EXECUTIVE SUMMARY
A small but growing number of health systems are implementing communication and resolution programs (CRP) to address adverse events that lead to patient harm. Experts note the approach involves a move away from a culture of deny and defend toward more openness and transparency with patients, families, and caregivers.
- A high-functioning CRP includes several elements ranging from early incident reporting and communication with patients and families to financial resolution (when warranted) and comfort for caregivers involved.
- Experts note that the biggest threat to the CRP field is the fact that many organizations are not implementing the model consistently, leaving patients and providers less likely to benefit from the process.
- Putting a CRP in place requires new infrastructure, support from leadership, and the right level of expertise within the organization. This ensures clinicians are equipped with appropriate guidance, and the conversations between providers and patients meet expectations.
- While CRPs are in development, experts maintain that progress would accelerate if people would think about transparency more broadly, including the multiple benefits it provides and its intrinsic value.
One of the most difficult and wrenching experiences that providers encounter is when patients are harmed while receiving care and treatment. It may not be immediately clear what caused the harm, but providers often are unsure what to communicate to patients and families, and they may be fearful of litigation. Indeed, some experts in the field of risk management maintain that many of the typical responses to patient harm, such as a lack of transparency, not only hurt patients and families, but also the caregivers themselves.
To address the issue, there is a growing movement away from what some refer to as a culture of deny and defend toward a more open and proactive approach to adverse events. Typically, such approaches are called communication and resolution programs (CRPs), and they have been adopted by more than 100 U.S. hospitals thus far. Some high-profile programs have reported good outcomes, including lower costs related to liability.
But what are CRPs and how do they work? These questions were addressed in a presentation sponsored by the Institute for Healthcare Improvement (IHI) on April 18. The program, “What’s an Apology Worth? The Case for Communication and Resolution,” included a review of the state of CRP adoption to date, best practices in the field, and some advice on how healthcare organizations can move toward more transparency in their handling of adverse events.
Thomas Gallagher, MD, is a general internist, professor of medicine, and the associate chair for patient care quality, safety, and value at the University of Washington (UW). He also serves as the executive director of the Collaborative for Accountability and Improvement, an organization at UW that focuses on advancing the spread of CRPs. During the IHI presentation in April, he maintained that while advances have been made since the groundbreaking “Too Err is Human: Building a Safer Health System” report was unveiled by the Institute of Medicine in 1999, there has been much less progress than many leaders in the field had hoped.
“My sense is that the primary root cause for that lack of progress is that when something goes wrong in healthcare, when we harm patients, we are not always transparent and we are not always learning,” he said. “It is not that we don’t want to be transparent. It is not that we don’t want to learn. It is that we don’t have the mechanism in place to make sure [those things] are happening as reliably as [they] should.”
While there has been a lot of focus on how and when to apologize to patients when errors have caused harm, Gallagher noted that an apology is not sufficient.
“What we are learning in the field is that by itself, an apology is not worth a lot,” he said. “What patients and families want is a much more robust response. That is what a communication and resolution program involves.”
Gallagher estimated that roughly 8% to 10% of harm events are due to an error or system failure. He noted that in these cases, there should be a proactive offer of financial compensation rather than requiring that patients and families resort to using the traditional malpractice system to obtain compensation. In addition, in these instances when patient harm occurs, Gallagher noted that “care for the caregiver” needs to be integral to the program and offered immediately.
“When I have been involved in serious harm events in my career, more often than not I just put my head down and moved on to the next patient,” he shared. “We know that is not only not good for the healthcare worker ... there are clear data [showing] that healthcare workers’ unmet need for distress after adverse events predisposes them to making more errors.” Through all the various elements of the CRP system, it is vital that patients and families are involved, Gallagher stressed. Further, he noted that every element is an integral part of the process, beginning with early incident reporting and going all the way through to patient and family engagement.
“It is important that [people] think of [CRPs] as comprehensive and systemic programs both for preventing as well as responding to adverse events,” he explained. “The different elements are hardwired to work with one another.”
While there is increasing uptake of CRP-styled approaches across the country, Gallagher noted that the biggest threat to the field is the fact that many organizations are not implementing the model consistently. “Either they are using it for some cases and not for others, or they use some elements of the CRP approach, but not the whole model, most often choosing not to offer proactively financial compensation when that would be warranted,” he said.
