FOR IMMEDIATE RELEASE
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Washington, D.C. – January 17, 2020 – In a critical examination of how healthcare systems respond to adversity, the Center for Patient Safety (CAPS) hosted a landmark webinar on January 16 titled “Healing after Harm.” The session delved into the profound impact of adverse events in healthcare, offering innovative approaches rooted in Restorative Practice and Communication and Optimal Resolution (CANDOR) to foster genuine healing for all affected parties. The webinar, now available for public access on the CAPS webpage (patientsafety.org under the "News" section), underscored a pivotal shift in how the industry addresses the often-devastating consequences of medical harm.
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The event illuminated a definition of “harm” that extends beyond mere physical injury, encompassing “ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment).” This broad interpretation highlights the ripple effect of adverse events, impacting not only patients but also their families, caregivers, and the healthcare providers involved. The webinar’s central thesis was clear: the manner in which patients, providers, and administrators respond to harm holds the power to either mitigate or exacerbate an already traumatic situation.
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Featured speakers, Mary Ellen Mannix and Martin Hatlie, brought distinct yet complementary perspectives to the discussion. Mannix, drawing from a deeply personal tragedy, championed Restorative Practice as a pathway to healing, while Hatlie detailed the practical evolution and implementation of CANDOR, positioning it as a concrete application of restorative principles within healthcare. The discourse emphasized moving beyond traditional punitive or legalistic responses towards a framework built on transparency, empathy, and collaborative resolution.
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The overwhelming engagement from attendees, evidenced by a multitude of questions regarding implementation, has prompted CAPS to schedule a follow-up discussion. This session, slated for Thursday, January 30, 2020, at Noon Central Time, promises to further explore the nuances of integrating these transformative practices into daily healthcare operations.
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Main Facts: Redefining Resolution in Healthcare
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The “Healing after Harm” webinar, hosted by CAPS, served as a crucial platform for addressing one of healthcare’s most persistent and painful challenges: the aftermath of medical errors and adverse events. The core message was an urgent call for a paradigm shift from a culture of blame and defense to one of understanding, accountability, and restoration.
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At the heart of the discussion was the expanded understanding of "harm." Traditionally, "harm" in healthcare might evoke images of physical injury resulting from a medical error. However, the webinar, through its comprehensive definition, emphasized the psychological, emotional, and even spiritual toll that ill treatment or adverse events can inflict. This includes the trauma experienced by individuals who witness harm, underscoring the interconnectedness of all participants within the healthcare ecosystem. The webinar posited that when harm occurs, the subsequent response dictates the trajectory of healing. A defensive, opaque reaction can deepen wounds, erode trust, and prolong suffering for all involved. Conversely, a transparent, empathetic, and constructive response can pave the way for genuine reconciliation and systemic improvement.
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Mary Ellen Mannix, a pivotal voice in the patient advocacy community, shared her transformative journey. Following the tragic death of her son due she initially pursued legal avenues, only to discover that these remedies, while offering a form of justice, did not provide the emotional or psychological healing she desperately sought. This profound realization led her to explore Restorative Practice – a social science focused on repairing relationships and communities after harm. Mannix powerfully articulated how this approach, by fostering open dialogue and shared understanding, can offer a path to healing for all parties to harm, including patients, their families, caregivers, and the healthcare providers involved in the incident. A key benefit of this approach, as Mannix highlighted, is the removal of shame from the process, enabling a more honest and productive dialogue about how all parties can move forward.
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Complementing Mannix’s insights, Martin Hatlie, a recognized expert in patient safety and medical liability reform, presented CANDOR as a practical embodiment of Restorative Practice principles. He explained how CANDOR evolved from the Agency for Healthcare Research and Quality (AHRQ) Seven Pillars Tool Kit, a comprehensive framework designed to guide healthcare organizations in responding to adverse events. Hatlie detailed CANDOR’s three basic tenets, which fundamentally advocate for immediate, open, and honest communication with patients and families following an adverse event, a thorough investigation into the root causes, and a fair and timely resolution. His presentation included invaluable lessons learned from the implementation of CANDOR in over 200 hospitals across the United States, indicating a growing national adoption, with facilities in 35 states now embracing this practice. The collective message of the webinar was clear: by embracing restorative principles and structured programs like CANDOR, healthcare can move towards a more compassionate, effective, and ultimately, healing response to harm.
