The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.

The Agency for Healthcare Research and Quality (AHQR) developed the CANDOR (Communication and Optimal Resolution) Event Checklist, which is a guide to be used by the CANDOR team after an adverse event occurred in the healthcare setting. The checklist includes effective ways of reporting, assessing, investigating, and analyzing the adverse event to decrease the likelihood of future incidents occurring, as well as improving the overall quality of patient care and safety.

The CANDOR Event Review Report Template is a guide used to analyze and investigate barriers that contributed to an adverse health event. Barriers include poor communication behaviors, unsafe physical environment, inadequate care, and equipment device failure. This template also includes a guide to assess who was responsible for the adverse event, and ways to develop solutions for it so it.

Read how the AMA pursues medical liability laws on the state level to reshape the current medical liability system to better serve both physicians and patients.

The authors discuss trends in the medical malpractice liability insurance market, consider the impacts COVID-19 has had, and suggest using a CRP approach during the pandemic to lessen the consequences of a hardening insurance market.

39 states have apology laws, with over a third applying to healthcare or other contexts. After over a decade of experience with apology laws, the authors explore whether apology laws reduce malpractice liability risk and why, and whether there is a reason to have them.

Background
Many health care organizations want to improve their responses to patients who suffer medical injuries. Their ability to understand how well they meet patients’ needs is limited by the lack of suitable instruments for assessing injured patients’ experiences.
Methods
This study aimed to generate items for a patient experience questionnaire that medical facilities can use to assess how well resolution met patients’ needs. The Medical Injury Reconciliation Experiences Survey (MIRES) was based on findings from previous studies of New Zealand and American patients’ experiences of non-litigation resolution of medical injuries. The researchers performed a content analysis of 24 transcripts from a stratified random sample of 92 interviews from the prior studies. Themes were extracted to develop a draft questionnaire, which was revised following feedback from experts. Cognitive debriefing interviews were conducted with 24 New Zealand and American injured patients.
Results
There were 40 items in the following domains: perceptions of communications with health care providers after the injury (15 items), perceptions of remedial gestures (11 items), indicia of the patient’s overall satisfaction with the reconciliation process (4 items), the nature and impacts of the injury (5 items), and patients’ characteristics (5 items). Participants’ feedback about the questionnaire was predominantly positive. Their suggestions led to 37 revisions.
Conclusion
The MIRES was comprehensible and acceptable to this group of post-injury patients. While further testing is desirable, the MIRES offers promise as a practicable approach that health care organizations can use to assess how well their reconciliation processes met patients’ needs.

Medical errors are associated with significant emotional, financial, physical and sociobehavioural impacts including reduced trust and willingness to seek healthcare. These impacts can last for years. The study sought to understand whether greater open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error.

Background: The emotional impact of medical errors on patients may be long-lasting. Factors associated with prolonged emotional impacts are poorly understood.

Methods: The authors conducted a subanalysis of a 2017 survey (response rate 36.8% [2,536/6,891]) of US adults to assess emotional impact of medical error. Patients reporting a medical error were included if the error occurred ≥ 1 year prior. Duration of emotional impact was categorized into no/short-term impact (impact lasting < 1 month), prolonged impact (> 1 month), and especially prolonged impact (> 1 year). Based on their reported experience with communication about the error, patients’ experience was categorized as consistent with national disclosure guidelines, contrary to guidelines, mixed, or neither. Multinomial regression was used to examine associations between patient factors, event characteristics, and organizational communication with prolonged emotional impact (> 1 month, > 1 year).

Results: Of all survey respondents, 17.8% (451/2,536) reported an error occurring ≥ 1 year prior. Of these, 51.2% (231/451) reported prolonged/especially prolonged emotional impact (30.8% prolonged, 20.4% especially prolonged). Factors associated with prolonged emotional impact included female gender (adjusted odds ratio 2.1 [95% confidence interval 1.5–2.9]); low socioeconomic status (SES; 1.7 [1.1–2.7]); physical impact (7.3 [4.3–12.3]); no organizational disclosure and no patient/family error reporting (1.5 [1.03–2.3]); communication contrary to guidelines (4.0 [2.1–7.5]); and mixed communication (2.2 [1.3–3.7]). The same factors were significantly associated with especially prolonged emotional impact (female, 1.7 [1.2–2.5]; low SES, 2.2 [1.3–3.6]; physical impact, 6.8 [3.8–12.5]; no disclosure/reporting, 1.9 [1.2–3.2]; communication contrary to guidelines, 4.6 [2.2–9.4]; mixed communication, 2.1 [1.1–3.9]).

