Forging a Path to Healing: CAPS Webinar Illuminates Restorative Practice and CANDOR in Healthcare

Washington D.C. – January 20, 2020 – In a significant move towards transforming how healthcare systems respond to patient harm, the Collaborative for Accountability and Patient Safety (CAPS) hosted a pivotal webinar on January 16, 2020, titled "Healing after Harm." This crucial online event brought together leading experts to discuss innovative approaches, specifically Restorative Practice and Communication and Optimal Resolution (CANDOR), aiming to foster genuine healing for all parties affected by adverse events in medical settings. The webinar, now accessible on the CAPS webpage (patientsafety.org) under the News section, underscored a growing consensus that traditional responses often fall short of providing comprehensive resolution and emotional recovery.

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The central theme revolved around a nuanced understanding of "harm," defined expansively as "Ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment)." This definition acknowledges the far-reaching ripple effects of medical incidents, impacting not only the patient but also their families, the involved healthcare providers (often referred to as "second victims"), and the wider institutional fabric. The webinar emphasized that the manner in which patients, providers, and administrators respond to such harm can critically either mitigate or exacerbate the situation, shaping the trajectory towards resolution or prolonged suffering.

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Main Facts: A New Paradigm for Addressing Harm

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The "Healing after Harm" webinar served as a clarion call for a fundamental shift in healthcare’s response to adverse events. Historically, the prevailing paradigm often leaned towards a "deny and defend" strategy, driven by fears of litigation and reputational damage. However, this approach frequently alienates patients and families, erodes trust, and leaves healthcare providers feeling isolated and traumatized. The webinar champions a more empathetic, transparent, and restorative approach, recognizing that true healing extends beyond legal or financial settlements.

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At the core of this new paradigm are two interconnected frameworks: Restorative Practice and Communication and Optimal Resolution (CANDOR). Mary Ellen Mannix, a prominent advocate for Restorative Practice in healthcare, shared her profound personal journey, illustrating the limitations of legal remedies in achieving emotional and psychological healing. Her insights, born from personal tragedy, laid the groundwork for understanding how a social science focused on repairing relationships could be profoundly transformative in the clinical context.

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Martin Hatlie, another distinguished speaker, provided comprehensive details on CANDOR, a structured process designed to facilitate open communication and compassionate resolution after unexpected medical outcomes. Hatlie detailed CANDOR’s evolution from the foundational AHRQ Seven Pillars Tool Kit, highlighting its practical application and widespread adoption across numerous healthcare facilities in the United States. The enthusiastic engagement from webinar attendees, evidenced by numerous questions, underscored the urgent need and keen interest within the healthcare community for actionable strategies to address harm more effectively and humanely.

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Chronology: From Personal Tragedy to Systemic Solutions

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The narrative of "Healing after Harm" is deeply rooted in both personal experience and systemic evolution. The webinar itself, held on January 16, 2020, marked a significant moment in CAPS’s ongoing commitment to fostering a culture of patient safety and accountability. However, the conceptual underpinnings of the discussion trace back much further.

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Mary Ellen Mannix, a central figure in the webinar, shared her poignant story that began with the tragic death of her son. In the wake of this profound loss, Mannix, like many in her situation, initially sought legal remedies to the harm that occurred. However, she candidly explained that while legal avenues might offer a form of justice or compensation, they often fail to address the deeper, more complex emotional and relational wounds suffered by all parties involved. "That did not lead to healing," Mannix articulated, capturing the essence of a common experience for those navigating medical harm through traditional legal channels.

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This realization propelled Mannix into a new intellectual and professional pursuit: the study of Restorative Practice. Originating largely from the criminal justice system as "Restorative Justice," this social science focuses on improving and repairing relationships between people and communities when harm has occurred. Rather than solely focusing on punishment or blame, Restorative Practice emphasizes understanding the impact of the harm, identifying the needs of those affected, and collectively determining how to repair the harm and prevent its recurrence. Mannix’s expertise lies in translating these principles into the unique, high-stakes environment of healthcare, advocating for a process that acknowledges the humanity of patients, families, and providers alike. In the webinar, she meticulously explained how Restorative Practice can assist in providing healing to all parties to harm, crucially by removing shame from the process, thereby enabling open dialogue and a collective path forward.

