1. Culture of Safety and CANDOR Webinar
Patient Safety Movement Foundation
Presents
Culture of Safety and CANDOR Webinar
July 26th, 2017
History of the PSMF; Motivation for starting the PSMF
Ariana Longley, MPH, Vice President, PSMF
Expert Presenters: Dave Mayer, MD, MedStar Health and Tim McDonald, MD, JD, MedStar Institute for Quality and Safety

2. Agenda
10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)
35 Minutes: Patient Safety Movement Foundation’s Expert Presentation
David Mayer, MD, MedStar Health
Tim McDonald, MD, JD, MedStar Institute for Quality and Safety
15 Minutes: Q&A

3. ZERO Preventable Patient Deaths
PSMF Vision:
ZERO Preventable Patient Deaths
by 2020 (0X2020)

4. Without Reinventing the Wheel
We Strive to Foster New Efforts and Build On Existing Patient Safety Programs Through Commitments to
ZERO
A Fresh Approach to an Old Problem
Without Reinventing the Wheel

5. Who Can Take Action? Hospitals & Healthcare Organizations
Make a Commitment
Committed Partners
Sign the Commitment to Action letter
Healthcare Technology Companies
Sign the Open Data Pledge
Patient & Family Advocates
Share their Patient Story, Utilize Resources
Policy Makers
Increase awareness and promote patient safety Legislation
Many programs look at the relative avoidance of harm we need them to demonstrate the number of lives saved so that we can demonstrate to regulators and policy makers that these programs should become mandates.

6. Actionable Patient Safety Solutions (APSS)
1. Culture of Safety
2. Healthcare-associated Infections (HAIs)
3. Medication Errors
5. Anemia + Transfusions
6. Hand-off Communications
4. Failure to Rescue: Monitoring for Opioid Induced Resp. Dep.
8. Airway Safety
9. Early Detection & Treatment of Sepsis
7. Neonatal Safety
13. Mental Health
History
13 Challenges
3 New Challenges
Pediatric Adverse Drug Events
Purpose of APSS
10. Optimal Resuscitation
11. Optimizing Obstetric Safety
12. Venous Thromboembolism (VTE)
Download at patientsafetymovement.org

7. In order to reach our goal of ZERO by 2017:

8. David Mayer, MD, Vice President of Quality and Safety, MedStar Health
Tim McDonald, MD, JD, Director for Open and Honest Communication, MedStar Institute for Quality and Safety
Oversees the infrastructure for clinical quality and its operational efficiency for MedStar and entities
Designs and directs system wide activity for patient safety and risk reduction programs
Presented with the 2017 Humanitarian Award from the Patient Safety Movement Foundation for lifelong achievements in patient safety
International recognized patient safety expert
Former Inaugural Chair of Anesthesiology and Medical Director of Quality and Safety at the Sidra Medical and Research Center in Doha, Qatar
Physician-attorney involved in patient care for 30 years and patient safety efforts for past 20 years

9. When Words and Actions Matter Most: The Case for CANDOR

10. Safety Moment
A lack of transparency results in distrust and a deep sense of insecurity. Honesty and transparency make you vulnerable. Be honest and transparent anyway. Trust, honesty, humility, transparency and accountability are the building blocks of a positive reputation. Mother Teresa

12. Making Matters Worse

14. How Did We Shatter the Wall of Silence at the University?

15. 2005 Leaders at the University approved: Comprehensive “communication- resolution” program to prevent and respond to harm – a CANDOR process
Created urgency
Comprehensive – with leadership and stakeholder buy-in
Integrate safety, risk, quality, credentialing, claims and the Office of Business and Finance
Linking transparency to learning: patient safety education plan
Agreement to shift the paradigm for response to harm
Started small
Celebrated wins
Continuous RPI

16. Apology with Remediation
The Original Seven Pillars Approach to “When Words and Actions Matter Most”
Event Occurs
Data Base No
Harm??
Yes
Event Investigation No
Inappropriate care??
Yes
Apology with Remediation

17. What’s Wrong With This Picture?
Event Occurs
Data Base No
Harm??
Yes
Event Investigation No
Inappropriate care??
Yes
Apology with Remediation

18. Didn’t Get it Quite Right in the Beginning
With Patient Advocates connecting our hearts with our heads ...

19. Didn’t Get it Quite Right in the Beginning
With Patient Advocates connecting our hearts with our heads at the Telluride Patient Safety Roundtable, 2005
We needed a rapid and ongoing response to harm
We needed to include patients and families in event analysis.
Learning and improvement needed to be hard-wired
We need to learn to listen and not just disclose
Billing patients for inappropriate care adds salt to the wound – we must stop that!

