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Classic articles every manager and aspiring leader should read and share with their teams.

The Collaborative for Accountability and Improvement Program is currently based at the University of Washington. The goal of the Collaborative is to bring together leading experts to support the growth and spread of Communication and Resolution Programs (CRPs), advocate on behalf of these programs with a shared voice, and exchange ideas. CRPs drive quality improvement, enhance patient safety, and facilitate patient-centered accountability. This CRP (Communication and Resolution Program) brochure describes CRP Core Commitments, Key Steps in the CRP Process and Launching a CRP.

 

 


In communication-and-resolution programs (CRPs), health systems and liability insurers encourage the disclosure of unanticipated care outcomes to affected patients and proactively seek resolutions, including offering an apology, an explanation, and, where appropriate, reimbursement or compensation. Anecdotal reports from the University of Michigan Health System and other early adopters of CRPs suggest that these programs can substantially reduce liability costs and improve patient safety. In this study, CRP participants were interviewed. They identified several factors that contributed to their programs’ success, including the presence of a strong institutional champion and investing in building and marketing the program to skeptical clinicians.


Sidney Dekker, PhD supervises the Safety Science Innovation Lab at Griffith University in Brisbane, Australia. In Dekker’s book, Just Culture: Restoring Trust and Accountability in Your Organization (3rd ed.), he discusses how to effectively create a just culture of accountability and responsibility. This includes learning strategies on how to appropriately approach adverse incidents such that knowledge is maximized and the negative effects are minimized.

 


The purpose of this study was to identify certain communication behaviors linked with poor healthcare practice history in medical professionals. Researchers identified specific communication acts correlated with fewer malpractice allegations for physicians. Effective communication behaviors included utilizing humor and encouraging patients to express their opinions. Physicians can use these results to not only increase effective communication with their patients but to also decrease the risk of misbehavior and carelessness in the healthcare setting.

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Process for Early Assessment, Resolution and Learning (PEARL), Risk Authority Stanford

The Risk Authority Stanford is a healthcare risk management organization established at Stanford University School of Medicine, Stanford Children’s Health, and Stanford Health Care. This organization developed the Process for Early Assessment, Resolution and Learning (PEARL), a communication-and-resolution program (CRP) aimed to approach unexpected adverse incidents with respect and honesty, which also decreasing litigation fees and overall risk. The Risk Authority also offers solutions and services to medical organizations and healthcare systems outside of Stanford.

 


Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
PSNet: Root Cause Analysis

Root cause analysis (RCA) is a systematic method used to analyze adverse incidents, especially in the healthcare setting. This approach identified both active and latent errors that contribute to adverse incidents. Active errors occur between humans and the system, while latent errors are known as the hidden issues in a healthcare system. An important principle of RCA is to recognize the source of problems that contribute the increased risk of medical errors, while not concentrating on individual mishaps as the sole cause of the issue.

 

 


Sidney Dekker, the author of Second Victim: Error, Guilt, Trauma, and Resilience, discusses how healthcare professionals are considered second victims in medical mishaps, because of the trauma and guilt they experience int the wake of these incidents. In his book, Dekker details efficient ways to investigate medically adverse events so that healthcare professionals do not feel neglected or more guilty in the process. Dekker also emphasizes the importance of having support systems in healthcare settings for second victims.

 


The Charter on Medical Professionalism, endorsed by the US Accreditation Council for Graduate Medical Education, requires physicians to engage in honest communication with their patients, especially regarding risks and benefits regarding medical procedures. However, researchers found that not all physicians abided by these rules which raises the concern that physicians may not fully disclose pertinent information with their patients, so they do not receive complete information. Honest communication between patients and their physicians is associated with patient comfort and willingness to move forward in medical procedures.

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Web resource/Digital Article
General website that contains CRP related information, may be non-specific or general or mixed resources on a website. Article published on-line. Not available as paper version.
University of Missouri’s ForYou and Caring for the Caregiver

University of Missouri’s forYOU Team is an organization that supports caregivers in the aftermath of traumatic medical incidents or during the stress of their job. The institution offers multiple resources on identifying symptoms of distress as well as how to support caregivers.