AHRQ Toolkit Helps Health Care Organizations and Providers Communicate With Patients and Families When Harm Occurs
Press Release Date: May 23, 2016
The Agency for Healthcare Research and Quality (AHRQ) today released a new online toolkit to help hospital and health system leaders and clinicians communicate accurately and openly with patients and their families when something goes wrong with their care.
The toolkit will help expand use of an AHRQ-developed communication and resolution process called Communication and Optimal Resolution, or CANDOR, which gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.
Despite the best efforts of hospitals, doctors, nurses and other health care professionals, about 1 in 10 patients are harmed by the care they receive. Effective communication following harm can be challenging, leaving patients and families to wonder what happened and possibly seek legal action to find answers. The toolkit, which includes facilitator notes, slides, and online videos, enables health care organizations to make care safer by implementing the CANDOR process to encourage proactive, open communication with patients and their families when harm occurs.
"Medical harm can impact patients twice—first by the harm itself, and then by the wall of silence that can follow," said AHRQ Director Andy Bindman, M.D. "This toolkit helps foster honest and transparent communication in an effort to rebuild trust and support safer care for patients."
The CANDOR process was developed by AHRQ and is based on expert input and lessons learned from the agency's $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the largest federal investment in research linking improved patient safety to reducing medical liability.
CANDOR is an example of a communication and resolution program, which some hospitals are already using. These programs help remove barriers to the reporting of near misses and errors and encourage open communication about how to prevent future harms. The CANDOR process was tested and applied in 14 hospitals across three health systems, which plan to expand its use: Christiana Care in Delaware, Dignity Health in California, and MedStar Health in the Baltimore/Washington, D.C., metropolitan area.
"Every day in American hospitals, countless doctors, nurses and other caregivers perform miracles for patients. And while one incident is one too many, sometimes errors occur," said Richard J. Pollack, President and CEO of the American Hospital Association, whose Health Research and Educational Trust foundation developed the CANDOR tools under a contract with AHRQ. "This toolkit helps everyone involved—patients, families, clinicians, and administrators—discuss what happened, agree on a resolution and make care safer in the long run."
The CANDOR toolkit, which is customizable and available at no charge, is the latest in a series of AHRQ materials to teach, train, and catalyze health care providers to build capacity to make care safer. Read more about CANDOR and the importance of honesty when patient harm occurs in a new blog by Dr. Bindman.
AHRQ is a health services research agency within the U.S. Department of Health and Human Services that invests in evidence and research to understand how to make the health care system safer and improve quality. AHRQ also generates measures and data used to track and improve performance and evaluate progress of the U.S. health system. Its mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within HHS and with other partners to make sure that evidence is understood and used.
Editor's Note: An introductory video, factsheet, blog and additional statements of support for the CANDOR process from consumers, doctors, nurses and hospital leaders, are available by contacting Lorin Smith at Lorin.Smith@ahrq.hhs.gov or 301-427-1864.