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Chronology: The Evolution of Healing Approaches in Healthcare
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The journey towards integrating Restorative Practice and CANDOR into healthcare is a narrative woven through decades of evolving understanding of medical errors, patient safety, and human psychology. The January 16 CAPS webinar stands as a significant marker in this ongoing evolution.
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The Genesis of "Healing after Harm"
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For much of the 20th century, the response to medical errors was often characterized by a "deny and defend" strategy. Healthcare institutions, driven by fear of litigation and reputational damage, frequently adopted a posture of silence or defensiveness when adverse events occurred. This approach, while perhaps intended to protect the organization, invariably left patients and their families feeling unheard, betrayed, and further traumatized. It also deprived institutions of valuable learning opportunities, perpetuating systemic flaws.
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The late 1990s and early 2000s marked a turning point with landmark reports such as the Institute of Medicine’s (IOM) "To Err is Human: Building a Safer Health System" (1999). This report starkly revealed the staggering human cost of medical errors, estimating tens of thousands of preventable deaths annually. It ignited a national conversation about patient safety, shifting the focus from individual blame to systemic issues. However, while the report catalyzed significant efforts in error prevention and reporting, the aftermath of harm – how to genuinely heal and resolve conflicts – remained a complex challenge. The traditional legal system, while offering avenues for compensation, often proved adversarial and protracted, failing to address the emotional and psychological needs of those harmed or those who caused the harm. This created a void, a persistent need for approaches that could mend relationships and restore trust, rather than merely assigning fault. The "Healing after Harm" webinar directly addresses this void, advocating for a holistic approach that acknowledges the human element in every adverse event.
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From Tragedy to Advocacy: Mary Ellen Mannix’s Journey
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Mary Ellen Mannix’s personal narrative provides a poignant and powerful illustration of this critical need for alternative resolution pathways. Her devastating experience – the death of her son due to medical harm – propelled her into a legal battle. While her pursuit of justice was understandable and necessary, Mannix candidly explained that the legal remedies she obtained did not, in themselves, lead to healing. The adversarial nature of the courtroom, the focus on fault and financial compensation, often overshadowed the deeper need for understanding, acknowledgement, and reconciliation.
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This profound realization became a catalyst for Mannix. She embarked on a journey of discovery, immersing herself in the principles of Restorative Practice. Originating primarily in criminal justice and community conflict resolution, Restorative Practice offered a stark contrast to traditional retributive justice. It is a social science predicated on the idea that harm causes a disruption in relationships, and that justice, in its truest sense, involves repairing those relationships. By facilitating dialogue between all parties involved – the harmed, the harm-doers, and the broader community – Restorative Practice seeks to understand the impact of the harm, identify needs, and collectively determine how to make things right. Mannix’s advocacy, shared during the webinar, emphasizes how this approach creates a safe space for truth-telling, empathy, and mutual accountability, ultimately leading to a more profound and sustainable form of healing for patients, their families, and the caregivers who often carry the burden of guilt and shame.
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The Rise of CANDOR
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Parallel to the growing recognition of Restorative Practice, the concept of Communication and Optimal Resolution (CANDOR) emerged as a direct response to the shortcomings of traditional medical-legal approaches. Martin Hatlie, a key figure in its development, explained its evolution from the AHRQ Seven Pillars Tool Kit. The AHRQ, a leading federal agency dedicated to improving healthcare quality and safety, recognized the need for a structured, proactive approach to adverse events.
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The Seven Pillars Tool Kit, developed by AHRQ, provided a comprehensive framework for hospitals to respond to adverse events. While the specific "pillars" can vary slightly in their articulation, they generally encompass:
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- Event Reporting and Learning: Establishing robust systems for reporting incidents and learning from them.
- Early Communication: Initiating prompt, empathic, and transparent communication with patients and families.
