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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.

 

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Research: At the Heart of Patient Safety Improvement

Posted By Administration, Friday, August 12, 2016
Updated: Friday, August 12, 2016

The National Patient Safety Foundation has joined with 250 other organizations in the Friends of AHRQ
to voice our support for the agency and its mission.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

As noted in the recent NPSF report Free from Harm, the scientific process does not always move in a straight line. This can be illustrated by conflicting studies. For example, in a 2009 paper, Haynes and colleagues demonstrated a benefit from the use of surgical safety checklists. Several years later, Urbach and others were not able to replicate the results.

 

Researchers wisely recognize that the latter studies illustrate the need for both safety science research (the development of the checklist) and implementation science research (how best to put them into use). Because of this, one of the NPSF report’s eight recommendations to accelerate patient safety calls for increased research funding for both safety science and implementation research.

 

Since 1999, the U.S. Agency for Healthcare Research and Quality (AHRQ), has played an essential role in funding, conducting, and sharing results of patient safety research. A section of the federal Department of Health & Human Services, AHRQ was created by Congress with the purpose of “producing evidence to make health care safer; higher quality; more accessible, equitable, and affordable; and to ensure that the evidence is understood and used.”

 

In addition to compiling the National Healthcare Quality and Disparities Reports, AHRQ has funded and helped promulgate numerous evidence-based tools and resources. Among these are the Comprehensive Unit-Based Safety Program (CUSP), which is now being used in hospitals throughout the country; Team STEPPS®, developed in collaboration with the Department of Defense to improve teamwork in clinical settings; and the new CANDOR Toolkit, which provides a roadmap for organizations to learn how to communicate with patients about medical errors and adverse events.

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My own entrée to the patient safety field was as a researcher with a focus on ambulatory safety and the use of technology to improve quality and safety. AHRQ funded key research that my colleagues and I conducted on missed and delayed diagnosis errors and their causes, and the impact of barcode technology on medication safety, among many other topics. This critical research really helped advance our understanding of ambulatory safety and the benefits of technology. And it likely would never have happened without AHRQ providing the funding.

 

Regrettably, AHRQ recently saw its budget reduced to $280.24 million, a $54 million reduction from current levels, even though the AHRQ budget has historically represented less than 1% of all federally funded research. (See AHRQ: 15 Years of Transforming Care and Improving Health.) The National Patient Safety Foundation has joined with 250 other organizations in the Friends of AHRQ, which is being led by Academy Health, a leading health services research organization, to voice our support for the agency and its mission.

 

Now is not the time to reverse course in patient safety research. We need to expand patient safety research throughout all health settings if we are going to continue to make progress in ensuring safety care.

 

To read more about the NPSF report Free from Harm and the tactics recommended for increasing research funding, visit www.npsf.org/free-from-harm.   Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  AHRQ  research 

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Using CANDOR to Improve Communication and Resolution in Health Care

Posted By Administration, Friday, July 15, 2016
Updated: Friday, July 15, 2016
A customizable resource from the Agency for Healthcare Research and Quality

helps facilitate vital conversations.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

A cornerstone of the National Patient Safety Foundation’s work involves a push for greater transparency in health care. The NPSF Lucian Leape Institute report on this topic outlines four domains where greater transparency can lead to safer care: between clinicians and patients, among clinicians, between organizations, and with the public.


At its core, transparency between clinicians and patients would demand disclosing medical errors and doing the right thing to mitigate harm when it occurs. Some health systems, such as the University of Michigan Health System, have long recognized that such practices bring benefits for all parties. Patients and families receive an explanation and understanding of what went wrong and why; clinicians involved are permitted to apologize if a mistake was made and to help patients and families heal; and the organization often benefits, because when errors are brought out into the open, solutions can be effected that prevent them from happening again.


Often called Communication and Resolution Programs (CRPs), these efforts get to an essential fact: That most patients and families do not want to punish or sue a hospital, provider, or health system. They simply want to know what happened and that the hospital and clinicians are taking steps to make sure it does not happen again to another patient or family. Financial compensation is also a part of these programs, because it is often necessary support for patients and families after a preventable event.


NPSF has partnered with the Collaborative for Accountability and Improvement to create an educational program for those interested in learning how to implement a CRP in their organization. The program was offered as a full-day immersion workshop at the NPSF Congress in May (read more about that program here).

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If you missed the complimentary
NPSF webcast,
Implementing an
Effective Communication and
Resolution Program,
listen to the replay.

 
   

During the session, Erin Grace, MHA, of the Agency for Healthcare Research and Quality (AHRQ) presented details of a new resource to help clinicians and health systems that want
to set up their own CRP. The AHRQ-developed communication and resolution process, called Communication and Optimal Resolution, or CANDOR, gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication
and timely resolution for patients and caregivers.


“The CANDOR process is a proactive approach that health care institutions and practitioners can use to respond in a timely, thorough, and just way to unexpected patient harm events,” Ms. Grace said.


Apologizing for errors or bad outcomes runs counter to the culture in which many health care professionals and administrators have long worked. A big fear among many health and risk management professionals is that medical malpractice claims will go up in an institution that readily admits to error. But at the University of Michigan, for example, that has not been the case.


Rick Boothman, JD, chief risk officer at University of Michigan, a long-serving member of the NPSF Board of Directors, and a leading voice at the national level for CRP programs, has spoken often about his organization’s experience. At University of Michigan, since the start of the “Michigan Model” of communication and resolution, malpractice claims have decreased, along with malpractice payments.


Says Mr. Boothman, “At its heart, CANDOR is aimed at stimulating patient safety and optimal patient care…It is only through honesty that we can identify our problems and improve. By focusing on safety improvement, the claims crisis will take care of itself.”


I encourage health professionals—and especially leaders of health care organizations—to take the time to review the CANDOR Toolkit and consider putting it into action.

Does your organization have a formal program for communication around medical errors? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  AHRQ  communication and resolution  CRP 

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