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.

Read how the AMA pursues medical liability laws on the state level to reshape the current medical liability system to better serve both physicians and patients.

Resources for patients and families in need of information and support after a medical error or adverse medical event.

Webinar Date: January 21, 2021

Wesley R. Butler discusses the role of confidentiality and privilege within the context of Communication and Resolution Programs.

Presenter: Wesley R. Butler is an attorney at Barnett Benvenuti & Butler PLLC in Lexington Kentucky who focuses on advising health care providers on regulatory matters that implicate safety, quality, and reimbursement.

Objectives: 

• Outline the elements of typical confidentiality and privilege interests in patient safety and quality analyses, and explore the public policies that support such interests
• Outline the fundamental components of common CRP processes in health care, and explore the public policies and ethical considerations that support CRPs for responding to patient harm events
• Analyze the interplay between CRPs and confidentiality and privilege interests to identify complementary and divergent points
• Conclude with practical suggestions to illustrate that health care providers can fully implement CRP processes while respecting the boundaries of confidentiality and privilege and,  ultimately, gain the benefits that both perspectives offer

Webinar Date: April 26, 2022

Moderator

• Caitlin Harrington. MD, JD

Speaker Panel

• Jeffrey N. Catalano, JD
• Jeff Goldenberg, MD
• Naomi Kirtner
• Jo Shapiro, MD, FACS

Webinar Date: March 18, 2021

Richard Boothman, JD, Michael Severyn, JD, and Kyle Sweet, JD, discuss important the role of attorneys in advancing the CRP field.

Presenters: Richard Boothman, JD, Michael Severyn, JD, and Kyle Sweet, JD

Learning Objectives: 

• Describe the role of attorneys who counsel and represent healthcare systems, healthcare providers, insurers, and patients and families in the CRP process
• Examine how the traditional role of an attorney following an unplanned clinical outcome might need to shift to better serve client’s interests and everyone involved in healthcare
• Learn about the goals, work stream, future opportunities, and ways to get involved with the Attorney Alliance

Webinar Date: June 24, 2021

Presenters:

Objectives:

Webinar Date: January 20, 2022

Moderator

• Caitlin Harrington. MD, JD

Speaker Panel

• Jason Lees, MD, FACS
• Lydia Nightingale, MD, FACOG
• Shapiro, MD, FACS

Learning Objectives

• Understand the emotional impact on clinicians after harm events as well litigation
• Apply strategies as litigators to support clinicians through the process of litigation
• Connect clinician defendants with peers who have been through the process of litigation

Webinar Date: February 24, 2022

Moderator

• Caitlin Harrington. MD, JD

Speaker Panel

• Wesley R. Butler, JD
• Jeffrey N. Catalano, JD
• Elizabeth A. Leedom, JD

Webinar Date: March 17, 2022

Moderator

• Caitlin Harrington. MD, JD

Speakers

• Dr. Jeff Goldenberg and Naomi Kirtner, co-founders of Talia’s Voice

Webinar Date: July 21, 2022

Presenters: Kyle Sweet, JD

Kyle Sweet is an Oklahoma-based defense lawyer represents healthcare providers in catastrophic injury cases around the United States. Kyle teaches in medical schools, dental schools and teaches seminars regularly to healthcare providers on how to avoid litigation by improving quality of care through more effective communication. Kyle is proud to serve on the CAI and looks forward to helping make Communication Resolution Programs the industry standard.

WEBINAR DATE: May 1, 2020

The COVID-19 pandemic is posing a host of potential medicolegal risks for healthcare providers, institutions, and liability insurers. How should one respond to the patient with behavioral challenges who refuses to comply with social distancing? How do COVID requirements affect consent and surrogate decision-making? What new legal issues are arising with rapid expanding telehealth programs or deploying providers to new care environments such as nursing homes? In what situations should healthcare providers or organizations be provided with immunity for potential adverse events associated with COVID-19 care?

PRESENTERS:

Moderator
Thomas H. Gallagher, University of Washington
Panelists
Marcia Rhodes, University of Washington
Leilani Schweitzer, Stanford Health
Michael Severyn, ProAssurance
Kyle Sweet, Sweet Law Firm

OBJECTIVES:

1. Identify current medicolegal issues associated with COVID-19
2. Consider how medicolegal issues associated with COVID-19 may evolve in the future
3. Discuss possible ways to address these issues

Communication-and-resolution programs (CRPs) aim to increase disclosure, learning, and responsibility following adverse medical incidents. The authors of this article identify five obstacles that prevent CRPs from being successful: 1) public policy, 2) compensation for patients following medical errors, 3) application fidelity, 4) evidence of CRPs increasing patient safety, and 5) alignment of CRP methods with patient needs. To increase the success of CRPs, it is recommended that they should be coupled with CRP quality programs. Overall, health institutions are advised to implement these programs into their systems to promote transparency and patient and family engagement.

