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Patient safety remains a top priority for all healthcare systems. One method that systems use to provide an organized approach for responding to unintended patient harm is a Communication and Resolution Program. MedStar has a been a leader in this field by making it an active area of research.
“Lessons Learned from Implementing a Principled Approach to Resolution Following Patient Harm” describes lessons learned after implementing the resolution component of Communication and Optimal Resolution, a comprehensive contemporary communication and resolution program at MedStar Health. Some healthcare systems have struggled with implementing Communication and Resolution Programs, mainly around the components to resolving events that have caused serious patient harm. The recent research publication sought to share the findings from an implementation science study that helps support other systems.
MedStar Health initiated a five-year strategic plan to improve patient safety at our 10 acute care hospitals and 250 ambulatory care sites in 2012. In 2013, MedStar collaborated with leaders from around the US to develop and pilot test a Communication and Optimal Resolution (CANDOR) toolkit. MedStar piloted the toolkit in eight hospitals in partnership with the Agency for Healthcare Research and Quality (AHRQ). In 2015, MedStar extended its CANDOR implementation to all 10 MedStar hospitals and has since expanded its implementation to all ambulatory care sites and diversified business units.
At MedStar, CANDOR is initiated when a serious patient harm event is reported. This is followed by starting an immediate investigation at the local care site, a discussion with the patient safety and local care team, early communication to the patient and family, and activation of the health system’s critical incident response process including care for the care teams and notification of leadership and claims and risk management.
The authors formed seven strategies to support the resolution process at MedStar Health. These included processes to:
- provide immediate support to patients and families,
- hold and waive bills,
- activate event review processes early to inform resolution,
- embrace a paradigm shift in legally defensible cases,
- develop a communication and resolution program legal community,
- accept sacrifices with a principled resolution, and
- commit to address challenges with open medical staffs.
While the CANDOR program is still quite new, the research team has found that the resolution process is complex, and improvements can be made in support of organizational transparency. MedStar is committed to patient safety and recognizes the importance of partnering with patients and/or families to prevent serious patient harm from happening to others.
The authors for this publication are: Kelly M. Smith, PhD (MedStar Institute for Quality and Safety); Larry L. Smith (Risk Management for MedStar Health; Greenspring Financial Insurance Limited, Inc. of Cayman); John C. (Jack) Gentry (MedStar Health System Patient and Family Advisory Council for Quality and Safety); and David B. Mayer (MedStar Institute for Quality and Safety).
This research received funding from the Association of American Medical Colleges, Learning Health Systems Award. The demonstration project for CANDOR was funded by the Agency for Healthcare Research and Quality under an ACTION II contract to the Health Research and Educational Trust.
Journal of Patient Safety and Risk Management, 2019. DOI: 10.1177/2516043518813814