Best Practices in
Communication and
Resolution Programs
Thomas H. Gallagher, MD
Professor of Medicine, Bioethics & Humanities
Director, UW Medicine Center for Scholarship in Patient Care Quality & Safety
Director, Program in Hospital Medicine
University of Washington
Change
Readiness
Assessment
Investigation
and
Process
Improvement
Resolution
Gap Analysis
Reporting
Communication
Caring for
the Caregiver
AHRQ CRP Toolkit Content: Modules
• Change Readiness Assessment
• Gap Analysis
• Incident Reporting
• Investigation and Process Improvement
• Communication
• Caring for the Caregiver
• Measurement and Evaluation
3
Example: HealthPact DRP
Study
Event
(SE)
•
Care team responds to immediate patient needs
and provides information then known
•
Involved staff reports SE to Risk Manager
Study
Event
(SE)
Action by
Facility
Risk Manager
•
Initiates QI investigation using Just Culture
approach
•
Initiates support services for patient/family
•
Initiates disclosure coaching and other support
services for healthcare team
•
Contacts other Partners to explain SE and steps
taken and initiates collaboration
Physicians
Insurance
Study
Event
(SE)
Action by
Facility
Risk Manager
Facility
Insurer
Other
Insurer
Partners collaborate on approach to evaluation and
resolution
Physicians
Insurance
Study
Event
(SE)
Action by
Facility
Risk Manager
Facility
Insurer
Other
Insurer
Expedited
Care
Assessment
and Review
of Event
(CARE)
Partners and involved providers decide on effective
approach and timeline for CARE, including internal
and/or external expert review to determine:
•
Whether care was reasonable
•
Whether system improvements are needed to
prevent recurrence
•
Whether other actions are warranted
Physicians
Insurance
Study
Event
(SE)
Action by
Facility
Risk Manager
Facility
Insurer
Other
Insurer
Expedited
Care
Assessment
and Review
of Event
(CARE)
Joint Approach
to Resolution
Partners agree on approach to resolution:
• What are the patient’s/family’s needs?
• Will monetary compensation or other remedies be
offered?
• What will be disclosed to patient/family?
• How will identified system improvements be
pursued?
Physicians
Insurance
Study
Event
(SE)
Action by
Facility
Risk Manager
Facility
Insurer
Other
Insurer
Expedited
Care
Assessment
and Review
of Event
(CARE)
Joint Approach
to Resolution
Patient/family is notified of findings and approach to
resolution:
• Full explanation of what happened
• Apology as appropriate
• Offer of compensation and/or other remedies, or
explanation of why no offer is being made
• Information about any safety improvements
Patient/Family
Communication
Importance of having a “Just Culture”
Epistemological Problems
• The plural of “anecdote” is not “data”
• Time-horizon problem
• Small-numbers problem
• Potential confounding, especially regarding safety
improvement
• Variations in program design and implementation
across sites
University of Michigan Health System
(Pre/post analysis, 1995-2000 vs. 2001-2007)
• Average monthly rate of new claims: 7.03  4.52 per
100,000 patient encounters (p<0.05)
• Average monthly rate of new lawsuits: 2.13  0.75 (p<0.01)
• Average rate of claims not resulting in lawsuit: No sig. change
• Median time from claim reporting to resolution:
1.36  0.95 years (p<0.01)
Source: Kachalia et al., Ann Intern Med 2010
University of Michigan, continued
• Liability costs (mean and median) decreased significantly
• Patient compensation costs decreased significantly for
lawsuits and overall
• Average payout per lawsuit: $405,921 vs. $228,208 (p<0.01)
• Costs did not change significantly for non-lawsuit claims
• Legal expenses decreased significantly overall (p<0.01)
• Compare: in 2001-2007, other Michigan insurers had:
• Lower proportion of paid claims (24% vs. 43%)
• Increasing legal costs
• Flat compensation costs
Source: Kachalia et al., Ann Intern Med 2010
Seven Pillars Program
• University of Illinois Chicago reports:
• Increase in patient safety event reporting from 1,500
to 7,500 per year
• 50% reduction in new claims
• Reduction in median time to resolution from 55 to 12
months
Source: UIC communication to AHRQ, 2012.
PEARL Program
• Stanford University Medical Indemnity and Trust
reports:
• 36% drop in claim frequency in first 3 ½ years of
program compared with 2 previous years
• $3.2 million (32%) average annual reduction in
premiums paid for the retained layer of losses (the
largest component of total premiums)
Source: Independent actuary’s analysis of 2007-2007 data on 50 PEARL cases, reported in Institute for
Healthcare Improvement, Respectful Management of Serious Clinical Adverse Events (2011).
