The Apology and Disclosure Grand Rounds NWH incorporates a video simulated error and a presentation about “When Things Go Wrong”. The presentation discusses disclosure coaching & peer support, the emotional impact of errors on clinicians, and principles for transparent & compassionate disclosure and apology.

The Collaborative for Accountability and Improvement’s CRP Attorney Alliance has developed a certification webinar for attorneys.

CRPs are the clear way of the future in terms of response following patient harm. Competency in this area is quickly becoming fundamental for all attorneys involved in the field of medical malpractice, including those working within the plaintiff and defense bars, in-house counsel/risk management, and third-party payors.

Jackie Ewuoso, MPH, PMP is a Senior Program Manager at the Betsy Lehman Center for Patient Safety where she manages peer support programs and other patient safety initiatives. She has several years of experience in community health addressing social determinants of health and working in chronic disease prevention. Before coming to the Betsy Lehman Center, Jackie was a public health prevention specialist at the Worcester Division of Public Health and the Central Massachusetts Public Health Alliance. In this position, she managed community health grants aimed at addressing chronic diseases by increasing access to healthy food and opportunities for physical activity. She coordinated projects and initiatives focused on policy, systems, and environmental change as a way to increase healthy eating and active living in the city of Worcester and six surrounding towns. Jackie holds a Master’s in Public Health from Boston University and a Bachelor of Arts in Psychology from the University of Ill

Linda Kenney, the Director of Peer Support Programs at the Betsy Lehman Center for Patient Safety, has had a personal experience with a near-fatal medical event many years ago. Linda identified the need for support services in cases of adverse medical events and outlined an agenda for change. For more than twenty years, she has been encouraging organizations to tackle the challenges that impair effective communication, apology, and support programs for patients, families, and clinicians following medical errors and unanticipated outcomes. Linda serves as a patient representative on numerous task forces and is on the board of the Massachusetts Coalition for the Prevention of Medical Errors.

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: February, 2021

Overview: COVID-19 has fundamentally altered our care processes and standards.  Care is being delayed, visits are happening by telemedicine, there are changes in how staff are deployed and interact with patients, and everyone is exhausted and emotionally depleted. These all make potential for patient harm events higher.  COVID-19 is also adding stress to already tightening medical professional liability insurance market. While it may be tempting to abandon ship when it comes to implementing CRP during COVID-19 times, CRPs are more important now than ever.  Fundamental principles of the CRP model-supporting patients, families, and clinicians after harm with open communication, empathy, learning, and accountability – are critical elements of how we respond to COVID-related harm events.  This webinar examines two cases of COVID-associated adverse events to help lead a discussion on the challenging aspects in implementing CRPs during this time.

Presenters: Michelle Mello, JD, PhD, and Thomas H. Gallagher, MD

Commentary by: Jeffrey Catalano, JD, Marcia Rhodes, Jonathan Steward, JD, MS, RN-BC, CEN, CPHRM

Learning Objectives: 

• Examine potential communication and legal issues associated with COVID-related harm events
• Describe how CRPs can be used as a strategy to address these COVID-related adverse events
• Learn about CRP resources to help address COVID-related challenges

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: September 15, 2022

Presenters: Melinda B. Van Niel, MBA, CPHRM

Melinda B. Van Niel, M.B.A., C.P.H.R.M., has been working to help resolve adverse events through Communication Apology and Resolution (CARe) for ten years. She is the Director of CARe programs at the Betsy Lehman Center for Patient Safety in Massachusetts (formerly MACRMI) leading its implementation team, and consults on CARe implementation for institutions across the country. In the past she worked as the Manager of Patient Safety at Beth Israel Deaconess Medical Center in the department Healthcare Quality where she helped build one of the first CARe programs in the state, and was a contributor and advisor to the AHRQ’s CANDOR Toolkit. Ms. Van Niel received her Bachelor of Arts degree from Harvard University and her Master’s in Business Administration from Villanova University with a concentration in healthcare management.

Join Dr. Daniel B. Kramer, MD, MPH, at Harvard Medical School

Learning Objectives:

1. To understand potential clinical manifestations of medical device malfunction

2. To review opportunities to communicate known and emerging risks related to medical device use with patients

3. To explore financial and ethical responsibilities of different stakeholders when patients experience harm from medical device malfunction

Webinar Date: September 23, 2021

Presenters: 

• Alan Lembitz, MD, MMM, Chief Medical Officer, COPIC
• Eric Wei, MD, MBA Senior Vice President and Chief Quality Officer, NYC Health + Hospitals
• Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation

Learning Objectives:

• Understand the importance of physician involvement in the CRP process and how it helps both physicians and patients
• Examine the benefits of CRPs to physicians
• Explore the barriers to CRP implementation from a provider’s perspective
• Learn why psychological safety a critical component of provider support

Webinar Date: May 20, 2021

Moderator:

• Barbara Pelletreau, RN, MPH, Senior Vice President, Patient Safety, CommonSpirit Health

Speaker Panel:

