University of California, San Diego



KHN CARING through CANDOR Guidelines ManualKHN Communication AND Optimal Resolution guidelines and training materialsfor supporting patients, families, and clinicians who are impacted by adverse events or unexpected outcomes.Table of ContentsHow to Use This ManualGuiding Philosophy and Principles for KHN CARING through CANDORWhy KHN Values a Communication and Resolution ProcessBest Practices for Communication and Resolution ProgramsDisclosure: Basis for Support and a Historical PerspectiveKHN CANDOR General Process Flow (see policy and protocol in Appendix)Overcoming Barriers Definitions and CARING through CANDOR Roles and ActionsEvery Patient, Every Time, Everywhere CARING through CANDOR Communication GuidelinesWECARE for YOU – Care for the CaregiverEvent AnalysisDocumentationResolutionSustainability and Organizational LearningKHN CARING through CANDOR Education and Training AppendixAcknowledgementsKHN CANDOR policy and protocolBest Practice organizations/resource linksWE CARE for YOU Policy and ProtocolCase scenario practicePlease note that the information contained in this manual may be subject to change or clarification as new research and literature becomes available and/or as laws and regulations regarding disclosure change. It is important to always consult your organization legal counsel for specific guidance regarding communication and resolution after patient harm.HOW TO USE THIS MANUAL“…and because of their honesty and what they did to help us through a very difficult time, they have created an atmosphere of trust and I recommend this hospital to all my family and friends”(Mr. Malizzo regarding the death of his adult daughter due to medical errors. You Tube, “Meet the Malizzo-Ballog family”) Each Kettering Health Network (KHN) care facility in accordance with our mission, vision, and values- continuously improves the health and safety of patients and the quality of health care provided to our community. This includes our commitment to the rights of patients and their families to timely, transparent, and trustworthy communication and support following unanticipated outcomes, as well as the needs for caregivers to have systematic support. KHN has created this guideline and training manual as a result of extensive review and collaboration with communication and resolution best practice organizations (listed in the Appendix). Communication and Resolution programs are a principled, comprehensive, and systematic approach to responding to patients who have been harmed by their healthcare. They are an integral component of a larger commitment to patient quality and safety, and are implemented for the benefit of both patients and the professionals who deliver care.This toolkit is designed to be used in conjunction with CANDOR training at KHN. It is intended to be used by all staff, leaders, and care providers as a reference guide and is not a substitute for training, education, or legal advice. Care providers are encouraged to contact their Risk Management department leaders for any questions.NOTE: The trend is to lessen the use of the word “Disclosure” as it can imply something has been kept from patient and families. As far as possible, KHN will use the language of “Communication and support after unexpected outcome,” yet through this manual, you will note the use of “Disclosure” in some descriptions or resources..GUIDING PRINCIPLES for KHN CARING through CANDOR“If our goal is to xix people, we may see them as weak.If our goal is to help people, we may see them as weak.But if our goal is to SERVE people, we create a relationship between equalsAnd something in us is healed too.”~Rachel Naomi Remen MDAt KHN, we believe we are called by God to lift the burden of suffering for others, and to improve the quality of life for those in our care. We believe that everything we say and do matters because every life matters.The primary driver at KHN in the program of communication and resolution after unanticipated patient outcomes, is not about legal liability – but rather is the compelling call to compassionately restore relationships, and improve care delivery.The primary challenges that exist in communication and resolution programs are relationship-centered, so trust is a thread that must run through an effective, systematic process. Genuine efforts to maintain or regain trust with those we serve are expected of all KHN caregivers.Care that is Compassionate and Respectful, Safe, Patient-Centered, Informative, Timely, Efficient, Equitable, and Effective – prevents and mitigates patient and family suffering.Effective Communication (sometimes called Disclosure) AND Optimal Resolution (CANDOR) following unanticipated patient harm is aligned with and supports the culture of caring, safety, and quality at munication after harm events: is an extension of the informed consent process; is not a one-time event - it is ongoing; supports a learning environment; meets regulatory requirements; meets patient expectations; and reduces legal liabilityEmpathy and emotional support for patient/family and care providers is always appropriate and expected at KHN.Analysis after unanticipated outcomes is done using human factors and Just Culture principles. Action plans are designed and implemented to prevent recurrences of adverse events.KHN seeks to create a culture of transparency, organizational learning, reliability, and sustainability. WHY KHN VALUES A COMMUNICATION AND RESOLUTION PROCESS“Sacred Work is the expression of God’s love in the work we do every day and is experienced when any need is met with love”~Erie Chapman, Radical Loving CareAt Kettering Health Network, we believe we are called by God to lift the burden of suffering and restore hope and healing to body, mind, and spirit. Everything we say and do matters because every life matters. Our Mission is to improve the quality of life in the communities we serve in an environment of God’s love and care. KHN is an award-winning health care system that continually strives to deliver the best outcomes and experience in quality, safety, and service. In keeping with the spirit of our “Called to Care” culture, we recognize that we are people caring for people and that despite our best efforts, there will be times when unanticipated events and outcomes occur for patients and their families.At no other time in our delivery of health care is there such a profound invitation to live our values than when there is patient harm. These are the times that call for a principled, transparent, timely, and systematic approach to compassionately restoring health and safety, and right relationship as far as possible. This includes caring for the caregiver – serving the servers – who often experience a “second-victim” response.What do patients want when there has been an unexpected outcome? The evidence now clearly shows that patients and families who are harmed by unanticipated outcomes (whether or not we met the standard of care), have the same basic quartet of needs: 1) Accurate and truthful information in real time close to the event rather than after a lengthy investigation, 2) An empathic acknowledgment of their pain and suffering and an apology if warranted, and 3) Follow-up and possible compensation, and 4) An assurance that what happened to them won’t happen to anyone else.All KHN caregivers are expected and encouraged to follow the Called to Care Presence Practices of: Listen with Respect; Communicate with Empathy; Act with Compassion; Partner with Dignity; and Serve with Humility. We will walk beside the patient and family- immediately and into their future – for as long as is needed.To that end, we embrace the following guidelines as a principled way to offer a skillful response of Communication AND Optimal Resolution (CANDOR) that we call CARING through CANDOR.When undesired outcomes, unfulfilled patient expectations, and/or unanticipated or harmful events occur - whether or not we met the standard of care – all KHN caregivers are empowered and encouraged to express empathy. It is through the act of communicating with empathy and honesty that we support the healing process and honor our relationships with those at the center of our care…our patients and their families.BEST PRACTICES FOR COMMUNICATION AND RESOLUTION PROGRAMS (CRP)“Whatever you do, work at it with all your heart – as working for the Lord…” ~Colossians 3:23The following components emerge in review of current best practices in communication and resolution approaches. All processes should be based on