CAPS Webinar Illuminates Path to Healing After Healthcare Harm, Spotlighting Restorative Practices and CANDOR

For Immediate Release

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ST. LOUIS, MO – January 20, 2020 – In a significant move to foster a more empathetic and effective response to adverse events within the healthcare system, the Center for Patient Safety (CAPS) hosted a compelling webinar titled “Healing after Harm” on January 16. The virtual gathering delved into the profound impact of healthcare harm on patients, providers, and institutions alike, advocating for innovative approaches rooted in restorative justice principles and transparent communication. The webinar, now accessible for review on the CAPS webpage (patientsafety.org) under its News section, served as a critical platform for discussing strategies that move beyond traditional blame-and-litigation models towards genuine healing and systemic improvement.

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The term "harm" in healthcare, as defined during the session, extends beyond mere physical injury. It encompasses "ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment)." This broad definition acknowledges the multifaceted trauma that can ripple through a healthcare encounter gone awry, affecting not only the directly impacted patient but also their families, the involved caregivers, and even observing colleagues. The central thesis of the webinar underscored that the manner in which all parties respond to harm can either exacerbate the suffering and breakdown of trust or, conversely, mitigate the damage and pave a path toward understanding, accountability, and eventual healing.

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The session featured two prominent voices in the patient safety movement: Mary Ellen Mannix, a passionate advocate for Restorative Practice, and Martin Hatlie, a leading expert on Communication and Optimal Resolution (CANDOR). Their combined insights illuminated a progressive framework for addressing the aftermath of medical errors and adverse events, emphasizing human connection, transparency, and systemic learning over punitive measures. The enthusiastic response from attendees, marked by numerous questions, has prompted CAPS to schedule a follow-up discussion, signaling a growing appetite within the healthcare community for these transformative practices.

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Chronology of the Webinar and Related Developments

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The January 16th Webinar: A Pivotal Discussion

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The "Healing after Harm" webinar on January 16th was not merely an informational session; it was a call to action for a paradigm shift in how healthcare navigates the inevitable complexities and failures inherent in a high-stakes environment. From its inception, the webinar aimed to provide practical, actionable insights into moving beyond the entrenched culture of silence and defensiveness that often follows medical errors.

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The session commenced with an introduction setting the stage for the profound human element of healthcare harm. Attendees were reminded that every instance of harm involves individuals – patients seeking care, providers striving to deliver it, and administrators overseeing the system. The broad definition of harm presented resonated deeply, acknowledging the often-overlooked psychological and emotional toll on all involved. This inclusive understanding laid the groundwork for the subsequent discussions on Restorative Practice and CANDOR, which fundamentally seek to address these diverse impacts. The flow of the webinar was thoughtfully structured, moving from the personal journey of healing and the theoretical underpinnings of restorative justice to the practical, systematic application within healthcare settings.

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Mary Ellen Mannix’s Journey: From Legal Recourse to Restorative Practice

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At the heart of the webinar was the profoundly moving testimony and expert insights of Mary Ellen Mannix. Her narrative began with a personal tragedy: the death of her son due to medical error. Like many in similar circumstances, Mannix initially sought legal remedies, believing that litigation would provide justice and, by extension, healing. However, she candidly shared her realization that while legal processes might assign fault or offer financial compensation, they often fall short in addressing the deep emotional wounds, the unanswered questions, and the fractured trust that characterize the aftermath of harm. The adversarial nature of legal proceedings frequently entrenches parties in positions of blame and defense, further isolating them from the shared human experience of suffering.

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This personal revelation propelled Mannix into the study and advocacy of Restorative Practice. Originating as a social science focused on improving and repairing relationships between people and communities, Restorative Practice offers a fundamentally different lens through which to view conflict and harm. Instead of asking "Who is to blame?" or "What punishment is deserved?", it shifts the focus to "Who has been harmed?", "What are their needs?", and "Whose obligation is it to meet those needs?". In the context of healthcare, Mannix explained how this framework allows for a safe space where patients, their families, caregivers, and even administrators can come together to discuss what happened, understand its impact, and collectively determine a path forward.

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A crucial element Mannix highlighted was the removal of shame from the process. Healthcare professionals, often driven by a strong desire to heal and do good, can experience immense guilt and shame after an error, leading to silence and isolation. Restorative Practice creates an environment where responsibility can be acknowledged without necessarily assigning blame in a punitive sense. It fosters empathy and mutual understanding, enabling all parties to grapple with the "how" and "why" of the incident, and crucially, to collaboratively answer the question of "how all parties will move forward." This collaborative approach not only aids in the emotional recovery of patients and families but also provides vital psychological support for healthcare providers, often referred to as "second victims" of medical errors.

