Confluence Health
Project Name/ Title: CRP
Point of Contact: Randal Moseley, MD, FACP, FHM, Medical Director of Quality | randal.moseley@confluencehealth.org

About Confluence Health

Confluence Health is an integrated healthcare delivery system located in North Central Washington. We serve a population of about 250,000 dispersed over 12,000 square miles. Our resources include two hospitals, 13 clinic locations, over 270 physicians covering more than 40 medical specialties and primary care, and 150 advanced practice clinicians.


Starting the Journey: CRP Foundations
Communication and Resolution Programs (CRPs) consist of a bundle of strategies to improve response to patient harm events, learn from them, and execute needed changes to prevent similar events in the future. In our quest for a best practice way to handle patient harm events in our system, we found CRP strategies to be culturally very compatible with Confluence Health quality philosophy.

To implement CRP strategies into our system, we began by educating leadership and key operational personnel in CRP principles and methods, and now have top executive support to adopt CRP as the foundation for the majority of our incident response and quality improvement activity within our facilities.

From what we’ve learned, the CRP journey requires:

  • Making a commitment to transparency with patients
  • Employing rigorous event analysis using just culture and human factors principles
  • Supporting the emotional needs of the patient and care team affected by the event
  • Proactively seeking appropriate financial and non-financial resolution for patients
  • Continuously assessing the impact of the program


From Vision to Action: Essential Building Blocks
Our core action team leading this work is called the Culture of Safety Committee, with representation from incident management, quality improvement, and members of the senior leadership team. We have used the “key steps” list from the Collaborative for Accountability and Improvement for our roadmap, and these are the lessons and tools we’ve employed:

1. Facilitating the Initial Response:
It is important to have an engaged workforce that is not hesitant to report patient harm events quickly. To gain the confidence of employees, it is critical to operate with just culture principles and a human factors perspective when approaching error events. While this foundation is critical to the success of CRP implementation, this cultural environment is impossible to create quickly. At Confluence, we had a fortunate accidental segue into CRP needs – we had been working on a “speak up” program from the beginning of our organization in 2013.

Our event reporting system, Quantros, gives the option of confidential reporting without alerting the normal management structure to the identity of the reporter, but we discourage truly anonymous reporting due to the information limitations that anonymity creates.

To address immediate clinical, safety and patient/family support needs that may arise with an adverse event, we utilize our “Now” call system. This consists of a rotation of senior leadership team members being available 24/7/365 to respond to serious events within 30 minutes. All members of the organization are empowered to report harm events and serious safety concerns as a “Now” call. Responding senior leadership have the authority to quickly marshal any needed resources the situation may require.

We also recognize the critical importance of having an effective and rapid disclosure discussion with patients and their families following such events. To build on our existing strengths in transitioning to a CRP system, we will soon be training the “Now” call responders to coach providers through this conversation.

Creating a system to meet the emotional needs of the care team involved in the event is a challenge. Our research revealed that Employee Assistance Programs typically fall short of the task, but we could not find a successful system to duplicate that we felt would effectively meet our ideals. In an effort to resolve this challenge, we engaged our Behavioral Health service line to design a system of our own that will involve trained peer support as well as professional Behavioral Health follow up if needed. We also recently hired a PhD psychologist to direct this effort.

Our Incident Management group integrates functions of patient relations as well as risk management. They are involved early in an event to monitor and respond to patient and family needs, facilitate ongoing communication, place holds on bills, and initiate the Root Cause Analysis and Action (RCA2) process.


2. Adopting Patient Safety and Quality Improvement Activities:

At Confluence, we have adopted the National Patient Safety Foundation RCA2 system. This resource gives a step-by-step guide to implementation of an updated root cause analysis process, and we follow it very closely. We have been impressed by the effectiveness of this method in rapidly gaining actionable information versus traditional root cause analysis techniques. Our Quality and Incident Management teams work together to implement needed changes revealed by this process, engaging all those affected. However, we have difficulties with ownership and accountability, and following up to be sure that change sticks can be challenging. To address this, we have created a new Quality Leadership Council to more effectively coordinate, track, and measure the success of improvement initiatives.


3. Continuing Patient Engagement and Movement Toward Resolution:
Navigating legal and financial factors consistently and appropriately is key to the process. By CRP principles, when all of the facts are known, our goal is to make a proactive offer of fair financial and non-financial resolution for all harm events. Most health care organizations do this at least some of the time, so it is not an unnatural stretch to consider this for all harm events. One of the main roadblocks we face, and that is faced on a national level, is how to appropriately engage patient legal representation that understands and is supportive of this process.


4. Disseminating Post-Event Patient Safety and Quality Improvement Lessons Learned:
How best to communicate the teachings gained through this process is also an important consideration for us. Currently, we try to engage all those who could benefit by lessons learned through our quality improvement process. However, it is sometimes difficult to identify all those who might benefit from this information. The ideal way of disseminating this valuable information is a current work in progress.


We hope our work will place us in a position soon to take advantage of the WPSC’s new CRP Certification Program.


This is not a simple journey, but there are extensive resources available to assist any organization that wishes to create an effective CRP. We encourage others to promote CRP methods in their institutions. It not only is the right thing to do for our patients, but also represents a huge step forward from the traditional “deny and defend” approach to healthcare errors.