Our health care ecosystem is filled with fantastic, dedicated, and talented people, but working within an imperfect system can still result in patient harm. Transparency and a framework to be able to learn when harms occur is pivotal to a high-quality health care state.

Washington State has been a national leader in responding to patient harm by using Communication and Resolution Programs (CRPs). CRPs are a best practice for addressing patient harm and preventing future harm by providing a systematic approach for openly engaging with patients and moving toward a positive resolution after an adverse event. CRPs use a common set of commitments, elements, and steps to improve safety and quality through event analysis and shared learning. However, turning CRP principles into practice can be challenging and benefits often go unrealized and a state-wide framework can help close the gap.

Starting this year, we will be reconvening our CRP program to improve patient, provider, and systems outcomes after harm. CRP Certification involves submission of an application by organizations and providers that describes CRP steps in a particular case, review by a neutral panel, and feedback on opportunities for improvement. Peer feedback has been instrumental in supporting adoption of high-functioning CRPs statewide.

CRP requires that healthcare organizations and their clinicians commit to the following:

• Being transparent with patients around risks and adverse events, including sharing information about what happened, whether the adverse event was preventable, why the event happened, and how recurrences will be prevented in whatever detail the patient desires.
• Analyzing adverse events using human factors principles, and developing and implementing action plans designed to prevent recurrences of adverse events caused by system failure or human error.
• Supporting the emotional needs of the patient, family, and care team affected by the event.
• Proactively and promptly offering financial and non-financial resolution to patients when adverse events were caused by unreasonable care.
• Educating patients or their families about their right to seek legal representation at any time.
• Working collaboratively with other healthcare organizations and professional liability insurers to respond to adverse events involving multiple parties.
• Assessing continuously the effectiveness of the CRP program using accepted, validated metrics.

Are you interested in learning more? Would you like to learn how to be involved? Email us at fhcq@qualityhealth.org

Ginny Weir, MPH
CEO, Foundation for Health Care Quality