Conclusion: Prolonged emotional impact affected more than half of Americans self-reporting a medical error. Organizational failure to communicate according to disclosure guidelines after patient-perceived errors may exacerbate harm, particularly for patients at risk of health care disparities.

Webinar Date: February, 2021

Overview: COVID-19 has fundamentally altered our care processes and standards.  Care is being delayed, visits are happening by telemedicine, there are changes in how staff are deployed and interact with patients, and everyone is exhausted and emotionally depleted. These all make potential for patient harm events higher.  COVID-19 is also adding stress to already tightening medical professional liability insurance market. While it may be tempting to abandon ship when it comes to implementing CRP during COVID-19 times, CRPs are more important now than ever.  Fundamental principles of the CRP model-supporting patients, families, and clinicians after harm with open communication, empathy, learning, and accountability – are critical elements of how we respond to COVID-related harm events.  This webinar examines two cases of COVID-associated adverse events to help lead a discussion on the challenging aspects in implementing CRPs during this time.

Presenters: Michelle Mello, JD, PhD, and Thomas H. Gallagher, MD

Commentary by: Jeffrey Catalano, JD, Marcia Rhodes, Jonathan Steward, JD, MS, RN-BC, CEN, CPHRM

Learning Objectives: 

• Examine potential communication and legal issues associated with COVID-related harm events
• Describe how CRPs can be used as a strategy to address these COVID-related adverse events
• Learn about CRP resources to help address COVID-related challenges

Webinar Date: June 24, 2021

Presenters:

Objectives:

Webinar Date: September 23, 2021

Presenters: 

• Alan Lembitz, MD, MMM, Chief Medical Officer, COPIC
• Eric Wei, MD, MBA Senior Vice President and Chief Quality Officer, NYC Health + Hospitals
• Laurie C. Drill-Mellum, MD, MPH, Chief Medical Officer, Constellation

Learning Objectives:

• Understand the importance of physician involvement in the CRP process and how it helps both physicians and patients
• Examine the benefits of CRPs to physicians
• Explore the barriers to CRP implementation from a provider’s perspective
• Learn why psychological safety a critical component of provider support

Webinar Date: May 20, 2021

Moderator:

• Barbara Pelletreau, RN, MPH, Senior Vice President, Patient Safety, CommonSpirit Health

Speaker Panel:

• Claire Hagan, MJ, CPHRM Director of Risk Management Programs, Providence St. Joseph Health
• Brittnie Hayes, JD, Claims Manager, COPIC
• Linda Ubaldi, RN, CANDOR Training Specialist and Former Quality and Patient Safety Officer, CommonSpirit Health

Learning Objectives:

• Learn practical advice from “claims professionals” on how to transition a CRP case to claims
• Describe several of the key components for an ideal partnership and transition to claims from the perspectives of health systems, insurers, and patients and families
• Understand the needs of patients and families, and how and when to appropriately engage them, in this transition to “claims process”

Webinar Date: June 17, 2021

Presenters: Jonathan D. Stewart, JD, MS, RN-BC, CPHRM

Jonathan is a Senior Director of Risk Management and Patient Safety at BETA Healthcare Group, where he serves as a consultant to hospitals, health care facilities and medical groups. His current professional focus includes helping health care organizations operationalize communication and resolution programs, particularly the investigation and analysis of patient harm events.

Objectives:

• Identify conflicting notions of success and failure regarding CRPs
• Discuss the relationship between incomplete CRP implementation and irregular application of CRPs
• Describe lessons learned from unsuccessful applications of CRPs to individual events

Webinar Date: October 21,2021

Moderator

• Carole Hemmelgarn, MS, MS

Speaker Panel

• Jack and Teresa Gentry
• Naomi Kirtner and Jeff Goldenberg, MD

Learning Objectives

• Understand what elements are important for patients and families to hear after medical harm
• Compare and contrast patient experiences with and without a Communication and Resolution Program (CRP) following harm
• Explain the importance of a highly reliable CRP for patients and families

Webinar Date: October 12, 2022

Presenter: WilliamM.  Sage, MD, JD

William M. Sage, MD, JD, an authority on health law and policy, is a tenured professor in Texas A&M’s medical and law schools, a professor by courtesy in the Bush School of Government and Public Service at Texas A&M, and a vice president in the university’s Health Science Center.   From 2006-2022, he held professorships in law and medicine at the University of Texas at Austin, where he also served as vice provost for health affairs.  He was previously a tenured professor at Columbia Law School, and has been a visiting professor at Yale, Harvard and NYU.  Prof. Sage is a member of the National Academy of Medicine, where he serves on the Board on Health Care Services and recently served on the Committee on the Future of Nursing 2020-2030.  Prof. Sage is a member of the Healthcare System and Value Research (HSVR) study section for the Agency for Healthcare Research and Quality (AHRQ), an elected Fellow of the Hastings Center on bioethics, and a longtime editorial board member of the journal Health Affairs.  He has written over 200 articles and has authored or edited four books, including the Oxford Handbook of U.S. Health Law (2016).  He holds an undergraduate degree from Harvard College, medical and law degrees from Stanford University, and an honorary doctorate from Universite Paris Descartes.

