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.

“Annie’s Story” is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system’s approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. This video specifically focused on Nurse Andrea’s personal experience with an adverse health event with a patient who underwent a hypoglycemic emergency due to a misreading of a glucometer. The video then details the steps she and the hospital took to prevent future adverse health events, as well as other ways to increase overall patient safety and quality.

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.

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: 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: 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

The Communication and Optimal Resolution (CANDOR) process is a patient-centered approach used by health care institutions and practitioners to respond in a timely, thorough, and just way when unexpected patient harm events occur. It focuses on early disclosure of adverse events and a proactive method to achieving an amicable resolution for the patient/family and health care providers.

The video demonstrates an example of the care team’s disclosure meeting conversation with the affected family.

Discerning complicated approach of ethics and professionalism in medicine can be difficult. It’s similarly challenging when clinicians have to navigate through clinical or relational situation and develop an understanding of ethical, legal and more issues.

The Case Files consist of carefully crafted cases designed to stimulate proper approach and decision-making process. Case 18 focuses on transparent and compassionate disclosure and apology, and recognizing emotional challenged clinicians may face after an adverse event.

The Sweet Law Firm in Oklahoma City, one of the Collaborative for Accountability and Improvement’s partners in promoting the spread of CRPs, has developed a COVID-19 Consent for Treatment/Procedure/Surgery form.

2020-04-24 Proposed COVID-19 Consent Form (Final)

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.

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

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

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 video includes three scenarios to demonstrate how different approaches to disclosure can have an effect on the course of communication with a patient’s loved one.

Disclosure Scenarios:

1. Disclosure with No Apology
2. Disclosure with Apology of Sympathy
3. Disclosure with Apology or Responsibility

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.

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.

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.

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

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.

Marx discusses uses a legal viewpoint to discuss how to be more tolerant of errors in the workplace, while also holding people accountable for their mistakes. He outlines four important behavior concepts, and how they can be applied to the healthcare system to decrease risk of adverse events and increase accountability: malpractice, understanding violations, ignorance, and mishaps.

The Medical Event Reporting System for Transfusion Medicine published the “Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives” report, which consists of collected data and analyses on transfusion medicine practices and other related errors. This report also serves as a guide for healthcare administrators, human resource manages, and lawyers to understand current policies and how to successfully implement new investigating and reporting systems that acknowledge human errors and promote overall safety in the workplace.

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.

This is a tip sheet for healthcare leaders about how to create an environment for CRP to succeed.

Serious Illness Care Program COVID-19 Response Toolkit by Ariadne Labs, first version was published on April 3, 2020.

Ariadne Labs, one of Collaborative for Accountability and Improvement’s partners in cultivating high-quality, patient-centered care, has developed the Serious Illness Care Program’s COVID-19 Response Toolkit to help clinicians with difficult conversations with high risk COVID-19 patients.

Table of Contents: 

1. COVID-19 Conversation Guide for Outpatient Care
2. Telehealth Communication Tips
3. Recommendation Aid
4. Care Planning Resources

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.

The Charter on Medical Professionalism, endorsed by the US Accreditation Council for Graduate Medical Education, requires physicians to engage in honest communication with their patients, especially regarding risks and benefits regarding medical procedures. However, researchers found that not all physicians abided by these rules which raises the concern that physicians may not fully disclose pertinent information with their patients, so they do not receive complete information. Honest communication between patients and their physicians is associated with patient comfort and willingness to move forward in medical procedures.

This article describes recommendations that extend existing guidelines for clinicians and institutions on communicating with patients about colleagues’ harmful errors.

Dr. Shapiro talks about the importance of having disclosure coaching program and fundamental principles of disclosure coaching. For more videos related to Disclosure and Apology, view the video gallery.

The Medstar’s Patient Safety and Quality Program included this video in their patient safety and care program. This video illustrates the story of Michael Skolnik, who lost his life due to medical malpractice. The error involved the surgeon not being completely transparent with the patient or his family about the surgical procedure. This video emphasizes the importance of shared decision making between patients, families, and physicians to avoid future adverse medical outcomes, especially ones in which lives are lost.

In this narrative medicine essay, an internist asks the doctors who for 5 months could not diagnose her son’s agonizing illness to apologize and, when most could not, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologize as essential to the healing process.