Back in 1999, the U.S. Institute of Medicine issued the landmark report—To Err Is Human: Building a Safer Health System―that shined a spotlight on the number of medical errors and their associated costs to the healthcare industry, including the deaths of millions of people from harmful events. It also created what could be considered “the constitution” of patient safety—or the guiding principles and safe practices―to improve patient safety and quality care.
Ten years later, in 2009, the Agency for Healthcare Research and Quality distributed $23 million in grant funding aimed at studying the interface between patient safety incidents and medical liability. Based on the preliminary research, AHRQ funded the development of the Communication and Optimal Resolution (CANDOR) Toolkit—further “amending” and solidifying the framework to reduce patient harm while mitigating liability. This toolkit provides guidance for hospitals and health systems to respond in a principled way following a harmful patient event, including the importance of honestly engaging patients and families, providing care for the caregivers, learning from the incidents, revising an organization’s processes, and resolving them for the benefit of all involved.
Now, 20 years after to Err is Human, and 10 years after the development of CANDOR, we are at a new inflection point. As a result of the recent Coronavirus pandemic and a report from the Chinese Center for Disease Control and Prevention, the JAMA Network has released next steps—or further amendments—to the patient safety constitution. Among those steps are improving international surveillance, cooperation, coordination and communication.
But the questions are, how is all of this accomplished when every hospital and health system is different and made of disparate systems, processes and people? And, ultimately, why are we doing this?
What has become blindingly clear is the need to bring together the hearts and minds of everyone at all hospitals and health systems to pursue the elimination of preventable harm, mitigate the impact of adverse events, learn from them, openly communicate and change internal cultures.
The Relationship between Patient Safety and Risk Management
It’s a simple fact that we can’t fix what we don’t know. After the “To Err is Human” report and with the aid of advanced technologies, health care institutions have collected vast amounts of data. It can be argued, however, that this data is not being used effectively. This past fall, many articles and reports were issued acknowledging that—although a lot of data has been collected—there still remains a lot to do on the patient safety front.
It’s also incredibly difficult to mitigate risks without a thorough review and understanding of all the curated data. Getting to that singular understanding, however, has been challenging since patient safety and risk management have traditionally been separate functions within the healthcare setting. For example, patient safety data may tell us that an event occurred. But that’s not sufficient. We must now analyze the events and the associated data, and then openly share the lessons learned, within and across healthcare institutions to prevent those harm events from happening again.
There must also be a deep understanding of the information as it relates to the CANDOR toolkit – especially how an organization actively learns from its data and uses it to reliably improve the organization’s processes for communicating with patients, families, and caregivers. Organizations must have the right consultative tools to factor in the “human touch” as well as a comprehensive and principled approach to preventing future patient harm.
Open and honest communication
Traditionally, after an adverse event occurs there’s been a wall of silence due to fears of a shame and blame culture and potential litigation. While understandable on one level, this wall inhibits potential learnings and information sharing within the institution and the healing that needs to occur. Indeed, what we need is the complete opposite.
Hospitals and health systems should help in adopting and implementing the components of the CANDOR toolkit while embracing the concepts of open and honest communications—with each other inside the healthcare institution, with patients their family members and their loved ones.
Through this transparency, we can maintain and begin to build trust that’s been lost back into provider and patient relationships, which is critical after a harm event has occurred. Open, honest and clear communication also fosters deep, meaningful relationships with patients and their family members, who could be severely impacted—mentally and emotionally—after a patient safety event has occurred. Frankly, it’s the right and just thing to do.
This starts first with preparing physicians and care teams to have difficult conversations with patients, families and loved ones. Although many institutions fear that this form of open and honest communication might lead to a disastrous increase in litigation and potential financial ruin, it has been demonstrated that over time, honesty and openness result in improvement in learning after events and less litigation and financial risk to the health delivery institution.
Also important is providing emotional first aid to the members of the care team, especially when unexpected—and often traumatic—outcomes occur. Support is crucial, and when it’s offered with compassion and sincerity—supported by the institution—we strengthen organizational cultures and optimize their capacities to learn from patient harm in order to reduce the instances in the future. The critical need for this type of support has been highlighted by the current pandemic that is ravaging many healthcare institutions and senior living facilities.
There’s now abundant evidence that using an open communication and resolution approach to patient harm is associated with improved patient safety processes, including incident reporting and reduced medical liability outcomes such as statistically significant reductions in numbers of lawsuits, legal fees and settlement costs. In a 2016 article published in Health Services Research, my peers and I studied the University of Illinois Hospital and Health Sciences System and the impact of its communication and resolution approach to patient harm on patient safety processes and medical liability outcomes. In that article, we reported an increase in incident reports, interdisciplinary event reviews with associated process improvements, communication with patients and families following harm, and a statistically significant reduction in numbers of lawsuits, legal fees and settlement costs. No research article has shown an increase in liability with an open and honest approach.
Where the heart meets the mind
This is an exciting time as we enter the next generation of patient safety. Integral to that will be bringing together technology and tools along with the training and support to roll out new programs that improve patient safety and quality care throughout the healthcare institution. By hardwiring the appropriate techniques, learnings, communications and information sharing into the software that exists at health delivery organizations, we can help them to make greater returns on the investments they’ve made.
Fortunately, based on key findings from CANDOR, along with customized training programs, we are now able to successfully create cultures of trust throughout any and all hospitals or health systems. By vertically and horizontally working with all constituents within the health delivery ecosystem—hospital leadership, administrators and staff—we can collectively bring their hearts and minds together for greater patient good
Be the first to learn how RLDatix can help your organization adopt the CANDOR approach. Visit RLDatix.com.