Webinar Date: July 15, 2021

Presenters: 

• Jo Shapiro, MD, FACS, Associate professor of Otolaryngology-Head and Neck Surgery at Harvard Medical School; Principle Faculty for the Center for Medical Simulation in Boston; Consultant for the Massachusetts General Hospital Department of Anesthesia, Pain and Critical Care
• Allan Frankel, MD, Chief Executive Officer, Safe & Reliable Healthcare

Learning Objectives:

• Identify conflicting notions of success and failure regarding CRPs
• Discuss the relationship between incomplete CRP implementation and irregular application of CRPs
• Describe lessons learned from unsuccessful applications of CRPs to individual events

Webinar Date: April 15, 2021

Presenters:

• Suz Schrandt, JD,  Senior Patient Engagement Advisor, Society to Improve Diagnosis in Medicine; Founder, CEO, & Chief Patient Advocate at ExPPect
• Eric J. Thomas, MD, MPH Associate Dean for Healthcare Quality, McGovern Medical School, University of Texas Health Science Center at Houston; Board President, Collaborative for Accountability and Improvement

Objectives:

• Understand the individual and system factors that can cause diagnostic errors
• Explore the benefits of a CRP response following a diagnostic error
• Examine the consequences of a poor response to a diagnostic error
• Understand the importance of engaging, listening, and learning from patients and families following diagnostic errors

CRPs: Why the insurance industry hasn’t embraced them . . . and why it should presented by Richard Boothman, JD

The driving ideas behind CRPs continue to draw interest and debate, now twenty years after Steve Kraman and Ginny Hamm published their Lexington, KY VA experience with “Extreme Honesty”.  After more than 17 years, the University of Michigan continues to draw attention transparent with their “Michigan Model”, the most successful and longest continual example of a principled, and proactive approach to patients injured in unexpected clinical outcomes.  After years of balking at abandoning “deny and defend” more health systems around the country and around the world are exploring the transition, but a skeptical insurance industry continues to hold back and sometimes, frustrate the desires of their insureds to move in this direction.  Why?  Is the industry’s skepticism well-founded and prudent?  Or is it missing a valuable opportunity?

Rick Boothman, the architect of the “Michigan Model” will initiate a long-deserved discussion into this topic.  His experience suggests that there are multiple insurance advantages in the CRP approach and the insurance industry should rethink old beliefs, practices and prejudices and embrace this model.

Outline

1. Insurance 101 – a dummy’s guide to the construct
2. True CRPs – the essential elements and how the model differs from “deny and defend”
3. What holds the insurance industry back from jumping on board?
4. What is the insurance industry missing and why should it matter?

Learning Objectives

• That too many equate CRPs only with selective, early resolution of potential and asserted claims – what are the essential elements that distinguish a true CRP from established, traditional risk management practices?
• What are the unique outcomes of a CRP and why do they matter?
• Why a CRP better serves the interests of healthcare insureds?
• What unique consequences of a CRP would benefit the insurance industry especially?

Large Scale Implementation of Communication and Resolution Programs

Presented by: Heather Gocke, M.S., RNC-OB, CPHRM, C-EFM

Webinar Date: January 29, 2020

Ms. Gocke introduces a comprehensive program and a holistic approach in reducing harm in healthcare through large scale implementation of CRP. In her presentation, she highlights the importance of disclosure and engagement, and she shares real-life challenges and secrets to success.

Learning Objectives:

1. Outline the method used to engage member sites in culture transformation
2. Learn  how culture measurement, survey data debriefs, and cognitive interviewing techniques are used to inform this body of work
3. Introduce the five domains and components of BETA HEART

Mitigating the Toll of Medical Errors on Clinicians by Jo Shapiro, MD, FACS

Webinar Date: October 31, 2019

As a clinician, being involved in adverse events can have devastating emotional consequences. How we react to these events – as individuals, colleagues and organizations – has a major effect on our organizational culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.  Dr. Shapiro’s presentation will detail these effects and address the unique role that frontline physicians can play in supporting one another after adverse events. She will describe the peer support program developed at Brigham and Women’s Hospital and adopted by dozens of healthcare organizations. She will describe the building blocks of a creating and sustaining a peer support program, including providing the participants with the rationale to bring to leadership in advocating for peer support program resources.