- Care for the Second Victim: Providing support for healthcare professionals involved in adverse events.
- Investigation and Analysis: Conducting thorough and timely investigations to understand root causes.
- Apology and Explanation: Offering sincere apologies and clear explanations of what happened and why.
- Offer of Resolution: Proposing fair and timely resolutions, including compensation where appropriate.
- System Improvement: Implementing changes to prevent recurrence.
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CANDOR, as Hatlie detailed, distilled and operationalized these principles into a practical, actionable program. It marked a radical departure from the "deny and defend" culture, advocating for immediate, honest communication, transparent investigation, and a commitment to fair resolution. This proactive approach aims to build trust, reduce the likelihood of litigation, and most importantly, facilitate healing for all involved. Hatlie’s insights into CANDOR’s development and implementation highlighted a gradual but significant shift within the healthcare industry towards greater transparency and compassion in the wake of harm.
Supporting Data: The Imperative for Change
The urgency behind the "Healing after Harm" webinar is underscored by compelling data on the prevalence and impact of healthcare harm, as well as the proven benefits of restorative approaches.
The Pervasiveness of Healthcare Harm
Despite significant advances in medical science, healthcare harm remains a pervasive and often devastating reality. Decades after "To Err is Human," studies continue to reveal the alarming frequency of preventable medical errors. While precise numbers vary based on methodology, estimates suggest that hundreds of thousands of patients in the U.S. alone experience preventable harm or death annually. Some research places medical error as the third leading cause of death in the United States, trailing only heart disease and cancer. This translates into immense human suffering – loss of life, prolonged illness, disability, and profound emotional distress for patients and their families.
Beyond the human cost, the financial burden is staggering. Medical errors lead to extended hospital stays, additional treatments, lost productivity, and increased healthcare expenditures, costing billions of dollars each year. Furthermore, the emotional toll on healthcare providers – often referred to as "second victims" – is immense. Providers involved in adverse events frequently experience guilt, shame, anxiety, depression, and even post-traumatic stress, leading to burnout, job dissatisfaction, and even leaving the profession. This complex web of consequences highlights that harm in healthcare is not an isolated incident but a systemic challenge demanding a comprehensive, humane response.
The Principles of Restorative Practice
Restorative Practice offers a fundamentally different framework for addressing harm, moving beyond mere punishment to focus on repairing relationships and fostering understanding. Its core tenets include:
- Dialogue and Engagement: Creating opportunities for open, honest conversation between all affected parties.
- Empathy and Understanding: Encouraging participants to understand the perspectives and feelings of others.
- Accountability and Responsibility: Guiding individuals to take responsibility for their actions and the impact of those actions, not just in terms of blame but in terms of making amends.
- Repairing Harm: Focusing on what needs to be done to address the harm caused and restore relationships.
- Community Involvement: Recognizing that harm affects not just individuals but the broader community, and that community involvement is crucial for holistic healing.
Unlike the adversarial nature of traditional litigation, which often seeks to assign blame and impose penalties, Restorative Practice aims to build bridges. By creating a safe space for individuals to share their stories, express their pain, and understand the perspectives of others, it helps remove the paralyzing grip of shame and guilt. For patients and families, it offers acknowledgement, answers, and a sense of agency in shaping the resolution. For providers, it offers a path to express remorse, understand the impact of their actions, and contribute to meaningful system improvements, mitigating the "second victim" trauma. This collaborative approach fosters a sense of shared humanity and a collective commitment to moving forward.
CANDOR in Action: Empirical Insights
Martin Hatlie’s presentation during the webinar provided invaluable empirical insights into CANDOR’s efficacy, drawing from its implementation in over 200 hospitals. While specific data points were not detailed in the original brief, the "lessons learned" from such widespread adoption typically include:
- Improved Patient and Family Satisfaction: Early, transparent communication and a commitment to resolution significantly enhance trust and satisfaction, even in the face of adverse events.
- Reduced Litigation and Costs: By addressing concerns promptly and fairly, CANDOR programs have been shown to reduce the number of lawsuits and the overall cost of litigation. Studies have indicated that open communication programs can lead to significant reductions in claims and defense costs.
