Our numerous columns on disclosure and apology after medical error (listed below) have stressed that such are not only the right things to do but in the long run help patients and families reach closure and help prevent other similar errors and adverse outcomes. In addition, that approach is now widely accepted as reducing litigation and malpractice settlements.
But the healthcare professions and organizations have
historically done a poor job in preparing individuals in providing disclosure
and apology. A new toolkit provided by AHRQ, the CANDOR toolkit, provides
excellent resources for organizations in this process (AHRQ
2016). CANDOR stands for Communication
and Optimal Resolution. The toolkit comes with 8 modules and an implementation
guide. The modules come with PowerPoint slides and videos that illustrate key
principles and speaker notes to guide the discussions.
start with identification of a CANDOR event and how to activate your CANDOR
Response Team. Ideally, activation of the CANDOR Response Team should begin
within 30 minutes after a CANDOR event has been identified. In addition to
initiating the fact-finding investigation of the event, a CANDOR Communication
Lead should be identified and immediate emotional support to the patient,
family, and caregiver should be provided, the latter by activating the Care for
Caregiver program. The CANDOR Response Team and/or CANDOR Communication Lead
are responsible for the initial communication with the patient and/or
family. The CANDOR Communication Lead coordinates all communications, and
ensures that all caregivers are consistent in their communication, i.e., that
they stay "on message." Following the initial disclosure
conversation, the CANDOR Response Team ensures that a trained communicator
establishes ongoing regular communication with the patient and/or family.
As we’ve so often
pointed out in the past, we also need to remember that all these unfortunate
events also have “second victims”, that is the caregivers involved in the
incidents. One of the other key functions of the CANDOR Response Team is
assessing the needs of caregivers involved in the harm event and providing
initial emotional support and activating the programs your organization
hopefully have implemented for providing ongoing support for the caregivers.
Details and resources for dealing with the caregivers are provided in Module 6.
Modules 2 and 3 deal
with developing the culture your organization needs and preparing your
organization for implementation of the CANDOR program.
The first module also
describes the Event Investigation and Analysis and timeframes for its optimal
initiation and completion, which is further described in detail in Module 4.
This is basically the root cause analysis (RCA) plus other considerations and
has a checklist to help guide the team(s). Throughout the process the
importance of maintaining a “Just Culture” with shared accountability is
That fourth module
also notes it is important to inform the patient, family, and the involved
caregivers of the investigation and analysis results. It provides resources to
help your organization engage patients and families. It also discusses how to
communicate with and involve your organization’s liability carrier. One of the
resources is a link to discussions of the University of Michigan's early
disclosure and offer program (see our September 2010 What's New in the Patient
Safety World column “Followup
to Our Disclosure and Apology Tip of the Week”).
Module 5 discusses
the response and disclosure and provides some excellent resources and
recommendations, such as how to deal with challenging communications. It
provides checklists, case scenarios, and videos of both appropriate and
inappropriate disclosures to patients.
Module 7 deals with
resolution. Resolution in the CANDOR process involves actions associated with
addressing the patient, family, and staff expectations. The main objective of
resolution in the CANDOR process is to meet the needs and expectations of the
patient. It stresses that failure to do this can lead to a loss of trust from
the patient. This component of the overall process might lead to a financial
settlement, but notes that such settlements might not always lead to resolution
of all issues related to the adverse event. Financial recompense is not always
the most important need of the patient and/or family. They often want to know
that their unfortunate event may lead to implementation of processes that will
prevent others from suffering the same consequences. It stresses the importance
of the organization taking responsibility and showing legitimate remorse. It
also has excellent resources regarding the skills required in properly
communicating with multiple parties throughout this phase.
The final module
deals with organizational learning and how to ensure sustainability of the
CANDOR program and, more importantly, the culture needed to ensure its
Overall, the CANDOR
toolkit is an outstanding resource that every healthcare organization must take
advantage of. Many organizations have had to stumble through handling adverse
events and had to learn the hard way. The CANDOR toolkit can help organizations
take a very proactive approach to establishing programs that are the right way
to do things.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious
Incident Response Checklist”
June 16, 2009 “”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup
to Our Disclosure and Apology Tip of the Week”
November 2010 “ ”
April 2012 “Error
Disclosure by Surgeons”
June 2012 “Oregon
Adverse Event Disclosure Guide”
December 17, 2013 “The
Other very valuable resources on disclosure and apology:
AHRQ (Agency for Healthcare Research and Quality). Communication and Optimal Resolution (CANDOR) Toolkit. AHRQ 2016; Rockville, MD http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html