transparency, empathy, and responsiveness, and be guided by “the right thing to do.”The CARING through CANDOR approach for KHN is built on these best practices identified by the Collaborative for Accountability and Improvement:A CRP requires that healthcare organizations and their clinicians commit to the following:Being transparent with patients around risks and adverse events, including sharing information about what happened, whether the adverse event was preventable, why the event happened, and how recurrences will be prevented in whatever detail the patient desires.Analyzing adverse events using human factors principles, and developing and implementing action plans designed to prevent recurrences of adverse events caused by system failure or human error.Supporting the emotional needs of the patient, family, and care team affected by the event.Proactively and promptly offering financial and non-financial resolution to patients when adverse events were caused by unreasonable care.Educating patients or their families about their right to seek legal representation at any time.Working collaboratively with other healthcare organizations and professional liability insurers to respond to adverse events involving multiple parties.Assessing continuously the effectiveness of the CRP program using accepted, validated metrics.KEY STEPS IN THE CRP PROCESSInitial ResponseFollowing recognition of an unsafe condition/practice or an adverse event, the following key steps in the CRP process should be carried out:Immediately report the adverse event to the institution or organization (within 30 minutes of the event’s discovery).Ensure the patient’s immediate clinical needs related to the risk or adverse event are addressed.Ensure the immediate needs of the involved clinicians are addressed, as it is common for clinicians involved in an event that harmed a patient to experience acute distress.Engage the patient and family as soon as possible after the event’s discovery in establishing priorities and expectations. This includes listening to and communicating with the patient and family about what happened, how the patient’s immediate needs are being addressed, what the patient should expect from the CRP process going forward, and unqualified expressions of empathy.Monitor and respond to the patient’s and family’s needs, questions and concerns and share factual (as differentiated from speculative) information about the event as it becomes available.6) Hold the patient’s bills, pending outcome of the event analysis.Patient Safety and Quality Improvement ActivitiesUndertake a rigorous, human-factors-based event analysis that incorporates information and perspectives from the patient and family. Develop and implement plans for preventing recurrences of the event, based on human factors and Just Culture principles.Continued Patient Engagement and Movement Toward ResolutionHold a resolution discussion with the patient and family and share the final results of the event analysis and prevention plans.Proactively offer fair financial or non-financial compensation to the patient and family for adverse events determined to be caused by unreasonable care, rather than waiting for the patient and family to request compensation.Educate patients or their families about their right to seek legal representation at any time.Post-Event Dissemination of Patient Safety and Quality Improvement Lessons LearnedSummarize the lessons learned with identifying information removed and disseminate throughout the organization.Take steps to ensure wide distribution of lessons learned so other clinicians and institutions can prevent the same kinds of mistakes. Share with other healthcare institutions, professional associations, and stakeholder groups.DISCLOSURE: Basis for Support and a Historical Perspective“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”-- Lucian Leape, MD, Professor, Harvard School of Public Health, Testimony to CongressThe rational for transparent communication (disclosure) to patients and their representatives after unexpected outcomes include:Disclosure is an extension of the informed consent processTruth-telling honors the relationship between caregiver and patient/familyTo meet Regulatory requirements; Joint Commission, state laws; hospital policy The need to meet patient expectationsThe possible reduction in legal liabilityBy 2017, the evidence is clear about the relationships between disclosure and litigation and the need for an integrated, comprehensive approach.Patient who pursue legal action cite:The perception that the truth was hidden from themExperienced a problem or discomfort with MD-patient communicationDisclosure reduces the intention to sue, and promotes more favorable settlementsDisclosure significantly reduces number of claims, and the size of jury rewardsREGULATORYThe Joint Commission Standard RI.01.01.01 - “The licensed independent practitioner responsible for managing patient care, treatment and services – or his or her designee – informs the patient about unanticipated outcomes of care, treatment, and services related to sentinel events when the patient is not already aware of the occurrence or when further discussion is needed.”RESEARCH AND ADVOCACYNational Patient Safety Foundation Statement of Principle – “When a health care injury occurs, the patient and the family or representative are entitled to a prompt explanation of how the injury occurred and its short-and on-term effects. When an error contributed to the injury, the patient and the family or representative should receive a truthful and compassionate explanation about the error and the remedies available to the patient. They should be informed that the factors involved in the injury will be investigated so that steps can be taken to reduce the likelihood of similar injury to other patients.”American Society for Healthcare Risk Management – (2013) Disclosure of Unanticipated Events: Prologue to the Re-lease of the three ASHRM Disclosure Monographs. “Disclosure is not now and never will be, a risk management technique. Disclosure is not intended to stop people from suing or requesting compensation. Disclosure honors the patient’s right to autonomy to make decisions about care. Disclosure is the only path to obtaining, maintaining, or regaining patient and family trust, yet disclosure will not do this by itself – it must be reinforced by good faith and efforts to share what is learned and to show genuine compassion for the needs of patients and families. This will demonstrate that we live up to our values and care about those we serve.”Institute for Healthcare Improvement (Conway J, Federico F, Stewart K, Campbell M, Respectful Management of Serious Clinical Events [Second Edition]. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011). “Everyday, clinical adverse events occur within our health care system, causing physical and psychological harm to one or more patients, their families, staff (including medical staff), the community, and the organization…the risks of not responding to these adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the sending of mixed messages about what it really important to the organization, increased likelihood of regulatory action or lawsuits, and challenges by the media.”National Quality Forum Safe Practice Number 7 - “Following serious unanticipated outcomes, including those that are clearly caused by systems failures, the patient and, as appropriate, the family should receive timely, transparent, and clear communication concerning what is known about the event.” When things Go Wrong: A Consensus Statement if the Harvard Hospitals, March 2006 –“Medical care must be safe: Hospitals must become ‘learning organizations’ defined by Peter Senge as organizations that ‘continually expand their capacity to create the results they truly desire.’ We must commit ourselves to relentless self-examination and continuous improvement… Medical care must be patient-centered: The primary objective is to support gthe patient and maintain the healing relationship. Patients and families are entitled to know the details of incidents and their implications. Communication should be open, timely, and sustained…and consider the full breadth of patient’s needs. We are making a moral argument here….we are committed to full disclosure because it is the right thing to do.”Wu, A. Huang, I, Stokes, S, Pronovost, P, presented in part at the 28th Annual Meeting of the society of General Internal Medicine, New Orleans, May 11-14, 2005, Published online July 4, 2009. Disclosing Medical Errors to Patients: It’s not what you say, it’s what they hear. - “Patients are likely to respond more favorably to physicians who apologize and accept responsibility for medical errors than those who give ambiguous responses…Patient perceptions of what is said may be more important than what is actually said.”PROFESSIONAL SOCIETIESAMA Ethical Guidelines: Ethical Responsibilities to Study and Prevent Error and Harm (E-8.121) “Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help to reduce the risk of liability.” American College of Physicians: Annuls of Internal Medicine – Ethics Manual, 6th Edition, January 2012 – “Effective patient-physician communication can dispel uncertainty and fear and enhance healing and patient satisfaction…However uncomfortable for the clinician, information that is essential to and desired by the patient must be disclosed…Errors do not necessarily constitute improper, negligent, or unethical behavior – but failure to disclose them may.” American College of Surgeons Code of Professional Conduct- “As fellows of the American College of Surgeons, we treasure the trust that our patients have placed in us, because trust is integral to the practice of surgery. During the continuum of pre-, intra-, and postoperative care, we accept responsibilities to…fully disclose adverse advents and medical errors.”American College of Emergency Physicians Position Statement, September, 2003.- “If, after careful review of all relevant information, an emergency physician determines that an error has occurred in the care of a patient in the emergency department, he or she should provide information about the error and tis consequences to the patient…or to the patient’s representative in a timely fashion, in accordance with the hospital policy on medical error disclosure.”HISTORICAL PERSPECTIVE (not all-inclusive of all participating entities)1980American Society of Healthcare Risk Management (ASHRM) is founded – dedicated to the patient safety movement, through advocacy, education, research, and publication.1986Massachusetts introduces the first Apology Statute1987Veterans Affairs Medical Center, Lexington Kentucky adopts program to disclose, apologize and compensate (versus deny and defend)1999Institute of Medicine releases its landmark report, To Err is Human declaring that medical injury in a major cause of preventable deaths, and calling on health care to make the reduction of medical errors a priority. In a subsequent report Crossing the Quality Chasm, the IOM proposed six aims for the redesign of health care – to provide care that is: safe, patient centered, effective, timely, efficient, and equitable. 2000The literature addressing Patient Safety dramatically increases. 2001Joint Commission releases disclosure requirements and establishes a sentinel event database.2002Medically Induced Trauma Support Services (MITSS) is established as a non-profit dedicated to supporting healing and restoring hope to patients, families, and clinicians who have been impacted by adverse medical events.2003National Quality Forum (NQF) endorsed 30 “safe practices” for reducing error and improving care. Through 2008, NQF had endorsed more than 500 measures, indicators, practices, and products.Agency for Healthcare Research and Quality (AHRQ) creates patient safety indicators and a survey for use by hospitals in developing cultures of safety2004HealthGrades releases a study “Patient Safety in American Hospitals” which applied 16 safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ). Report revealed that 1.14 million patient safety events occurred among the 37 million hospitalized Medicare recipients between 2000-2002 at an inpatient cost of $8.54 billion.2005Congress passes the Patient Safety and Quality Improvement Act creating Patient Safety Organizations to collect, aggregate, and analyze confidential information reported by health care providers. Included provisions for increased protection under federal law for information voluntary shared. Regulation’s became effective January 2009.SorryWorks! Coalition founded2006Rick Boothman JD, (University of Michigan) testifies before the U.S. Senate Committee on Health, Education, Labor and Pensions regarding the disclosure journey and results at UMHSB2009Analysis of the UMHS approach is published, citing ethical and financial support of the program (Boothman, R, et al, :A Better Approach to Medical Malpractice Claims”).2010The Institute of Healthcare Improvement (IHI) and the National Patient Safety Foundation release studies and publication regarding the impact of disclosure on claims costs, individual program results, methods, and best practice recommendations.2011Release of IHI White Paper and ASHRM Pearls regarding Disclosure2013 39 states have Apology laws.2014AHRQ develops the CANDOR (Communication And Optimal Resolution) ToolkitGENERAL CANDOR PROCESS (from the AHRQ CANDOR Toolkit)KHN CARING through CANDOR PROCESS FLOW (See Appendix for KHN Policy and Protocol)GOAL ACTIVITY (timeline may vary according to events) REAL AND IMAGINED BARRIERS TO DISCLOSURE“Just as it would never be thought acceptable that a clinician fail to be technically proficient, so it can never be acceptable that a clinician fail to be relationally proficient.~Mary Koloroutis, MSN, See Me as a PersonTransparent and timely communication after unexpected outcomes is challenging for most clinicians. Physicians and nurses and other front-facing patient caregivers come to work each day intending to bring their best. When unexpected outcomes occur, they may feel they have failed, and even question their fitness for their work – even when their care met the standard. In these times, clinicians are faced with choices to do the right thing, to honor their relationship with patients/families, or to protect themselves or what they think is protecting the organization. Without understanding of the evidence, receiving and education in the evidence-based steps to take and how to take them, clinicians may lack the confidence and withdraw from the opportunity to bring a unique type of courage and compassion to the patient’s experience, a safer care delivery, and an opportunity for the organization to learn and improve.Acknowledging the real and imagined barriers may help to alleviate fear and result in a more timely and effective resolution for patient and their families – and for caregivers.Clinicians may experience:Belief that they lack the ability to communicate compassionately or effectivelySense of having failedFear that they will add to the patient harmShame in the perception of breaching the trust with patients/familiesMisunderstanding of the patient’s preferenceLack of confidence in skills and own emotional pathMight face negative reactions from peersMixed messages: “Don’t say anything till we have a plan…”Past tendency to focus on who is to blameEfforts to protect “image” and reputationMalpractice fearsSupporting and mitigating these fears is the responsibility of all involved. Emotional first aid along with ongoing support, coaching, and guidance of care providers should be the standard. (See WE CARE for YOU – for the component of caregiver support)In rare cases, it may be the consensus of the care provider and the CANDOR team that disclosure itself may be more of a burden than benefit for the patient at this time. This decision should be made by consensus and may need to go before the Ethics Committee for evaluation of ethical obligations and the considerations of possible decompensation of the patient/family member’s health or mental condition.For a clinician, the goal of being transparent can be challenged by the barrier of potential legal ramifications. Understanding applicable laws and best practices, and being connected to internal Risk and Legal guidance, is essential and will help to alleviate these concerns. The evidence strongly shows that when a clinician delivers timely and transparent information in an empathic manner, patients and families perceive genuine caring, feel respected, and are less likely to pursue legal means of being heard. Reducing legal liability is however, not the primary driver of KHN’s pursuit of excellence in communication and resolution. Our primary focus is on the patient and family, and on a culture of reliable safety.Being compassionate and truthful is not a guarantee that all patients and families will not respond with anger, or that they will be forgiving. It is a traumatic experience for them to have to face into an unexpected outcome and possible loss of health – or life. Treating