Case Outcomes in a Communication-and-Resolution Program in New York Hospitals.

OBJECTIVE: To determine case outcomes in a communication-and-resolution program (CRP) implemented to respond to adverse events in general surgery. STUDY SETTING: Five acute-care hospitals in New York City. STUDY DESIGN: Following CRP implementation, hospitals recorded information about each CRP event for 22 months. DATA COLLECTION METHODS: Risk managers prospectively collected data in collaboration with representatives from the hospital's insurer. External researchers administered an online satisfaction survey to clinicians involved in CRP events. PRINCIPAL FINDINGS: Among 125 CRP cases, disclosure conversations were carried out in 92 percent, explanations were conveyed in 88 percent, and apologies were offered in 72.8 percent. Three quarters of events did not involve substandard care. Compensation offers beyond bill waivers were deemed appropriate in 9 of 30 of cases in which substandard care caused harm and communicated in six such cases. In 44 percent of cases, hospitals identified steps that could be taken to improve safety. Clinicians had low awareness of the workings of the CRP, but high satisfaction with their experiences. CONCLUSIONS: The bulk of CRPs' work is in investigating and communicating about events not caused by substandard care. These CRPs were quite successful in handling such events, but less consistent in offering compensation in cases involving substandard care.

How policy makers can smooth the way for communication-and- resolution programs.

Communication-and-resolution programs (CRPs) in health care organizations seek to identify medical injuries promptly; ensure that they are disclosed to patients compassionately; pursue timely resolution through patient engagement, explanation, and, where appropriate, apology and compensation; and use lessons learned to improve patient safety. CRPs have existed for years, but they are being tested in new settings and primed for broad implementation through grants from the Agency for Healthcare Research and Quality. These projects do not require changing laws. However, grantees' experiences suggest that the path to successful dissemination of CRPs would be smoother if the legal environment supported them. State and federal policy makers should try to allay potential defendants' fears of litigation (for example, by protecting apologies from use in court), facilitate patient participation (for example, by ensuring access to legal representation), and address the reputational and economic concerns of health care providers (for example, by clarifying practices governing National Practitioner Data Bank reporting and payers' financial recourse following medical error).

Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.

In 2010 five New York City hospitals implemented a communication-and-resolution program (CRP) in general surgery. The program's goals were to improve reporting of serious adverse events to risk management, support clinical staff in discussing these events with patients, rapidly investigate why injuries occurred, communicate to patients what was discovered, and offer apologies and compensation when the standard of care was not met. We report the hospitals' experiences with implementing the CRP over a twenty-two-month period. We found that all five hospitals improved disclosure and surveillance of adverse events but were not able to fully implement the program's compensation component. These experiences suggest that strong support from top leadership at the hospital and insurer levels, and adequate staff resources, are critical for the success of CRPs. Hospitals considering adopting a CRP should ensure that their organizations can tolerate risk, their leaders are willing to reinforce CRP implementation, and resources are in place to educate clinical staff about how the program can benefit them.

Demographic patterns of a widespread long-lived tree are associated with rainfall and disturbances along rainfall gradients in SE Australia.

Predicting species distributions with changing climate has often relied on climatic variables, but increasingly there is recognition that disturbance regimes should also be included in distribution models. We examined how changes in rainfall and disturbances along climatic gradients determined demographic patterns in a widespread and long-lived tree species, Callitris glaucophylla in SE Australia. We examined recruitment since 1950 in relation to annual (200-600 mm) and seasonal (summer, uniform, winter) rainfall gradients, edaphic factors (topography), and disturbance regimes (vertebrate grazing [tenure and species], fire). A switch from recruitment success to failure occurred at 405 mm mean annual rainfall, coincident with a change in grazing regime. Recruitment was lowest on farms with rabbits below 405 mm rainfall (mean = 0-0.89 cohorts) and highest on less-disturbed tenures with no rabbits above 405 mm rainfall (mean = 3.25 cohorts). Moderate levels of recruitment occurred where farms had no rabbits or less disturbed tenures had rabbits above and below 405 mm rainfall (mean = 1.71-1.77 cohorts). These results show that low annual rainfall and high levels of introduced grazing has led to aging, contracting populations, while higher annual rainfall with low levels of grazing has led to younger, expanding populations. This study demonstrates how demographic patterns vary with rainfall and spatial variations in disturbances, which are linked in complex ways to climatic gradients. Predicting changes in tree distribution with climate change requires knowledge of how rainfall and key disturbances (tenure, vertebrate grazing) will shift along climatic gradients.