholders. Besides, improving the quality of healthcare services was suggested as the best potential intervention to enhance patient trust and the doctor-patient relationship in medical errors. Nonetheless, one participant insisted that people’s participation in healthcare quality control and improvement is more crucial and should be identified as a critical point instead. Without enough time to elaborate and discuss to reach the consensus among the stakeholders, it was not clear to many why and how people’s participation in healthcare quality control can be the high-leverage points.
Looking back, we might need further discussions in our GMB sessions on the term “people’s participation” in healthcare quality control and improvement, as a different group of stakeholders has different interpretations. We have learned first-hand that people from different backgrounds usually bring about different assumptions in problem-solving that sometimes can create the barriers to the synthesis of our shared understanding of this complex problem of the diminishing trust in healthcare services by the public.
Multiple perspectives are needed to create sustainable solutions
Inviting patients and families who are the victims of medical errors to be actively involved in our GMB process could be seen as one of the strengths of our study. Many workshop participants also indicated that the GMB process encouraged them to learn and collaborate with people from various organizations in both the public and private sectors of Thailand. They significantly benefited from hearing direct experiences of those who had been impacted by medical errors. Research also showed that patients could provide a unique perspective. For instance, it is found medical record accessibility contributes to co-management of personal health care from the patient perspective, which can contribute to better communications, patient participation, and doctor-patient relationship . The benefits of having learned from multiple views of all relevant stakeholders can be seen in all four domains of our final CLD.
Reforms should go beyond liability issues; they should also harness and enhance physicians’ ability to act. More visible efforts by physicians to reduce harm, better communication with patients and others, and actual evidence of improved patient safety should reduce patient anger and litigiousness . Reforms should pay a good deal of attention to developing a better rapport with patients, providing information, and involving the patient in decision-making about care . Nonetheless, we also observed that the participants who advocate for patient rights especially emphasized that the remedies for the victims are the definitive solution to this complex problem. Remedies, which can be monetary or non-monetary, were also suggested as a possible solution to promote the doctor-patient relationship when medical errors happen.
Currently, all the remedy programs provided under the National Health Services Act 2002 covers only about 70% of Thai populations under the Universal Coverage Scheme (UCS) under Thailand’s Universal Health Coverage (UHC), leaving patients under other payment schemes uncovered by any remedy programs. The UCS remedy program pays up to 400,000 Baht (13,000 USD) and has no support for permanent loss or damage that needs long-term treatment . A new bill specifically designed to support patients who were affected by medical error was already drafted. It was aimed to reduce the patient’s hassle by fastening the process of remedy payment to be within one year, and to extend the coverage to all Thai patients under the other public healthcare financing schemes besides the UCS. But to date, this bill has not been passed into law despite more than ten years of urging from the patient’s network.
By prioritizing a monetary option, it could create a tangible solution. According to our CLD, however, advancing the patient’s remedy bill would be only a part of the potential policy interventions. There was hope that this bill will help provide a powerful remedy to the patient and lessen the number of cases proceeding to a lawsuit by utilizing mediation instead. Nonetheless, the result from our GMB suggested that the financial compensations might not be enough in alleviating the suffering of patients and families.
A balance of monetary and non-monetary remedies for victims of medical errors is needed. Research has shown that a prompt sincere apology and communication to investigate the case and develop future prevention from healthcare providers can reduce the situation’s escalation to a lawsuit in several countries and settings [18–20]. Physicians who understand and can respond appropriately to the emotional needs of their patients are less likely to be sued . As suggested by this stream of patient safety literature, a new governance mechanism that can promote straightforward apologies and communications of healthcare providers should be included the bill or the policy discussions. The public trust in healthcare services can be nurtured by fostering psychological safety among health professionals[3, 22], which would allow them to apologize and communicate with the victims of medical errors appropriately. Furthermore, as social media can amplify the situation and be utilized for both sides, developing its regulatory environment is also appealing for policymakers. These lessons learned can only be obtained by seeing the problem from the perspectives of all stakeholders during the GMB process, and hence multiple perspectives are needed to create sustainable solutions
Although our study was very focused on involving a diverse group of stakeholders in health systems, the diversity within each group of stakeholders was limited. For instance, we only learned after the workshop that most participants who represented patients and families in the GMB process have already been involved in the networks that advocate for enacting the law to finance the remedies fund. Consequently, the relationship to the ‘remedies’ variable in our CLD is mainly focused on the remedies fund, but not on other aspects of the remedy process. Consultations with experts from various areas, such as lawyers, and additional literature reviews in the related fields, such as health policy and systems research, are required to explore every aspect of the problems. Consultations with experts from other areas of study and additional literature reviews can lead to a more comprehensive causal mapping. But it should be more focused on some confusing terms, as experienced in our GMB process—either to clarify the concepts or to elaborate some interconnected relationships among them.
Lastly, to test policy options and identify the high-leverage policy quantitively, a stock and flow diagram based on the present CLD is needed to be further developed for a system dynamic simulation modeling. The findings from system dynamic simulation modeling presented as a visualized trend of outcomes could lead to a more rigorous design of interventions and a more decisive, evidence-informed policy decisions.