them with dignity goes a long way to help their emotional recovery. Many will later want the opportunity to participate with the organization in improving care processes and care delivery.For a compelling story that supports these concepts, see the __________family experience at (YOU tube address).DEFINITIONS“When I am not here in the room with you – I am still thinking of you”~Nurse overheard talking with patientCANDOR Event: A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial) to a patient. These events trigger the CANDOR process even when a cause for the event is not yet known. CANDOR Response Team: Specially trained communication coaches available 24/7 who support the clinicians who respond and communicate with patients and families. The CANDOR Response Team also helps activate the Care for the Caregiver Team. (See Care for the Caregiver protocol).CANDOR Communication: The early and ongoing conveying to a patient, their relative and/or their representative of known information surrounding an unanticipated or adverse outcome.Apology/Admission: Acknowledgement of error or responsibility after a full investigation systematic analysis…and only when the review has revealed error. Admissions must include expressions of empathy.Empathy: An immediate and sincere expression of caring, support, and sympathy. It is appropriate and expected at all times by everyone in our organization.Harm: Temporary or permanent deformity, impairment, or loss of use of a bodily function or organ system requiring medical intervention which may include monitoring the patient’s condition, change in therapy, or active medical or surgical treatment. Harm also includes death of a patient that results from medical care provided or not provided rather than their underlying disease process or health.Unanticipated Outcome: The outcome of a medical treatment or procedure that differs from an expected result. An unanticipated outcome does not imply medical error, medical negligence, or substandard care. An unanticipated outcome may or may not result in harm to a patient. An unanticipated outcome may be a CANDOR event.Adverse Event: An event caused by medical care provided (an act of commission) or not provided (an act of omission) to a patient rather than their underlying disease that results in harm to the patient. An adverse event does not imply medical error, medical negligence, or substandard care. An adverse event may be a CANDOR event.Serious Reportable Event: A serious reportable event (SRE) such as the following may be a CANDOR event, subject to review and determination by the CANDOR Response Team. These follow the definitions as per the National Quality Forum and can be obtained from the Patient Safety Manager or Quality Director: Surgical or Invasive Procedure eventProduct or Device eventsPatient Protection eventsCare Management eventsEnvironmental eventsRadiologic eventPotential Criminal eventsSerious Patient Safety Event: A serious patient safety event may be a CANDOR event, subject to review and determination by the CANDOR Response Team. These include events in categories E through I of the National Coordinating Council for Medication Error Reporting and Prevention. These definitions can be obtained from the Patient Safety Manager or Quality Director.Relative: A patient’s spouse, parent, grandparent, stepfather, stepmother, child, grandchild, brother, sister, half-brother, half-sister, or spouse's parents. The term includes said relationships that are created as a result of adoption. In addition, "relative" includes any person who has a family-type relationship with a patient.Resolution: Appropriate restoration of right relationship with the patient and family according to their needs after the outcomes of the analysis and review are clear. This may include some form of compensation which must be vetted through and approved by Chief Legal Counsel, KHN Legal Services before any offer of compensation is made. Resolution includes the organizational application of all learnings. Representative: A legal guardian, attorney, person designated to make decisions on behalf of a patient under a medical power of attorney, or any person recognized in law or custom as a patient's agent. CARING through CANDOR ROLES AND ACTIONS“By love – serve one another”~Galatians 5:13ExecutivesCultivate a culture of transparency, communication, and empathySupport and participate in education and trainingAdvocate for CARING through CANDOR policy and processesSet and maintain expectations and accountabilityEncourage all stakeholder participation and accountabilitySupport patient and family centered careSupport WECARE for YOU – care for the caregiver Physician Leadership – and medical staffParticipate in education and trainingSet and maintain expectations for medical staffSupport and advocate for the CARING through CANDOR approachModel and advocate for transparency and accountabilityModel the CARING trough CANDOR communication GuidelinesParticipate in event analysis as indicatedFollow guidelines for documentationAssess the well-being of physicians and advocate for the resilience strategies for physicians impacted by patient unexpected outcomes. Activate the WECARE for YOU team as indicated.Nurse Leadership – and nursing staffParticipate in education and trainingSet and maintain expectations for nursing staffSupport and advocate for the CARING through CANDOR approachModel and advocate for transparency and accountabilityModel the CARING through CANDOR Communication Guidelines.Participate in event analysis as indicatedFollow guidelines for documentationAssess and the well-being of nurses and other care providers and advocate for the resilience strategies for nurses impacted by patient unexpected outcomes. Activate the WECARE for YOU team as indicated.Risk Management – and Patient Safety, Patient RelationsParticipate in and help lead in education and training for the CARING through CANDOR approachCoordinate Event Analysis of unexpected outcome events and patient concerns following the CANDOR policy and protocolModel and advocate for transparency and accountabilityModel the CARING through CANDOR Communication Guidelines.Support/assist communication and resolution with patients/familiesEnsure accurate and timely documentationFacilitate connection with KHN Risk, legal, and insurance Incorporate learnings into performance improvementInternal LegalParticipate in CARING through CANDOR education and trainingAssist in developing and administrating the KHN CANDOR policyParticipate in Event Analysis as indicatedAdvocate for transparency and accountabilityCarry primary coordination and guidance for the Resolution component of CANDORCANDOR Response TeamParticipate and assist in leading CARING through CANDOR education and trainingBe on call 24/7 to support and coach clinicians who will have conversations with patient/family/representatives, incorporating the CARING through CANDOR Communication Guidelines.Model the CARING through CANDOR Communication Guidelines.Participate in Event Analysis and Resolution as indicated Participate in assessing the well-being of impacted caregivers and activate the WECARE for YOU team as indicated. EVERY PATIENT, EVERY TIME, EVERYWHERE(creating a safe and caring culture BEFORE any adverse event can occur)““The meaning and essence of care are experienced in the moment when one being connects with another.”