Table 4

Factors facilitating successful implementation of CARe programme

FacilitatorIllustrative quotations from interviews and conference call notes
Support from top institutional leaders and risk managers
  • ‘I think that there’s a very strong commitment in this institution to the CARe programme and to the process and to doing the right thing for our patients and our providers. I don’t question that at all. The commitment is clear.’ (Baseline interview, small hospital)

  • ’You’ve got to have somebody who’s got boots on the ground …. who’s going to direct this and take ownership and make sure that it’s going to happen. … If you look at [senior clinical leader], he clearly takes ownership of this for this hospital. … People have to own the challenge to make it happen or it’s just going to fizzle away.’ (End-of-project interview, large hospital)

Heavy investments in engaging physicians
  • ‘[Project staff member] kept a list of every single clinical department and was relentless about asking us, “Did we get to that clinical department?” …[Y]ou really need that. It's like a political campaign.’ (End-of-project interview, large hospital)

  • ‘Extensive education throughout organization for medical staff—during CME and medical committee meetings, as well as communication to those who could not attend these. Several sessions for non-medical staff; approximately 90% are apprised of program. Greatest concerns [are] from medical staff and what it would mean for them.’ (Conference call notes, small hospital)

  • ’It seems to need to be constantly reinforced. … We have posters. We have cards that go on people’s badges. … It’s part of the orientation of every new provider and certainly of our residents … So the education piece is ongoing and very necessary to keep the awareness on the front burner….’ (End-of-project interview, large hospital)

Active cultivation of the relationship between hospital risk managers and insurer representatives
  • ’That “Yes, we really are potentially going to pay a lot of money in a situation where we have no letter from an attorney,” that’s a big cultural change. … It has to have the insurance company standing right by your side.’ (End-of-project interview, small hospital)

  • ’[Hospital representatives] have a very, very good relationship with the claims reps and they trust each other. I feel like without that, it would be really hard to do this. The relationships have a lot to do with it.’ (End-of-project interview, large hospital)

  • ’It’s more of a collaborative relationship that only works I think because there’s mutual respect for our assessments and for their assessments. We can have what I consider to be sometimes heated but scholarly discussions about each particular case.’ (End-of-project interview, large hospital)

Use of formal decision protocols and structures
  • ‘I think the objective classification of harm was very helpful. …That NCC MERP scale has just been adopted across the organization. … You’ve got to be objective. … The algorithms are important. It’s nice to be able to go back and have this not be “Because A said so” that this is the case, but it’s like, the algorithm. … “this happened and it is this harm severity”.’ (End-of-project interview, small hospital)

  • ’There’s a weekly huddle that happens between the quality, [insurer], and risk folks so in a sense they can run their cases: “What do you know? What do I know?”’ (End-of-project interview, small hospital)

Oversight and assistance from project managers
  • ‘They are keeping my staff … to task with the communications. They’ll say, “Do you think we’ve met the standard of care on that one?” And they’re just riding, they’re riding them.’ (End-of-project interview, large hospital)

  • ’Like so many things in healthcare, you spend your day dealing with the firefighting and the tyranny of the urgent. Unfortunately this [CARe] requires some maintenance and a steady rhythm … [project manager was instrumental in] sustaining that commitment to us all getting together to talk … And pushing out and writing the brochures and writing up the best practices. … If we’d had to write them or pull ourselves together to create it, it wouldn’t have happened.’ (End-of-project interview, small hospital)

  • ’I don’t think we can just leave it up to the risk managers and claims [managers]. We’re going to need somebody that sort of is the glue between them.’ (End-of-project interview, large hospital)

Group implementation
  • ‘It has been helpful to be doing this alongside other institutions. The shared learning and the ability to discuss situations with other institutions was very helpful, especially other local institutions who understand the state systems and the other state entities. … I would encourage others to think strongly about that model just because there’s a lot of times when it’s not in the manual what you should do next or what’s the right way to approach a case.” (End-of-project interview, large hospital)

  • ‘I think a whole group of people that really believe in it, I think that’s what carries us on.’ (End-of-project interview, small hospital)

  • ’The [hospital] system, CARe and the MACRMI initiative coming together, other facilities and learning from them in terms of how CARe approached various events that might occur, that was helpful. That was supportive.’ (End-of-project interview, small hospital)

Small hospital size
  • ’I think if you were in a big 180-bed hospital and people don’t know each other by their first names and it hasn’t got that sort of small-family feel, I think in fact it would be tougher and you would need a larger army of disciples.’ (End-of-project interview, small hospital)

  • ’We all really know each other well. …To do something it doesn’t take up and down the chain of command like it would at a larger organization sometimes. Just our smaller size where folks are seen, we’re visible, we’re out there. … But that said, we have the incredible support of [the hospital system and AMC].’ (End-of-project interview, small hospital)

  • ’The benefit of [small size] is that it is a core group of individuals … It also allows us to move cases much more quickly. … The benefit as well is that when you have a contact person from the patient to the hospital, they [patients] become familiar with that person. They have a connectedness to that person. They learn to trust you.’ (End-of-project interview, small hospital)

  • AMC, academic medical centre; CARe, Communication, Apology and Resolution; CME, continuing medical education; MACRMI, Massachusetts Alliance for Communication and Resolution following Medical Injury; NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.