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Mannix’s work naturally converges with Communication and Optional Resolution (CANDOR), which she views as a direct application of Restorative Practice principles within a structured healthcare framework. Martin Hatlie, a key architect and advocate for CANDOR, further elaborated on its journey. CANDOR, as Hatlie explained, evolved from the Agency for Healthcare Research and Quality’s (AHRQ) Seven Pillars Tool Kit. This toolkit, developed through extensive research and pilot programs, provided a comprehensive framework for healthcare organizations to respond to adverse events in a more transparent, compassionate, and proactive manner. The "seven pillars" typically include:

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1. Care for the Second Victim: Providing immediate support to staff involved in adverse events.

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2. Early Reporting and Investigation: Encouraging prompt reporting and thorough analysis of incidents.

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3. Communication and Transparency: Openly communicating with patients and families about what happened.

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4. Apology and Empathy: Offering sincere apologies and demonstrating understanding of the patient’s experience.

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5. Offer of Resolution: Proposing fair and timely resolutions, which may or may not involve financial compensation.

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6. System Improvement: Using lessons learned from adverse events to prevent future harm.

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7. Organizational Culture Change: Fostering a culture of safety, trust, and continuous learning.

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Hatlie described how CANDOR distilled these pillars into a practical, implementable program, built upon three basic tenets that prioritize early engagement, transparent communication, and a commitment to resolution and learning. The success of CANDOR’s implementation, now spanning over 200 hospitals across thirty-five states, speaks volumes about its effectiveness and the growing readiness of the healthcare industry to embrace more humane and constructive responses to harm. The significant interest generated by the webinar led CAPS to schedule a follow-up discussion for Thursday, January 30, 2020, at Noon Central Time, offering attendees a continued platform to delve deeper into the nuances of these transformative practices.

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Supporting Data: The Evidence and Frameworks for Change

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The foundational premise of "Healing after Harm" rests on a clear understanding of what constitutes harm in healthcare and the empirical evidence supporting alternative, more effective responses. The webinar’s definition of harm – "Ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment)" – is crucial. This expansive view acknowledges the often-overlooked psychological and emotional toll on patients, families, and even the healthcare providers themselves, who are frequently termed "second victims" when involved in medical errors or adverse events. Studies consistently show that unchecked harm, whether physical or emotional, can lead to prolonged trauma, loss of trust, and a breakdown in the patient-provider relationship, often escalating to litigation.

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Restorative Practice in Detail:nRestorative Practice, as championed by Mary Ellen Mannix, offers a powerful antidote to the isolating and adversarial nature of traditional responses. Drawing from principles of Restorative Justice, it operates on the belief that when harm occurs, the focus should be on:

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• Repairing Relationships: Rebuilding trust and understanding between all affected parties.

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• Accountability and Responsibility: Encouraging those responsible for harm to acknowledge their actions and participate in making things right.

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• Meeting Needs: Identifying and addressing the emotional, informational, and material needs of victims and offenders.

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• Community Involvement: Empowering all stakeholders to collaboratively determine how to move forward.

In the healthcare context, this translates into facilitated dialogues where patients, families, and providers can share their experiences, ask questions, express their feelings, and collectively brainstorm solutions. This process is instrumental in removing the debilitating element of shame, which often silences providers and alienates patients. By creating a safe space for open communication, Restorative Practice fosters empathy, mutual understanding, and a shared commitment to learning and preventing future harm. The benefits extend beyond individual cases, contributing to a more just and resilient organizational culture.

