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An Innovative Approach to Creating a Continuously Learning Healthcare System - Implementation of a Communication and Resolution Program

Project Description: Transparency is the keystone for a learning healthcare system. Organizational courage is required to be transparent with ourselves, with our patients, and with the communities in which we serve. There is no greater opportunity for organizational transparency than in the wake of preventable harm or medical error. Despite this opportunity, few organizations have adopted an open and honest approach to communicating with patients and families after preventable harm. This lack of courage leads to patient isolation and abandonment, perpetuates to the medical-legal crisis and limits the opportunity for organizational learning. Communication and resolution programs (CRP) effectively link organizational transparency to continuous process and quality improvement within healthcare organizations. CRP effectiveness within large academic affiliated medical centers is well known, however, few systems with a complement of academic and community hospitals have embarked on this journey. The Seven Pillars approach to CRP is grounded in several National Quality Forum safe practices, allowing an institution to respond quickly to patient safety concerns and remedy them in an expedited fashion enhancing opportunities to learn and improve from the identification, mitigation, and tracking of patient safety risks and hazards. Comprehensive CRPs couple an organization’s safety mission with continuous learning and improvement. The goal of this Pioneer Research Award application is to implement and evaluate a communication and resolution program, known as the Seven Pillars, into practice within ten hospitals of MedStar Health, a distributed healthcare system in the mid-Atlantic region of the US.

Primary contact: Kelly M. Smith, Ph.D.; Scientific Director, Quality and Safety Research
Institution: MedStar Health Research Institute

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