Free Patient Safety Tools With Proven Results From MedStar Health’s IQS CANDOR Program
At last month’s 7th annual World Patient Safety Summit, the expert “Hospital Leadership Panel” discussed the need for open transparency by hospital systems regarding their medical errors. During the presentation, the MedStar Health’s Institute for Quality and Safety developed CANDOR (Communication and Optimal Resolution) program through the Center for Open and Honest communication in Healthcare, was shared as a shining example of ownership by a hospital system regarding medical error. The panel agreed that recognition, ownership, and transparency of the issue was the only way to guard against such errors from taking place again. Today we take a look at the importance of transparency when dealing with medical errors with a closer look at MedStar’s CANDOR program, which has shown to provide a 74% reduction of serious safety events and a 55% decrease in total medical liability costs.
Hospital Leadership Panel on Transparency
Dr. Mayer, Executive Director of MedStar Institute for Quality & Safety, started by asking the panel if hospital legal departments can win 90% of cases, what incentive is there for c-suite executives to take responsibility? “Even though 70% of claims and costs go to lawyers” he added. To start the process of moving beyond litigation, he said that healthcare providers have to be open and honest with themselves. Savings come later from better care, not from malpractice legal strategies.
He then shared about the CANDOR (Communication and Optimal Resolution) program, a foundational element of the comprehensive patient safety program at MedStar Health. CANDOR, along with a commitment to fostering a learning culture, the principles of high reliability organizations, and a systems approach to identifying, examining, and resolving weaknesses in our system are hallmarks of the MedStar safety program. CANDOR itself is a paradigm shift from “delay, deny and defend” to early communication with patients and families leading to timely resolution and systems improvements where appropriate.
Dr. Kachalia, MD, JD Senior Vice President at Johns Hopkins Medicine and Director Patient Safety and Quality at the Armstrong Institute of Patient Safety and Quality, explained that disclosure is becoming more prevalent, and that in fact, in many cases after starting transparency programs, litigation costs go down.
As a lawyer, Jon Schochor JD, Senior Managing Partner at Schochor, Federico, & Staton, shared that it is not so much the medical error that brings patients and their families to lawyers. Rather, victims come to lawyers because the hospital system turns against them when they need the help most; ignoring them, or lying to them. Read more on the panel discussion on hospital transparency or watch the entire panel below:
Supported by the MIQS Center for Open and Honest Communication in Healthcare, CANDOR (Communication and Optimal Resolution) is a foundational element of the comprehensive patient safety program at MedStar Health. CANDOR, along with a commitment to fostering a learning culture, the principles of high reliability organizations, and a systems approach to identifying, examining, and resolving weaknesses in our system are hallmarks of the MedStar safety program. CANDOR itself is a paradigm shift from “delay, deny and defend” to early communication with patients and families leading to timely resolution and systems improvements where appropriate. Quality management in healthcare means ownership of the responsibility when something goes wrong.
Unexpected patient harm is far too common, and the response typically fails to meet the patient’s and family’s needs, or promotes learning that could prevent future harm. Communication and Resolution Programs (CRPs), like CANDOR, are a principled approach for responding to patient harm. They are an integral component of an effective, empathic patient safety and quality improvement program, implemented for the benefit of patients, care professionals and our healthcare communities.
Driven by the transformative policies of President Barack Obama, a new CRP resource, the CANDOR (Communication and Optimal Resolution) Toolkit, was recently published by the Agency for Healthcare Research and Quality (AHRQ). MedStar Health was a leader in the development and testing of the CANDOR Toolkit, and was selected as the largest CANDOR pilot site because of its demonstrated commitment to open and honest communication with patients and families when serious, unanticipated outcomes occur. MedStar has fostered a culture of transparency throughout every patient interaction, relying on a just culture and a state-of-the-art event review process engineered by human factors experts to learn from every event. These same cultural tenets are the basis of MedStar’s high reliability journey, and this foundation was intentionally built in order to achieve the system-wide goal of zero preventable harm.
CANDOR Consulting Available
Because MIQS faculty were intimately involved in the development and dissemination of the AHRQ CANDOR Toolkit, they have been asked by a number of health systems across the country and around the world, to share their approach to implementing the tenets that support a CANDOR approach to patient harm. Their training consists of dynamic workshops and consulting on the following, and they have now worked with a number of clients, tailoring their approach to meet the needs of each individual organization.
CANDOR Results Include Stats such as:
- 112% Increase in Event Reporting
- 27-Fold Increase in Event Reviews
- 74% Reduction of Serious Safety Events
- 55% DECREASE in Total Medical Liability Costs
- 42% Decrease in Claims
- 47% Decrease in lawsuits
MedStar medical error victim Jack Gentry, joined the panel to share that although his heart breaking experience at MedStar left him quadriplegic, the immediate communication and apologies from the doctors, risk management team members, and hospital executives helped him start his healing process. By being open and transparent not only with the patient and the family, but also amongst themselves, is the most important aspect of such errors — so that something can be learned from the unfortunate circumstance.