~Mary Koloroutis, MSN—MS, RNAt Kettering Health Network, we believe that everything we say and do matters because every life matters. We commit to excellence in quality and service every patient, every time, everywhere. With that high standard which every patient and family in our care deserves, it is imperative that our first duty is to ensure that every interaction and every intervention reaches for excellence. In the unexpected event that the patient experiences harm -regardless of whether we met the standard of care – we must submit an accurate report, and not try to protect our reputation for “every patient, every time, everywhere.” We cannot make it right for the patient/family and improve our care delivery without accurate and timely reporting of events.Our goal is to prevent patient harm at all cost. All are expected to actively work towards a patient and family centered culture of safety and compassionate care, and to consistently enhance the 3 primary relationships of Relationship-Based Care: Care of Self; Care of Team; and Care of Patient and Family. (Refer to a Called to Care booklet)While we could fill pages with “Do’s and “Don’ts in creating a healing, harm-prevention environment, we offer the following general Presence Practices found in our Called to Care guide. Working from these Presence Practices enables patients and families to know that we see them as persons – not as a series of tasks or a diagnosis – and that we care about their well-being. Patients who see us engaged primarily with tasks and not with them may feel unseen, unheard, and unsafe. And research shows that our lack of genuine presence makes it harder for patients to engage with us and participate in their care plan- or they may unknowingly withhold information we need to provide the best care. Working from these Presence Practices also help us keep the joy of our work alive. All of this builds mindfulness, collaboration, and contributes to a safety culture that lessens the risk of harm events.Patients and families want to feel safe and significant, which begins by feeling heard and understood. This is why our conversations matter. At the heart of Called to Care at Kettering Health Network is the moment of encounter—the connection—between the caregiver and the person they are serving. The primary message to convey is respect for the patient’s life and dignity, demonstrated by our kindness, compassion, and acceptance.What we say and how we say it—our facial expressions, body language, the tone and pace of our voice, and our use of touch and eye contact—are all parts of the message we send. Do we convey concern and engagement, or are we looking at the clock, tapping our toe, talking fast, and thinking about everything else we need to do? There is a profound difference between communicating with and talking at patients and their families. Our patients will notice right away whether we are really present with them or are preoccupied.The following are general Presence Practices that are to be part of every caregiver’s care of patient/family and examples of phrases that build connection: (See the Communication Guidelines chapter for further skills related to communication after unanticipated patient outcomes)PRESENCE PRACTICE AND LANGUAGE THAT CREATES CONNECTIONListen with Respect – Listen for what is true for the patient/family. Be in the moment. Sit at eye level, lean in with an open posture. Your first 6 seconds of any interaction create a primary impression and serve as a filter for the rest of your interaction. Give focused attention. Listen for a full minute. Avoid interruptions. Listen for themes – for what is not being said. Listen with your eyes and your heart.“What is on the front of your mind right now?”“What do you want me to understand?”“Can you say more about that? I want to make sure I hear you”Communicate with Empathy – Imagine what it must be like for the patient/family. Attune to their feelings. Suspend assumptions or judgments. Aknowledge and validate their feelings. Remain open – accepting. Remember – everyone has a back-story. Observe patient/family for confusion/overload of information“I can’t imagine what this must be like for you”“What is the hardest part of this for you?”“You seem (anxious – worried,…) is that right?”Act with Compassion – Take action to reduce anxiety. Anticipate their needs. Follow through on what you say you will do. Go beyond what is expected. Address their anxieties, not just the facts. Elicit their concerns.“What else can we be doing to make this any easier for you?”“When we are not in here with you, we are still thinking of you”“I see your tears – do you want to talk about it?”Partner with Dignity – Use partner language – “We,” “Us,” “With you,” Together”…Be led by patient/family preferences. Learn from them. Allow as much choice and control as possible. Honor their cultural and spiritual needs. Hold their confidence – share only what is necessary for their care.“What should I know about you as a person to give you the best care?”“How would you like to be involved in decisions about your care?”“Thank you for speaking up – that takes courage”Serve with Humility – Remember – they are the experts on what matters most to them. Enter their room as a sacred space. Acknowledge their courage. Accept them where they are, while advocating for their wholeness. Use Teach-back methodology to check their understanding. Let them know you do this work because you want them to feel safe and cared for.“What is your understanding of what we have talked about?”“You can count on me to look out for you”“It is my privilege to serve you” LANGUAGE THAT DIMINISHES CONNECTIONWe want to use verbal and body language that exhibits respect and creates connection and avoid verbal and body language that creates disconnect.Think about a time when you were experiencing grief, fear, or uncertainty, and imaginesomeone saying these things to you. (Examples of language that creates disconnect)Invalidating the patient’s experience“Don’t worry; don’t cry.”“It’s not as bad as you think.”“Well, at least you have…”“This could happen to anyone”Drawing comparisons“That’s nothing, you should have seen my…”“Well, lots of other people have also had…”“You have no idea how hard this has been for ME”Giving advice“What you really need to do is think positive…”“You should______.”“You will just have to learn to move on”Suggesting guilt“You shouldn’t feel that way.”“Think of all the stress your actions are causing your family.”“If you had only told us sooner or followed our medical advice…”“Well, I’m sorry you feel that way”Offering clichés“It could have been worse.”“Every cloud has a silver lining.”“Everything happens for a reason”.“Maybe this is a blessing in disguise”Pitying and patronizing“Poor dear, I feel so bad for you.”“It must be just awful.”“There, there, it will be all right.”Telling horror stories“Well, I heard another one of your doctor’s patients died…”“Boy, we sure had a crisis earlier today…”Pretending their situation is different than what it is to them“You’re going to pull through this, I just know it.”“I bet you’ll be going home any day now.”“Everything will be alright.”Caring TouchTouch is a form of non-verbal communication. Gentle, caring touch conveys presence, empathy, and reassurance, and people can feel strengthened physically, emotionally, and spiritually through the use of appropriate touch. It can reduce anxiety and feelings of vulnerability, lower blood pressure, and activate healing potentials. Caring touch also can create a bond of trust between us as caregivers and those we serve.Everyone is comfortable with a different level of touch. Be observant for cues from the patient about how comfortable they are with touch. Ask, “Is it helpful and comforting to you if we touch you gently on your hand or arm?” This will give you an idea about the patient’s preferences regarding touch. Some patients may welcome a hand or foot massage, which can be very therapeutic. The joy of our work is strengthened when our care-giving actions are centered on what matters most to those we serve.EMPATHYEmpathy which is a component of Compassion, recognizes and senses the other person’s experience of pain and distress, and holds a willingness to remain fully present in the face of it – without judgment or a rush to fix it or retreat from it. Empathy is “feeling with,” “suffering with”, “feeling into.” It is rooted in the genuine desire to know the inner experience of the other, to be of loving service, and to lift the burden of suffering. Empathy means caring enough to see the world through the other person’s eyes. It means frequently checking with him/her as to the accuracy of what you sense, and being guided by the response you receive. You wonder without prejudice, labels, or assumptions. Empathy is at the heart of our caring work. Without the deep understanding that empathy generates, we can’t know what people really need or how best to serve them.Research shows that people engaged in empathetic interactions literally share their physiology. Your heart rhythm and brain waves try to synch- up with the other person. This is the state in which compassion and loving kindness occurs. So, it is critical to have a steady positive and compassionate approach so you don’t “synch-up” with the other person’s pain or chaos. If you slow your breathing and envision a state of calm, the other person’s breathing and heart rate are affected and try to “calm” as well.The body language of Empathy:Personal space – be aware of how physically close the other person wants to be. Eye contact – full attention – looking at the person (Being conscious of how comfortable they are with this. Some cultures believe eye contact to be disrespectful.) Orienting