CANDOR Framework:
Martin Hatlie’s presentation on CANDOR further substantiated the practical application of restorative principles. CANDOR (Communication and Optimal Resolution) is not merely a philosophy but a structured program designed to facilitate timely, empathetic, and just resolution of harm. Its evolution from the AHRQ Seven Pillars Tool Kit highlights its evidence-based foundation. The key components of CANDOR, which mirror and operationalize many of the AHRQ pillars, include:

1. Early Reporting and Response: Encouraging immediate reporting of adverse events and prompt activation of a CANDOR team.
2. Transparent Communication: Engaging in honest, empathetic, and ongoing communication with patients and families from the outset, explaining what happened and what steps are being taken.
3. Comprehensive Investigation: Conducting a thorough and timely investigation into the event to understand root causes, not to assign blame.
4. Support for Patients and Families: Providing emotional, psychological, and practical support to those affected by the harm.
5. Support for Healthcare Professionals: Offering psychological and peer support to staff involved in adverse events, acknowledging their potential "second victim" status.
6. Apology and Offer of Resolution: Extending a sincere apology when appropriate and offering a fair and timely resolution, which may include compensation, an explanation, or a commitment to system changes.
7. Systemic Learning and Improvement: Using every adverse event as an opportunity to learn, improve processes, and prevent recurrence.

The most compelling supporting data for CANDOR comes from its widespread implementation. Hatlie noted that over 200 hospitals across 35 states have adopted CANDOR practices. While specific outcome data was not detailed in the brief, general findings from CANDOR initiatives typically indicate:

• Reduced Litigation: A decrease in the number and cost of medical malpractice claims, as open communication and fair resolution often prevent disputes from escalating to lawsuits.
• Improved Patient and Family Satisfaction: Patients and families report greater satisfaction with the transparency, empathy, and responsiveness of healthcare providers.
• Enhanced Staff Morale and Retention: Providers feel more supported and less fearful of blame, leading to a more positive work environment and reduced burnout.
• Faster Resolution Times: Cases of harm are resolved more quickly and efficiently, reducing prolonged distress for all parties.
• Stronger Culture of Safety: Healthcare organizations develop a more robust culture of learning from mistakes, leading to tangible improvements in patient safety.

These collective insights and data points underscore the efficacy of Restorative Practice and CANDOR as not just ethical imperatives, but also as pragmatically superior models for managing harm in healthcare, fostering trust, and driving continuous improvement.

Official Responses: Shifting Paradigms in Healthcare Governance

The official response of healthcare institutions to patient harm has historically been a contentious issue. For decades, the dominant approach, often driven by legal counsel and risk management strategies, was characterized by silence, denial, and vigorous defense against any claims of error. This "deny and defend" paradigm, while ostensibly aimed at protecting the institution, inadvertently created a culture of fear, secrecy, and mistrust. Patients and families felt unheard and disrespected, leading to heightened anger and a greater propensity to pursue litigation. Healthcare providers, in turn, often suffered in silence, experiencing significant psychological distress (the "second victim" phenomenon) without adequate institutional support.

The insights shared in the CAPS webinar on Restorative Practice and CANDOR represent a monumental paradigm shift in how healthcare leadership and administration are encouraged to respond. This new approach advocates for transparency, empathy, and proactive engagement, transforming a potentially adversarial encounter into an opportunity for healing and learning.

Healthcare administrators and leaders are now being urged to move beyond merely managing risk to actively fostering a culture of safety and accountability. This involves:

• Leadership Commitment: Senior leadership must visibly champion transparent communication, open disclosure, and a non-punitive approach to learning from errors. This commitment sets the tone for the entire organization.
• Empowering Staff: Training and empowering frontline staff to engage in difficult conversations with patients and families, providing them with the skills and support needed to disclose errors and apologize sincerely.
• Dedicated Resources: Allocating resources for CANDOR teams, patient/family support services, and "second victim" support programs.
• Policy and Process Integration: Integrating Restorative Practice and CANDOR principles into existing policies for incident reporting, investigation, and resolution. This ensures that these practices are not ad-hoc responses but ingrained components of the organizational workflow.
• Legal and Risk Management Evolution: Collaborating with legal and risk management departments to adopt a more conciliatory and transparent approach, recognizing that early, honest communication often mitigates legal exposure more effectively than stonewalling. Many states have even enacted "apology laws" that protect expressions of regret from being used as admissions of liability in court, further enabling candid conversations.

