Communication to Prevent and Respond to Medical Injuries: WA State Collaborative

描述（由申请人提供）：有效的团队沟通是安全护理的关键因素。这对于预防医疗伤害和应对发生的伤害至关重要。当医疗伤害确实发生时，医疗保健提供者和患者之间的公开沟通，包括适当的赔偿，是道德上的当务之急。然而，公开的沟通是例外，而不是常态。华盛顿州为改善医疗保健沟通提供了独特的环境，包括在受保护的环境中共享护理数据质量的全州基础设施，为同行领导的系统变革提供支持;患者安全和质量改进的国家领导人;以及医生保险，为该州一半以上的医生提供保险。因此，在州长克莉丝汀·格雷瓜尔、美国参议员帕蒂·默里和玛丽亚·坎特韦尔、医生保险公司以及主要州利益相关者的支持下，我们提出了一个示范项目，其具体目标如下： 1.在整个华盛顿州建立多方利益相关者协作机制，以加强沟通，预防和应对医疗伤害。 2.在10个合作医疗机构实施强化沟通培训，以预防和应对医疗伤害。 3.制定并评估这10家合作医疗机构中的5家与医师保险公司之间的不良事件分析、披露和赔偿合作方法。 4.通过交互式电子学习模块在全州范围内传播沟通培训，并评估其对患者安全和医疗事故责任的影响。 在利益相关者会议之后，我们将与10家医疗机构合作，通过在外科临床结局评估计划（SCOAP）中创建一个新模块来跟踪通信敏感事件（CSE），该模块将测量CSE（NQF Never事件，用药错误，检查表失败）。利用这些数据，我们将为医生、护士和药剂师提供定制的沟通培训，以预防医疗伤害（TeamSTEPPS）、高级冲突解决方案（Advanced Conflict Resolution）以及在医疗伤害后与患者沟通。培训的有效性将通过一个基于网络的事前事后评估进行评估。我们还将衡量培训对通信敏感事件的影响。此外，Physicians Insurance和五家合作医疗机构将实施一种创新方法，在多机构、多保险公司的环境中对患者进行联合不良事件分析、披露和赔偿。最后，通信培训将通过电子学习模块在全州范围内传播。我们的团队包括患者安全沟通（托马斯Gallagher，医学博士），质量改进（大卫Flum，医学博士，公共卫生硕士），团队沟通（Brian Ross，医学博士，博士），医疗事故索赔（Michelle Mello，博士，法学博士），跨专业合作（Brenda Zierler，博士，注册护士）和评估（道格拉斯Brock，博士，Beth Devine，博士，MBA，PharmD）的国家领导者。 公共卫生相关性：有效的团队沟通是安全、高质量医疗保健的关键因素。然而，这种公开的沟通，特别是关于不良事件和错误的沟通，是例外而不是常态，向患者提供快速和公平的赔偿也是如此。我们建议创建一个全州范围的倡议，涉及医疗工作者的沟通培训，并与医院和医疗事故保险公司合作，以改善不良事件分析，披露和赔偿，以加强医疗保健沟通的文化，提高患者安全和减少医疗事故责任。

DESCRIPTION (provided by applicant): Effective team communication is a key ingredient of safe care. It is essential for preventing medical injuries and responding to injuries that take place. When medical injuries do occur, open communication between healthcare providers and the patient, including compensation when appropriate, is a moral imperative. Yet open communication is the exception not the norm. Washington State provides a unique environment for improving healthcare communication, including a statewide infrastructure for quality of care data sharing in a protected setting that feeds a peer-led approach to system change; national leaders on patient safety and quality improvement; and Physicians Insurance, which insurers over half the state's physicians. Therefore, with the support of Governor Christine Gregoire, U.S. Senators Patty Murray and Maria Cantwell, Physicians Insurance, and key state stakeholders, we propose a demonstration project with the following specific aims: 1. To create a multi-stakeholder collaborative across Washington State to enhance communication to prevent and respond to medical injuries. 2. To implement intensive communication training to prevent and respond to medical injuries at 10 partner healthcare institutions. 3. To develop and evaluate a collaborative approach to adverse event analysis, disclosure, and compensation between 5 of these 10 partner healthcare institutions and Physicians Insurance. 4. To disseminate the communication training statewide via interactive e-learning modules and assess its impact on patient safety and malpractice liability. After stakeholder meetings, we will partner with 10 healthcare institutions on tracking communication-sensitive events (CSEs) by creating a new module within the Surgical Clinical Outcomes Assessment program (SCOAP) that will measure CSEs (NQF Never Events, Medication Errors, Checklist Failures). Using these data, we will provide customized communication training for physicians, nurses, and pharmacists to prevent medical injuries (TeamSTEPPS), advanced conflict resolution) and to communicate with patients after medical injuries. The training's effectiveness will be assessed with a pre-post Web based assessment. We will also measure the training's impact on communication-sensitive events. In addition, Physicians Insurance and five partner healthcare institutions will implement an innovative approach to joint adverse event analysis, disclosure, and compensation for patients in a multi-institution, multi-insurer setting. Finally, the communication training will be disseminated state-wide via engaging e-learning modules. Our team includes national leaders in patient safety communication (Thomas Gallagher, MD), Quality Improvement (David Flum, MD, MPH), Team Communication (Brian Ross, MD, PhD), Malpractice Claims (Michelle Mello, PhD, JD); Interprofessional Collaboration (Brenda Zierler, PhD, RN), and Evaluation (Douglas Brock, PhD, Beth Devine, PhD, MBA, PharmD). PUBLIC HEALTH RELEVANCE: Effective team communication is a key ingredient of safe, high quality health care. Yet such an open communication, especially around adverse events and errors, is the exception rather than the norm, as is the provision of fast and fair compensation to patients. We propose to create a statewide initiative involving communication training of healthcare workers and a collaborative with hospitals and a malpractice insurer to improve adverse event analysis, disclosure, and compensation, in order to enhance the culture of healthcare communication to improve patient safety and decrease medical malpractice liability.