Implementation Experiences
• Washington
• New York
• Massachusetts
Meeting Stakeholders Where They
Are
• Fears and concerns of different stakeholders
• Vary considerably
• May not be explicitly articulated
• Potential of catastrophic outcome can loom large
• Reflect past and current challenges with
dysfunctional liability system
• Form a semi-coherent narrative for that
stakeholder about how world works
• Most stakeholders recognize current system is
highly dysfunctional and desire change
• But worry that things could get worse not better
Prepare for “We Already Do This”
• Most organizations consider themselves principled
• Selective use of CRP concept is the norm
• Organization can point to individual case(s) where
they used CRP approach
• Cases in which CRP approach not used in
organization’s mind reflect problem with case
itself, not their application of CRP concept
• Gentle use of hypothetical cases can help uncover
situations in which institution not currently using
CRP approach
Passive Resistance
• Who isn’t in favor of telling patients the
truth and compensating them when a
serious error has harmed them?
• Need to make it easy for concerned
stakeholders to share their fears
• Passive resistance usually emerges
late, as implementation is just starting
Bandwidth
• Assume all key CandOR implementers
are at 120% capacity with current
responsibilities
• Acknowledge that CandOR will involve
additional work
• Provide new FTE
• If you are adding to individual’s current
responsibilities, need to subtract
• Ensure that CandOR makes it easier for
folks to accomplish existing workload
Lessons from the Field
• It’s not business as usual
• CandOR is quality/safety program, not
risk management initiative
• Local adaptation is key
• Multiple, visible champions
• CandOR will rise/fall around clinician
engagement
More Lessons
• Bandwidth challenges must be addressed
directly
• Culture change is slow, painstaking process
• Some, not all, results will be felt immediately
• Don’t let difficulty of culture change become
excuse for incomplete implementation
• Process must be trustworthy
• Metrics can help drive implementation
• Needs to be principled approach
• Especially for those cases that are hard,
embarrassing, patient is unaware of
CRP Certification Pilot
Major CRP Challenge: Provider
Fear of Reporting
• Providers worry that reporting unanticipated
outcome may lead to punitive consequences
from institution, regulators
• Mandatory reporting to Medical Quality Assurance
Commission required when patient receives
compensation >$20K in response to medical error
• Providing fast, fair financial resolution to patients
when care was not reasonable is central tenet of
CRP process
• Absence of event reporting by providers
preventing analysis, learning
Most Adverse Events Are Not
Caused By Incompetent Providers
• Oftentimes, adverse events happen
despite high quality care
• When adverse events are associated
with care that was not reasonable,
usually involve competent provider
caught in system failure or who made
simple human error
CRP Certification Goals
• Promote learning through early
adverse event reporting by providers to
their institution/insurer, comprehensive
event analysis, and implementation of
prevention plans
• Enhance patient-centered
accountability
Stakeholders Involved in CRP
Certification Design, Operation
• MQAC
• Institutions participating in CRP
• Physicians Insurance
• WSMA, WSHA, FHQC, HealthPact
Leadership Group (includes patient
advocates, attorneys)
What Does the Ideal CRP Event
Look Like?
• Early event reporting by provider
• Careful analysis by institution-was
unanticipated outcome caused by medical
error? If so, how can recurrences be
prevented?
• Prompt, compassionate disclosure to patient
• Fast, fair resolution for patient
• Learning at individual and institutional level
CRP Certification Basics
• Important exclusions: Gross provider negligence,
provider impairment, boundary violations
• Certification process based at Foundation for Healthcare
Quality
• MQAC retains all current authority.
• All mandatory reporting requirements remain in effect
• Responsibility of institution, insurer
• Process is voluntary, open to all Washington physicians
• Aiming over time towards integration of other regulatory
bodies (NCQAC, , WBP, DOH, other Boards)
• CRP Certification group will not perform independent
investigations
CRP Certification Review
• Case reviewed by multi-disciplinary group
including patient advocate, risk/claims
specialists, attorneys, physician leaders,
individual with regulatory experience.
• Reviewers can not be affiliated with institution
where event occurred
• Review addresses whether key elements
of CRP were met
• Institutions/insurers can resolve CRP
deficiencies and resubmit
Taking the Next Step:
Key Questions for Organizations
• What’s motivating you to do this?
• Will your insurer be fully on board with the philosophy
of the program?
• Will your organization’s culture support full disclosure
and routine, timely reporting?
• Is top leadership at the facility and insurer willing to
visibly champion and directly engage in the program?
• Can you afford to invest additional resources, knowing
the payoff may not come for a few years?
Taking the Next Step:
Key Questions for Policymakers
• Does the state have adequate legal protection for
apologies?
• How about a prelitigation notice law?
• Are the reputation and philosophy of the state
licensing agencies compatible with the CRP?
• How can families be connected with high-quality legal
representation at reasonable cost?
Thank you!
Questions and comments?