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Martin Hatlie and the Evolution of CANDOR

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Following Mannix’s compelling exposition, Martin Hatlie, a seasoned leader in the patient safety domain, provided an insightful overview of Communication and Optimal Resolution (CANDOR). Hatlie affirmed Mannix’s perspective by positioning CANDOR as a structured, systematic embodiment of Restorative Practice principles within the often-complex world of healthcare. He detailed how CANDOR did not emerge in a vacuum but evolved from the foundational work of the Agency for Healthcare Research and Quality (AHRQ) Seven Pillars Tool Kit. This toolkit, developed by AHRQ, aimed to help hospitals implement comprehensive programs to respond to adverse events, focusing on aspects like early reporting, investigation, and communication.

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CANDOR distills these broader principles into three basic tenets, which, though not explicitly listed in the original article, are widely recognized and form the bedrock of the program:

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1. Early Communication and Empathy: The immediate aftermath of an adverse event requires prompt, compassionate, and transparent communication with the patient and family. This involves acknowledging the event, expressing empathy for their experience, and committing to a full investigation. It moves away from the traditional "deny and defend" approach.

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2. Thorough and Transparent Investigation: A rapid, objective, and comprehensive review of the event is crucial. This investigation aims to understand what happened, why it happened, and how similar events can be prevented in the future, rather than solely identifying individual culpability. The findings are then shared openly with the affected patient and family.

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3. Fair and Timely Resolution: If an error or preventable harm is identified, CANDOR advocates for an offer of fair resolution, which may include an apology, an explanation, and appropriate compensation for the harm suffered. This "optimal resolution" aims to meet the needs of the patient and family without resorting to prolonged and adversarial litigation, while also incorporating system improvements to prevent recurrence.

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Hatlie’s presentation underscored that CANDOR is more than just a communication strategy; it’s a comprehensive process that integrates immediate response, investigation, resolution, and system improvement. He shared compelling lessons learned from the implementation of CANDOR across a significant portion of the American healthcare landscape, noting that over 200 hospitals have adopted CANDOR practices. Furthermore, facilities in thirty-five states have embraced this model, demonstrating a growing national recognition of its efficacy and ethical imperative. This widespread adoption suggests a measurable shift in how healthcare institutions are choosing to confront and learn from harm.

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The Forthcoming Follow-Up Discussion

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The sheer volume of questions and the evident engagement during the webinar highlighted a strong desire among attendees for deeper understanding and practical guidance on implementing Restorative Practice and CANDOR. Recognizing this need, CAPS swiftly organized a follow-up discussion scheduled for Thursday, January 30, 2020, at Noon Central Time. This session is designed to be an interactive forum, allowing participants to pose specific questions, share their own challenges and successes, and engage in a collaborative dialogue about the nuances of integrating these progressive approaches into diverse healthcare settings. The continued engagement underscores the healthcare community’s commitment to fostering environments of learning, transparency, and healing.

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Supporting Data and Research

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The Imperative for Change: Understanding Healthcare Harm Statistics

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The drive for Restorative Practice and CANDOR is rooted in the stark reality of patient safety statistics. Medical errors and adverse events are a significant public health concern, consistently ranking among the leading causes of death and injury in developed nations. Decades ago, the landmark 1999 Institute of Medicine (IOM) report, "To Err Is Human: Building a Safer Health System," estimated that up to 98,000 Americans die each year due to preventable medical errors in hospitals. While methodologies and estimates have varied since then, more recent studies, such as one published in the BMJ in 2016, suggest the number could be even higher, potentially exceeding 250,000 deaths annually, positioning medical errors as the third leading cause of death in the U.S.

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These staggering figures underscore the urgent need for systemic change. Beyond mortality, countless patients experience preventable harm, leading to prolonged hospital stays, disabilities, and immense emotional distress. The financial burden is also substantial, with billions of dollars spent annually on treating injuries caused by errors, not to mention the costs associated with litigation.

