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.

Medical errors are associated with significant emotional, financial, physical and sociobehavioural impacts including reduced trust and willingness to seek healthcare. These impacts can last for years. The study sought to understand whether greater open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error.

Webinar Date: June 24, 2021

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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: January 18, 2024

Presenter: Bruce Lambert, PhD, professor in the Department of Communication Studies and the Department of Medical Social Sciences at Northwestern University

Learning Objectives: 

• Describe the role and capabilities of AI in empathetic interactions in healthcare: Participants will learn about the current state of AI in replicating empathetic responses, including the mechanisms through which AI mimics empathy and its effectiveness compared to human empathy.
• Weigh competing ethical implications of AI-generated empathy in healthcare: Attendees will gain insights into the ethical considerations involved in using AI for empathetic purposes in healthcare contexts, focusing on issues of transparency, authenticity, and the balance between practical benefits and ethical responsibilities.
• Critically evaluate the impact and future directions of AI in empathy: The audience will be encouraged to critically evaluate the potential impacts of AI on the future of empathetic interactions in healthcare and other professional settings, considering both the opportunities and challenges presented by AI integration.

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.

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.

The rapid rate of change in the world of management continues to escalate. New government regulations, new products, growth, increased competition, technological developments, and an evolving workforce compel organizations to undertake at least moderate change on a regular basis. Yet few major changes are greeted with open arms by employers and employees; they often result in protracted transitions, deadened morale, emotional upheaval, and the costly dedication of managerial time. Kotter and Schlesinger help calm the chaos by identifying four basic reasons why people resist change and offering various methods for overcoming resistance.

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.

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.

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.

The existing structures and processes that together form an organization’s operating system need an additional element to address the challenges produced by mounting complexity and rapid change. The solution is a second operating system, devoted to the design and implementation of strategy, that uses an agile, network-like structure and a very different set of processes. The new operating system continually assesses the business, the industry, and the organization, and reacts with greater agility, speed, and creativity than the existing one. It complements rather than overburdens the traditional hierarchy, thus freeing the latter to do what it’s optimized to do. It actually makes enterprises easier to run and accelerates strategic change. This is not an “either or” idea. It’s “both and.” I’m proposing two systems that operate in concert.

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)

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.

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 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)

Improving how health care providers respond to medical injury requires an understanding of patients’ experiences. Although many injured patients strongly desire to be heard, research rarely involves them. Institutional review boards worry about harming participants by asking them to revisit traumatic events, and hospital staff worry about provoking lawsuits. Institutions’ reluctance to approve this type of research has slowed progress toward responses to injuries that are better able to meet patients’ needs. In 2015-2016, we were able to surmount these challenges and interview 92 injured patients and families in the USA and New Zealand. This article explores whether the ethical and medico-legal concerns are, in fact, well-founded. Consistent with research about trauma-research-related distress, our participants’ accounts indicate that the pervasive fears about retraumatization are unfounded. Our experience also suggests that because being heard is an important (but often unmet) need for injured patients, talking provides psychological benefits and may decrease rather than increase the impetus to sue. Our article makes recommendations to institutional review boards and researchers. The benefits to responsibly conducted research with injured patients outweigh the risks to participants and institutions.

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.

This white paper introduces an overall approach and tools designed to support two processes: the proactive preparation of a plan for managing serious clinical adverse events, and the reactive emergency response of an organization that has no such plan.

Every day, clinical adverse events occur within our health care system, causing physical and psychological harm to one or more patients, their families, staff (including medical staff), the community, and the organization. In the crisis that often emerges, what differentiates organizations, positively or negatively, is their culture of safety, the role of the board of trustees and executive leadership, advanced planning for such an event, the balanced prioritization of the needs of the patient and family, staff, and organization, and how actions immediately and over time bring empathy, support, resolution, learning, and improvement. The risks of not responding to these adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the sending of mixed messages about what is really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.

The paper includes three tools for leaders (as appendices) — a Checklist, a Work Plan, and a Disclosure Culture Assessment Tool — and numerous resources to guide practice. The three tools are also included below as individual documents for ease of use.

The 2011 (second edition) update reflects a number of suggested improvements and clarifications, including new content on reimbursement and compensation as part of any discussion of disclosure and resolution, and disclosure of errors that have occurred at another institution, among other updates. Additional citations, resources, and examples from organizations mounting effective crisis responses are also included.

Dr. Jo Shapiro of Brigham and Women’s Hospital is interviewed about disclosure, peer support, and resilience following medical error on Ireland’s national public radio, RTÉ Radio 1 (July 9, 2017).

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.

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.