• Claire Hagan, MJ, CPHRM Director of Risk Management Programs, Providence St. Joseph Health
• Brittnie Hayes, JD, Claims Manager, COPIC
• Linda Ubaldi, RN, CANDOR Training Specialist and Former Quality and Patient Safety Officer, CommonSpirit Health

Learning Objectives:

• Learn practical advice from “claims professionals” on how to transition a CRP case to claims
• Describe several of the key components for an ideal partnership and transition to claims from the perspectives of health systems, insurers, and patients and families
• Understand the needs of patients and families, and how and when to appropriately engage them, in this transition to “claims process”

Webinar Date: June 17, 2021

Presenters: Jonathan D. Stewart, JD, MS, RN-BC, CPHRM

Jonathan is a Senior Director of Risk Management and Patient Safety at BETA Healthcare Group, where he serves as a consultant to hospitals, health care facilities and medical groups. His current professional focus includes helping health care organizations operationalize communication and resolution programs, particularly the investigation and analysis of patient harm events.

Objectives:

• Identify conflicting notions of success and failure regarding CRPs
• Discuss the relationship between incomplete CRP implementation and irregular application of CRPs
• Describe lessons learned from unsuccessful applications of CRPs to individual events

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: November 17, 2022

Presenters: Lauge Sokol-Hessner, MD, CPPS

Lauge Sokol-Hessner, MD, CPPS is a hospitalist, Clinical Associate Professor of Medicine at the University of Washington, QI Mentor at the UW Medicine Center for Scholarship in Patient Care Quality and Safety, speaker and consultant for the Institute for Healthcare Improvement, and a guest speaker for the Harvard Medical School Masters in Healthcare Quality and Safety (HMS MHQS). He has experience in operational quality & safety, developing leaders in quality & safety, teaching communication skills, coaching health care organizations to implement highly-reliable CRP programs, and he champions patient and family engagement, ethics, humanism, equity, and respect in health care. He completed medical school and residency at the University of Pennsylvania.

Webinar Date: October 21,2021

Moderator

• Carole Hemmelgarn, MS, MS

Speaker Panel

• Jack and Teresa Gentry
• Naomi Kirtner and Jeff Goldenberg, MD

Learning Objectives

• Understand what elements are important for patients and families to hear after medical harm
• Compare and contrast patient experiences with and without a Communication and Resolution Program (CRP) following harm
• Explain the importance of a highly reliable CRP for patients and families

Webinar Date: October 12, 2022

Presenter: WilliamM.  Sage, MD, JD

William M. Sage, MD, JD, an authority on health law and policy, is a tenured professor in Texas A&M’s medical and law schools, a professor by courtesy in the Bush School of Government and Public Service at Texas A&M, and a vice president in the university’s Health Science Center.   From 2006-2022, he held professorships in law and medicine at the University of Texas at Austin, where he also served as vice provost for health affairs.  He was previously a tenured professor at Columbia Law School, and has been a visiting professor at Yale, Harvard and NYU.  Prof. Sage is a member of the National Academy of Medicine, where he serves on the Board on Health Care Services and recently served on the Committee on the Future of Nursing 2020-2030.  Prof. Sage is a member of the Healthcare System and Value Research (HSVR) study section for the Agency for Healthcare Research and Quality (AHRQ), an elected Fellow of the Hastings Center on bioethics, and a longtime editorial board member of the journal Health Affairs.  He has written over 200 articles and has authored or edited four books, including the Oxford Handbook of U.S. Health Law (2016).  He holds an undergraduate degree from Harvard College, medical and law degrees from Stanford University, and an honorary doctorate from Universite Paris Descartes.

Webinar Date: July 15, 2021

Presenters: 

• Jo Shapiro, MD, FACS, Associate professor of Otolaryngology-Head and Neck Surgery at Harvard Medical School; Principle Faculty for the Center for Medical Simulation in Boston; Consultant for the Massachusetts General Hospital Department of Anesthesia, Pain and Critical Care
• Allan Frankel, MD, Chief Executive Officer, Safe & Reliable Healthcare

Learning Objectives:

• Identify conflicting notions of success and failure regarding CRPs
• Discuss the relationship between incomplete CRP implementation and irregular application of CRPs
• Describe lessons learned from unsuccessful applications of CRPs to individual events

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: December 17, 2020

Presenter: Julianne Morath, RN, MS, CPPS, Founding member of the Lucian Leape Institute of the National Patient Safety Foundation

Objectives:

1.  Define the term precondition and its relevance to Transparency

2. Identify at least two reasons to embrace transparency

3. Identify at least three levels of transparency

4. Demonstrate an understanding of why being transparent is so difficult

Webinar Date: April 15, 2021

Presenters:

• Suz Schrandt, JD,  Senior Patient Engagement Advisor, Society to Improve Diagnosis in Medicine; Founder, CEO, & Chief Patient Advocate at ExPPect
• Eric J. Thomas, MD, MPH Associate Dean for Healthcare Quality, McGovern Medical School, University of Texas Health Science Center at Houston; Board President, Collaborative for Accountability and Improvement

Objectives:

• Understand the individual and system factors that can cause diagnostic errors
• Explore the benefits of a CRP response following a diagnostic error
• Examine the consequences of a poor response to a diagnostic error
• Understand the importance of engaging, listening, and learning from patients and families following diagnostic errors

Webinar Date: October 22, 2020

Dr. Urmimala Sarkar discusses healthcare disparities and specific challenges to adverse event communication among diverse populations within the CANDOR process.

