Tools and Resources[ Show all or clear results ]

Book/Report
Reference to book or report
Shining a Light: Safer Health Care Through Transparency

The NPSF Lucian Leape Institute Roundtable on Transparency published “Shining a Light: Safer Healthcare Through Transparency,” a report focused on being honest in four healthcare settings: between healthcare workers and patients; between healthcare professionals and the institutions; between institutions; and between institutions and the greater public. Transparency is defined as “the free flow of information that is open to the scrutiny of others,” and it is related with better healthcare outcomes, decreased rates of medical mishaps, lower healthcare costs, and increased rates of patient satisfaction.

 


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.
Slow Ideas: Atul Gawande

Dr. Atul Gawande, general surgeon and part-time professor at Harvard University, analyzed the histories of various medical innovations, such as anesthesia and oral re-hydration therapy, and why they were successful or unsuccessful in swift diffusion. General obstacles included resistance from healthcare professionals, as well as weariness that the method was unsuccessful. However, general reasons why other methods were successful was because they combat the negative effects of germs and pain.

 


Data from case studies support the fact that apologies from physicians to patients promote reconciliation and forgiveness. To promote a culture that supports apologizing and disclosure, 39 states, including Washington, D.C., are enacting apology policies to decrease the litigation problems surrounding medical malpractice. This article is delves into the implications surrounding the enactment of these laws. The article is divided into four parts. The first part of the article explains why states are passing apology laws and how they can help reduce lawsuits associated with medical malpractice. The second part presents data that supports the effectiveness of apology laws. The third part illustrates how apology laws affect various legal outcomes, especially the probability that medical providers will be presented with litigation fees. The fourth part of the article delves into the legal significance of their results. It is important to note that apology laws do not replace communication-and-resolution programs (CRPs), nor do they mitigate the existing data that these programs are effective in lowering the incidence rates of medical error claims.


Streamed live on May 6, 2015 Clinicians encounter many stressors during their careers, none more significant than a difficult patient event that results in harm. Acknowledging that clinicians make seldom use of traditional support services, leading health centers across the US are pioneering Peer Support Programs that make available a trained and compassionate network of peers who can reach out and provide 1:1 support to a clinician experiencing stress.

In this live video event, we are honored to host the leading authority in the field, Dr. Jo Shaprio of Brigham and Women’s Hospital and Harvard Medical School, in conversation with Dr. Bryan Bohman, physician leader of Stanford Medicine’s Peer Support Program, to explore the following questions:

• What is motivating leading institutions to establish Peer Support Programs?
• How do Peer Support Programs work? How do they differ from existing support services?
• How effective are they? What do the data say?
• What best practices have emerged?
• What challenges need to be overcome?

The Risk Authority – Stanford, in partnership with Aon Risk Solutions, Lockton UK and MedPro Group invite you to participate in this exciting opportunity to learn about and explore Peer Support Programs from leading experts in the field.

Read more here.


Expectations for how radiologists should communicate with patients are in rapid evolution. Of all the communication challenges radiologists may encounter, disclosing harmful radiologic errors to patients looms as perhaps the most difficult. Calls are increasing for radiologists to communicate directly and transparently with patients after errors. This article explores the direct radiologist-to-patient disclosure of harmful radiologic errors. It further explores the profession’s aspirations toward enhanced patient care, professionalism, and visibility.


In the BMJ Quality & Safety Study (2009), researchers studied why clinicians are often considered “second victims” in the wake of medical errors. The researchers delved into how healthcare providers recover from the guilt and stress involved medical errors, and discuss the elements related to recovery and delineate from the second victim phenomenon. These factors include moving forward, receiving emotional support, and reestablishing a sense of integrity. Researchers recommended that it is important to for healthcare institutions to implement support systems that not only offer emotional aid but also decrease the likelihood of future adverse events.

 

 

 


The Covid-19 pandemic has amplified the immediate need for medical institutions to better support the emotional well-being of clinicians who are facing important emotional stressors, including grief from seeing so many patients die, fears of contracting the virus and infecting their family members, and anger over health care disparities and other systems failures. This article highlights the cultural and structural barriers that have caused existing emotional support programs to fail and describes key strategies that institutions can use to design peer-support programs that clinicians will embrace, such as reframing emotional stress, proactively engaging clinicians, making professional mental health services accessible, and holding institutional leadership accountable for clinician well-being.


Researchers acknowledged how a majority of adverse medical events involve patient harm. Patients and family are known as first victims. Researchers also acknowledged how healthcare professionals are also considered victims after an adverse event, due to the emotional and psychological trauma experienced after it. In other words, healthcare professionals are also known as second victims. In this study, researchers analyzed the various coping strategies that clinicians use in the wake of adverse events. These strategies include attending programs that offer emotional aid second victims, as well as taking accountability for the situation and learning from it.

