FOR IMMEDIATE RELEASE
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WASHINGTON D.C. – January 20, 2020 – In an era where healthcare safety is paramount, but medical errors and adverse events remain a persistent challenge, the Canadian and American Patient Safety (CAPS) organization is spearheading a transformative conversation on how the healthcare system responds to harm. On January 16, CAPS presented a pivotal webinar titled "Healing after Harm," bringing together leading experts to advocate for a more empathetic, transparent, and restorative approach to incidents that cause physical or mental suffering. The insightful discussion, now accessible on the CAPS webpage patientsafety.org, delved into the profound impact of harm on patients, providers, and institutions alike, and offered concrete strategies for moving forward from a place of accountability and healing rather than blame and litigation.
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The webinar underscored a critical shift in perspective: how patients, providers, and administrators respond to harm can either exacerbate an already traumatic situation or pave the way for genuine healing and systemic improvement. Central to this discussion were the principles of Restorative Practice and the Communication and Optimal Resolution (CANDOR) process, both championed as vital tools for navigating the complex aftermath of healthcare harm. The overwhelming response from attendees, marked by numerous questions and a palpable desire for deeper understanding, has prompted CAPS to schedule a follow-up discussion, signaling a growing recognition across the healthcare landscape of the urgent need for these innovative approaches.
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Main Facts: Shifting Paradigms in Healthcare Harm Response
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The "Healing after Harm" webinar, hosted by CAPS, served as a crucial platform for discussing modern strategies for addressing the profound and multifaceted impact of harm within the healthcare system. At its core, the event challenged traditional, often adversarial, responses to adverse medical events, advocating instead for methodologies rooted in empathy, transparency, and collective problem-solving.
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The term "harm" itself was given a broad and compassionate definition during the webinar: "Ill treatment; the impairment of physical or mental health (including that suffered from seeing, or hearing another person suffer ill treatment)." This expansive definition acknowledges not only the direct victim of an adverse event but also the indirect suffering experienced by family members, caregivers, and even other healthcare providers who witness or are involved in such incidents.
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A key highlight was the presentation by Mary Ellen Mannix, a passionate advocate for Restorative Practice. Mannix shared her deeply personal journey, recounting how the tragic death of her son led her to seek legal remedies, only to find that such avenues, while offering a form of justice, did not provide the holistic healing she desperately sought. Her experience propelled her into the study of Restorative Practice, a social science dedicated to improving and repairing relationships within and between people and communities. Mannix articulated how these principles, traditionally applied in criminal justice and educational settings, are profoundly relevant to healthcare, offering a framework for healing all parties affected by harm – patients, their families, and the healthcare professionals involved. Her message resonated with the idea that by removing shame from the process, individuals and institutions can openly address what happened, understand its impact, and collectively determine how to move forward constructively.
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Complementing Mannix’s insights, Martin Hatlie, a recognized authority in patient safety, provided an in-depth explanation of the Communication and Optimal Resolution (CANDOR) process. Hatlie positioned CANDOR not merely as a protocol but as a tangible application of Restorative Practice within healthcare settings. He traced CANDOR’s origins to the Agency for Healthcare Research and Quality (AHRQ) Seven Pillars Tool Kit, highlighting its evolution into a robust framework designed to foster open communication, offer sincere apologies, and facilitate fair resolutions in the wake of medical errors. Hatlie’s presentation also offered compelling evidence of CANDOR’s growing adoption and success, noting its implementation in over 200 hospitals and the widespread embrace of its practices across 35 states.
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The webinar concluded with an undeniable testament to its impact: a flurry of questions from attendees eager to understand the practicalities of implementing Restorative Practice and CANDOR. This intense interest underscored the urgent need for further dialogue and practical guidance, prompting CAPS to promptly schedule a follow-up discussion to delve deeper into these crucial topics. The event, therefore, was not merely an informative session but a catalyst for ongoing engagement and a significant step toward transforming how healthcare addresses and heals from harm.