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Crucially, the impact extends beyond the patient. Healthcare providers themselves are deeply affected. The "second victim" phenomenon describes the emotional trauma experienced by clinicians involved in an adverse event, often characterized by guilt, anxiety, depression, and even post-traumatic stress. This can lead to burnout, reduced job satisfaction, and a higher propensity to leave the profession. Traditional responses, often characterized by silence, blame, and legal defensiveness, only exacerbate this suffering for both patients and providers. It is this pervasive and damaging cycle that Restorative Practice and CANDOR seek to break.

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Evidencing the Efficacy of Restorative Practices

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While Restorative Practice is perhaps most widely known in the criminal justice and educational sectors, its core principles of repairing harm, fostering dialogue, and building relationships are universally applicable and increasingly recognized within healthcare. Studies in other fields have shown that restorative approaches can lead to higher satisfaction among victims and offenders, reduced recidivism, and improved community relations.

In healthcare, the application of restorative justice principles is yielding promising results. By creating a space for open dialogue, these practices can:

• Improve Patient and Family Satisfaction: Patients and families often seek answers, apologies, and assurance that lessons have been learned. Restorative approaches directly address these needs, leading to a greater sense of closure and trust.
• Reduce Litigation: When patients feel heard, respected, and believe that appropriate action has been taken, their likelihood of pursuing legal action often decreases.
• Enhance Provider Well-being: By fostering a culture of learning over blame, providers can process their emotional trauma, learn from errors without fear of disproportionate punishment, and remain engaged in their work.
• Strengthen Organizational Culture: Restorative practices promote transparency, psychological safety, and a shared commitment to patient safety, leading to a more resilient and ethical organizational culture. While specific quantitative data for healthcare is still emerging, the qualitative evidence of improved trust and communication is compelling.

CANDOR’s Tangible Impact: A National Landscape

Martin Hatlie’s data on CANDOR’s implementation provides tangible evidence of its growing acceptance and utility. The adoption of CANDOR in over 200 hospitals across 35 states is a significant milestone, indicating that these practices are not theoretical ideals but practical, implementable solutions within diverse healthcare systems. These numbers reflect a widespread recognition that the traditional "deny and defend" approach is not only ethically questionable but also often financially and reputationally detrimental.

Hospitals that have adopted CANDOR programs frequently report:

• Earlier Resolution of Claims: By engaging in open communication and offering fair resolution, many incidents are resolved more quickly, reducing the protracted and costly nature of litigation.
• Reduced Litigation Costs: While not always eliminating lawsuits, CANDOR can significantly reduce the number of cases that proceed to full-blown litigation, leading to substantial cost savings.
• Improved Patient-Provider Relationships: Openness and empathy in the face of harm can paradoxically strengthen the bond of trust between patients and providers, even after an adverse event.
• Enhanced Learning and Safety: The systematic investigation and commitment to system improvement inherent in CANDOR lead to concrete changes that prevent future harm, thereby improving overall patient safety performance.
• Better Morale for Caregivers: By providing a structured and supportive process for addressing errors, CANDOR helps alleviate the emotional burden on clinicians, fostering a more supportive work environment.

These benefits, both qualitative and quantitative, underscore why CANDOR is gaining traction as a best practice in patient safety and risk management.

Official Responses and Endorsements

CAPS’s Role in Championing Patient Safety

The Center for Patient Safety (CAPS) stands at the forefront of advocating for safer healthcare. As a non-profit organization dedicated to improving patient safety through education, collaboration, and the dissemination of best practices, CAPS plays a crucial role in bringing discussions like "Healing after Harm" to a wider audience. This webinar is a testament to CAPS’s unwavering commitment to its mission: to provide independent, trusted expertise and resources to promote a culture of safety. By hosting such events, CAPS actively empowers healthcare professionals and institutions with the knowledge and tools necessary to implement transformative practices like Restorative Practice and CANDOR, thereby directly impacting the quality and safety of patient care across the nation. Their efforts are instrumental in shifting the conversation from reactive crisis management to proactive system improvement and compassionate response.

AHRQ’s Foundational Contribution

The credibility and systematic nature of CANDOR are significantly bolstered by its origins in the Agency for Healthcare Research and Quality (AHRQ). As the lead federal agency charged with improving the safety and quality of America’s healthcare system, AHRQ’s involvement signals a strong governmental and scientific endorsement. AHRQ’s meticulous research and development of tools like the Seven Pillars Tool Kit provide a robust, evidence-based foundation for programs like CANDOR. This connection assures healthcare providers and administrators that CANDOR is not merely a theoretical concept but a rigorously developed, tested, and supported framework for effective adverse event response. AHRQ’s broader work in patient safety, including its support for patient safety organizations (PSOs) and its continuous funding of safety research, creates an environment where innovative solutions like CANDOR can thrive and be widely adopted.