 


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)
The Beryl Institute

The Beryl Institute is a community of practice with the goals of improving patient care and experience though teamwork and share values. The institute define patient experience as the sum of all interactions, influenced by an institution’s culture, that impact patient perceptions of healthcare. Among the Beryl Institute’s various goals to improve patient experience and care, they are committed to prioritizing patients, families, and care providers first; emphasizing the importance of the entire healthcare team; and engaging a variety of perceptions and voices from various sectors.

 


In April 2012, Glenn Clarkson died after a medical error at a rural Kansas hospital. Melissa and Nancy Clarkson describe the three-and-a-half-years of work it took for them to learn what happened in his medical care. Filmed at the Communication and Resolution Program (CRP) Training.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
The Collaborative for Accountability and Improvement

The Collaborative for Accountability and Improvement is a network based at the University of Washington, Seattle, composed of the physicians, attorneys, and insurers who pioneered the earliest CRPs in the United States. It is our belief that communication-and-resolution programs (CRPs) are an essential strategy for preventing medical errors and cultivating high-quality, patient-centered healthcare. Our mission is to radically accelerate the adoption of CRPs nationally and internationally, particularly through education, training, and hands-on support.


Journal Article
Published articles related to CRP
The Disclosure Dilemma — Large-Scale Adverse Events

Large-scale adverse events are individual events or a series of related events that injured or increased the risk that many patients would be injured because of health care management. There are ethical reasons why institutions may hesitate to disclose large-scale adverse events to patients. Practical, legal, and financial considerations, such as the difficulty in predicting the likelihood of harm and identifying the injured patients, may also lead well-meaning institutions to consider not disclosing large-scale adverse events. This article discusses two ethical frameworks often used in determining whether to disclose large-scale adverse events: utilitarian and duty-based. It also describes three examples of large-scale adverse events and discuss their distinguishing features.


Book/Report
Reference to book or report
The field guide to understanding ‘human error’

In The Field Guide to Understanding ‘Human Error,’ Sidney Dekker discusses how organizations can successfully deal with perceived “human error” without implementing new rules, punishing people, or requesting compliance. Dekker discusses how people embody “the Bad Apple Theory,” which states that an institution would be safe and reliable albeit a few irresponsible individuals in it. To combat this theory and “human error,” Dekker encourages organizations to learn to understand mistakes, how to improve investigative processes, and how to increase the safety climate of the workplace. He does this by offering specific strategies that encourage organizations and employees to think creatively to foster a safe environment that mitigates “human error.”

 


This report from the Betsy Lehman Center details two sets of research findings and proposes a coordinated response through which Massachusetts’s providers, policymakers, and public can accelerate safety and quality improvement and lead the nation on this urgent health care challenge.


Healthcare professionals are reluctant to apologize for medical errors, because they fear it could be used against them in lawsuits. In response to this issue, some states are developing policies that legally protect physicians, so they feel more comfortable apologizing to patients involved in medical errors. Even though these policies seem beneficial in theory, researchers found that these laws could discourage apologies and honest communication between patients and physicians following adverse medical events. Thus, researchers emphasize the importance for states to develop policies with modified legal protections and implications to not only promote disclosure between patients and physicians following adverse medical incidents, but also do not weaken the legal influence on lawsuits involving malpractice.


Journal Article
Published articles related to CRP
The Handbook of Communication and Social Interaction Skills

The Handbook of Communication and Social Interaction Skills is a holistic guide that draws form theories and surveys to improve communication and social interaction skills in various environments and settings. This handbook is divided into five sections: theoretical and methodological concepts (gaining and assessing skills); basic social interaction skills; persuading, informing, and supporting skills; various relationship skills (marriages, friendships, and romances); and skills necessary for public leadership and management (teaching and supervising).


Journal Article
Published articles related to CRP
The hard side of change management.

Authors of this article discuss how hard factors act as obstacles in change management. Hard factors have three characteristics: 1) Corporations can measure them in implicit and explicit ways, 2) corporations can communicate these factors both within in and outside of organizations, and 3) corporations can rapidly influence the previous elements. Authors emphasize that it is necessary for businesses to prioritize the hard factors before they can move forward and improve.


Journal Article
Published articles related to CRP
The Impact of Adverse Events on Clinicians: What’s in a Name?

The authors of this article discuss how physicians are dubbed “second victims,’ due to the negative emotional and psychological challenges they experience as a result of patient adverse incidents. The authors also illustrate how the term “second victim” can be a harmful term, since it implies passivity and mitigates the experiences of patients and families also affected by medical errors. It is argued that this term points to the necessity of healthcare institutions to implement support programs to help physicians heal and cope following the negative effects of adverse health outcomes.