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Chronology: From Personal Tragedy to Systemic Transformation
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The journey towards embracing Restorative Practice and CANDOR in healthcare has been a gradual, yet increasingly urgent, evolution, driven by both personal tragedy and a growing recognition of systemic shortcomings.
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The Genesis of the Webinar: A Call for Change
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The "Healing after Harm" webinar did not emerge in a vacuum. It represents a culmination of decades of efforts within the patient safety movement to move beyond a culture of blame and silence that has historically surrounded medical errors. For too long, the default response to adverse events in healthcare was to "deny and defend," a strategy that protected institutions legally but often left patients and families feeling unheard, disrespected, and further harmed. Simultaneously, healthcare providers involved in errors, often dubbed "second victims," suffered in silence, grappling with guilt, trauma, and professional isolation. Organizations like CAPS, dedicated to advancing patient safety, have been at the forefront of advocating for more humane and effective responses, creating a fertile ground for discussions on restorative justice and transparent communication. The January 16th webinar was a direct response to this ongoing imperative, aiming to equip healthcare leaders and practitioners with actionable strategies.
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The January 16th Event: Personal Stories and Practical Frameworks
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The webinar itself was structured to first establish the human cost of harm and then offer tangible solutions. Mary Ellen Mannix’s opening narrative was particularly powerful. Her personal tragedy – the death of her son – led her down the traditional path of seeking legal recourse. While understandable, her experience highlighted a critical flaw in the conventional system: legal remedies, focused on fault and compensation, often fail to address the profound emotional and relational wounds suffered by all parties. Mannix’s subsequent immersion into Restorative Practice illuminated a different path. She explained that Restorative Practice, originating from indigenous traditions and widely applied in justice systems, focuses on repairing harm by involving all stakeholders in a collaborative process. It asks not "Who is to blame?" but "Who has been harmed? What are their needs? Whose obligations are these?" This shift in inquiry facilitates dialogue, fosters mutual understanding, and empowers those affected to collectively determine how to make things right and move forward. Mannix powerfully articulated how this approach, by foregrounding empathy and shared responsibility, effectively removes the debilitating element of shame that often paralyzes both patients and providers after an adverse event, paving the way for genuine healing and accountability.
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Following Mannix, Martin Hatlie connected these restorative principles to the practical framework of CANDOR. He meticulously detailed how CANDOR evolved from the foundational work of the AHRQ Seven Pillars Tool Kit, which itself was a comprehensive guide designed to help healthcare organizations develop robust patient safety programs. Hatlie explained that CANDOR distills these broader principles into a streamlined, proactive process focused on immediate, honest, and compassionate engagement with patients and families following an adverse event. He emphasized that CANDOR’s three basic tenets are:
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- Open Communication and Transparency: This tenet mandates immediate, honest, and empathetic communication with patients and families following an adverse event, including a sincere apology and a clear explanation of what is known about the incident, even if details are incomplete initially. It involves active listening and ensuring patients’ questions are answered.
- Support and Fair Resolution: CANDOR commits to providing comprehensive support to all affected parties – patients, families, and involved healthcare providers. For patients, this might include immediate medical and psychological support, and an offer of fair resolution (which can include financial compensation) that is not contingent on litigation. For providers, it involves peer support, counseling, and a non-punitive environment for learning.
- Systemic Learning and Improvement: Beyond individual apologies and resolutions, CANDOR emphasizes a thorough, non-punitive investigation of the adverse event to identify root causes, rather than individual blame. The findings are then used to implement system-level improvements and prevent similar incidents from recurring, fostering a culture of continuous learning and safety.
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Hatlie’s presentation showcased the tangible benefits of CANDOR, drawing from lessons learned through its implementation in over 200 hospitals. He highlighted how these facilities, across 35 states, have seen not only a reduction in litigation but, more importantly, an improvement in patient trust, provider morale, and overall safety culture.
