CRP: A Proactive Approach to Physician Wellness

By Andy Smith | AAPL
May 7, 2019

Organizations are finding personnel benefits from changing how it deals with error.

Beth Kaye had read enough about communication and resolution programs to understand the benefits they afforded patients in cases of harm events and to realize that’s how they were being promoted.

EDITOR’S NOTE

  • This article accompanies the cover story in the May-June 2019 issue of the Physician Leadership Journal, “Medical Errors and CRP: Beyond Denial and Defense.” Learn how adopting communication and resolution programs that emphasize just culture, patient safety and physician wellness can lead to a drop in malpractice expenses. Click here to read it.
  • Also read “Deny, Defend, Death: Salt in the Wound.” Discover how “deny and defend” tactics backfired on one hospital after the medical-error death of a newborn — and inspired a mother to take action. Click here to read it.

As director of Early Discussion and Resolution for the Oregon Patient Safety Commission, however, she was surprised by the level of interest from providers when the commission began its Oregon Collaborative on Communication and Resolution Programs. Much of that interest was for the extensive peer support it afforded the clinicians.

Given the sparsity of support teams at many organizations, she says, the collaborative’s emphasis on peer support groups was enthusiastically received by clinicians when its rollout began at Oregon hospitals and large group medical practices in 2016.

“If you look at the stats on clinician burnout — doctors, nurses, anyone who works in a hospital setting — they’re traumatized when they’re part of an unexpected harm event, especially when something goes really bad and they have nobody to talk to,” Kaye says. “The full CRP approach really addresses and speaks to that, and we’ve gotten a really warm reception for that.”

Alarmed by rising burnout and suicide rates statewide, many medical societies within the Oregon Wellness Coalition are now offering psychological support to clinicians.

“And that’s a great thing,” Kaye says. “But here’s the problem they have: Doctors don’t call. Doctors are conditioned not to ask for help. So, one of the things we do is recommend to the organizations that employer-supported peer support programs be proactive.”

How does that work? Rather than wait for clinicians to ask for help after serious unintended harm events, the support team calls everyone involved in the event to check on their status: “Do you want to talk about it?”

“That way doctors and nurses and so on don’t have to reach out,” Kaye says. “The call comes to them and no one is singled out.”

At the clinician’s discretion, that outreach may lead to a face-to-face discussion followed by recommendations to a program or psychologist that best suits their needs.

“Just culture” business philosophy, which mitigates much of the worry, stress and burnout otherwise associated with its deny-and-defend counterpart, is the foundation for any successful CRP and is essential to organizational wellness.

Conversely, burnout is a product of the shame-and-blame, deny-and-defend culture of secrecy that takes an emotional, debilitating toll on clinicians by forcing them to internalize mistakes while facing the threat of malpractice lawsuits and lingering litigation that can haunt them for years.

“I have friends who are doctors who worry about lawsuits all the time,” Kaye says. “Being a defendant in a lawsuit is devastating to a doctor. I also have friends who have a lot of interaction with the health care system as patients, and it seems as though there were no winners from the status quo.”

That is, some say, there are no winners in deny-and-defend error practice.

Although there is a trend toward the organizational acceptance of CRP and its principles, there remain physicians and nurses “who might be suffering from PTSD [post-traumatic stress disorder] after some of these really upsetting incidents,” says Albert Wu, a Johns Hopkins professor and editor of the Journal of Patient Safety and Risk Management who is considered by his peers to be among the early pioneers of CRP.

CARE FOR THE CAREGIVER

Organizations can demonstrate support for caregivers by developing and implementing a Care for the Caregiver program, which includes a process for clinicians to quickly access support and guidance following a patient harm event.

Developed by the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality, it is part of the Communication and Optimal Resolution toolkit widely used in CRPs.

Key steps for CFC team infrastructure:

  • Creating a business case and budget for the team.
  • Defining how services will be activated and delivered.
  • Creating a deployment timeline.
  • Recruiting team members.

“People have trouble going back to work; they say it’s like going back to a war zone.” Wu says. “You need to treat disclosures so that [clinicians] feel really safe and supported. We don’t have enough training in general yet, and we certainly don’t have enough support for second victims.”

As “second victims,” clinicians might feel personally responsible for patient outcomes — that they have failed the patient, according to the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality. They also might begin second-guessing their clinical skills and knowledge base. And Wu cautions that angst-ridden, unsupported staff can perpetuate a cycle of low morale, high turnover and poor patient care.

Despite its wellness benefits, CRP remains such a radical departure from deny-and-defend that many physicians remain fearful of open communication with patients after adverse events.

“They may feel they’ll be punished by their organization and may wind up in a lawsuit, which they certainly might,” Wu concedes, “but the consequences are likely to be much more severe if there really is a lawsuit and if they do not disclose.”

He says that clinicians need assurance that the organization’s just culture is in fact nonpunitive — “a feeling that you’re not going to be punished for telling people what’s going on.”

The Agency for Healthcare Research and Quality estimates that one in seven patients is affected by adverse events, and as many as half of all clinicians will be involved in at least one serious adverse event during their careers. Such a high probability should serve as a warning to physician leaders to explore the wellness benefits of CRP or else run the risk of correspondingly high rates of burnout and costly retention issues.

“I think hospitals and health systems that are still in the days of blame-and-shame are really behind in the game,” says Beth Daley Ullem, founder and president of Quality and Safety First, which advocates for patients’ quality health care. “It’s just an unhealthy way to deliver healthy employees, and it’s an unhealthy way to try to give care.”

As more hospitals transition to “just culture,” CRP is helping physicians rediscover the joy in their work, she says, and “is something that they need to think about.”

“It really impacts your care and improvement as an organization, and people’s joy in work,” Daley Ullem says, “so why wouldn’t you do something that’s going to give people care and make most of your employees want to come to work every day? That’s a win-win.”

Andy Smith is a staff writer for the American Association for Physician Leadership.

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