your body toward the person. Leaning your head in gently. Open posture – arms or legs NOT crossed. Gentle touch (if person seems comfortable) – on the arm, top of hand, shoulder. Facial expression – a genuine, gentle smile. Tone of voiceOne of the only well-validated measures of empathy using patient feedback is an instrument called CARE – the Consultation and Relational Empathy measure. The ten measures in the questionnaire, rated by patients on a scale from poor to excellent serves physicians (or any caregiver) as a great guide to empathic practice:SELF-CHECKSA Word about Patient and Family AngerLiterature on anger and illness identifies the root causes of anger as fear and vulnerability, powerlessness, and grief/loss. These are normal, expected responses that any one of us could experience if in similar circumstances. With this understanding guiding us, we can respond by connecting, rather than distancing ourselves. What if, instead of personalizing anger or becoming fearful ourselves, we were able to wonder about what is being conveyed by the anger? What if we saw anger as an emotional equivalent to bleeding? We don’t react to, judge, or disconnect from the person who begins to hemorrhage; we move right into action. We see it as physiological distress—we don’t order the bleeding patient to “stop bleeding and calm down.”So, if we could understand anger as a way that the angry person is trying to say,“I am scared,” we can move into action, using HEAL.HEAL is our model of service recovery, used when a patient or family member communicates a concern or is experiencing an extended wait time. HEAL stands for: (See Called to Care booklet) Hear concerns; Empathize; Apologize; Leap into actionWould a Prayer Be Helpful?When patients are feeling vulnerable or worried, or are experiencing pain, it is natural for them to go to deeper questions of the heart and soul such as, “Where is God in all of this?” or, “Am I being punished?” Research shows that as many as 80% of hospitalized patients wish that someone would offer to pray with them – that they believe their spiritual well-being has as much or more to do with their healing and recovery than does their medical care. At Kettering Health Network we believe in the power of prayer. It is respectful and ethical to give choices when we offer to pray for (with) someone. A comforting and non-threatening way to offer prayer is to say, “Would a Prayer be Helpful?” If the patient says yes, you can ask, “Is there anything specific you want me to pray for?” The exact words you use are not as important as your compassionate presence.CARING through CANDOR --- COMMUNICATION GUIDELINES“Everything hinges on the quality of the relationships we create with those we serve”~Robyn Youngson MD, Time to Care(See chapter Every Patient, Every Time, Everywhere for Presence Practices, Empathy concepts, Mindfulness and Empathy self-checks, and the language that creates connection/disconnection. Use that chapter’s guidelines for every interaction)This chapter is devoted to the communications with patient/family surrounding unanticipated munication guidelines should begin with an understanding of what patients/families want at times of unexpected outcomes: 1) Accurate and truthful information in real time close to the event rather than after a lengthy investigation2) An empathic acknowledgment of their pain and suffering and an apology if warranted3) Follow-up and possible compensation4) An assurance that what happened to them won’t happen to anyone munication and support to patients and caregivers after patient harm is sacred work. It requires a courageous vulnerability and a resolve to stay present through the challenge and to honor the sacred trust we have with those we serve who are now anxious and uncertain. Preferably, it is the primary or attending physician who conducts the conversation. It may be appropriate to have 2-3 other roles in the room, but be careful to not overwhelm the patient/family with organizational members.The following is a guide taken largely from the Collaborative for Accountability and Improvement. (See KHN CARING through CANDOR Policy and Protocol)The CARING through CANDOR Response Team will respond and support clinicians who will have initial and ongoing conversations with patient/family/representative. (See CARING through CANDOR Protocol)Ascertain that the clinicians who are identified to have the conversation with the patient/family are indeed ready and capable.**On a rare occasion, the burden of disclosure outweighs the benefit based on the condition of the patient. Withholding disclosure in such cases should require consensus of the CANDOR team, involved clinicians, Risk, and Legal counsel. The case may need to go forward to the Ethics Review.KEY INITIAL DISCLOSURE SKILLS: (and then minimize the time between initial and follow-up discussions)ALWAYS REMEMEBER TO:Show empathyAllow patient/family to express feelingsName and validate their emotions “I hear that you are feeling ________ and that is understandable. Say, “You know him/her (name of patient) best.” They may not be forgiving – and that is their rightBe honest and transparentExplain the facts that are known about the event without the patient/family having to probeGive direct answers to their questions – if you do not know the answer, state this directly and explain your plan to find out for them.Utilize effective communication strategiesPrepare for the discussionReview the Mindfulness and Empathy self-checks Be yourself – it is possible to be “too careful” is choosing your words.Show sincere interest in the patient and family’s questions and concernsListen for what is true for themAnticipate their questions and needsSit at eye levelKeep an open posture, gentle eye contact and other positive body languageAvoid Medical jargon and acronymsCheck for patient and family understanding throughout the conversationAllow for silence and slow your pace for clarityParaphrase back to the patient/family what they saidDo a Perception Check occasionally – “So what I hear you saying is…..is that right?”Use Teach-Back – “What is your understanding of what we have talked about just now?”Avoid speculation or blame“Use lead-ins and responses such as:“I know you must have many questions”“I am sorry that this has been your experience”“Can you tell me more?” “What is your understanding so far?” “What is on the top of your mind right now?”“I can hear your frustration – I would feel the same way.”“This is an unacceptable outcome for us as well”“I can’t imagine what you are experiencing”“What do you want to know?” “This is what we know now – we will be actively analyzing this event and will keep you informed as we know more.”“Have I answered all your questions?”Get ReadyReview the event with the CANDOR Response Team and others as applicable, so that you are familiar with all relevant informationAnticipate the patient’s emotional response and how you will respond empathicallyConsider whether a surrogate or family member should be presentAnticipate likely questionsConsider rehearsing the conversation with a CANDOR coach (Response Team)Questions to consider prior to patient/family communication: (Role play if possible)When is the best time and where is the best place to have the conversation?What are the goals of the conversation?When should you respond to the patient/family?Who should respond to patient/family and be present for the conversationWhat questions do you anticipate getting from the patient/family?What are you going to say to the patient/family?What information should be shared/discussed?Who continues to stay connected with and respond to patient/family as more information becomes known?How do you respond to the caregivers?Who else needs to be with you for the discussion? If at all possible, do not have the discussion alone with patient/familyRecognize that the initial conversation is usually not a one -time event but will be an ongoing conversation and connection with patient and family as the CANDOR protocol moves forward.Consider your own feelings and take advantage of the WECARE for YOU (care for the caregiver) component of CANDORSet the StageChoose a private, quiet, calm location to have the conversation if possibleSilence cell phones/beepersGreet the patient/family warmly and describe the purpose of the conversation. Accompany them to the private locationListen and empathize throughoutAssess the patient/family understanding of what happened and their level of anxietyIdentify the patient/family concernsActively listen for themes and for what