The Patient Safety Movement is recommending all healthcare organizations around the world implement the U.S. Agency for Healthcare Research and Quality’s (AHRQ) new CANDOR Toolkit that can help hospitals handle any situation where a patient gets harmed during care – regardless if a true error occurred.
The customizable Communication and Optimal Resolution (CANDOR) toolkit is the latest in a series of AHRQ materials to help teach, train and catalyze healthcare providers to build capacity to make care safer – and it’s available to hospitals and health leaders at no charge.
The CANDOR toolkit gives hospitals, health systems and clinicians the tools to respond immediately when a patient is harmed; to promote candid, empathetic communication; and to reach a timely resolution for patients and clinicians. It provides a framework to assess readiness; get buy-in from key stakeholders such as liability insurers; and expedite supportive, time-sensitive responses to unexpected patient-harm events.
The CANDOR process was developed by AHRQ with help from MedStar Health, which also ran the CANDOR pilot – implementing and testing the toolkit in 14 hospitals across three health systems – Christiana Care in Delaware; Dignity Health in California and MedStar Health in the Baltimore/Washington, D.C. metropolitan area – all of which plan to expand its use.
The toolkit was built using processes already working at hospitals and health systems around the country, like the University of Michigan Health System’s "Michigan Model” and the University of Illinois, Chicago’s “Seven Pillars” of patient safety:
- Occurrence reporting
- Assessment and investigation
- Disclosure and apology
- Process or performance improvement
- Data analysis
Seth Krevat, MD, assistant vice president for Safety and the leader in implementing CANDOR practices across MedStar, says a key element of the program’s success is a culture of transparency, and that those “key elements are buy-in from the top … and empowering our people through training, simulation and support.”
Training to empower its people comes in many forms at MedStar, which offers three kinds of training centered around CANDOR at its simulation centers, says Anne Nichols, a MedStar Spokeswoman. There is training to help prepare physicians and other clinicians for having difficult conversations with patients and/or their families, training for the Event Process Reviews held to understand what happened and make sure it doesn’t happen again, and training to support colleagues through grim events.
Support for colleagues, Nichols says, is an example of changing the culture to providing care for the caregiver. “Nobody comes to work on any given day with the intention of harming somebody. So when something like that happens – a physician makes an error or something goes wrong in a surgery and somebody is harmed – it is devastating, not only to the physician who is performing the surgery, but to the whole OR team.”
Disclosing an error with a colleague or an unexpected complication with patients and/or family members are all difficult conversations, so MedStar gives clinicians communication of disclosure and resolution training. “Having difficult conversations is something you have to practice,” says Nichols -- how to deliver these messages, how to be present, how to listen, how to give feedback, how receive feedback.” Employees get that practice by participating in simulations with standardized patients (actors) where they recreate – as stressful as possible – lifelike situations where the actors are prepped beforehand on how to react.
MedStar’s goal is for everyone to be able to respond. In the meantime – and because some people are just better at helping others through hard conversations, MedStar has Care Teams at each hospital made up of trained employees who are always available to help – it could be a nurse manager, a risk manager, a clinical chaplain, or a physician. And with patient safety in mind, MedStar’s human factors engineers are trained in conducting event process reviews – to learn from what happened, understand it, learn from it and ensure that it doesn’t happen again.
“Dealing with unintentional patient harm transparently and forthrightly is not only the right thing to do but is also critical to our ability to learn and make improvements to our care systems and processes,” according to David Mayer, MD, MedStar Vice President for Quality and Safety. “Since MedStar Health began using CANDOR principles as a key component of its safety program, the health system has seen its rate of serious safety events cut in half.”
Richard Boothman, J.D., who has led the University of Michigan Health System’s effort in his role as chief risk officer and executive director of clinical safety and helped AHRQ develop some of the toolkit’s materials, says “there’s real momentum behind this idea of transparency and learning, with the patient at the center. We’ve built a culture of admitting when we’re wrong, learning from our mistakes and apologizing — but also of defending appropriate care to the fullest.
“The ultimate goal is to be honest about unexpected clinical outcomes,” he says. “The patients impacted deserve it, our staff deserves it, and, most importantly, we will only improve by being honest and accountable.”