Implementing hospital-based communication-and-resolution programs: lessons learned in New York City

Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence

OBJECTIVES

Investigations of healthcare harm often overlook the valuable insights of patients and families. Our review aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.

METHODS

The authors searched three databases (Medline, PsycInfo, and CINAHL) and Connected Papers software for qualitative studies in which patients and families were involved in serious incident investigations until no new articles were found.

RESULTS

Twenty-seven papers were eligible. The perspectives of patients and families, healthcare professionals, nonclinical staff, and legal staff were sought across acute, mental health and maternity settings. Most patients and families valued being involved; however, it was important that investigations were flexible and sensitive to both clinical and emotional aspects of care to avoid compounding harm. This included the following: early active listening with empathy for trauma, sincere and timely apology, fostering trust and transparency, making realistic timelines clear, and establishing effective nonadversarial communication. Most staff perceived that patient and family involvement could improve investigation quality, promote an open culture, and help ensure future safety. However, it was made difficult when multidisciplinary input was absent, workload and staff turnover were high, training and support needs were unmet, and fears surrounded litigation. Potential solutions included enhancing the clarity of roles and responsibilities, adequately training staff, and providing long and short-term support to stakeholders.

CONCLUSIONS

Our review provides insights to ensure patient and family involvement in serious incident investigations considers both clinical and emotional aspects of care, is meaningful for all key stakeholders, and avoids compounding harm. However, significant gaps in the literature remain.

Ensuring successful implementation of communication-and-resolution programmes

BACKGROUND

Communication-and-resolution programmes (CRP) aim to increase transparency surrounding adverse events, improve patient safety and promote reconciliation by proactively meeting injured patients' needs. Although early adopters of CRP models reported relatively smooth implementation, other organisations have struggled to achieve the same. However, two Massachusetts hospital systems implementing a CRP demonstrated high fidelity to protocol without raising liability costs.

STUDY QUESTION

What factors may account for the Massachusetts hospitals' ability to implement their CRP successfully?

SETTING

The CRP was collaboratively designed by two academic medical centres, four of their community hospitals and a multistakeholder coalition.

DATA AND METHODS

Data were synthesised from (1) key informant interviews around the time of implementation and 2 years later with individuals important to the CRP's success and (2) notes from 89 teleconferences between hospitals' CRP implementation teams and study staff to discuss implementation progress. Interview transcripts and teleconference notes were analysed using standard methods of thematic content analysis. A total of 45 individuals participated in interviews (n=24 persons in 38 interviews), teleconferences (n=32) or both (n=11).

RESULTS

Participants identified facilitators of the hospitals' success as: (1) the support of top institutional leaders, (2) heavy investments in educating physicians about the programme, (3) active cultivation of the relationship between hospital risk managers and representatives from the liability insurer, (4) the use of formal decision protocols, (5) effective oversight by full-time project managers, (6) collaborative group implementation, and (7) small institutional size.

CONCLUSION

Although not necessarily causal, several distinctive factors appear to be associated with successful CRP implementation.

Whose experience is it anyway? Toward a constructive engagement of tensions in patient-centered health care

Purpose

Healthcare delivery faces increasing pressure to move from a provider-centered approach to become more consumer-driven and patient-centered. However, many of the actions taken by clinicians, patients and organizations fail to achieve that aim. This paper aims to take a paradox-based perspective to explore five specific tensions that emerge from this shift and provides implications for patient experience research and practice.

Design/methodology/approach

This paper uses a conceptual approach that synthesizes literature in health services and administration, organizational behavior, services marketing and management and service operations to illuminate five patient experience tensions and explore mitigation strategies.

Findings

The paper makes three key contributions. First, it identifies five tensions that result from the shift to more patient-centered care: patient focus vs employee focus, provider incentives vs provider motivations, care customization vs standardization, patient workload vs organizational workload and service recovery vs organizational risk. Second, it highlights multiple theories that provide insight into the existence of the tensions and how they may be navigated. Third, specific organizational practices that engage the tensions and associated examples of leading organizations are identified. Relevant measures for research and practice are also suggested.

Originality/value

The authors develop a novel analysis of five persistent tensions facing healthcare organizations as a result of a shift to a more consumer-driven, patient-centered approach to care. The authors detail each tension, discuss an existing theory from organizational behavior or services marketing that helps make sense of the tension, suggest potential solutions for managing or resolving the tension and provide representative case illustrations and useful measures.

