WASHINGTON D.C. – January 20, 2020 – In a significant step towards fostering a more compassionate and just healthcare system, the Collaborative Alliance for Patient Safety (CAPS) hosted a groundbreaking webinar on January 16, titled "Healing after Harm." The insightful session delved into the profound impact of adverse events in healthcare and championed the adoption of restorative practices, particularly the Communication and Optimal Resolution (CANDOR) approach, as a pathway to comprehensive healing for all affected parties.
n
The webinar, now available for review under the "News" section of the CAPS webpage (patientsafety.org), brought to light the often-overlooked emotional and psychological aftermath of harm in medical settings. Defining "harm" broadly as "Ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment)," the session underscored a critical reality: the way patients, providers, and administrators respond to such incidents can either mitigate or tragically exacerbate the situation. The core message was clear: traditional responses often fall short, and a new paradigm focused on understanding, communication, and collective healing is urgently needed.
n
Main Facts: Redefining Responses to Healthcare Harm
n
The "Healing after Harm" webinar, presented by CAPS, served as a pivotal platform to introduce and advocate for a human-centered approach to adverse events in healthcare. At its heart, the discussion centered on the transformative potential of Restorative Practice and the structured framework of Communication and Optimal Resolution (CANDOR) in navigating the complex emotional, ethical, and practical challenges that arise when harm occurs.
n
The session featured two prominent voices in the patient safety movement: Mary Ellen Mannix and Martin Hatlie. Mannix, whose personal journey through medical tragedy led her to explore alternative healing modalities, illuminated how Restorative Practice offers a departure from the adversarial nature of conventional legal remedies. She eloquently articulated how this social science, focused on improving and repairing relationships, can provide a genuine path to healing for all stakeholders – patients, their families, caregivers, and healthcare providers. A key takeaway from her presentation was the emphasis on removing shame from the process, thereby enabling open dialogue and a collective path forward.
n
Martin Hatlie complemented Mannix’s insights by detailing the evolution and implementation of CANDOR, which Mannix herself views as a practical application of Restorative Practice principles. Hatlie, a recognized authority in patient safety, outlined how CANDOR has emerged from foundational work, particularly the AHRQ Seven Pillars Tool Kit, to become a robust framework for transparent communication and fair resolution. His presentation provided tangible evidence of CANDOR’s growing acceptance, citing its adoption in over 200 hospitals across 35 states, and sharing crucial lessons learned from these implementations.
n
The immediate interest generated by the webinar highlighted the pressing need for such discussions within the healthcare community. Attendees posed numerous questions regarding the practical implementation of Restorative Practice and CANDOR, signaling a strong desire for deeper engagement and guidance. In response to this enthusiastic feedback, CAPS promptly scheduled a follow-up discussion, underscoring the organization’s commitment to fostering ongoing dialogue and education on these vital topics. This initial webinar, therefore, marked not an endpoint, but a significant beginning in a broader conversation about transforming how healthcare addresses harm.
n
Chronology: From Blame to Restoration in Healthcare
n
The journey towards restorative justice in healthcare is built upon decades of evolving understanding regarding medical errors and patient safety. For many years, the default response to adverse events was often characterized by a "deny and defend" posture, driven by fear of litigation and damage to reputation. This approach, while perhaps protective in the short term, frequently left patients feeling unheard, exacerbated their suffering, and prevented healthcare institutions from learning effectively from mistakes. Simultaneously, healthcare providers involved in such incidents, often referred to as "second victims," suffered in silence, grappling with guilt, trauma, and professional isolation.
n
The Rise of the Patient Safety Movement: The modern patient safety movement gained significant momentum with the release of the Institute of Medicine’s (IOM) landmark report, "To Err is Human: Building a Safer Health System," in 1999. This report shocked the nation by revealing that medical errors were a leading cause of death and injury in the United States. It catalyzed a paradigm shift, moving the focus from blaming individuals to understanding systemic failures. However, while "To Err is Human" initiated a crucial conversation about prevention, the question of how to respond after harm had occurred remained a complex challenge.
n
Origins of Restorative Justice: The concept of Restorative Practice itself has deeper roots, primarily emerging from the criminal justice system in the latter half of the 20th century. Dissatisfied with punitive justice models that often failed to address the needs of victims or rehabilitate offenders effectively, proponents sought alternatives that focused on repairing harm, engaging all affected parties, and building community. Restorative Justice principles emphasize dialogue, accountability, and collective problem-solving, aiming to restore relationships rather than simply assign blame or impose punishment. Over time, these principles have been adapted and applied successfully in diverse settings, including schools, workplaces, and, increasingly, healthcare.