The inconsistent implementation of a CRP is a problem for multiple reasons. For instance, Gallagher noted that patients, families, and caregivers are less likely to benefit from such an approach. Furthermore, this inconsistent implementation creates skeptics who view CRPs as nothing more than sophisticated claims management efforts.
“We really have to figure out how to overcome this inconsistent implementation by making these programs hardwired and by developing the performance improvement tools to track them effectively,” Gallagher added.
Allen Kachalia, MD, JD, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins and another participant in the IHI April presentation, explained that in the context of a CRP, there are many elements that go into communicating effectively with patients and families.
“We are not just talking about simple conversations that occur,” he said. “It turns out that to do this right, there is a lot that has to happen in a very timely fashion, which means that after a patient is harmed, whether or not there is an error, we have to make sure that there is timely and meaningful communication.”
For instance, Kachalia noted that the investigation that follows has to be expeditious.
“We can’t take months to sort this out. Of course, once we figure out what happened, it is important to provide an explanation to the family and patients as well as emotional support,” he said. “[This is] not just the patients and families, but also to all the providers who were involved.”
For the process to work well, the health system needs to figure out what went wrong and also how to make it right. This can become complicated, considering the number of providers and healthcare workers who may be involved.
“You can imagine an example where a patient is admitted to a medical service for some sort of medical problem and ends up going to surgery ... and after coming out of surgery, the patient is found to have had a really bad post-operative complication,” Kachalia shared. “Now, you’ve got a whole host of providers who are involved, from the medical team to the surgical team to the anesthesia team to the nurses ... and we know that at this point if something goes wrong, there needs to be clear communication with the family.”
However, all providers may not understand what happened. They also may be reluctant to throw a colleague under the bus, Kachalia related. “As a result, they may be simply afraid to talk with the family because they don’t know what to say given how difficult the situation is,” he said.
How should one handle this situation? “This is a classic example of where you need coordination and support from your organization to make sure that all the providers know there will be communication,” Kachalia said. “[There need to be] people who help guide these sensitive and thoughtful conversations with the family and provide support to everyone involved.”
Putting this type of system in place requires new infrastructure, support from leadership, and the right level of expertise within the organization. But once in place, this system will help clinicians learn the appropriate guidance and ensure conversations between providers and patients meet expectations, Kachalia advised.
Certainly, it is a challenge to overcome the traditional culture in America around how health systems consider errors, the courts, and lawsuits, Kachalia acknowledged. “The general approach has been what we call deny and defend, which is when something goes wrong, we have our courts there as a place to sort out the truth,” he explained. “Many systems have been built ... so that if there is a claim brought, [they] will say no, they haven’t erred. Let’s see what happens in court.”
Alternatively, the CRP approach is to come together, figure out what happened, and then assess what the resolution needs to be. It is a more practical approach, to be sure, but it requires bringing insurance companies on board as well, Kachalia noted.
A big concern for providers is how a CRP-style approach will affect liability. There are not a lot of comparison data on this issue, but Kachalia pointed to what happened at the University of Michigan Health System (UMHS) when it implemented a CRP in 2001.1 “When we looked at their results about 10 years later, what we saw was that when you compare before to after, they actually had a 36% drop in the amount of money that they were paying to their lawyers, about a 60% drop in defense costs,” Kachalia shared. “They also saw a 60% drop in compensation costs. Again, this drop occurred despite the fact that they were telling people [when they made a medical error] and offering them compensation.”
A closer look at the data revealed that instead of paying larger settlement amounts in lawsuits, the health system was paying smaller amounts because they were settling these cases much more quickly, which was better for everyone involved, Kachalia noted.
Since the experience of UMHS, other health systems have produced similar results. For example, in Massachusetts, an observational study offered a comparison of hospitals that implemented CRPs and those that did not over the same period.2 “What we found was that a site that did not implement a CRP really found no changes in its liability trends with regard to claims, the amount of compensation being paid out, and defense costs,” Kachalia said. However, investigators found that community hospitals that implemented CRPs saw a lower rate of new claims, along with one of the two academic medical centers. (Both academic medical centers saw lower defense costs, Kachalia noted.) “Doing the right thing, owning your mistakes, and sitting down and proactively resolving with patients, can result in better liability outcomes and, at worst, leave them the same,” he said.