Video
CRP related video, movie
The Lewis Blackman Story – YouTube Video

This YouTube video recounts the true story of Lewis Blackman, a 15-year-old boy who died in a hospital following routine surgery. This story sheds light on the importance of healthcare providers to not only be cognizant of their patients’ conditions,  but to also frequently engage with families so they feel involved in patient care.

This story has been taken from the Book “Wall of Silence” authored by Rosemary Gibson and Janardan Prasad Singh. The story can be found in Part One “Breaking the Silence”-“The Human Face of Medical Mistakes” page no-31.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
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.
The Michigan Model: Medical Malpractice and Patient Safety at UMHS

University of Michigan Health System developed the Michigan Model. This approach involves reducing and acknowledging medical errors through open communication between the patient and health institution, peer-reviewing the complaints to analyze the cause of the adverse event and how to prevent it in the future, and meeting with the patient and legal counsel to discuss the adverse event. With these implementations, the University of Michigan Health System successfully helped reduce the number of malpractice accusation against physicians, medical error fees, and total time it takes to manage a malpractice claim. Thus, the University of Michigan Health System is a leading innovator in increasing patient care and safety while also decreasing the adverse outcomes associated with medical malpractices.


Medical errors not only negatively affect patients involved but also healthcare workers, to the point that they have been dubbed “second victim” due to the psychological and emotional stress caused from the event. In this study, researchers examined how healthcare workers recover from medical errors. Recovery methods include receiving emotional first aid, re-developing a sense of integrity, and learning to cope with the negative event.

 


Journal Article
Published articles related to CRP
The path to safe and reliable healthcare

This article discusses the importance of implementing a holistic approach to address both processes and culture in providing safe and exceptional care to patients. This article also includes a road map for healthcare providers, so they can efficiently assess the strengths and weakness of their current care system, so they can organized and intentional in their work, allowing them to improve overall patient care and safety in any clinical setting.

 


Learning Community
Resources associated with CAI Learning Community
Video
CRP related video, movie
THE ROLE OF THE DISCLOSURE COACH

Dr. Shapiro talks about the importance of having disclosure coaching program and fundamental principles of disclosure coaching. For more videos related to Disclosure and Apology, view the video gallery.


Journal Article
Published articles related to CRP
The Science of Human Factors: Separating Fact from Fiction

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Read more here.


Journal Article
Published articles related to CRP
The Second Victim of Adverse Health Care Events, Nursing Clinics

This article discusses on how healthcare professionals are often considered “second victims” of adverse medical events, due to the psychological and emotional trauma they experience. To support second victims, it is important for health institutions to implement early warning systems that address harm risks associated with adverse incidents. In this article, researchers specifically focus on nurses and how respond to adverse medical events.

 


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.
The second victim phenomenon: A harsh reality of health care professions

This article focuses on the negative impacts adverse events have on healthcare professionals. Specifically, they feel a sense of inadequacy, shame, and personal grief. As a result, healthcare professionals are dubbed “second victims” of these incidents. The article also delves into obstacles that prevent healthcare professionals from seeking assistance. These obstacles include not wanting to be perceived as vulnerable or weak in front of their coworkers. To assist second victims and their recovery and combat the stigma associated with seeking help, health institutions are encouraged to develop holistic support systems.

 


Journal Article
Published articles related to CRP
The Sorry Works! Coalition making the case for full disclosure.

This thesis paper delves into the importance of classifying healthcare conflicts into relationship-based groups  to appropriately address the dynamics, goals, and interventions associated with the conflict. These dynamics include ways of improving communication and rapports, as well as efficiently saving money.

 


The Medstar’s Patient Safety and Quality Program included this video in their patient safety and care program. This video illustrates the story of Michael Skolnik, who lost his life due to medical malpractice. The error involved the surgeon not being completely transparent with the patient or his family about the surgical procedure. This video emphasizes the importance of shared decision making between patients, families, and physicians to avoid future adverse medical outcomes, especially ones in which lives are lost.

 

 


The objective of this study was to determine whether a communication-and-resolution program (CRP) to adverse patient events is correlated with changed in medical litigation actions and outcomes.  Researchers found that the implementation of a communication and optimal resolution (CANDOR) program was most successful. These programs consist of methods for effectively identifying an event, investigation, resolution, and care for healthcare providers. The CANDOR program was correlated with long-lasting fiscal and clinical improvements. It also helped increase incident report rates, as well as decrease the number of litigation and malpractice claims and fees.