n
The Genesis of CANDOR: Within the healthcare context, the recognition that an open, empathetic, and just response to harm was essential began to coalesce. This understanding paved the way for the development of the Communication and Optimal Resolution (CANDOR) process. CANDOR did not emerge in a vacuum; it built upon earlier initiatives aimed at improving transparency and communication after adverse events. A crucial precursor was the Agency for Healthcare Research and Quality’s (AHRQ) Seven Pillars Tool Kit. This comprehensive resource, developed to guide hospitals in implementing effective communication and resolution programs, laid much of the groundwork.
n
From this foundation, CANDOR was specifically designed to provide a structured, proactive response. Martin Hatlie, a key figure in its development, explained that CANDOR evolved to establish a clearer pathway for institutions to move beyond reactive and defensive postures. The initiative sought to empower healthcare organizations to:
n
- n
- Engage in early and transparent communication: This involves promptly and openly informing patients and families about adverse events, expressing empathy, and explaining what is known and what will be done to investigate.
- Conduct thorough and timely investigations: Moving beyond surface-level explanations to identify the root causes of harm, thereby fostering organizational learning and preventing recurrence.
- Provide comprehensive support for all involved: Recognizing that harm impacts not only patients and families but also healthcare providers (second victims), CANDOR emphasizes offering emotional, psychological, and professional support to all parties.
- Facilitplicate fair and expeditious resolution: This includes offering apologies, explaining preventive measures taken, and providing appropriate compensation or other forms of resolution when medical errors have occurred, often outside of traditional litigation.
n
n
n
n
n
The systematic development of CANDOR, from conceptualization through pilot programs and widespread adoption, reflects a growing consensus within the healthcare community that a compassionate and transparent approach is not only ethically imperative but also clinically and organizationally beneficial. It represents a significant chronological shift from a culture of silence and defensiveness to one of openness, learning, and genuine healing.
n
Supporting Data: The Compelling Case for Restorative Practices
n
The arguments for adopting Restorative Practice and CANDOR are not merely theoretical; they are backed by compelling data and profound human experiences that underscore the inadequacy of traditional responses to healthcare harm. The scope of the problem itself provides a stark backdrop against which these new approaches shine.
n
The Pervasiveness of Harm: Medical errors and adverse events remain a significant public health challenge. While precise figures vary depending on methodologies, studies consistently indicate that hundreds of thousands of patients suffer preventable harm in U.S. hospitals annually. Beyond mortality, these incidents lead to prolonged hospital stays, increased healthcare costs, disability, and immense psychological distress for patients and their families. The financial burden on the healthcare system, including litigation costs, is staggering, but pales in comparison to the human cost.
n
The Human Toll: Beyond the Patient: Mary Ellen Mannix’s personal narrative powerfully illustrates the limitations of legal remedies in achieving true healing. Her experience of seeking justice after the death of her son revealed that while legal processes might address culpability and compensation, they often fail to mend the emotional wounds, restore trust, or provide a sense of closure. This personal testimony resonates with countless others who find that adversarial systems perpetuate suffering rather than alleviating it.
n
Furthermore, the concept of "second victims" highlights another critical dimension of healthcare harm. These are the healthcare providers who are traumatized by their involvement in an adverse patient event, experiencing symptoms akin to post-traumatic stress disorder, including guilt, anxiety, depression, and self-doubt. Without adequate support, second victims face increased risk of burnout, job dissatisfaction, and even leaving the profession. Traditional "deny and defend" strategies leave these providers isolated and unsupported, exacerbating their suffering and hindering their ability to learn and recover. Restorative Practice, by its very design, acknowledges and seeks to heal all parties to harm, providing a crucial lifeline for these often-overlooked victims.
n
Evidence of Restorative Practice Effectiveness: While nascent in healthcare, the principles of Restorative Practice have demonstrated efficacy in other complex human interactions. By focusing on dialogue, empathy, and mutual understanding, restorative approaches have been shown to:
n
- n
- Improve relationships: By providing a safe space for all voices to be heard, trust can be rebuilt.
- Increase accountability: True accountability emerges from understanding impact and taking responsibility, rather than merely facing punishment.
- Foster learning: Open communication about what happened and why facilitates organizational learning and systemic improvements.