Lessons learned from implementing a principled approach to resolution following patient harm

Background

Communication and resolution programs have emerged as central to organizational responses to serious patient harm events, with demonstrated evidence of patient safety and medicolegal outcome improvements within a handful of healthcare systems. Hospitals, including those with open medical staffs, have struggled implementing communication and resolution programs, particularly around the components supporting resolution. Here, we describe our lessons learned early after implementing the resolution (“R”) component of Communication and Optimal Resolution, a comprehensive contemporary communication and resolution program at MedStar Health, a large community health system in the United States.

Context

MedStar Health is a regional healthcare system with 10 hospitals, 250 ambulatory care delivery sites, and 20 diversified businesses in the mid-Atlantic region of the United States. MedStar Health initiated Communication and Optimal Resolution implementation in 2015.

Approach

Our approach to resolution following patient harm yielded seven strategies supporting our resolution process. These included infrastructure and processes to (i) provide immediate support to patients and families, (ii) hold and waive bills, (iii) activate event review processes early to inform resolution, (iv) embrace a paradigm shift in legally defensible cases, (v) develop a communication and resolution program legal community, (vi) accept sacrifices with a principled resolution, and (vii) commit to address challenges with open medical staffs.

Summary

The resolution process in response to serious patient harm is complex. Our early experience in implementing the “R” of Communication and Optimal Resolution required enhanced infrastructure, embracing the clinician, legal, and insurance communities and instructing them in the principles of communication and resolution program, and a strong organizational commitment to “doing the right thing” for patients and families.

Patients' Experiences With Communication-and-Resolution Programs After Medical Injury

IMPORTANCE

Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs.

OBJECTIVE

To explore the experiences of patients and family members with medical injuries and CRPs to understand different aspects of institutional responses to injury that promoted and impeded reconciliation.

DESIGN, SETTING, AND PARTICIPANTS

From January 6 through June 30, 2016, semistructured interviews were conducted with patients (n = 27), family members (n = 3), and staff (n = 10) at 3 US hospitals that operate CRPs. Patients and families were eligible for participation if they experienced a CRP, spoke English, and could no longer file a malpractice claim because they had accepted a settlement or the statute of limitations had expired. The CRP administrators identified hospital and insurer staff who had been involved in a CRP event and had a close relationship with the injured patient and/or family. They identified patients and families by applying the inclusion criteria to their CRP databases. Of 66 possible participants, 40 interviews (61%) were completed, including 30 of 50 invited patients and families (60%) and 10 of 16 invited staff (63%).

MAIN OUTCOMES AND MEASURES

Patients' reported satisfaction with disclosure and reconciliation efforts made by hospitals.

RESULTS

A total of 40 participants completed interviews (15 men and 25 women; mean [range] age, 46 [18-67] years). Among the 30 patients and family members interviewed, 27 patients experienced injuries attributed to error and received compensation. The CRP experience was positive overall for 18 of the 30 patients and family members, and 18 patients continued to receive care at the hospital. Satisfaction was highest when communications were empathetic and nonadversarial, including compensation negotiations. Patients and families expressed a strong need to be heard and expected the attending physician to listen without interrupting during conversations about the event. Thirty-five of the 40 respondents believed that including plaintiffs' attorneys in these discussions was helpful. Sixteen of the 30 patients and family members deemed their compensation to be adequate but 17 reported that the offer was not sufficiently proactive. Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.

CONCLUSIONS AND RELEVANCE

As hospitals strive to provide more patient-centered care, opportunities exist to improve institutional responses to injuries and promote reconciliation.

Case Outcomes in a Communication-and-Resolution Program in New York Hospitals

OBJECTIVE

To determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery.

STUDY SETTING

Five acute-care hospitals in New York City.

STUDY DESIGN

Following CRP implementation, hospitals recorded information about each CRP event for 22 months.

DATA COLLECTION METHODS

Risk managers prospectively collected data in collaboration with representatives from the hospital's insurer. External researchers administered an online satisfaction survey to clinicians involved in CRP events.

PRINCIPAL FINDINGS

Among 125 CRP cases, disclosure conversations were carried out in 92 percent, explanations were conveyed in 88 percent, and apologies were offered in 72.8 percent. Three quarters of events did not involve substandard care. Compensation offers beyond bill waivers were deemed appropriate in 9 of 30 of cases in which substandard care caused harm and communicated in six such cases. In 44 percent of cases, hospitals identified steps that could be taken to improve safety. Clinicians had low awareness of the workings of the CRP, but high satisfaction with their experiences.

CONCLUSIONS

The bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.

Progress at the Intersection of Patient Safety and Medical Liability: Insights from the AHRQ Patient Safety and Medical Liability Demonstration Program

OBJECTIVE

To identify lessons learned from the experience of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Medical Liability (PSML) Demonstration Program.