is not saidAdhere to the communication strategies aboveUse gentle touch if the patient seems comfortable with it.Disbelief (denial) is a normal reactionExplain the facts known (See the Empathy, Disclosure, and Admission discussion below)What happened?Identify the adverse event early in the disclosure Explain what happened in a way easy to understandExplain what is known without speculating or suggesting blameTell the patient whether at this time you know if the event was preventableWhat are the consequences?Tell the patient how the event will be analyzed and managedTell the patient how the event may impact his/her short-term treatment and long-term healthAssure them on ongoing support and communicationGeneral ApologySay you are sorry that they are experiencing this event – but give no admission of error unless the event has obviously been caused by error (such as wrong site surgery… see Admission below)If the patient or family ask about financial compensation earlyAcknowledge that the question is legitimateExplain that you are not qualified or authorized to address those issuesAssure them you will get them connected to the right people who can speak to them in the near future.Avoid making promises you can’t keepResponsibility/AdmissionExplain your role in the eventAvoid blaming others or the “system”If the event was preventable (due to error)Consider using the work “mistake” or “error” only AFTER consultation with Risk Management and internal Legal counsel.Tell the patient what should have happenedTell the patient what will be done differently to make recurrences less likely, or that a plan to prevent recurrences will be developedClose the DiscussionSummarize the conversation and discuss next steps and set a plan for a follow-up conversationUse Teach-Back to clarify their understanding “What is your understanding of what we have d discussed?”Ask the patient/family for any other questionsDesignate a contact person the patient can reach with questions or concernsThe following is a general guide to the different types of CANDOR conversations. Every situation is different and should be evaluated based on the facts and circumstances of the event. Contact your risk manager for assistance.EMPATHY – Always appropriate and legally protected-not admissible in Ohio“I am (we are) sorry you are experiencing this” “I am sorry you now have to undergo another surgery to correct this complication. This must be frustrating for you to have to spend more time in the hospital.”Avoid blaming the “system” or colleagues, “The lab always does…” or giving apologies with “buts” “I’m sorry, but if the nurse had only called me…”Conveyed immediately and ongoing. Do not wait until the Event Analysis is complete to express empathy. (It is possible that the facts of the event are so clear that you may move to Disclosure or to Admission initially which should NOT be done without the involvement of Risk Manager and Legal counsel input)Be cautious of the possible tendency to avoid patients/families in order to avoid their questions. Their stress level and breach of trust will only increase.Utilize CANDOR Response Team support. They will prepare and support the clinician for the necessary conversationGenuine sincerity/compassion – “Feeling with”Provided by allHelps the care provider to stay centered on what matters most and to rebuild the relationship with patient/familyThe initial empathy discussion requires further follow-up.Follow through on what you say you will do.DISCLOSURE – The use here is to describe conversations that take place after Event Analysis. Discoverable and admissible“I am (we are) sorry that this has been your experience. After thorough review, we have found that our care did meet the standard, and yet, these unfortunate complications occurred…”Appropriate when patient and family are ready Will most likely occur after Event Analysis has taken placeDone by clinicians; Coaching by CANDOR Response Team may be helpfulMay not require an admission of errorIntended to keep patient and family fully informed of impact on careDoes not include assumption or blameAs needed, respectfully agree to disagree with patient and family. “It’s ok if we don’t agree on this point…”We understand this may not be the answer you were looking for. We are committed to supporting you to the fullest extent possible.”Have the medical record availableADMISSION – If appropriate- after Event Analysis. Discoverable and admissible“I am (we are) so sorry. After thorough review we know that we made a medical error that resulted in your….” “We did not meet the standard of care…” “I am sorry that you have to undergo another surgery. I take full responsibility for having operated on the wrong site the first time.”Requires utmost empathyAppropriate when negligence is clearWill most likely occur many weeks after Event Analysis and CANDOR Solutions and Consensus meetings.Patients should be encouraged to have legal counsel presentCarries liability and legal implicationsMust have the participation of internal Risk and Legal servicesConversation may be conducted by the clinician or administrator. Other key stakeholder roles may be present.Every effort is made to meet patient needs and expectations which may include compensation.Have the medical record availablePOTENTIAL IMPACT OF POOR COMMUNCATION WITH PATIENTS AND FAMILIESFailing to communicate with care providers or the CANDOR teamThe resulting lack of clarity and not following the process causes confusion and anxiety among the care teamCan result in inconsistent messages to patient/familiesMay lead to clinicians avoiding patients/familiesCriticism of the “system” or other care providersReflects negatively on you and the organizationCreates a disconnect for the care teamDiminishes trust of the patient and family and compounds their stressDiminishing patient/family questions, concerns or complaintsMay lead to missed opportunities to prevent an event, injury, or delay in treatmentLeads to dissatisfactionMay trigger litigation if concerns are not adequately addressedAvoiding patients/families Leaves room for patients/families to create their own interpretation of what is happeningConveys a perception of lack of genuine empathy and compassionDelays the exchange of vital information and potentially needed physical, emotional, and spiritual careIsolates the caregiver and delays addressing his/her own needsSpeculating or offering opinionsCannot be retracted and makes accurate explanation more difficultMay be inconsistent with actual facts and information provided to patient/familyMay be incorrect or prematureFailing to be empathicCreates a sense of distrust, frustration, and negative feelings for patients and familiesDiscounts the efforts of care providers who are trying to do the right thingIs counter to KHN mission and valuesWHAT NOT TO COMMUNICATEOpinions, assumptions, speculation, blameA denial of the event or defending of yourself or the organizationCriticism of or frustration with any other care providers or the “system”Any statement where you say “this is off the record”Promises that can’t be deliveredImpatience with the expression of feelings by patient and familyIn order to maintain legal protection and the privacy of our physicians and staff, the following should not be shared in the disclosure or stated in the documentation:Any reference to the Event Analysis or “Root Cause Analysis” – it is OK to mention the “thorough review” that will take placeAny reference to “Peer Review” or Quality processesAny reference to consultation with Risk Management, insurance carriers, or legal counselAny reference to any other information that may carry a legal protection or privilegeEXAMPLES OF INTIAL COMMUNICATION AND ADMISSION COMMUNICATION (with Empathy)(Initial Communication) “I am so sorry that your father fell and was injured – and you feel this had caused his condition to worsen. We will move forward with our review of this event so we can talk more with you about exactly what has happened. In the meantime, I want to focus on his care and treatment, and how we can support you and your family while he recovers.”(Admission) “I am so sorry that I miscalculated the medication dosage. I can understand that you have concerns about the impact of this on your recovery and I want to make sure all of your questions are answered and that we are doing all we can to support you. Let me explain what we found in our review process and then we will discuss your care going forward. Is now a good time?”