- Reduce recidivism/recurrence: By addressing root causes and empowering participants to find solutions, the likelihood of similar incidents can decrease.
n
n
CANDOR Implementation Data and Lessons Learned: Martin Hatlie’s presentation provided robust evidence of CANDOR’s practical application and growing success. The adoption of CANDOR in over 200 hospitals across 35 states signifies a critical shift in institutional mindset. Lessons learned from these implementations underscore several key benefits:
- Enhanced Trust and Transparency: Hospitals implementing CANDOR report improved patient and family trust, as open and honest communication replaces secrecy.
- Reduced Litigation and Costs: While not its primary goal, CANDOR has often led to a reduction in medical malpractice lawsuits and associated legal costs. By offering timely apologies and fair resolutions, many cases are resolved outside of court, saving both time and resources.
- Faster Resolution: The structured CANDOR process often allows for quicker investigation and resolution of incidents, providing closure to patients and families more rapidly than lengthy legal battles.
- Improved Provider Well-being: By providing immediate support, resources, and a safe space for dialogue, CANDOR programs significantly reduce the psychological distress experienced by second victims, contributing to better staff morale and retention.
- Strengthened Safety Culture: CANDOR fosters a "just culture" where errors are viewed as opportunities for learning and systemic improvement, rather than solely as individual failings. This encourages reporting, analysis, and proactive risk reduction.
The collective data, both qualitative and quantitative, paints a compelling picture: Restorative Practice and CANDOR are not just idealistic concepts but pragmatic, effective strategies for addressing harm in healthcare. They offer a pathway to healing that is more comprehensive, compassionate, and ultimately, more effective than the traditional reactive and defensive models they seek to replace.
Official Responses: Endorsement and Integration
The "Healing after Harm" webinar and the concepts it promotes reflect a growing consensus among leading healthcare organizations and policymakers that a new approach to adverse events is not merely desirable but essential. Official responses from bodies like CAPS and AHRQ, along with the increasing adoption by healthcare facilities, demonstrate a strong endorsement of restorative models.
CAPS’s Leadership Role: As the host of this critical webinar, CAPS (Collaborative Alliance for Patient Safety) reaffirms its commitment to advancing patient safety and quality improvement. CAPS’s mission inherently involves fostering collaboration, sharing best practices, and driving innovation in healthcare. By championing Restorative Practice and CANDOR, CAPS positions itself at the forefront of a movement that recognizes the human dimension of patient safety, moving beyond purely technical fixes to address the emotional and relational aspects of care delivery. The decision to host a follow-up discussion speaks volumes about their dedication to facilitating continued learning and implementation within the broader healthcare community.
AHRQ’s Foundational Contribution: The Agency for Healthcare Research and Quality (AHRQ) has been instrumental in laying the groundwork for initiatives like CANDOR. As a primary federal agency dedicated to improving healthcare quality and safety, AHRQ’s development of the Seven Pillars Tool Kit provided a robust, evidence-based framework for hospitals to communicate with patients and families after adverse events. This tool kit emphasized transparency, empathy, investigation, and fair resolution, directly influencing the design and principles of CANDOR. AHRQ’s ongoing support for research, implementation guides, and educational resources underscores the federal government’s recognition of these proactive communication and resolution strategies as vital components of a safe and high-quality healthcare system. Their involvement lends significant credibility and an evidence-based foundation to the CANDOR program.
Healthcare System Adoption and Policy Alignment: The fact that facilities in 35 states have adopted CANDOR practice, as highlighted by Martin Hatlie, signifies a widespread shift in institutional policy and culture. This adoption is driven by several factors:
- Ethical Imperative: Many healthcare leaders recognize the moral obligation to be transparent and supportive when harm occurs.
- Risk Management Benefits: While counterintuitive to older "deny and defend" strategies, transparent communication and fair resolution often lead to fewer lawsuits, faster resolutions, and lower overall litigation costs.
- Improved Reputation and Trust: Hospitals that openly address errors and support affected parties build stronger relationships with their communities and enhance their reputation for patient-centered care.
- Workforce Retention and Well-being: A just culture that supports "second victims" is crucial for staff morale, reducing burnout, and retaining experienced healthcare professionals.
Beyond individual hospitals, professional organizations, state hospital associations, and regulatory bodies are increasingly exploring and endorsing these approaches. There is a growing recognition that effective responses to harm must be integrated into broader quality improvement and risk management frameworks. This includes aligning internal policies, providing comprehensive staff training, and allocating necessary resources to support CANDOR and other restorative initiatives. The official embrace of these practices signals a mature evolution in the patient safety landscape, moving towards a more holistic and humane response to the inevitable complexities of healthcare.
