Tools and Resources[ Show all or clear results ]

The Joint Commission Journal on Quality and Patient Safety (2012) created a toolkit to help health care organizations implement support programs for clinicians suffering from the emotional impact of errors and adverse events. Based on the best available evidence related to the second victim experience, the toolkit consists of 10 modules, each with a series of specific action steps, references, and exemplars.


Journal Article
Published articles related to CRP
Legislation/Regulation/Other legislative
Laws relating to CRP
Organizational Policy
Organizational, institutional policy
How U.S. Teams advanced communication and resolution program adoption at local, state and national levels

This article explains the methods used by nine teams in their efforts to get hospitals to implement CRP, state legislators to pass state laws to encourage CRP adoption by hospitals, and national medical societies to endorse CRP to their members. It also identify reasons for the successes, failures, and obstacles faced by the teams in their effort to advance CRP.


Journal Article
Published articles related to CRP
Human error: models and management

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.

 


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.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Institute for Patient and Family-Centered Care

The Institute for Patient- and Family-Centered Care (IPFCC), a non-profit organization founded in 1992, takes pride in providing essential leadership to advance the understanding and practice of patient- and family-centered care. By promoting collaborative, empowering relationships among patients, families, and health care professionals, IPFCC facilitates patient- and family-centered change in all settings where individuals and families receive care and support.

Read more here.


Legislation/Regulation/Other legislative
Laws relating to CRP
Iowa Candor Statute

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


This article discusses that just culture is balance between holding organizations and individuals accountable for implementing safe practices and change in the workplace. This is especially important in healthcare settings to decrease patient mortality and increase patient safety. Benefits of fostering a just culture include increasing effective communication and innovation across various departments.


Sidney Dekker, PhD supervises the Safety Science Innovation Lab at Griffith University in Brisbane, Australia. In Dekker’s book, Just Culture: Restoring Trust and Accountability in Your Organization (3rd ed.), he discusses how to effectively create a just culture of accountability and responsibility. This includes learning strategies on how to appropriately approach adverse incidents such that knowledge is maximized and the negative effects are minimized.

 


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.

 

 


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.


Legislation/Regulation/Other legislative
Laws relating to CRP
LETTERS FROM THE POLICY COMMITTEE

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.

 


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.


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
MACRMI

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.


Journal Article
Published articles related to CRP
Legislation/Regulation/Other legislative
Laws relating to CRP
Malpractice Liability and Health Care Quality – A Review

Publish Date: January 28, 2020

A systematic review of 37 studies of malpractice deterrence  published between January 1, 1990, and November 25, 2019 was conducted to examine the association between malpractice liability risk and health care quality and safety. This review found that most studies suggest that higher risk of malpractice liability is not significantly associated with improved health care quality. The findings also suggested that greater tort liability was not associated with the improvement of quality of care.

 

 


Journal Article
Published articles related to CRP
Legislation/Regulation/Other legislative
Laws relating to CRP
Malpractice Liability and Quality of Care: Clear Answer, Remaining Questions

Publish Date: January 28, 2020

This issue presents a thorough and rigorous analysis of recent research and draws findings from 37 studies.  It conclude that increased liability exposure, such as numbers of malpractice claims or changes to state malpractice laws, was not associated with improvement in the quality of patient care.


Legislation/Regulation/Other legislative
Laws relating to CRP
Massachusetts Payment Reform Legislation

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


Learning Community
Resources associated with CAI Learning Community
Video
CRP related video, movie
Medical Error: A Case Based Approach to Apology and Disclosure Video – Brigham & Women’s Hospital

The video demonstrates how medical professionals can talk about medical errors with the care team, patients and their families. It includes two disclosure scenarios and didactic lecture on disclosure.

Key points:

  1. common emotional response
  2. preparing for the conversation
  3. the initial conversation
  4. avoiding common mistakes
  5. physician support

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.


The University of Michigan Health System (UMHS) systematically adopted the “open disclosure with offer” model, a principle-based strategy that emphasizes honesty and disclosure, to effectively respond to adverse patient outcomes and healthcare malpractices. When the UMHS adoped this model, there was a gradual reduction in litigation fees and the number of malpractice and patient harm claims.

 


Institution/Organization/Business
Reference to primary CRP related organization (e.g. CAI website)
Oregon Collaborative on Communication and Resolution Programs

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.


Legislation/Regulation/Other legislative
Laws relating to CRP
Oregon Resolution of Adverse Health Care Incidents Act

Oregon Resolution of Adverse Health Care Incidents Act (2013)


Communication-and-resolution programs (CRPs) are used by healthcare providers, administrators, and insurers to effectively communicate with and apologize to patients in the wake of adverse incidents; to investigate the occurrence; and offer compensation if appropriate. Researchers examined the effects of CRPs in two community hospitals and two academic medical centers in Massachusetts. They analyzed surveys and recorded data gathered by program members and clinicians at the hospitals. Researchers concluded, that CRPs are effective in increasing patient safety, but there were some barriers in implementing these programs. Barriers included lack of patient participation in disclosing data, as well as some compensation needs not being fulfilled.


Communication-and-resolution programs (CRPs) help healthcare providers and insurers effectively communication with patients when  medically adverse event occurs, as well as offer the necessary steps to take to give compensation. Researchers examined the effectiveness of CRP implementation in two Massachusetts hospitals. They concluded that, when the hospitals followed the CRP protocols, there were no drastic increases in liability fees associated with adverse health outcomes. Thus, CRPs helped these hospitals proactively handle adverse incidents and any related litigation fees.


Alberta Health Services (AHS) adopted the Patient and Family Centered Care (PFCC) program to increase patient and family engagement in the healthcare settings. The PFCC encourages and trains patients, families, and healthcare workers to share their experiences and improve care. This program also offers methods to measure the effectiveness of this program.

 


The COVID-19 pandemic has exacerbated well understood challenges that exist in our sophisticated health systems. This article discusses how to apply a human factors approach to best respond to the many unprecedented challenges that have been brought about by the COVID-19 pandemic to the healthcare system.