Learning Objectives:

1. Identify the emotional impact of adverse events on clinicians
2. Recognize the impact this has on a culture of psychological safety, provider wellbeing, disclosure and reporting, and patient safety.
3. Provide a rationale to leadership for developing a peer support program
4. Delineate the foundational aspects of a peer support program

Webinar presented by Dr. Tom Gallagher on Thursday, June 6, 2019

Large-scale adverse events, situations in which a breakdown in care has affected multiple (sometimes thousands) of patients, pose significant challenges for institutions related to responding in ways that inform potentially affected patients without unduly alarming them and managing the follow-up. This webinar will highlight lessons learned from the field around responding effectively to adverse events, as well as key unanswered questions.

Learning objectives:

1. Describe the diversity of large-scale adverse events, and how responding to these events differs from managing adverse events that affect individual patients
2. List the key elements of an effective response to a large-scale adverse events and the tools that are currently available to assist with this process
3. Critique an actual large-scale adverse event patient notification letter and press release, and articulate opportunities for improvement in these documents.

Communication-and-resolution programs (CRPs) aim to increase disclosure, learning, and responsibility following adverse medical incidents. The authors of this article identify five obstacles that prevent CRPs from being successful: 1) public policy, 2) compensation for patients following medical errors, 3) application fidelity, 4) evidence of CRPs increasing patient safety, and 5) alignment of CRP methods with patient needs. To increase the success of CRPs, it is recommended that they should be coupled with CRP quality programs. Overall, health institutions are advised to implement these programs into their systems to promote transparency and patient and family engagement.

This article explains how healthcare providers and insurers were skeptical of the Agency for Healthcare Research and Quality’s Communication (AHQR) Communication and Optimal Resolution (CANDOR) toolkit, which is a guide for healthcare providers to use if there was patient injury. Healthcare providers and insurers are weary of the CANDOR toolkit, since it does not quickly fix litigation scandals. This toolkit also does not effectively identify patient safety risks. However, the CANDOR toolkit is an effective step for healthcare providers to take in being honest and transparent with their patients about any malpractice or increased risk of injury.

The Journal of Patient Safety and Risk Management published study of an “open” hospital system shows that a Collaboration Communication-and-Resolution Program (CRP) cut lawsuits by two-thirds and reduced legal expenses and the time needed to resolve claims. Due to this program’s success, physicians are encouraged to integrate CRPs into their health practices to increase overall patient health quality and safety.

This study analyzed if a communication-and-resolution program (CRP) was effective in lowering adverse events among patients with chest pain, as well as lowering medical costs. The study concluded that the implementation of the CRP was efficient, since it helped increase the number of chest pain diagnoses as well as significantly reduced associated health costs.

Colorado Candor Act: ARTICLE 51 Communication and Resolution After an Adverse Health Care Incident (2019)

This is the website for the Washington Patient Safety Coalition’s (WPSC) Communication and Resolution Certification Program. When healthcare providers and organizations have utilized a CRP following an adverse event, they can apply for “CRP Certification.” A neutral group of patient safety experts and patient advocates has been convened to review responses to adverse events and certify whether the patient’s needs have been met, any individual or system-level inadequacies have been addressed, and learning has occurred. The certification process provides valuable feedback to healthcare organizations and demonstrates that they achieved all the essentials of a CRP.

The Washington Patient Safety Coalition is a program of the Foundation for Health Care Quality (The Foundation). The Foundation is a nonprofit organization dedicated to providing a trusted, independent, third party resource to all participants in the health care community – including patients, providers, payers, employers, government agencies, and public health professionals.

The Collaborative for Accountability and Improvement Program is currently based at the University of Washington. The goal of the Collaborative is to bring together leading experts to support the growth and spread of Communication and Resolution Programs (CRPs), advocate on behalf of these programs with a shared voice, and exchange ideas. CRPs drive quality improvement, enhance patient safety, and facilitate patient-centered accountability. This CRP (Communication and Resolution Program) brochure describes CRP Core Commitments, Key Steps in the CRP Process and Launching a CRP.

This letter to the Editors emphasizes the importance of CRPs in allowing hospitals to learn from all adverse events, even those that may not be traced by loss adjusters, and that the benefits of CRPs exceed their potential to mitigate economic burdens, even during the challenging time of COVID-19.