Beyond these data, work is underway on a set of CRP metrics that healthcare organizations can use to measure performance. “We want the metrics to be able to support high-functioning CRPs, not only for internal improvement in the short run, but down the road for external accountability,” Gallagher shared. “We developed the metrics from looking at the literature, doing a lot of interviews, and [convening] an expert panel.” Gallagher added that the metrics relate to three domains:
- How to define a CRP event, determine how many events are eligible for CRP, and describe the CRP culture;
- An outline of the steps involved with CRP and where these steps are followed;
- Outcomes related to quality and safety litigation and the experience of the participants.
“We are at the stage now where we are starting to pilot test [the metrics]. After that, we will develop an implementation guide,” Gallagher said. “Then, they will go through another round of extensive pilot testing.”
While CRP development work is ongoing, Gallagher noted that progress would accelerate if people in the healthcare community think about transparency more broadly. “Transparency when something goes wrong has multiple benefits,” he observed. “It is an important part of promoting autonomy and respect for patients; there is some deterrent effect potentially; it is clearly what the patient and the public expect; and it is aligned with regulatory requirements.”
While transparency is associated with benefits, people should be thinking of it more as an instrumental value for its own sake. “It serves the greater good,” Gallagher said. “We are not trying to be open for its own sake, we are trying to be open because openness advances quality, safety, and patient centeredness of care.”
Openness goes beyond just sharing information with patients and families. It involves making it easier for patients and families to bring their own concerns forward, Gallagher explained. “In our research, we found up to 40% of hospitalized patients think something has gone wrong in their care, but only 10% let us know,” he said. “Why not? Because they worry if they raise their hand it may adversely affect their care.” Healthcare organizations should be thinking about how they can make it easier for peers to speak up and share concerns when something has gone wrong, Gallagher observed. “We need to start thinking about these things as a bundle ... and really go through the benefit of considering these as linked practices,” he explained.
Gallagher acknowledged that this work will require considerable time, resources, and attention. Organizations will have to make an investment to execute it well. “Think about how to take improvement practices that have been so helpful in other domains of healthcare delivery. Start applying them to the practice of being open and promoting quality, safety, and patient experience when something has gone wrong,” he said.
REFERENCES
- Kachalia A, Kaufman SR, Boothman R, et al. Does admitting mistakes to patients lead to more lawsuits? Ann Intern Med 2010;153:1-28.
- Kachalia A, Sands K, Van Niel M, et al. Effects of a communication-and-resolution program on hospitals’ malpractice claims and costs. Health Aff 2018;37:1836-1844.
SOURCES
- Thomas Gallagher, MD, General Internist, Professor of Medicine and Associate Chair for Patient Care Quality, Safety and Value, University of Washington, Seattle; Executive Director, Collaborative for Accountability and Improvement, Seattle. Email: [email protected].
- Allen Kachalia, MD, JD, Senior Vice President, Patient Safety and Quality, Director, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore. Email: [email protected].
Elements of a High-Functioning CRP
There are several integrated elements that characterize a well-crafted CRP, including the following:
- Early incident reporting by clinicians;
- Open and ongoing communications with patients and families;
- Event analysis;
- Quality improvement;
- Financial resolution when warranted;
- Comfort for caregivers;
- Extensive patient and family involvement.
Additional Resources
For more information about CRPs, consider the following resources:
- The Collaborative for Accountability and Improvement: http://bit.ly/2IHfA2i.
- Agency for Healthcare Research and Quality. Communication and Optimal Resolution (CANDOR) Toolkit: http://bit.ly/2ZAtUPx.
- Massachusetts Alliance for Communication and Resolution Following Medical Injury (MACRMI): http://bit.ly/2UBqVTa.
A small but growing number of health systems are implementing communication and resolution programs (CRP) to address adverse events that lead to patient harm. Experts note the approach involves a move away from a culture of deny and defend toward more openness and transparency with patients, families, and caregivers.
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