Implications: Reshaping the Future of Healthcare
The embrace of Restorative Practice and CANDOR in healthcare carries profound implications, promising to reshape the very culture of medical institutions and redefine the relationship between patients, providers, and organizations. This shift represents not merely a change in protocol, but a fundamental transformation in values and approach.
Transforming Healthcare Culture: Perhaps the most significant implication is the potential to cultivate a genuine "just culture" throughout healthcare. A just culture moves beyond individual blame to focus on systemic issues, encouraging open reporting of errors without fear of unjust punishment. Restorative Practice and CANDOR reinforce this by providing a framework where transparency is rewarded, learning is prioritized, and empathy is central. This cultural shift fosters psychological safety, allowing providers to speak up about potential risks and learn from mistakes, ultimately making care safer for everyone. It moves organizations from a reactive, defensive posture to a proactive, learning-oriented stance.
Benefits for Patients and Families: For patients and their families, the implications are transformative. Instead of feeling marginalized or forced into adversarial legal battles, they are brought into a process that acknowledges their suffering, offers explanations, and provides opportunities for genuine healing. This can lead to:
- Increased Satisfaction and Trust: Patients feel heard, respected, and supported, leading to higher satisfaction with their care experience, even in the face of adverse events.
- Faster Emotional Healing: Open communication and resolution can provide closure and reduce the long-term psychological distress associated with medical harm.
- Reduced Need for Litigation: When organizations communicate openly and offer fair resolutions, patients are less likely to pursue lengthy and emotionally draining lawsuits.
- Empowerment: Patients and families become active participants in understanding what happened and ensuring it doesn’t happen to others.
Benefits for Healthcare Providers and Institutions: The advantages extend equally to healthcare professionals and the organizations they serve:
- Support for Second Victims: Providers who are often traumatized by their involvement in adverse events receive crucial emotional and psychological support, reducing burnout, moral injury, and the likelihood of leaving the profession.
- Improved Morale and Retention: A culture that supports its staff through difficult times fosters loyalty, increases job satisfaction, and helps retain experienced professionals.
- Enhanced Organizational Learning: By investigating harm openly and non-punitively, institutions can identify root causes more effectively, implement robust preventive measures, and continuously improve safety systems.
- Reduced Financial and Reputational Risk: While requiring initial investment, these approaches often lead to lower litigation costs, fewer lawsuits, and a stronger, more trustworthy public image, ultimately benefiting the institution’s long-term financial health and reputation.
- Ethical Fulfillment: Providers can feel more ethically aligned with their profession’s commitment to "do no harm" when they are empowered to communicate openly and contribute to healing.
Challenges and Future Directions: Despite the immense potential, widespread adoption of Restorative Practice and CANDOR faces challenges. These include overcoming deeply ingrained cultural resistance to transparency, securing adequate resources for training and implementation, and navigating complex legal and regulatory landscapes. Future efforts will need to focus on:
- Sustained Education and Training: Ensuring all levels of healthcare staff, from frontline providers to senior leadership, are proficient in restorative communication and CANDOR principles.
- Policy Support and Incentives: Developing policies that encourage and protect institutions adopting these transparent approaches.
- Research and Evaluation: Continuing to gather evidence on the long-term impacts and effectiveness of these programs across diverse healthcare settings.
- Integration with Existing Systems: Seamlessly embedding Restorative Practice and CANDOR into existing quality improvement, risk management, and patient experience initiatives.
The "Healing after Harm" webinar is a vital contribution to this ongoing evolution. By highlighting the power of Restorative Practice and CANDOR, CAPS and its presenters are advocating for a future where healthcare organizations respond to harm not with defensiveness, but with compassion, transparency, and a steadfast commitment to healing for everyone involved. The ripple effects of this shift promise a more humane, just, and ultimately, safer healthcare system for generations to come.
Join the Follow-Up Discussion!
Given the significant interest and numerous questions arising from the "Healing after Harm" webinar, CAPS has scheduled a follow-up discussion. This interactive session will provide an invaluable opportunity to delve deeper into the practicalities of implementing Restorative Practice and CANDOR, allowing attendees to pose questions directly and engage in a collaborative dialogue.
Date: Thursday, January 30, 2020
Time: Noon Central Time
Please join my meeting from your computer, tablet or smartphone.
https://global.gotomeeting.com/join/369235157
You can also dial in using your phone.
United States: +1 (872) 240-3212
Access Code: 369-235-157
Don’t miss this opportunity to contribute to and learn from the ongoing conversation about fostering healing and trust in healthcare.