This article explains how healthcare providers and insurers were skeptical of the Agency for Healthcare Research and Quality’s Communication (AHQR) Communication and Optimal Resolution (CANDOR) toolkit, which is a guide for healthcare providers to use if there was patient injury. Healthcare providers and insurers are weary of the CANDOR toolkit, since it does not quickly fix litigation scandals. This toolkit also does not effectively identify patient safety risks. However, the CANDOR toolkit is an effective step for healthcare providers to take in being honest and transparent with their patients about any malpractice or increased risk of injury.

The Journal of Patient Safety and Risk Management published study of an “open” hospital system shows that a Collaboration Communication-and-Resolution Program (CRP) cut lawsuits by two-thirds and reduced legal expenses and the time needed to resolve claims. Due to this program’s success, physicians are encouraged to integrate CRPs into their health practices to increase overall patient health quality and safety.

This study analyzed if a communication-and-resolution program (CRP) was effective in lowering adverse events among patients with chest pain, as well as lowering medical costs. The study concluded that the implementation of the CRP was efficient, since it helped increase the number of chest pain diagnoses as well as significantly reduced associated health costs.

Colorado Candor Act: ARTICLE 51 Communication and Resolution After an Adverse Health Care Incident (2019)

This is the website for the Washington Patient Safety Coalition’s (WPSC) Communication and Resolution Certification Program. When healthcare providers and organizations have utilized a CRP following an adverse event, they can apply for “CRP Certification.” A neutral group of patient safety experts and patient advocates has been convened to review responses to adverse events and certify whether the patient’s needs have been met, any individual or system-level inadequacies have been addressed, and learning has occurred. The certification process provides valuable feedback to healthcare organizations and demonstrates that they achieved all the essentials of a CRP.

The Washington Patient Safety Coalition is a program of the Foundation for Health Care Quality (The Foundation). The Foundation is a nonprofit organization dedicated to providing a trusted, independent, third party resource to all participants in the health care community – including patients, providers, payers, employers, government agencies, and public health professionals.

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.

This article explains how communication-and-resolution programs (CRPs) are successful in decreasing litigation fees and compensation that results from patient harm. However, the success of CRPs depends on patient satisfaction, making it necessary for healthcare professionals to focus on factors that increase this. Even though there is little evidence to support the idea that CRPs reduce adverse medical events that result in patient harm, these programs do have the potential to do so.

This article dissects the meaning of “disclosure-and-resolution” programs, which call health organizations to disclose medical errors to patients and families involved; apologize; and offer compensation when necessary. Health systems that used approach found decreased litigation fees. Researchers analyzed surveys in which individuals used “disclosure-and-resolution programs where appropriate. They found that increasing compensation allowances following an adverse event did not improve results, nor did it decrease the likelihood of patients and families filing lawsuits following an adverse event. Thus, it is important for healthcare systems to remember that “disclosure-and-resolution” programs may help promote effective and honest communication between patients and families, but it does not decrease associated legal costs or the possibility of a lawsuit.

Doctors and Litigation is a website produced by Dr. Gita Pensa, an Emergency Medicine physician at Brown was a defendant for 12 years, and regularly speaks on the topic at conferences and has a podcast “Doctors in Litigation: the ‘L’ word.”

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.

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. To make these programs more successful, legal entities should support them. State and federal policy makers should try to allay potential defendants’ fears of litigation, facilitate patient participation, and address the economic concerns of health care providers.

The Agency for Healthcare Research and Quality (AHRQ) published the Communication and Optimal Resolution toolkit, which is a guide for the implementation of communication-and-resolution programs (CRPs). These are holistic and systematic methods for preventing and responding to adverse medical events involving patients. The toolkit also guides on how to promote sincere communication between patients, families and the healthcare team; appropriate financial compensation; and efficient ways to decrease future adverse medical events. The authors describe their personal experiences with applying CRPs in their medical practices in more than 200 hospitals. From their experiences, the authors describe the obstacles that prevented the success of CRP implementation, as well as how they overcame them.

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.

Iowa’s Candor Statute – Iowa Code §135P (2017)

Communication-and-resolution programs (CRPs) are a systematic response to address adverse medical events, as well as to promote patient safety and healthcare quality. In this study, researchers analyzed the effectiveness of implementing the Communication and Optimal Resolution, a CRP, at MedStar Health, an American community health organization. Researchers found that this program was effective in increasing the number of incident reports, as well as decreased the number of adverse events associated with lawsuits.

The Policy Committee works to educate and engage various groups on how to support CRP at the institutional, state, and federal level. This past year, the committee reached out to the National Practitioner Data Bank (NPDB) and to the Centers for Medicare & Medicaid Services (CMS).

The letter to NPDB is part of a continued conversation about efforts to expand alternatives to medical liability litigation.

The letter to CMS illustrates how CRPs are consistent with the principles of Person and Family Engagement.

In an era of calls for greater transparency in health care, disclosure is often cited as a practice necessary to physician ethics and patient safety. The University of Michigan Health System (UMHS) experience demonstrates that disclosure with offer can be conducted—in a setting similar to many other centers in the United States—without exacerbating liability costs. UW Medicine hope that this study will encourage further disclosure efforts, as well as the detailed evaluation of their effects.