Table 4.

Interview Themes and Quotes by CERC Model Stage

CERC model stage	Theme	Quote
Pre-Crisis	Better facility preparation	Regional leader: “When this happens, it feels like everyone is scrambling. We need to figure out an approach and have it in place for when endoscopes or dental service or Katrina happened.”
Initial event	Creating rapid communications	Patient: “I was just surprised that the letter took so long and then the info in the letter was the same as what we had talked about on the phone—there was nothing new. I was expecting it to tell me when my appointment was.”
	Modifying language	Patient: “The first paragraph, last sentence, they say ‘discovered’ which seems like it was something new they just found out about. It had been going on for a long time. Then the last sentence ‘While we are deeply regret…’ that’s B.S. They’re trying to make like it was all one guy at fault but they covered it up for years. It took the VA a long time to get the right people to work on it.”
	Addressing perceptions of harm	Patient: “That was one of those that the first question pops in your mind. And the, you know, how ‘bout if it on me? Did I get, did I get contaminated or not? You know, that’s how you got scared…It is important that, you know, they got their record, they went through the process to find out who was and who was not. I think that was the right, the right procedure.”
	Reducing complexity	Facility leader: “One of the things is having one point of contact. There was a day when I gotten calls asking for the same piece of information. If there was one contact, I could have saved a lot of time responding to requests and only answered once.”
	Seeking assistance from others	Facility staff: “I reached out to.facility] because there was some stuff on the Sharepoint that [facility] had put together, but it really wasn’t enough detail to help us with the nuts and bolts of how to put this data plan together. So we kinda in secret called the clinical application coordinator at [facility] and said, you know, ‘what should we be looking out for, what are we not thinking about, how can you help us?’ And they were very helpful, incredibly helpful.”
Maintenance	Managing communication with others (media, elected officials, service organizations)	Facility leader: “We had a conference call for those who couldn’t join the in person meeting. I gave a full briefing and gave them firsthand information. We gave the bullet points on a handout. It was very helpful, more open. We had the right people at the table to answer their questions. There was no time limit for the meeting; I wanted to be sure they had all the info they needed
Resolution	Decreasing effect on staff	Facility staff: “The first m–, uh, month I had an enormous amount of anxiety. Um, I had no idea what I was doing. I was in a system that I was unfamiliar with and I just was overwhelmed. I was working probably 10 to 12 h a day 5 days a week and, um, it affected my home life.”
	Improving trust	Facility staff: “My feeling was that we did more harm to patients than we did good for them um, because the anxiety they went through the, and, and, and really big harm is the loss in trust in the facility.”
Evaluation	Addressing identified needs	Facility staff: “We’ve just bashed our head against the wall so many times with this and it’s just silly that, you know, we, that there isn’t a central clearing house of information—a set of, you know, recommendations everyone can follow.”