20. After Patient, Family, and Clinician Input – to the Seven Pillars Approach

21. Communication and Optimal Resolution (CANDOR ) Process
Paradigm
Shift
Traditional Response
Communication and Optimal Resolution (CANDOR ) Process
Incident reporting by clinicians
Delayed, often absent
Immediate
Communication with patient, family
Deny/defend
Transparent, ongoing
Event analysis
Physician, nurse are root cause
Focus on just culture, system, human factors
Quality improvement
Provider training
Drive value through system solutions, disseminated learning
Financial resolution
Only if family prevails on a malpractice claim
Proactively address patient/family needs
Care for the caregivers
None
Offered immediately
Patient, family involvement
Little to none
Extensive and ongoing

22. How We Respond At The Most Difficult Times Defines Who We Are
Crash July 6th 11:28am. This photo was posted on the web on July 7th.
How do we deal with this complexity? We get the right people, boots on the ground, to the site of the event as quickly as possible to start gathering information.

23. SSE Go Team
At the core of NTSB investigations is the "Go Team." The purpose of the Safety Board Go Team is simple and effective: Begin the investigation of a major accident at the accident scene, as quickly as possible, assembling the broad spectrum of technical expertise that is needed to solve complex transportation safety problems.

24. CANDOR “Go Team” Processes
Three CANDOR “Go Team” components
Discovery and Learning Team
Care for the Caregiver Team
Patient/Family Communication Consult Service

25. Event Review Process
National Center for Human Factors in Healthcare and MedStar Safety – Subject Matter Experts
Reviewed RCAs from other industries.
Consulted with aviation industry

26. Current State: Event Review 2.0
Immediate Response
In-Depth Event Review
Confirmation & Consensus Meeting
Solutions Meeting
Follow Up
Interviews
Templates, project management techniques
and documentation
Care for Patient and Family
Understand
Context
Current State: Event Review 2.0
Care for Caregiver
As you can see from the info graph there is new language, and a sense of urgency surrounding the event.
New process new language
Focus is up front
Focus is on quickly identifying causal factors and then getting everyone on board
Look at the immediate response steps. Notice that each of these steps can happen at the same time. Keep in mind that they are happening within minutes to hours of discovery and that they are happening at the same time. So what does this mean? It means you have to move….everything is time sensitive you need to get up and get to the unit or to the area where the event occurred. The same holds true for in depth event review. Upper steps remain linear – you shouldn’t go onto the confirmation consensus meeting until you complete your response and in depth review.
Identify Causal Factors
Gather time sensitive info
Identify Core Team

27. Importance of Having a “Human Factors” Mindset

28. “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
—Lucian Leape
This is a concept that is really uncomfortable for leaders – we’ve seen this on the front lines. We need to make it easier for them to manage this feeling so they don’t’ have to struggle with it – we said it is OK to forgo punishing.
We know that other industries such as commercial aviation, as we’ve heard from Jeff Skiles, have made the commitment to create an environment free from immediate blame; this builds the trust needed to share unsafe practices in order to create that learning environment to prevent future events.
Even if you’re tired of hearing about the airline industry, even tif you think healthcare is different, we need to pay attention to identifying the hazards, or no one will ever tell us.
Just Culture sheds light on the hazards BEFORE there is harm. A punitive culture reacts AFTER there is harm.
“The organization is accountable to understand what happened and to create a system in which people feel safe” Ivan Pupulidy, Director US Forest Service Office of Innovation

29. The Communication and Optimal Resolution: CANDOR Process
The CANDOR Process consists of five major “bundles” of activity that proceed in sequence and at times simultaneously.

30. Goals of the CANDOR Program
Reduce harm through transparency and learning
Reduce legal involvement through early, effective communication with all parties
Resolve inappropriate care cases early, efficiently
Support patient and family engagement
Support care professionals following harm events

31. Communication is the Key

32. After Patient, Family, and Clinician Input – to the Seven Pillars Approach

33. The Communication and Optimal Resolution: CANDOR Process
The CANDOR Process consists of five major “bundles” of activity that proceed in sequence and at times simultaneously.

34. Data

35. Confidential Pursuant to ARS 36-44501

36. Other Critical Data Time to resolution reduced more than 70%
Not just the right thing to do
Also the smart thing to do

37. AHRQ Research Grants Agency for Healthcare Research and Quality
Task Order to create a CANDOR Toolkit
Toolkit completed September, 2015
Organizational assessment tools
Event reporting
Event analysis – HF and process redesign
Communication training
Care for the Caregiver program implementation guide
Optimal Resolution tools
Patient and Family Partnership and Engagement

38. Q & A

39. Thank you!