CANDOR Promotes Safety Reporting, Employee Support at Christiana Care Health System

Christiana Care Health System, a Delaware teaching health system with hospitals in Newark and Wilmington, has seen a 23 percent increase in patient safety events reported by its workforce since introducing AHRQ's Communication and Optimal Resolution (CANDOR) toolkit in 2014. The health system implemented the CANDOR process after testing the concepts for an AHRQ project.

Stephen Pearlman, M.D., quality and safety officer for Women and Children’s Services and physician lead for the CANDOR program at Christiana Care, said the increase in patient safety reporting includes some "near misses." Christiana Care commonly refers to these as "good catches" because staff are encouraged to report and correct unsafe conditions before they contribute to patient harm.

One example of a good catch was discovering that Christiana's medication storage areas contained two similar 50 ml bags—one containing a 5 percent dextrose solution and the other containing 0.9 percent normal saline. "If a nurse hung the wrong bag, the consequences could have impacted the patient," Dr. Pearlman said. "Those bags are now separated so there can be no mix-up."

He added that Christiana Care has developed a true team approach to reporting adverse events. "By learning from these events, we expect to see further improvements in our delivery of care processes, which will ultimately mean less harm for our patients," he said.

The CANDOR process has also helped health system leaders improve interaction with patients and families when there is an unexpected outcome from care. According to studies, this happens to about 1 in 10 patients nationally, despite the best efforts of doctors, nurses, and other health care professionals. The CANDOR toolkit gives hospitals the tools they need to engage in candid, empathetic communication with patients and families to achieve a timely resolution of the situation, without the need for litigation.

"We've done a much better job at communicating with patients and their families, and our medical staff has a better understanding of the importance of immediate disclosure following a patient safety event," Dr. Pearlman said. "Patients feel positive about this more open approach. It speaks to the importance of transparency as well as the improvement we've seen in our patient safety culture."

Patients are not the only ones harmed when something unexpected happens during the course of care. Medical personnel can feel traumatized due to their involvement in an unanticipated event that causes patient harm. This is often referred to as the "wounded healer" or "second victim" phenomenon. As part of implementing the CANDOR process, Christiana Care established a "Care for the Caregiver" program, a peer support system in which health care team members know they will be supported and treated in a just and fair manner and can quickly return to practice.

"Our staff has heartily embraced the CANDOR process, particularly the Care for the Caregiver program," noted Heather L. Farley, M.D., Christiana Care's director of provider wellbeing. "Training on the CANDOR process permeates throughout our organization. The value of the CANDOR process and Care for the Caregiver is widely recognized. It's a 'win' for the whole organization."

Christiana Care was one of three health systems in the Nation to participate in an AHRQ-funded, 2-year demonstration project that tested the effectiveness of the CANDOR process. The others were Dignity Health in California, and MedStar Health in the Baltimore, M.D./Washington, D.C., metropolitan area.

Dr. Pearlman noted that Christiana Care benefitted greatly by participating in the CANDOR demonstration project. "There has been a big shift in our patient safety culture," he said. "We've been reaping rewards that have been shown on many levels, both for our patients and for our employees. The CANDOR process has strengthened our commitment to promote staff's willingness to speak up about patient safety concerns and to create psychological safety within their work environment."