Why CANDOR is Important After Adverse Events in the Hospital

By Robin Diamond, MSN, JD, RN | Published 9/1/2016 2

AHRQ's CANDOR toolkit helps hospitals and physicians respond promptly and appropriately when an adverse event occurs.

In the past, hospitals and physicians could appear cold and distant after adverse events. The fear of malpractice lawsuits created a culture in which physicians were expected to avoid most contact with a patient or family who might have reason to sue—and physicians certainly weren’t supposed to accept blame.

Even when a well-meaning physician wanted to acknowledge the tragedy and express concern, hospitals sometimes discouraged the conversation because they were afraid the doctor’s comments would implicate the hospital in a malpractice case. The actual effect of this way of thinking was just the opposite of what hospitals and doctors desired. Rather than shielding them from liability, patients and family members perceived this culture of silence as callous and uncaring, in some cases encouraging them to file lawsuits.


Saying “I’m sorry”

That was then. Over the past decade, the healthcare community has embraced the idea that saying “I’m sorry this happened,” or at least acknowledging that an unanticipated adverse event occurred with genuine sympathy and concern, can go a long way toward healing the relationship between the healthcare provider and patient. Physicians have moved progressively toward a culture that expects an adverse event—a medication error, for instance, or a death during routine surgery—to be followed by a full disclosure of the facts to the patient and family. Hospital administrators and physicians both can say they’re sorry for what happened and even acknowledge they made a mistake in some circumstances when a clear-cut error has occurred that could have been prevented.

This is not just the right thing to do; it also helps the hospital and physicians avoid malpractice litigation, especially the lawsuits motivated not by actual errors or substandard care but by patients and family members who were left angry and abandoned.

Now we have not just the right idea, but the right way to execute it.


When bad things happen to good doctors

The Agency for Healthcare Research and Quality (AHRQ) developed the Communication and Optimal Resolution (CANDOR) Toolkit with the input of healthcare professionals who studied the different tools, policies, and procedures in use at various hospitals, including the disclosure resources offered by The Doctors Company. David B. Troxel, MD, medical director at The Doctors Company, served on the oversight committee, and I served on the technical advisory committee, which assessed expert input and lessons learned from AHRQ’s $23 million Patient Safety and Medical Liability grant initiative launched in 2009. The CANDOR Toolkit then was tested in 14 pilot hospitals across three U.S. health systems: Christiana Care in Delaware, Dignity Health in California, and MedStar Health in the Baltimore/Washington, DC, metropolitan area. David Mayer, MD, Vice President of Quality and Safety at MedStar Health and one of the originators of the toolkit said,

CANDOR is one of the most important patient safety programs to be released in the last 10 to 15 years. [IT] promotes a culture of safety that focuses on organizational accountability; caring for the patient, family, and our caregivers; fair resolution when preventable harm occurs; and, most importantly, learning from every adverse event so our health systems are made safer.


The CANDOR toolkit

This tool is just as useful for doctors as for hospitals. When a hospital is sued, physicians who were involved in the case will likely be named in the suit, whether they are employed by the hospital or not. Even though the CANDOR Toolkit is designed for hospitals, physicians should become aware of the valuable resources available to them in this toolkit, such as the videos that demonstrate how to have an effective disclosure conversation and tools that help doctors assess their own interpersonal communication skills.

The toolkit facilitates communication between healthcare organizations, physicians, and patients while promoting a culture of safety, said John Morelli, MD, Vice President of Medical Affairs at Dignity Health’s Mercy General Hospital in Sacramento, California.

The CANDOR Toolkit helps our caregivers improve how we rapidly communicate with patients and families when harm occurs. Consistent with our mission and values, we have always communicated with compassion and empathy; however, the toolkit provides a framework to respond quickly and in a learned manner to patients and families while also offering support to our caregivers.

CANDOR calls for a prompt response and specific actions after an adverse event. Within one hour, specially trained hospital staff should:

  1. Explain the facts, and what might still be unknown, to patients and family members.
  2. Contact the clinicians involved and offer assistance because the stress and grief of the healthcare professionals can easily be overlooked in these incidents.
  3. Immediately freeze the billing process to avoid further stressing the patient with a bill for the services that may have caused harm.

CANDOR calls for the hospital to complete a thorough investigation within two months, keeping patients and relatives fully informed along the way. When the investigation is complete, the patient and family are provided with the findings and engaged in a discussion of how the healthcare organization will try to prevent similar adverse events in the future.


Encouraging open communication

The investigation will not always find that the physician or other clinicians failed to meet the standard of care, and, in those cases, the patient and family members can still benefit from understanding what happened. In many cases, they will not sue despite their loss because they are satisfied that the hospital and physicians did their best and were forthcoming with information.

The Doctors Company encourages physicians to disclose and speak to patients about unanticipated events as early as possible. We also suggest they go to their hospital administration to find out what the hospital’s disclosure process is and how closely it follows the CANDOR plan because a cooperative approach is ideal. Working in harmony with the hospital is easiest in a closed system, where the physician is employed and insured by the hospital. Even when the hospital and physician are in adversarial positions and limited in communication, both parties still can adhere to the best practices outlined in the CANDOR program.

The philosophy and actions outlined in the CANDOR Toolkit can help hospitals and physicians avoid malpractice litigation, but even when the matter cannot be resolved and goes to trial, the fact that the patient and doctor talked early on can make a huge difference in the outcome of the case. Patients tend to pursue litigation with a vengeance when they think the doctor doesn’t care, but they tend to be much more reasonable when they can see that the physician is a human being with emotions, regret, and sympathy for the patient.

This post was sponsored by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer.

Robin Diamond, MSN, JD, RN

Website: http://www.thedoctors.com

Robin Diamond, MSN, JD, RN has over 37 years of experience in healthcare administration, including nursing, quality, medical-legal consulting, and risk management. She frequently speaks at national conferences on risk management and patient safety and is the author of nursing textbook chapters, along with other publications on the topics of nursing leadership, risk management, and patient safety. In 2010, she served as an examiner for the Baldrige Performance Excellence Program. For the past 16 years, she has worked in the medical malpractice insurance industry and now leads strategic planning and operations at The Doctors Company for the Department of Patient Safety and Risk Management. In addition to her legal experience, Robin Diamond has a master’s degree in psychiatric nursing from Vanderbilt University.


  • The CANDOR process is flexible enough to allow organizations to determine how to measure compliance. Refer to Module 8 of the CANDOR program titled “Organizational Learning and Sustainability.” The organization should include HR and the medical staff office when training. Without their commitment, there is little chance that CANDOR or any disclosure policy will be a consistent and “just” process.

  • What procedures exist within Candor to monitor compliance? Specifically what happens if it is discovered that no one reported an egregious event in a hospital that has adopted the program. Thanks for your response.

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