CANDOR Comes to Arkansas: A Candid Approach to Care

May 5, 2020 Dr. Tim McDonald, MD, JD and Ryan Solomon, JD

Is your health care organization known for speaking openly and honestly, frankly, directly, and sincerely with patients, families and employees? Especially when a patient harm occurs, are you known for communicating quickly, truthfully, with compassion and with candor?

Though health care has straightforwardly tackled preventable harms in the two decades since To Err is Human was published, experts still believe that medical errors represent the third leading cause of death in the United States. (Heart disease and cancer are numbers one and two.) 

Though the goal of zero harms remains elusive, areas of excellence continue to emerge, and health care organizations are making great strides in patient safety and quality. Hospital leaders around the country continue the search for solutions that will eliminate preventable harms and hardwire a safety culture within the industry.

A NEW NORMAL

Arkansas Children’s is among the leaders in improving patient outcomes and safety and the system adopts specific programming to this end. During the last five years, the health system has assembled a team relentlessly focused on creating a culture of safety. 

Together, team members have reduced serious safety events by more than 80%. Marcy Doderer, President and CEO of the system, so firmly believes in creating cultures of safety that she advocates nationally for transparency in all aspects of patient safety reporting. She believes that full transparency results in better patient outcomes and fewer employee injuries across the spectrum of health care organizations. “Empowering team members to establish a safety culture that values everyone, including patients and the team members who serve them, is essential,” she says.

Under her leadership,  the Arkansas Children’s team very recently implemented a program called “Communication and Optimal Resolution” (CANDOR). This highly specific, innovative program focuses on normalizing compassion and transparency while creating processes to improve care for patients and caregivers in all areas of the organization. 

Two years ago, members of the Children’s system first learned about CANDOR through Solutions for Patient Safety, a network of 135 children’s hospitals across the United States formed to reduce preventable harm.

Earlier this year, Doderer, along with clinical and enterprise risk leaders, hosted a week-long intensive training for more than 200 clinical, administrative and medical staff members focused on how to communicate with families and team members following harm events, helping them develop the ability to have difficult conversations. Employing both didactic learning and simulations featuring professional actors, the training had a profound impact on all who attended.

CANDOR'S ORIGINS

The CANDOR approach began with Dr. Steven Kraman’s 1999 report, which demonstrated the importance of open and honest communication and early financial resolution following harms in health care. Each harm event presents its own set of challenges, and Kraman wanted to do right by his patients in every instance and to help others do so by describing his experience of being transparent with patients and families from the outset. 

In the years that followed the report, organizations began to think differently about how to respond to harm events. The University of Michigan, in what has become known as “the Michigan Model,” provided convincing evidence for its principled approach following unexpected harm: It includes the two-fold approach of early, open, and honest communication coupled with resolution. 

The University of Illinois Hospital and Health Sciences System in Chicago also built its patient safety program on the same principles. In addition, this approach focused on the establishment of shared accountability, event reporting, event analysis, peer support, and process improvement – all aimed at preventing harm to patients.

Inspired by this work, the U.S. Agency for Healthcare Research and Quality (AHRQ) funded a series of patient safety grants to accelerate innovative approaches to reducing both preventable patient harm and medical liability costs. Based on data from these grants, AHRQ next funded the creation of a toolkit designed to provide a comprehensive response to patient harm. The toolkit, developed by a multidisciplinary and multi- institutional team, was released in May 2016 and named CANDOR.

“Every hour that passes without effective communication represents another harm.”

NUTS AND BOLTS

CANDOR represents a paradigm shift from a guarded, defensive posture to a more timely, open and honest response to patient harm. CANDOR emphasizes immediate, ongoing and transparent communication with patients and caregivers; a human-factors-based analysis and process redesign; and a fair, transparent resolution process with families. Its focus is on transparency, honesty, and improvement.

When an organization starts its CANDOR journey, it will initially conduct a readiness/gap analysis with the expectation of designing a customized roadmap for education and integration. 

Organizations seeking to adopt CANDOR should have a robust and established event reporting system in place. Accurate event reporting is vital to the identification of variances and events that should trigger a rapid response to harm. It will also help point out events that may benefit from immediate review, communication with patients and families, or the provision of emotional first aid for clinicians or other hospital staff. This includes the identification and reporting of unsafe conditions and “near misses.” 

The CANDOR toolkit and its successful implementation rely upon several critical components. Leadership engagement is imperative: in order for clinical leaders to understand how CANDOR differs from traditional risk management strategies, they need to know they are operating on the same set of principles as are their administrators and risk managers. 

Following a harm event, CANDOR’s signature rapid response protocol calls for quickly addressing patient and family members’ concerns. Every hour that passes without effective communication represents another harm.

CANDOR helps with the crucial step of identifying people within your organization who are skilled in empathic communication. CANDOR provides tools, including a communication skills assessment, that assist in the identification of these exceptional communicators who can consult with or coach other clinicians in complex, harm-related situations. 

Empathic communication training teaches that “disclosure” is a process rather than a single event, and organizational communicators integrate proactive, immediate, and ongoing emotional first aid for staff, as well as patients and families, into the organization’s wellness and resilience efforts.

CANDOR then helps with the process of human-factors-focused event analysis. With improvement as a core goal, event analysis can help organizations develop processes that both apply just culture principles and lead to sustainable improvement. And of course, resolution is also at the heart of every analysis.

RESOLUTION

With this foundation, organizations can apply the principles of shared accountability in their quest for sustainable improvement. Resolution - both financial and non-financial –  requires organizations to create processes for communicating the results of every event review, whether it reveals that care was appropriate or inappropriate. If inappropriate, the process for coming to fair resolution must be understood and implemented. (Support occurs regardless of the appropriateness of care.)

Taken together, CANDOR’s components provide a road map for the principled management of patient harm from the moment it occurs – through review of the event and emotional support of patients, family members, clinicians and other health care staff – until resolution and learning have taken place. 

This article first appeared in the Spring 2020 version of Arkansas Hospitals magazine, a publication of the Arkansas Hospital Association.

 

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