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The Follow-Up Discussion: Sustaining the Momentum
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The sheer volume and depth of questions posed by attendees following Mannix’s and Hatlie’s presentations underscored the widespread hunger for practical guidance on implementing these restorative approaches. Healthcare professionals from various disciplines expressed curiosity about specific scenarios, logistical challenges, and the cultural shifts required for successful adoption. Recognizing this critical need for continued dialogue, CAPS promptly scheduled a follow-up discussion for Thursday, January 30, 2020, at Noon Central Time. This session is designed to provide a more interactive forum for answering specific questions, sharing best practices, and fostering a community of practice around Restorative Practice and CANDOR. The availability of a GoToMeeting link (https://global.gotomeeting.com/join/369235157) and dial-in option (+1 (872) 240-3212, Access Code: 369-235-157) ensures broad accessibility for all interested parties, reflecting CAPS’s commitment to democratizing access to these vital patient safety tools.
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Supporting Data: The Imperative for Change
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The urgency behind adopting restorative approaches like CANDOR is underscored by alarming statistics and the well-documented limitations of traditional responses to healthcare harm.
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The Pervasiveness of Healthcare Harm
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Medical errors and adverse events are not isolated incidents; they represent a significant public health burden. Studies from the Institute of Medicine (now National Academies of Sciences, Engineering, and Medicine) as far back as "To Err is Human" (1999) estimated tens of thousands of deaths annually due to preventable medical errors. More recent analyses, such as those from Johns Hopkins, suggest that medical error could be the third leading cause of death in the United States, accounting for over 250,000 deaths each year. Beyond fatalities, millions of patients experience non-fatal but serious harm, leading to prolonged hospital stays, disabilities, and significant emotional distress.
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Moreover, the impact of harm extends beyond the direct patient. The concept of the "second victim" has gained increasing recognition, referring to healthcare providers who are traumatized after being involved in an adverse patient event. These individuals often experience guilt, anxiety, depression, and even post-traumatic stress disorder, which can lead to burnout, reduced job satisfaction, and a desire to leave the profession. Healthcare organizations, too, suffer as "third victims," facing financial penalties, reputational damage, increased litigation, and a decline in staff morale. The pervasive nature of harm thus necessitates a comprehensive, systemic response that addresses the needs of all affected parties.
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The Limitations of Traditional Approaches
For decades, the prevailing culture in healthcare when faced with an adverse event was often characterized by "deny and defend." This approach, driven by fear of litigation and reputational damage, encouraged silence, minimized disclosure, and often left patients and families feeling betrayed and alienated. While intended to protect the institution, this strategy often backfired, escalating patient anger, prolonging legal battles, and ultimately eroding public trust in healthcare.
Legal remedies, while essential for accountability in some cases, frequently fall short of providing holistic healing. Litigation is inherently adversarial, pitting patients against providers and institutions. It is a lengthy, emotionally draining, and expensive process that rarely satisfies the deep-seated need for truth, apology, and understanding that patients and families often seek. For providers, the threat of legal action fosters a culture of fear, hindering open reporting of errors and impeding opportunities for organizational learning and improvement. The financial costs of litigation, including legal fees, settlements, and increased insurance premiums, are also substantial, diverting resources that could otherwise be invested in patient safety initiatives.
Evidence for Restorative Practices and CANDOR
In contrast to these traditional shortcomings, Restorative Practice and CANDOR offer a paradigm grounded in transparency, empathy, and collective responsibility. Restorative Practice, as highlighted by Mannix, emphasizes dialogue, active listening, and collaborative problem-solving. Its principles encourage direct communication between those who have caused harm and those who have been harmed, facilitated by a neutral party, to understand the impact of the harm, acknowledge responsibilities, and collectively agree on steps for repair and prevention. This approach has shown efficacy in fostering reconciliation and reducing reoffending rates in other sectors, demonstrating its potential for transforming healthcare relationships.
CANDOR, as a specific application of restorative principles in healthcare, is supported by a growing body of evidence. AHRQ, a federal agency tasked with improving healthcare quality, has championed CANDOR through its comprehensive toolkit, which provides hospitals with resources to implement the process. Studies and reports on CANDOR implementation have consistently shown:
- Improved Communication: Hospitals adopting CANDOR report more open, honest, and timely communication with patients and families after adverse events.