DATA SOURCES/STUDY SETTING

On September 9, 2009, President Obama directed the Secretary of Health and Human Services to authorize demonstration projects that put "patient safety first" with the intent of reducing preventable adverse outcomes and stemming liability costs. Seven demonstration projects received 3 years of funding from AHRQ in the summer of 2010, and the program formally came to a close in June 2015.

STUDY DESIGN

The seven grantees implemented complex, broad-ranging innovations addressing both patient safety and medical liability in "real-world" contexts. Some projects featured novel approaches, while others implemented adaptations of existing models. Each project was funded by AHRQ to collect data on the impact of its interventions. In addition, AHRQ funded a cross-cutting qualitative evaluation focused on lessons learned in implementing PSML interventions.

DATA COLLECTION/EXTRACTION METHODS

Site visits and follow-up interviews supplemented with material abstracted from formal project reports to AHRQ.

PRINCIPAL FINDINGS

The PSML demonstration projects focused on three broad approaches: (1) improving communication around adverse events through disclosure and resolution programs; (2) preventing harm through implementation of clinical "best practices"; and (3) exploring alternative methods of settling claims. Although the demonstration contributed to accumulating evidence that these kinds of interventions can positively affect outcomes, there is also evidence to suggest that these interventions can be difficult to scale.

CONCLUSIONS

In addition to producing at least preliminary positive outcomes, the demonstration also lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm. However, more empirical work needs to be carried out to quantify the effect of such interventions.

Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate

OBJECTIVE

To implement a communication-and-resolution program (CRP) in a setting in which liability insurers and health care facilities must collaborate to resolve incidents involving a facility and separately insured clinicians.

STUDY SETTING

Six hospitals and clinics and a liability insurer in Washington State.

STUDY DESIGN

Sites designed and implemented CRPs and contributed information about cases and operational challenges over 20 months. Data were qualitatively analyzed.

DATA COLLECTION METHODS

Data from interviews with personnel responsible for CRP implementation were triangulated with data on program cases collected by sites and notes recorded during meetings with sites and among project team members.

PRINCIPAL FINDINGS

Sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP. Barriers included the insurer's distance from the point of care, passive rather than active support from top leaders, coordinating across departments and organizations, workload, nonparticipation by some physicians, and overcoming distrust.

CONCLUSIONS

Operating CRPs where multiple organizations must collaborate can be highly challenging. Success likely requires several preconditions, including preexisting trust among organizations, active leadership engagement, physicians' commitment to participate, mechanisms for quickly transmitting information to insurers, tolerance for missteps, and clear protocols for joint investigations and resolutions.

Collaboration with Regulators to Support Quality and Accountability Following Medical Errors: The Communication and Resolution Program Certification Pilot

OBJECTIVE

Communication and resolution programs (CRPs) involve institutions responding to adverse events using transparency with patients, event analysis, recurrence prevention, and compensation. Collaboration with regulators around CRPs could enhance health care quality.

SETTING AND PARTICIPANTS

Health care institutions, liability insurers, and the Medical Quality Assurance Commission (MQAC, board of medicine) in Washington State.

STUDY DESIGN

MQAC has collaborated with the Foundation for Health Care Quality (FHCQ) on the CRP Certification pilot. A panel of physicians, risk managers, and patient advocates at FHCQ will review cases for use of the CRP key elements. Cases meeting this standard will be "CRP Certified." If MQAC determines that the CRP enhanced patient safety comparable or better than board action, the Commission may close the case.

PRINCIPAL FINDINGS

Developing this process identified the following issues: (1) protecting information submitted for CRP Certification; (2) determining what information the Commission needs to assess whether additional investigation is warranted; (3) preserving the Commission's responsibility to protect the public while working with health care organizations; and (4) addressing concerns that CRP Certification not shield incompetent providers.

CONCLUSIONS

The CRP Certification program is a promising example of collaboration among institutions, insurers, and regulators to promote patient-centered accountability and learning following adverse events.

The "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes

OBJECTIVE

To determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.

DATA SOURCES/STUDY SETTING

Administrative, safety, and risk management data from the University of Illinois Hospital and Health Sciences System, from 2002 to 2014.

STUDY DESIGN

Single health system, interrupted time series design. Using Mann-Whitney U tests and segmented regression models, we compared means and trends in incident reports, claims, event analyses, patient communication consults, legal fees, costs per claim, settlements, and self-insurance expenses before and after the implementation of the "Seven Pillars" communication and resolution intervention.

DATA COLLECTION METHODS

Queried databases maintained by Department of Safety and Risk Management and the Department of Administrative Services at UIH. Extracted data from risk module of the Midas incident reporting system.

PRINCIPAL FINDINGS

The intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs.

CONCLUSIONS

A communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.