by Gerald Zarlengo, MD, Chairman & CEO COPIC Insurance Company
Featured in the July-August 2019 Colorado Medicine Colorado Medicine.
Candor can be defined as “the quality of being open and honest.” In health care, this term has been adopted to describe a framework for addressing adverse medical incidents in a way that preserves the provider-patient relationship, allows for open communication, and supports improvements in patient safety. The recently passed Colorado Candor Act enables health care providers and facilities to utilize this voluntary framework with patients.
While Candor may be a new term to some, it is based on a decade of research and ideas that many of us have come across during our careers. Candor emerged out of efforts by the Agency for Healthcare Research and Quality (AHRQ) as part of a toolkit developed to promote open, honest conversations with patients after adverse outcomes occur. The toolkit outlines a process designed to investigate and learn from what happened, to address patients’ needs, and to disseminate any lessons learned to improve future outcomes.
Since the AHRQ toolkit was released, the Candor framework has been utilized in various health care systems, demonstrated positive results, and Candor-related legislation has been enacted in Massachusetts, Oregon and Iowa. Throughout these efforts, some key underlying principles have been identified as crucial to the Candor process based on the insight derived and expert evaluation on what factors made a difference. These include the following:
Focus on meeting the patient’s needs and expectations during the process
Trust forms the basis of the provider-patient relationship. Crucial to this, after an adverse outcome, is providing an explanation of what occurred and what actions are being taken to prevent this in the future as well as an apology
Reinforce early reporting and the identification of adverse events
Creating an effective reporting culture around this requires a shift from blaming the individual to focusing on identifying system processes and related factors that contributed to the adverse outcome. Supporting a system that encourages rapid response also allows those involved to gather valuable information while the incident is fresh in everyone’s minds.
Assess and improve communication skills
Breakdowns in the communication process, whether with patients/family or other members of the medical team, are often at the root of medical liability claims. Communication is not an equally shared skill. There are good communicators and there are good systems to enhance the coaching of communication. The Candor process seeks to develop the skills required in these situations such as empathy, sincerity, active listening, patience, tact and emotional intelligence.
Conduct investigations from a systems analysis approach
The reason for using a systems approach is that managing individual performance alone doesn’t ensure that an adverse event won’t happen again with a different provider. The Candor process highlights that, to strengthen system accountability, we want to learn what happened, why it happened, what normally happens, and what applicable procedures are required. Only then can we learn why adverse events occurred, and how we can implement policy, process and improvement mechanisms to prevent these from happening again.
Support education based on learning
All too often, we only learn about preventable causes of medical harm after the harm has occurred. Building a robust education platform based on analysis of adverse events will protect the next patient from harm. The education should be case-based, interactive and involve all members of the health care team. Debriefing following near-misses is an example of case-based education that protects the next patient and improves outcomes.
The Colorado Candor Act became effective on July 1, and it provides an opportunity to shift the way we address adverse outcomes and improve health care. COPIC will be on the forefront of this and we look forward to supporting the health care community in embracing this change.