The trend towards a hardening medical professional liability insurance market began in 2019. In recent months, it has been accelerated by COVID-19 and exacerbated by severe financial pressures most health care organizations are facing. Communication Resolution Programs (CRPs) can be leveraged now, more than ever.

While we have made great strides in patient safety improvement, medical error still occurs. And while we have also made significant progress in specific areas of our response to error and harm, we still struggle with a more comprehensive response that embraces all elements of event management from transparency in communication to timely resolution that supports patients, providers and organizations alike.

As part of our Candello community, members are invited to attend educational webinars where we bring together experts to discuss important topics, such as CRPs, that impact medical malpractice insurance and the delivery of care. We were fortunate to have Thomas H. Gallagher, MD, MACP from the University of Washington and Evan M. Benjamin, MD, MS, FACP from Harvard Medical School and Ariadne Labs to explore the benefits of CRPs on a recent webinar. Additional commentary came from members of our community from The Doctors Company, Constellation, and Michigan Medicine.

The following highlights are drawn from their presentation.

Highlights from the Webinar

WHAT IS A CRP?

Dr. Gallagher talked about the structure of CRPs as being principled, comprehensive, systematic programs for responding to and preventing adverse events.

Principled: We use them at every harm event.

Comprehensive: They start with early incident reporting and go all the way through patient and family involvement and care for the care giver.

Systematic: The different elements are hardwired to work effectively with one another which leads to highly reliable CRP response.

“Communication and resolution programs are about openness and learning. They have very important risk and claims dimensions to them but at their heart, they are about accountability, openness and quality improvement.” - Thomas H. Gallagher, MD, MACP

He stressed that while the use of CRPs is increasing, the success of them depends on the consistent implementation across all cases that involve medical error. Some organizations may choose to only use CRP with the most egregious cases or use some, but not all of the CRP approach. This inconsistent implementation can raise concerns that CRPs are really a claims management strategy dressed in quality/safety rhetoric.

BENEFITS OF THE CRP PROCESS

There are many benefits of a successfully implemented CRP. Based on the research and work developing CRPs they have conducted, Drs. Gallagher and Benjamin summarized the following  benefits of the CRP process.

First and foremost, they offer support to patients and families who have been harmed by care. This is accomplished with:

• Empathic, transparent, ongoing communication and emotional support
• Connection to learning from the harm event
• Financial and non-financial resolution

They also discussed other benefits CRPs can offer which include:

• Support to the clinicians—and others at the organization—affected by the harm event
• Strengthening a culture of accountability and learning
• Patient, family, clinician, and public trust
• In the aggregate, reductions in medico-legal expenses

IMPLEMENTING CPRS

Dr. Benjamin shared some tips for successful implementation of CRPs. He reminded us that using the CRP process does not always come naturally. A normal human reflex is to keep uncomfortable information to our self. Compounded by the mixed messages about responding to harm events and status quo and inertia, it can be difficult to change a culture to embrace CRPs. 

They discussed a role for medical professional liability carriers to play in implementing and supporting CRPs. The presenters suggested this may come in the form of moving from deny/defend to embracing transparency, accountability, and early resolution. They talked about a shift to think about should we defend this case instead of could we; and protecting our insureds instead of defending them.

Three steps Dr. Benjamin discussed to support consistent CRP implementation were:

• Step 1: Use metrics to track processes and outcomes. This is critical to improve adherence and may include culture of safety and patient experience surveys, or the total number of adverse events or claims. Benchmarks for success and accountability as well as facilitating ongoing reporting with transparent learning and communication is a key to success.
• Step 2: Create standard work. This can be done with training and tools and event reporting/management software.
• Step 3: Apply an implementation and Quality improvement systems approach. It is important to have a roadmap for implementation and improvement to ensure long-term success.

He also shared five key tenets of CRP implementation that emerged from research done by Ariadne Labs:

• Organizational buy-in. This includes board/c-suite engagement and generating the will for change so that it becomes mission critical language. This should also address alignment of internal groups essential to CRP implementation, including risk, claims, liability insurers, and defense attorneys.
• Timely response. Immediately communicating with the patient/family is critical. Providing clinicians with the proper resources, such as communication guides, can help facilitate these difficult conversations.
• Transparency. Sharing information throughout the process will help ensure all involved that you are being transparent. Providing guides to your staff about what to discuss and when it should be discussed is helpful to support them in the process.
• Patient safety analysis. As with any safety improvement program you want to analyze and develop action plans to prevent recurrences of adverse events.
• Resolution outcome. Offer compensation in cases of substandard care. Providing your staff with examples will help them in this process.

Dr. Gallagher summarized by reminding us that we have learned a lot about how to do this well and there are tools and resources to help organizations get started. There are areas that are challenging, and we need everyone to come together—as the Candello Convene Community did for this webinar—to work on implementing tools and best practices and collaborate on those difficult challenges. The CRP principles can help make sure that if a patient is harmed in an adverse event that their needs are addressed and that we learn from what happened.

We invite you to listen to the entire webinar recording with Drs. Gallagher and Benjamin as well as access some of the resources that were shared.

Resources

1. Iezzoni LI, Rao SE, DesRoches CM, Vogeli C, Campbell EG. “Survey shows that at least some physicians are not always open or honest with patients.” Health Affairs. Feb 2012. https://doi.org/10.1377/hlthaff.2010.1137
2. Collaborative for Accountability and Improvement. http://communicationandresolution.org/