The institutional benefits of adopting these official responses are profound. Beyond the moral imperative to do right by patients, organizations that embrace transparency and restorative justice often experience:

• Enhanced Reputation and Public Trust: A perception of honesty and compassion builds community trust, even when errors occur.
• Reduced Legal Costs and Litigation: Proactive communication and fair resolution often prevent cases from escalating to costly, protracted lawsuits.
• Improved Patient Safety Outcomes: A culture of open reporting and learning leads to more effective identification of systemic vulnerabilities and implementation of preventive measures.
• Greater Staff Engagement and Retention: Healthcare professionals feel valued and supported, reducing burnout, moral injury, and turnover, ultimately leading to a more stable and experienced workforce.

CAPS, through initiatives like the "Healing after Harm" webinar, plays a critical role as a facilitator and advocate for these systemic changes. By bringing together experts and providing platforms for dialogue, CAPS helps disseminate best practices and encourages healthcare organizations nationwide to embrace a more human-centered and effective approach to managing harm. This collective effort is crucial for transforming the official response from one of defense to one of genuine care, accountability, and continuous improvement.

Implications: A Future of Transparency, Trust, and True Healing

The implications of widely adopting Restorative Practice and CANDOR in healthcare are far-reaching and transformative, promising a future where medical harm, while never entirely avoidable, is met with greater transparency, empathy, and a genuine commitment to healing for all involved.

For Patients and Families: The shift from a "deny and defend" culture to one of open communication and resolution represents a monumental change. Patients and families, who have traditionally felt marginalized and disrespected after an adverse event, are empowered to become active participants in the healing and learning process. Genuine apologies, transparent explanations of what happened, and sincere efforts to prevent recurrence can significantly reduce the emotional distress and trauma associated with medical harm. This approach helps restore shattered trust, offering a path for families to move beyond anger and bitterness toward understanding and forgiveness, which are essential components of true healing. It allows them to transform from passive victims to active contributors to a safer healthcare system.

For Healthcare Providers: The impact on healthcare professionals is equally profound. The "second victim" phenomenon, where clinicians experience emotional distress, guilt, and self-doubt after involvement in a medical error, is a significant issue contributing to burnout, depression, and even career changes. Restorative Practice and CANDOR create a supportive environment where providers can honestly acknowledge mistakes without fear of punitive measures. This fosters psychological safety, allowing them to engage in open dialogue, learn from their experiences, and receive the support they need to cope with the emotional burden. By removing the debilitating element of shame, these practices help mitigate moral injury and reinforce the intrinsic motivation of healthcare workers to provide the best possible care, ultimately leading to a more resilient and compassionate workforce.

For Healthcare Systems: At an organizational level, the implications are equally revolutionary. Adopting these practices cultivates a robust culture of safety where errors are viewed not as individual failures, but as opportunities for systemic learning and improvement. This leads to a proactive approach to risk management, identifying root causes of adverse events, and implementing effective preventative strategies. Beyond safety, institutions benefit from enhanced public trust, reduced litigation costs, and improved staff morale and retention. A transparent, empathetic system builds stronger relationships with its community and its own employees, making it a more desirable place to receive and provide care. This ultimately strengthens the long-term sustainability and ethical standing of the healthcare organization.

Societal Impact: On a broader societal level, the widespread adoption of Restorative Practice and CANDOR contributes to a more just, humane, and empathetic healthcare system. It challenges the adversarial nature that has often defined the relationship between patients and providers in times of crisis, replacing it with a collaborative pursuit of understanding, healing, and improvement. This cultural shift can inspire similar transparency and accountability in other complex sectors, fostering a more trusting and resilient society.

The "Healing after Harm" webinar and the subsequent follow-up discussion on January 30, 2020, are more than just informational events; they are catalysts for change. They underscore the ongoing need for dialogue, education, and implementation support to fully integrate these transformative practices into the fabric of healthcare. As CAPS continues to champion these initiatives, the vision of a healthcare system where harm is met with compassion, transparency, and a commitment to genuine healing for all parties involved moves closer to becoming a reality, ultimately benefiting patients, providers, and the entire community.

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