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

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.

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.

Researchers reviewed patterns in healthcare policies and trends in five countries (the United States, the United Kingdom, New Zealand, Australia, and Canada) with histories of disclosing adverse incidents to patients. The researchers wanted to analyze the barriers that prevent healthcare providers and institutions from disclosing adverse events to their patients. They concluded that some barriers included difficulties with liability fees, patients’ beliefs on safety in the healthcare setting, and implementing policy changes on a large-scale. Effective ways to combat these challenges include carrying out a long-term program that involves educating patients and healthcare workers about safety.

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.

Many organizations have struggled to implement CRP models smoothly. The study looks at factors that accounts for the success of two Massachusetts hospital system in implementing a CRP with high conformity to protocol without raising liability costs. Identified factors include: support of top institutional leaders, heavy investments in educating physicians about the programme, active cultivation of the relationship between hospital risk managers.

Ernest Amory Codman MD (1869–1940) was a Boston surgeon who created a system in which he followed up with each of his patients years after hospitalization and recorded the end results of their care, including any errors in diagnoses and treatment. Dr. Codman then analyzed these errors and the correlation to patient health outcomes, and used them to make future improvements to not only increase patient safety but to excel as a healthcare provider.

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.

The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error management. Understanding these differences has important practical implications for coping with the ever-present risk of mishaps in clinical practice.

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 response to adverse events can lack patient-centered-ness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Researchers studied the factors that encourage and hinder reconciliation after an adverse patient incident occurs. They also discuss recommendations for health systems to follow to approach malpractice legal cases. It was concluded that healthcare organizations should not follow a “one size fits all” approach to all adverse events that compromise patients safety. Rather, they should be flexible when approaching them so they can follow guidelines that promote the best-practice policies for patient safety and exceptional healthcare.

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)

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.

Researchers of this article studied the long-term impacts (LTIs) of medically adverse events on families and patients years after they occurred. They found that the four main LTIs were 1) prolonged financial effects, 2) continuous anger and vivid recollections of the event, 3) changes in self-identity and health behaviors, and 4) chronic physical effects. The findings of this report emphasize the need for future research focusing on ways to help families and patients dealing with the effects of adverse health events.

The Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI) created the Communication, Apology, and Resolution (CARe) Approach. This strategy aims to further patient safety by fostering honest communication, apologies, and just compensation in adverse situations. MACRMI partners with patient advocacy organizations to to teach health insurers and hospitals about this strategy.

Inconsistent CRP implementation and focus on claims savings rather than nurturing a culture of accountability results to missed opportunities for improving quality and safety. The article includes four suggested strategies for implementing and spreading authentic CRPs.

MA 2012 Payment Reform Legislation (Ch 224) – Key Liability Provisions

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.

The Oregon Patient Safety Commission (OCCRP) seeks to advance, support, and encourage patient safety through education, shared learning, and improved transparency in Oregon. It is a multi-faceted, semi-independent state agency created by the state legislature to further patient safety in the state. The OCCRP operates multiple mission-driven programs, which include the Patient Safety Reporting Program, Early Discussion and Resolution, and various quality improvement initiatives.

Oregon Resolution of Adverse Health Care Incidents Act (2013)

This website offers resources and advice if you or a loved one has been harmed.

Patients and family members identified the factors that contributed to their respective adverse incidents, such as not following safety measures and lack of communication. Participants stated that they were not involved in the analysis process of the adverse events, so they missed out on ways to become more involved in learning about adverse events and how they can be decreased in the healthcare setting. Thus, the authors of this article emphasize that healthcare systems should implement educational modules that not only help decrease the risk of adverse events, but also teach healthcare professionals, patients, and family members on how to be proactive in preventing them.

The purpose of this study was to examine the experiences of families and patients with medically adverse incidents, as well as to understand how different healthcare organizations respond to these events. Researchers found that, following adverse events, patient satisfaction was at its peak when communication was compassionate and included discussion of compensation. Satisfaction was also at its highest when physicians attentively listened to patients without interjecting during the conversation.

This article discusses the importance for healthcare organizations to understand the patient’s perspective after they received disclosure following an adverse medical event, because it could help them develop more effective communication methods. Researchers found that patients preferred it when healthcare systems disclosed adverse events to them. They also found that these systems should implement policies that promote disclosure between patients and physicians.

Authors of this article emphasize how the “no blame” approach should be balanced with accountability when promoting patient safety in healthcare settings. However, this balance should be distributed among healthcare professionals, patients, and family members when effectively improving and promoting patient care and safety.

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.