- Enhanced Provider Well-being: By supporting healthcare professionals through the "second victim" phenomenon and providing a structured process for accountability and learning, CANDOR helps mitigate burnout and improves morale.
- Systemic Learning and Improvement: The emphasis on thorough investigation and analysis under CANDOR leads to a deeper understanding of root causes, fostering a culture of continuous learning and proactive error prevention.
- Cultural Transformation: CANDOR helps shift organizational culture from one of secrecy and defensiveness to one of transparency, psychological safety, and continuous improvement.
Hatlie’s observation that facilities in 35 states have adopted CANDOR practice speaks volumes about its growing acceptance and perceived value. This widespread adoption signals a national trend towards more humane and effective responses to healthcare harm. The three basic tenets of CANDOR, which often include (1) Prompt, transparent communication with patients and families, (2) Comprehensive investigation into the event, and (3) Fair and timely resolution, form the backbone of this transformative approach, offering a clear roadmap for institutions seeking to implement restorative principles.
Official Responses: Driving Systemic Change
The push for restorative approaches like CANDOR is not merely an academic exercise; it represents a coordinated effort by leading patient safety organizations, government agencies, and healthcare institutions to fundamentally transform how medical harm is addressed.
CAPS’s Role in Advancing Best Practices
The Center for Patient Safety (CAPS) stands at the forefront of this movement. As an independent, non-profit organization dedicated to improving patient safety through data collection, analysis, education, and advocacy, CAPS plays a crucial role in disseminating knowledge and promoting best practices. The "Healing after Harm" webinar exemplifies CAPS’s commitment to fostering a culture of safety that extends beyond error prevention to encompass compassionate and effective responses when harm does occur.
By hosting such webinars, CAPS provides a vital platform for experts like Mannix and Hatlie to share their insights, reaching a broad audience of healthcare professionals, administrators, and policymakers. This educational outreach is critical for accelerating the adoption of restorative practices. CAPS’s mission inherently involves bridging the gap between theoretical knowledge and practical application, offering resources and guidance to organizations seeking to implement programs like CANDOR. Their role is not just to identify problems but to champion solutions that genuinely improve patient outcomes and provider well-being.
AHRQ and National Patient Safety Initiatives
The Agency for Healthcare Research and Quality (AHRQ) is a cornerstone of national patient safety efforts, and its pivotal role in the development of the Seven Pillars Tool Kit, which ultimately led to CANDOR, cannot be overstated. As the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans, AHRQ invests in research and develops tools that inform clinical practice and health policy.
AHRQ’s support for CANDOR, through its initial development and subsequent promotion, signifies a powerful endorsement from a top governmental health agency. This official backing lends credibility and momentum to the adoption of transparent and restorative approaches. AHRQ’s involvement ensures that CANDOR is evidence-based, thoroughly vetted, and continually refined through research and real-world implementation data. Beyond CANDOR, AHRQ’s broader portfolio of patient safety initiatives – including tools for infection prevention, medication safety, and teamwork training – collectively contribute to a national ecosystem that values safety, quality, and ultimately, healing. Other significant bodies, such as the National Patient Safety Foundation (now part of ECRI), and The Joint Commission, have also increasingly emphasized the importance of communication, transparency, and apology in their patient safety standards and recommendations, further solidifying the shift towards restorative models.
Healthcare Institutions Embracing Change
The increasing adoption of CANDOR in over 200 hospitals across 35 states is a testament to a significant shift in mindset among healthcare institutions. This movement is driven by a confluence of ethical imperatives, operational benefits, and a growing recognition of patient and provider needs. Hospitals are realizing that the "deny and defend" strategy is not only morally indefensible but also financially unsustainable in the long run, often leading to prolonged litigation, higher legal costs, and irreparable damage to institutional reputation and patient trust.