Presenter: Urmimala Sarkar MD, MPH, Professor of Medicine at UCSF in the Division of General Internal Medicine, Associate Director of the UCSF Center for Vulnerable Populations, and primary care physician at Zuckerberg San Francisco General Hospital’s Richard H. Fine People’s Clinic

Objectives: 

• Examine disparities in healthcare and which populations are more likely to experience lower quality healthcare and adverse events
• Delineate how low-income, limited literacy, racially/ethnically diverse populations may experience the response to adverse events differently
• Characterize specific challenges for adverse event communication among diverse populations
• Identify best practices from lived experience among risk management professionals for communicating across differences in the aftermath of adverse events

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.

Challenging Conversations with Patients and Families presented by Dr. Tim McDonald

Communicating with patients and families following unexpected patient harm can be challenging even in optimal conditions; it is a learned skill. Taking into consideration factors such as socio-economic status, religion, cultural preferences, marital status, sexual orientation and gender identity is important to communicating effectively. This webinar covers methods successfully employed by healthcare institutions to recognize, plan for, and communicate effectively in complex situations and with special groups.

Learning Objectives

After completing this webinar, attendees will be able to…

1. Demonstrate recognition of situations that require advanced techniques for communicating unexpected patient outcomes;

2. Utilize communication enactments in conducting ongoing training in these complex situations within their organizations.

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

CRPs: Why the insurance industry hasn’t embraced them . . . and why it should presented by Richard Boothman, JD

The driving ideas behind CRPs continue to draw interest and debate, now twenty years after Steve Kraman and Ginny Hamm published their Lexington, KY VA experience with “Extreme Honesty”.  After more than 17 years, the University of Michigan continues to draw attention transparent with their “Michigan Model”, the most successful and longest continual example of a principled, and proactive approach to patients injured in unexpected clinical outcomes.  After years of balking at abandoning “deny and defend” more health systems around the country and around the world are exploring the transition, but a skeptical insurance industry continues to hold back and sometimes, frustrate the desires of their insureds to move in this direction.  Why?  Is the industry’s skepticism well-founded and prudent?  Or is it missing a valuable opportunity?

Rick Boothman, the architect of the “Michigan Model” will initiate a long-deserved discussion into this topic.  His experience suggests that there are multiple insurance advantages in the CRP approach and the insurance industry should rethink old beliefs, practices and prejudices and embrace this model.

Outline

1. Insurance 101 – a dummy’s guide to the construct
2. True CRPs – the essential elements and how the model differs from “deny and defend”
3. What holds the insurance industry back from jumping on board?
4. What is the insurance industry missing and why should it matter?

Learning Objectives

• That too many equate CRPs only with selective, early resolution of potential and asserted claims – what are the essential elements that distinguish a true CRP from established, traditional risk management practices?
• What are the unique outcomes of a CRP and why do they matter?
• Why a CRP better serves the interests of healthcare insureds?
• What unique consequences of a CRP would benefit the insurance industry especially?

Webinar Date: September 17, 2020

Dr. Gordon Schiff talks about diagnostic error and how efforts to reduce diagnostic error align with the principles of communication and resolution programs.

Presenter: Dr. Gordon Schiff (Brigham and Women’s Center for Patient Safety Research and Practice, Harvard Medical School)

Objectives: 

1. Describe the frequency/epidemiology of diagnostic errors based on published studies and surveys.
2. Define diagnosis errors, and using a Venn diagram model differentiate diagnostic process errors, misdiagnosis, and adverse outcomes.
3. List 3 approaches to minimizing and preventing diagnostic errors.
4. Explain ways that missed/under diagnosis and overdiagnosis are related rather than just opposites
5. Describe overlapping and synergistic domains between the diagnostic error/improvement movement andCommunication and Resolution Program (CRP) efforts.

Large Scale Implementation of Communication and Resolution Programs

Presented by: Heather Gocke, M.S., RNC-OB, CPHRM, C-EFM

Webinar Date: January 29, 2020

Ms. Gocke introduces a comprehensive program and a holistic approach in reducing harm in healthcare through large scale implementation of CRP. In her presentation, she highlights the importance of disclosure and engagement, and she shares real-life challenges and secrets to success.

Learning Objectives:

1. Outline the method used to engage member sites in culture transformation
2. Learn  how culture measurement, survey data debriefs, and cognitive interviewing techniques are used to inform this body of work
3. Introduce the five domains and components of BETA HEART