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.

The Communication and Optimal Resolution (CANDOR) process is used  by health care institutions and practitioners to respond in a timely, thorough, and just way when unexpected events cause patient harm. The CANDOR toolkit contains eight different modules, which contain PowerPoint slides with facilitator notes, tools, resources, or videos. Examples of modules include “Care for the Caregiver” and “Organizational Learning and Stability.” These modules focus on effective ways to reduce patient harm and increase overall healthcare quality and safety through family and patient engagement, as well as specific ways to decrease the risk of future adverse outcomes.

Webinar Date: June 24, 2021

Presenters:

Objectives:

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.

Webinar presented by Dr. Tom Gallagher on Thursday, June 6, 2019

Large-scale adverse events, situations in which a breakdown in care has affected multiple (sometimes thousands) of patients, pose significant challenges for institutions related to responding in ways that inform potentially affected patients without unduly alarming them and managing the follow-up. This webinar will highlight lessons learned from the field around responding effectively to adverse events, as well as key unanswered questions.

Learning objectives:

1. Describe the diversity of large-scale adverse events, and how responding to these events differs from managing adverse events that affect individual patients
2. List the key elements of an effective response to a large-scale adverse events and the tools that are currently available to assist with this process
3. Critique an actual large-scale adverse event patient notification letter and press release, and articulate opportunities for improvement in these documents.

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.

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.

Despite the obvious need for open conversations with patients and their families following an adverse event, many organizations still lack the structure to support providers during this difficult time. In many cases, clinicians who have to disclose errors to patients and families fail due to lack of provider education and training, lack of confidence, fears of litigation and emotional distress.

The Ask-Tell-Ask Model focuses on successful disclosure coaching conversations. It includes:

1. Case Scenario
2. Key elements
3. Practical step-by-step strategies for disclosure coaching
4. Pedagogical model using the “Ask-Tell-Ask” approach
5. Organizational considerations for establishing a coaching program

This video focuses on principles and skills for effective disclosure conversations, especially around delayed cancer diagnosis, and includes a case example.

Early Discussion & Resolution (EDR) Conversation Guidance from Oregon Patient Safety Commission offers general guidance that can serve as a foundation in initiating conversations and follow ups.

An adverse event can gravely affect both patients and their families and providers. Having a conversation between healthcare providers and patients about the incident can bring resolution and closure.

Goals of EDR from Oregon Patient Safety Commission:

1. Prevent an unfortunate situation from escalating
2. Restore the keystone of healthcare—the provider-patient relationship
3. Bring greater peace of mind to everyone
4. Learn from events to improve patient safety

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.

In April 2012, Glenn Clarkson died after a medical error at a rural Kansas hospital. Melissa and Nancy Clarkson describe the three-and-a-half-years of work it took for them to learn what happened in his medical care. Filmed at the Communication and Resolution Program (CRP) Training.

The Virtual Lecture Hall offers a two-hour course called Human Side of Medical Errors, which will effectively teach participants how to make ethical decisions when providing medical services to colleagues or loved ones, as well as how to constructively respond to a patient’s emotional reaction after they were involved an adverse incident.

The Foundation for Health Care Quality is a Seattle-based nonprofit foundation that offers third party sources to everyone involved in healthcare, including physicians, patients, government organizations, and payers. The institution offers various resources to promote healthcare quality and patient care, such as assessment and communication-and-resolution (CPP) programs.