- Reduced Litigation: Early, transparent communication and fair resolution offers often lead to a decrease in lawsuits and a quicker resolution of claims.
- Enhanced Patient and Family Satisfaction: Patients and families report greater satisfaction when they receive timely explanations, apologies, and support, even in the face of adverse outcomes.
- Increased Provider Support and Morale: By creating a non-punitive environment for disclosure and learning, CANDOR helps alleviate the psychological burden on "second victims," improving provider well-being and fostering a culture of psychological safety.
- Stronger Patient Safety Culture: CANDOR’s emphasis on thorough investigation and systemic improvement contributes to a stronger organizational culture of safety, where errors are seen as opportunities for learning rather than reasons for blame.
The fact that over 200 hospitals have adopted CANDOR practices and that its principles are being embraced across 35 states speaks volumes about its perceived effectiveness and the shift in institutional willingness to prioritize compassionate, transparent responses to harm.
Official Responses: Leadership in Patient Safety
The "Healing after Harm" webinar and the continued advocacy for Restorative Practice and CANDOR represent a concerted effort by leading organizations and experts to shape the future of patient safety.
CAPS’s Role: Catalyzing Change
The Canadian and American Patient Safety (CAPS) organization plays a pivotal role as a non-profit entity dedicated to improving patient safety across North America. Its mission extends beyond identifying problems to actively promoting solutions and fostering a culture of safety, transparency, and accountability. The "Healing after Harm" webinar is a testament to CAPS’s commitment to this mission. By hosting such an event, CAPS not only disseminates crucial information but also convenes experts and practitioners, creating a vital forum for dialogue and collaboration. Their proactive scheduling of a follow-up discussion demonstrates their responsiveness to the community’s needs and their dedication to supporting the practical implementation of these restorative practices. CAPS effectively acts as a catalyst, bridging the gap between innovative ideas and real-world application in healthcare settings.
AHRQ’s Influence: Architecting Solutions
The Agency for Healthcare Research and Quality (AHRQ) is a critical player in the evolution of patient safety initiatives. As a primary federal agency dedicated to improving the quality, safety, efficiency, and effectiveness of healthcare, AHRQ invests heavily in research and the development of practical tools. The fact that CANDOR evolved directly from AHRQ’s Seven Pillars Tool Kit underscores the agency’s foundational influence. AHRQ’s endorsement and comprehensive resources provide a robust, evidence-based foundation for CANDOR, giving healthcare organizations the confidence and guidance needed to adopt these complex processes. Their work ensures that practices like CANDOR are not merely theoretical but are supported by rigorous research and practical implementation strategies, making them accessible and actionable for hospitals nationwide.
Hospital Adoption and State-Level Support: A Growing Movement
Martin Hatlie’s data on CANDOR’s widespread adoption – over 200 hospitals in 35 states – signifies a critical inflection point in healthcare. This level of uptake is not merely anecdotal; it reflects a growing consensus among healthcare leaders that the traditional "deny and defend" model is unsustainable and ultimately detrimental to patient care, provider well-being, and organizational integrity. The willingness of institutions to embrace CANDOR indicates a significant cultural shift, moving towards greater transparency and a more patient-centered approach to adverse events. State-level support further legitimizes these practices, potentially influencing policy and encouraging broader implementation across healthcare systems, from large academic medical centers to smaller community hospitals. This collective embrace underscores a growing recognition that proactive, empathetic responses to harm are not just ethically sound but also strategically beneficial.
