Communication and Resolution Programs Can Help When Something Goes Wrong and a Patient Is Harmed

In the past, patient harm often was followed by a lack of transparent communication with patients about what went awry, ultimately leading to adversarial relationships among patients, physicians, and medical centers. Long delays between the harm and any resolution, lack of investigation, and slow rectification of issues contributing to the harm were common. Apologies are now an accepted and protected part of communication and may come with settlement offers.

Communication and resolution programs (CRPs) are a formal extension of recent approaches to apologies and settlement offers. They are principled, comprehensive processes designed to meet the following needs when patients are harmed by medical errors or have adverse outcomes in the absence of any substandard care:

  • the needs of the patient and his or her family, including financial settlement
  • the need to identify and rectify errors in patient care related to the harm
  • the need to widely disseminate lessons learned to prevent similar incidents of patient harm
  • the need to support caregivers who are adversely affected by the patient harm
  • the need for a timely resolution

The primary focus of CRPs is the welfare of patients and their families and avoiding harm in the future as a result of lessons learned and disseminated.

The benefits of CRPs to medical centers and their staffs are (1) a positive reputation for satisfying patients after adverse events (AEs), (2) better care from lessons learned, (3) support for the physicians and staff involved, and (4) possible mitigation of collateral problems with specialty societies, insurers, and disciplinary authorities.

The successful implementation of a CRP requires the support of a medical center’s administrative and clinical leadership, including physicians, risk managers, liability insurers, and lawyers, with a commitment to patient-centered quality and resolution of patient harm.

Communication breakdowns are common generators of AEs. Poor communication after an AE just makes things worse. On the other hand, good communication can help prevent AEs and improve outcomes when they do occur. Immediate, honest, and transparent communication is a key critical element of a successful CRP.

A CRP Certification Program has been set up by the Foundation for Health Care Quality in Washington State. The Washington State Hospital Association and Washington State Medical Association have endorsed it. The Medical Commission, the licensing and disciplinary authority in Washington State, publicly supports CRPs. A certified CRP is viewed as a mitigating factor for a physician before the Medical Commission. It is anticipated that, in time, CRPs will significantly reduce the number of cases being investigated and disciplined by the commission. The commission retains full authority to investigate and discipline, as appropriate.

The following is a summary of how a CRP works:

  1. A CRP event report is made immediately.
  2. The AE is summarized by those involved, the nature of the harm to the patient is specified, and relevant documentation is provided.
  3. Early, transparent communication with the patient and family is provided. The details of the event and the CRP process are described. Apologies and discussion of ongoing support and care for the patient are important. Communication is ongoing.
  4. A collaborative investigation of the event occurs, including the medical staff and providers involved. A root cause analysis is conducted to determine whether the AE was preventable.
  5. Quality and safety improvements are recommended based on the analysis of the event. These may involve both the institution and the licensees. The quality and safety improvements are reported and disseminated through the institution and associated healthcare system.
  6. A financial resolution, including management of bills and any financial or other settlement, is discussed.
  7. Support for the staff and licensees is offered. These individuals may be severely affected by patient harm and need help.
  8. Feedback is requested from patients, families, and licensees. The intent is to learn whether the CRP has been successful in achieving the desired benefits of providing for harmed patients and improving care.

Finally, there is a certification process to determine whether the key elements of the CRP have been completed. Matters of gross negligence are excluded from this process. A panel of relevant practitioners, patient advocates, risk managers, and insurers performs the review. They have been trained in the CRP certification process and follow a set of well-defined guidelines. The panel may reach one of three decisions:

  1. Certify: All elements of the CRP have been completed.
  2. Certify with Contingency: Some elements require further attention. Recommendations are made for further work on the CRP.
  3. Do Not Certify: Some element(s) of the CRP was omitted or not addressed completely.

The CRP certification is confidential. Those filing the report may use it accordingly. The Washington State Medical Commission views a certified CRP as a mitigating factor in a related complaint. The commission eventually may consider a CRP certification as a basis for closing a case without further investigation.

A key part of the certification panel’s review is direct communication with providers and individuals from the institution involved. Panel members attend the hearing in person or by phone to discuss the event and ask questions. The panel then makes a determination and delivers a confidential report to those reporting the event. It is a collaborative, not adversarial, process.

There is evidence that CRPs reduce liability costs. Benefits related to improved quality and support for patient needs are less clear and require further research.

All physicians have experienced AEs and are well aware of the handling of AEs through the tort system. We have been involved in reviewing hundreds of cases for a state medical board and now sit on a CRP certification panel. It is our view that the CRP process is a more professional and superior approach for all involved. We encourage AAOS fellows to become aware of, support, and participate in the CRP process.

Thomas Green, MD, is a retired orthopaedic surgeon and emeritus physician at Virginia Mason in Seattle. He was involved with the AAOS Professional Compliance Program for many years and was a member of the Washington State Medical Commission. Currently, he sits on a CRP certification panel.

Thomas Gallagher, MD, is a professor and associate chair in the Department of Medicine at the University of Washington. He is a national leader in CRP implementation and research and the author of many peer-reviewed articles on transparency and patient safety.

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