Taken in sum, what can the health care and policy communities learn from the PSML initiative? Clearly, the PSML demonstration projects generated a series of tools, training modules and curricula, program models, evaluation instruments, products, and other materials, and many of these have the potential to spur or assist in the replication of PSML interventions elsewhere and in the development of additional innovations. Moreover, preliminary findings from several of the PSML demonstration projects suggest positive (and in other cases, promising) outcomes associated with some facet of the interventions, either in terms of patient safety performance, malpractice risk/claiming, or both. An equally important aspect of the learning generated by the PSML demonstration projects involves the barriers and challenges encountered, as well as the facilitators that enabled progress, as much as any of the research findings and products generated by the projects. Put another way, the reasons why the PSML demonstrations were difficult to carry out may be at least as instructive to future efforts in this arena as are the tools and documented successes of the portfolio itself.
In this vein, it is important to recognize that the initial plans for the PSML portfolio (dating back to AHRQ’s original request for proposals and request for applications) implicitly assumed that (1) all the PSML projects would tie patient safety and malpractice liability together in basically similar ways in their interventions, such that common performance metrics could and would apply across projects; (2) national data resources for both patient safety and malpractice outcome variables would be available and appropriate for the projects to draw upon for use in the evaluation; and (3) the 3-year grant period would allow sufficient time for grantees to implement the demonstration projects and collect and analyze data on all relevant outcomes. None of these initial assumptions were realized in practice. Partly in consequence, results across the PSML portfolio cannot easily be reduced to a simple “box score.” Further, such a measure would not be the best way to understand what these seven demonstration projects actually did or to summarize what was learned from them.
While some of the initial expectations were unrealized and formal outcomes data and analysis from the PSML projects are limited, the projects have nevertheless contributed many useful and important learnings to the field’s knowledge base. For example, several of the PSML projects have done useful piloting, replication, and dissemination work on DRPs. The projects have helped to identify the conditions under which such programs can readily be adopted, as well as conditions under which their adoption becomes more difficult. The projects have demonstrated that under optimal conditions, DRPs can produce measurable, positive impacts on a series of patient safety and liability outcome measures. They also have demonstrated that under suboptimal conditions, DRPs can be quite difficult to implement, different stakeholder groups may have understandably different perspectives regarding the attractiveness and risk implications of DRP, and the early offer (or “resolution”) component of DRPs tends to be more difficult to carry out than the disclosure (or “communication”) component.
Other PSML projects focused on documenting the impact of a combined package of safety, communications, and training interventions in high-risk clinical settings (particularly around obstetrics practice) and the potential for improving both clinical and malpractice outcomes as a result. These projects showed that the implementation of specific patient safety interventions (and/or the standardization of clinical care through “best practices”) may indeed be associated with corresponding improvements in patient safety performance, and with at least suggestive findings that malpractice risk may be positively affected as well. That said, these projects also demonstrate that the relevant measures of patient safety outcome may be fairly specific to the clinical settings being studied; by extension, any related malpractice effects may need to be aggregated across settings and across time to be detectable.
It bears repeating that the wealth of toolkits, surveys, training modules, and other materials constructed and validated by the demonstration projects during the grant period represent some of the most important products resulting from the PSML initiative. Several projects developed Web sites that house intervention materials developed through their PSML demonstration grant. For example, the UW HealthPact Web site (http://www.healthpact.org/) offers HealthPact materials used for team communication training, disclosure coach training, and the Communication and Resolution Program (e.g., implementation, training, and evaluation material).
Other projects developed dissemination materials based on their experiences with the demonstration. One example is PROMISES, which created a four-page document and companion video that provides guidelines for outpatient primary care practice staff on how to communicate with patients after an error has occurred and has caused the patient harm. The tool, “When Things Go Wrong in the Ambulatory Setting,” contains “tips and suggested language for communicating with the patient, and responses to frequently asked questions about how to communicate, provide an apology, and offer needed emotional support” (http://www.macrmi.info/blog/valuable-tool-when-things-go-wrong-ambulatory-setting-guideline-communication-and-resolution-outpatient-practices/#sthash.jLyop6cm.dpuf). Demonstration projects also developed tools related to the patient experience. As previously described, the UT project constructed the patient-centered interview tool, IMproving Post-event Analysis and Communication Together (IMPACT) for eliciting patient and family perspectives on their harmful events. The Ascension Health project created a video on high reliability principles and the effects of disclosure, with highlights from parents of an infant injured from birth trauma. It relays the story of a family whose child was injured during labor and delivery at an Ascension Health hospital and how the organization responded to the family and involved staff members. A description of tools and other products developed by the PSML demonstration projects are described in the grantee profiles (Appendix A).
Finally, several of the PSML demonstration projects fundamentally sought to influence one or more elements of institutional culture (i.e., collective attitudes, practices, beliefs). Across projects, the nature of the “culture” focus varied. In some, for example, the focus was on error disclosure culture and factors that contribute to better uptake and fidelity in disclosure practice. In other projects, patient safety culture in clinical settings was emphasized. Regardless, “culture” was an interesting focus for intervention in several respects: (1) it is a mediating variable that does not directly translate into either patient safety or malpractice outcomes, (2) it nevertheless has the theoretical potential to influence both of these outcomes, and (3) the best way to measure it may depend on the goals of each specific PSML demonstration project. The experience of these projects in changing and measuring patient safety-related culture has relevance not only to the impact of the PSML portfolio but also more broadly to the design and assessment of future interventions in the patient safety and malpractice policy space.