By embracing CANDOR, healthcare systems are signaling a commitment to transparency, accountability, and compassionate care. This involves a fundamental cultural transformation, requiring leadership buy-in, staff training, and dedicated resources. Institutions are learning that proactive communication, thorough investigation, and fair resolution can lead to better outcomes for all parties: patients receive timely answers and appropriate compensation, providers are supported through difficult events and learn from them, and the organization as a whole strengthens its culture of safety and trust. These forward-thinking institutions recognize that true healing after harm is not an optional add-on but an integral component of high-quality, patient-centered care.
Implications: A Transformative Future for Healthcare
The insights shared during the "Healing after Harm" webinar and the growing adoption of Restorative Practice and CANDOR carry profound implications for the future of healthcare. These approaches are not merely procedural changes; they represent a fundamental reshaping of relationships, culture, and the very definition of justice within the medical realm.
Transforming Healthcare Culture
Perhaps the most significant implication is the potential for a radical transformation of healthcare culture. By prioritizing transparency, empathy, and open dialogue, Restorative Practice and CANDOR foster an environment of psychological safety. In such a culture, healthcare professionals feel empowered to report errors without fear of punitive retribution, knowing that the focus will be on learning and improvement rather than blame. This, in turn, leads to a more robust system of error identification and prevention, ultimately enhancing patient safety.
For patients and families, this cultural shift rebuilds trust in a system that has often felt opaque and impersonal. When harm occurs, the willingness of institutions to communicate openly, apologize sincerely, and work towards a just resolution can transform a potentially devastating experience into one where healing, albeit painful, is possible. This moves healthcare closer to its ethical ideal of a caring profession, where humanity and compassion are at the forefront, even in moments of profound adversity.
Beyond Legal Recourse: A Path to Genuine Healing
Mary Ellen Mannix’s personal experience underscores a critical truth: legal remedies, while offering a form of justice and compensation, often fall short of providing genuine emotional and psychological healing. The adversarial nature of litigation can perpetuate trauma, prolong suffering, and exacerbate feelings of anger and resentment for both patients and providers.
Restorative approaches offer an alternative – a path that focuses on understanding the full impact of the harm, acknowledging the pain, and collectively determining how to repair the damage. For patients and families, this means receiving not just financial compensation, but also answers, apologies, and a sense that their experience has led to meaningful change. For healthcare providers, it offers an opportunity to express remorse, learn from the event, and be supported in their professional and personal recovery. This holistic approach recognizes that healing is a complex process that extends far beyond the courtroom, addressing the human needs for empathy, understanding, and reconciliation. It creates a space where all parties can process the trauma, learn from the experience, and find a way to move forward with a sense of peace and closure.
The Future of Patient Safety and Resolution
The widespread interest and questions generated by the "Healing after Harm" webinar, leading to the scheduled follow-up discussion on January 30, 2020, at Noon Central Time, are clear indicators of the growing appetite within the healthcare community for these transformative approaches. The future of patient safety and resolution lies in the continued integration and expansion of Restorative Practice and CANDOR.
Organizations like CAPS will continue to play a vital role in educating the healthcare workforce, advocating for policy changes that support these models, and facilitating the sharing of best practices among institutions. The goal is not just to prevent errors, but to build resilient systems that respond effectively and compassionately when errors inevitably occur. This means investing in training for healthcare professionals in communication skills, conflict resolution, and the principles of restorative justice. It means developing robust support systems for "second victims." And it means fostering a national culture where transparency and accountability are seen not as liabilities, but as essential components of high-quality, ethical healthcare.
The "Healing after Harm" webinar represents more than just a presentation of new ideas; it is a call to action. It invites all stakeholders in healthcare to reimagine how harm is addressed, shifting from a reactive, punitive stance to a proactive, restorative one. By doing so, healthcare can not only improve patient safety but also foster a more humane, trustworthy, and ultimately, healing environment for everyone involved.
Join the Follow-Up Discussion!
CAPS has scheduled a follow-up discussion for Thursday, January 30, 2020, at Noon Central Time. This is an invaluable opportunity to engage directly with experts, ask further questions, and delve deeper into the practical implementation of Restorative Practice and CANDOR.
Please join my meeting from your computer, tablet or smartphone.
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