The Call for Broader Adoption

While the adoption of CANDOR in 35 states and over 200 hospitals is commendable, it also highlights the significant work that remains. The healthcare landscape is vast, encompassing thousands of hospitals and countless outpatient facilities. The fact that a substantial number of states and institutions have yet to fully embrace these transparent and restorative approaches underscores the ongoing need for advocacy, education, and resource allocation. The webinar and its follow-up discussion serve as a powerful call to action for healthcare leaders, policymakers, and frontline providers to explore, pilot, and ultimately integrate these practices into their standard operating procedures. The goal is not merely isolated pockets of excellence but a pervasive culture of safety and healing across the entire healthcare continuum.

Implications for Healthcare’s Future

Shifting Paradigms: From Blame to Learning and Healing

The most profound implication of embracing Restorative Practice and CANDOR is the potential for a fundamental cultural shift within healthcare. For decades, the default response to adverse events has often been characterized by a "blame and shame" mentality, where errors are hidden, individuals are scapegoated, and learning opportunities are lost. This punitive approach fosters a culture of silence, fear, and defensiveness, ultimately undermining patient safety.

Restorative Practice and CANDOR offer an alternative paradigm: one that prioritizes learning, transparency, accountability, and healing. By focusing on understanding why harm occurred rather than who to punish, these approaches encourage open reporting, honest dialogue, and systemic analysis. This shift transforms errors from catastrophic failures into invaluable learning opportunities, paving the way for continuous improvement and a more resilient healthcare system.

Enhancing Trust and Transparency

In an era where public trust in institutions, including healthcare, is increasingly fragile, transparency is paramount. Restorative Practice and CANDOR actively promote transparency by advocating for honest and empathetic communication with patients and families immediately following an adverse event. This commitment to openness, even in difficult circumstances, is crucial for rebuilding and maintaining trust. When patients feel that their concerns are heard, that their questions are answered, and that institutions are committed to learning from mistakes, their confidence in the healthcare system is strengthened. This enhanced trust is not just an ethical imperative; it is a critical component of effective patient engagement and positive health outcomes.

Fostering Provider Well-being and Retention

The chronic stress and burnout prevalent among healthcare professionals are well-documented crises. The fear of making a mistake, coupled with the emotional burden of adverse events and the lack of institutional support, contributes significantly to this phenomenon. The "second victim" phenomenon exacts a heavy toll, leading to psychological distress, professional disengagement, and even departures from the profession.

Restorative Practice and CANDOR offer a lifeline to these "second victims." By creating a supportive environment where errors can be discussed openly, where emotional support is provided, and where the focus is on systemic improvement rather than individual fault, these practices mitigate the isolating and shaming effects of adverse events. Supporting provider well-being through these compassionate responses is not merely an act of kindness; it is a strategic imperative for retaining a skilled and dedicated healthcare workforce and ensuring the long-term sustainability of the healthcare system.

The Economic and Ethical Imperatives

Beyond the moral imperative to do right by patients and providers, there are compelling economic reasons to adopt these practices. Prolonged litigation is incredibly expensive, consuming vast resources in legal fees, settlements, and administrative overhead. By facilitating earlier, fairer, and more amicable resolutions, CANDOR can significantly reduce these financial burdens, allowing resources to be redirected towards patient care and safety initiatives. Ethically, the commitment to transparency, accountability, and healing for all parties involved in harm aligns healthcare practices with its core mission of "do no harm." It affirms the dignity of both patients and providers, fostering a more just and humane healthcare environment.

A Continuous Journey: The Road Ahead

The "Healing after Harm" webinar is a testament to the fact that patient safety is not a destination but a continuous journey of learning, adaptation, and improvement. Restorative Practice and CANDOR are not quick fixes but represent a fundamental commitment to a different way of operating within healthcare – one that acknowledges human fallibility while striving for excellence, empathy, and systemic resilience. The enthusiasm generated by the webinar, evidenced by the need for a follow-up discussion, indicates a growing readiness within the healthcare community to embark on this journey. Continued education, robust implementation support, and ongoing research will be vital in ensuring that these transformative practices become the standard, not the exception, in healthcare’s response to harm.

The Center for Patient Safety urges all interested parties to participate in the upcoming follow-up discussion to deepen their understanding and contribute to this vital conversation.

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