Tools and Resources[ Show all or clear results ]

Patient Safety and Quality Improvement activities, disseminating lessons learned

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.
Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.


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.
Agency for Healthcare Research and Quality (AHRQ): Advances in Patient Safety

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last five years. This compendium is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs. The 140 articles in the 4-volume set cover a wide range of research paradigms, clinical settings, and patient populations. Where the research is complete, the findings are presented; where the research is still in process, the articles report on its progress. In addition to articles with a research and methodological focus, the compendium includes articles that address implementation issues or present useful tools and products that can be used to improve patient safety.


Tool/Toolkit
CRP resource or tool (e.g. CANDOR)
Canadian Patient Safety Institute: Patient Safety Management Toolkit

From the Canadian Patient Safety Institute

Prevent Patient Safety Incidents and Minimize Harm When They Do Occur
When a patient’s safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process.

Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.


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.


Case Study
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.
Comprehensive Unit-based Safety Program (CUSP)

The Comprehensive Unit-based Safety Program (CUSP) was created by Johns Hopkins University patient safety researchers and brought to the public domain through the Agency for Healthcare Research and Quality (AHRQ). CUSP aims to improve patient safety culture while providing front line caregivers with the tools and support that they need to tackle the hazards that threaten their patients. This program has been used to target a wide range of problems, such as patient falls, hospital-acquired infections, and medication administration errors.

The AHRQ toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety.


Journal Article
Published articles related to CRP
Effectiveness and efficiency of root cause analysis in medicine

Healthcare providers use root cause analysis to learn from malpractice and decrease the risk of adverse events. This method involves identifying the basic factors that cause performance variability. This model has three parts: 1) what occurred, 2) why did it occur, and 3) what strategies can be used to prevent the event from occurring in the future? This method is effective, because it helps healthcare providers identify the underlying causes of adverse events and take the necessary approaches to combat them.

 

 


The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety offers a detailed overview of ergonomics and and human factors, theories, methods, and models that are pertinent to patient care and safety. Specific topics included in this book include telemedicine, infection prevention, and anesthesia safety.

 


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.
Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF)

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) started collaborating together to utilize its combined resources and knowledge to further  patient safety efforts and create safety systems in various healthcare settings.


Journal Article
Published articles related to CRP
Leading Change. Why Transformation Efforts Fail

John P. Kotter is renowned for his work on leading organizational change. In 1995, when this article was first published, he had just completed a ten-year study of more than 100 companies that attempted such a transformation. Here he shares the results of his observations, outlining the eight largest errors that can doom these efforts and explaining the general lessons that encourage success.

 

 


Meeting/Conference Proceedings
Meeting/Conference Proceedings
Northwest Communication and Resolution Program Leader Retreat, Sept 2017

The Collaborative for Accountability and Improvement and the Foundation for Healthcare Quality hosted a two-day retreat in Seattle, Washington (09/2017) in which administrators and healthcare providers discussed ways to advance communication and resolution programs (CRPs) and other resources in Northwest Hospitals to increase patient safety and communication among hospital leadership, attorneys, and health insurers.


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.

 


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.
TJC Patient Safety Systems Chapter, Sentinel Event Policy and RCA2

The Joint Commission published three reports that address patient care and reducing risks of adverse health outcomes: the Patient Safety Systems , Sentinel Event Policy, and RCA2. The Patient Safety Systems report explains how healthcare professionals can develop effective measures to promote patient safety and compassion towards coworkers. The Sentinel Event Policy report details how the Joint Commission collaborates with healthcare institutions to promote patient safety and improve systems that reduce the risk of adverse incidents. The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm report illustrates strategies that institutions or individuals can utilize to analyze the hazards and faults in their systems to they can effectively prevent future adverse medical outcomes.

 


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.
Virtual lecture hall: The human side of medical errors

The Virtual Lecture Hall offers a two-hour course called Human Side of Medical Errors, which will effectively teach participants how to make ethical decisions when providing medical services to colleagues or loved ones, as well as how to constructively respond to a patient’s emotional reaction after they were involved an adverse incident.

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Washington Foundation for Health Care Quality

The Foundation for Health Care Quality is a Seattle-based nonprofit foundation that offers third party sources to everyone involved in healthcare, including physicians, patients, government organizations, and payers. The institution offers various resources to promote healthcare quality and patient care, such as assessment and communication-and-resolution (CPP) programs.

 


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.
When It Comes to Liability and Patient Safety What’s Good for Hospitals Can Be Good for Patient

Michelle Mello, the Director of the Program in Law and Public Health at the Harvard School of Public Health, analyzed the effectiveness of communication-and-resolution programs (CRPs) in this article. She found that these models are efficient at addressing healthcare liability issues revolving around adverse medical outcomes. These programs offer a guide for healthcare professionals on how to disclose medical errors to their patients, while also developing ways to prevent future adverse events.