Expert Commentary: The Voice of Experience
Both Mary Ellen Mannix and Martin Hatlie, through their respective expertise, serve as crucial voices in this evolving dialogue. Mannix’s personal journey grounds the theoretical aspects of Restorative Practice in a deeply human context, making the case for its emotional and psychological efficacy. Her advocacy highlights that true healing extends beyond legal or financial compensation. Hatlie, with his extensive experience in patient safety and policy, provides the empirical and structural framework for CANDOR, demonstrating its practicality and effectiveness within complex healthcare organizations. Together, their contributions offer a compelling argument for a fundamental reorientation in how healthcare systems confront and recover from harm, moving towards practices that prioritize truth-telling, compassion, and systemic learning for the benefit of all stakeholders.
Implications: Reshaping the Future of Healthcare Harm Response
The increasing adoption of Restorative Practice and CANDOR signals a profound shift with far-reaching implications for the entire healthcare ecosystem. This transformation promises to redefine patient-provider relationships, enhance organizational culture, and ultimately contribute to a safer, more humane healthcare environment.
A Paradigm Shift in Patient Safety
The embrace of Restorative Practice and CANDOR represents a significant departure from a blame-focused, punitive culture to one that champions learning, transparency, and support. Historically, fear of retribution often led to underreporting of errors, hindering crucial opportunities for systemic analysis and improvement. By fostering an environment where errors are acknowledged openly and compassionately, these restorative approaches encourage a "just culture" – one that distinguishes between human error, at-risk behavior, and reckless behavior, and responds accordingly. This paradigm shift means that rather than hiding mistakes, healthcare organizations can transform them into powerful learning experiences, leading to more robust safety protocols and a proactive approach to risk management. The very definition of "accountability" expands from mere punishment to include a commitment to understanding, apologizing, and making amends, fostering a deeper sense of responsibility across all levels of care.
Benefits for All Stakeholders
The implications of widespread adoption are overwhelmingly positive for every party involved in healthcare harm:
- For Patients and Families: This new approach offers a path to genuine healing that traditional legal avenues often fail to provide. Patients and families gain access to the truth about what happened, receive sincere apologies, and are offered support services. This transparency can help restore trust in the healthcare system, provide a sense of validation, and offer a path to resolution that avoids the emotional and financial toll of prolonged litigation. They are empowered to be part of the solution, contributing to a shared understanding and preventing future harm to others.
- For Healthcare Providers (Second Victims): Perhaps one of the most significant implications is the profound benefit for healthcare professionals. By creating a safe space for disclosure and providing immediate support, CANDOR addresses the immense emotional burden experienced by "second victims." Removing the fear of blame and legal reprisal allows providers to process their trauma, learn from the incident, and continue their work with renewed purpose and confidence. This support network can significantly reduce burnout, improve morale, and ultimately lead to better retention of experienced and compassionate staff, strengthening the overall healthcare workforce.
- For Healthcare Institutions (Third Victims): Organizations stand to gain substantially. Implementing CANDOR can lead to a reduction in legal costs, as more adverse events are resolved outside of court. Beyond financial benefits, there is a significant enhancement of the institution’s reputation, building public trust through a demonstrated commitment to transparency and patient safety. A positive safety culture, fostered by restorative practices, can also improve staff engagement and loyalty, leading to a more stable and effective workforce. Ultimately, these practices contribute to a more resilient organization, capable of learning from its mistakes and continuously improving the quality and safety of care it delivers.
The Future of Healthcare Harm Response
The discussions initiated by the CAPS webinar are not merely about current best practices; they are about charting the future course of healthcare harm response. The enthusiastic reception and the need for follow-up discussions underscore that this is an evolving field, requiring continuous education, research, and adaptation. The ultimate implication is a healthcare system that is not only highly skilled in treatment but also deeply compassionate in its response to human vulnerability and error.
As more hospitals and states adopt Restorative Practice and CANDOR, these approaches will likely become the standard of care, fundamentally altering expectations for how healthcare providers and institutions interact with patients and families after an adverse event. The vision is one where harm, though regrettable, becomes an opportunity for healing, learning, and systemic improvement, rather than a source of prolonged suffering and fractured relationships. This transformation represents a crucial step towards a truly patient-centered healthcare system – one that prioritizes human connection and restorative justice at every turn.