(Initial Communication) “I am sorry you have had these complications. We don’t currently know how this happened, but we want to assure you that we are in the process of conducting a thorough review and will keep you informed of what we learn, when we learn it. You can expect to hear from me in ______(days)…In the meantime, here is my contact information if you have any questions. Please don’t hesitate to call me.”(Admission) “I am very sorry that during surgery, we left a surgical sponge in your abdomen and now we must do a second surgery to remove it. We have safety processes in place to prevent this from occurring, During our thorough review, we found we made a mistake and there was a step in our process that was not carried out…”WE CARE for YOU (CANDOR Care for the Caregiver)“That which is to give light must endure burning” ~Viktor FranklThe WE CARE for YOU program at KHN is part of the Communication/Disclosure component of CANDOR and is activated at the time that an unexpected/adverse patient event occurs. At Kettering Health Network, we aim to hire caregivers with a servant’s heart and a passion for excellence. KHN is an award winning health system in quality and service. Our Call to Care culture seeks to cultivate compassion, ownership, and reliable care processes. Our patients and families regularly tell us that they perceived their care to be extraordinary.In the midst of this sacred work, is the reality that there will be unexpected adverse patient events. Medical errors are now the third leading cause of death in the U.S. Since the 1990’s, comprehensive efforts in healthcare- including efforts by the government, health care providers, industry, and consumers – have targeted the prevention of medical errors, the increase of reporting of events, and the creation of reliable strategies for transparent, timely communication and resolution when harm events occur.There is a cost to caring, and despite their best effort to provide the best care possible to patients, health care providers are sometimes faced with the personal impact and aftermath of adverse patient events. It is estimated that one in seven patients is affected by adverse events, and that as many as half of all clinicians will be involved in a serious adverse event at least once in their career. Recent research shows that the experience of being impacted by unexpected patient events is not only restricted to medical error events – but to any patient experience that evokes a strong emotional stress response in the caregiver. In the research and literature, this is called the “second victim” response. Examples of high risk situations that may induce a significant stress response:Pediatric casesFailure to rescue casesAny patient that “connects” a staff member to his/own familyFirst patient death for a caregiverUnexpected patient death with or without medical errorCo-worker death or co-worker family deathHigh profile community event victimsOne in a series of similar adverse patient outcomes in a short period of time on the same unitOrgan donor patient eventsAggressive or violent patient/familyAt KHN, we are committed to “taking care of the people who take care of people” – to serve the servers – and to provide strategies that help sustain their resilience. Over the last decade, the University of Missouri Health System (UMHS) under the direction of Sue Scott RN, PhD, Director of Patient Safety and Risk Management has conducted research and developed best practices for the “second victim” experience. The CANDOR toolkit developed by AHRQ (Agency on Healthcare Research and Quality) has incorporated the best practices of UMHS. Kettering Health Network has networked with UMHS who has graciously shared their practices and materials and we have adopted some of them with gratitude for their support. Additionally, UMHS and others have been guided for years by the resources and research of the Medically Induced Trauma Support System (MITSS).EXAMPLES OF CAREGIVER COMMENTS“I remember feeling horribly sad that I couldn’t do more for this child. This hit me harder than most of them. For some reason I related with this family – I guess one reason is that the child was the age of my oldest daughter and I felt it could have been my family. They did not deserve this outcome. I cried a lot over this case and I still cry when I think about her.”“…I had that patient’s name seared into my memory and as soon as I saw someone else with that name, my chest was up in my throat. Just randomly you forget and then something will happen and it just pops into your head. You go over and over it again – what could I have done differently, what could I have said that might have helped?”The following is a general description of the WE CARE for YOU support system for KHN. Of note is our intentional reluctance to use the title of “second victim” to describe our caregivers. We will refer to “caregivers experiencing significant stress impact.” Using the language of “victim” may denote an assumption of powerlessness – and our goal is to empower and support our care providers.Having said that, the definition of the “second victim” experience found in the literature is: “…a health care provider involved in an unanticipated adverse patient event, medical error, and/or a patient related injury who become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed their patient, second-guessing their clinical skills and knowledge base.” (Scott, et al. 2009. The natural history of recovery for the healthcare provider “second victim” after adverse patient event. Quality and Safety in Healthcare. 18: 325-330.)The challenges to providing support emerge from the following:There is a stigma to reaching out for helpHigh acuity areas have little time to integrate what has happenedWithout a systematic caregiver response and support, there is often no “safe zone” to discuss their experience.Intense fear of the unknown – what happens to me next?Fear of a wounding of collegial relationships because of the eventFear of future legal challenges – HIPPA, Confidentiality, etcThe research of Sue Scott at UMHS showed that participants developed their own unique Way of coping after an adverse patient event, yet each described a predictable recovery trajectory. The first 3 stages occur after “impact realization” and the caregiver may pass through one or more of the first 3 stages simultaneously. Throughout all stages, caregivers may experience physical or psychosocial symptoms. Triggering of symptoms and repetitive thoughts about the event can occur anytime during stages 2-6.The following represents Sue Scott’s assessment of 31 participating caregivers BEFORE implementing their ForYOU “second victim” program. The third column is their suggested organizational response – we have inserted mention of KHN CANDOR and WE CARE for YOU team:StagingCommon CharacteristicsCommon Self-TalkSuggested ActionStage 1Chaos & Accident ResponseEvent/error realizedTell someone – get help for patientDistractedExperience a wave of emotionMay not be able to continue care of patient(s)How did that happen?Why did it happen”“Right after the event, I was having trouble concentrating, I don’t think I was useful”Identify affected caregiver (s)Leader and peer compassion and support (ongoing)Assess ability to continue shiftActivate WE CARE for YOU teamStage 2Intrusive ReflectionsRe-evaluate scenarioTendency to self-isolateHaunted re-enactments of eventFeelings of internal inadequacyWhat did I miss?Could this have been prevented?“I started to doubt myself. It was all hindsight but I kept thinking over and over again. I lost my confidence for some time.”Ensure WE CARE for YOU team is involvedObserve for presence of lingering physical and/or psychosocial symptomsStage 3Restoring Personal IntegritySeeking support with trusted persons but not sure who to turn toConsuming doubt and fear regarding reputation and future professional career.Managing gossip/”grapevine”What will others think?Will I ever be trusted again?Am I in trouble?Why can’t I concentrate?“Every day I thought that everyone knew what happened…do they think of me as a loser…I though these people are never going to trust me again.”Provide management oversight of event (CANDOR process in place with completed incident reportingand communication and support to patient/family, as well as Event Analysis process)Leaders manage overall response and“rumor control”Is team event debrief needed?Stage 4Enduring the InquisitionRealization of level of seriousnessReiterating case scenarioResponding to multiple “why’s” and review of caseInteracting with variety of event respondersAware of event disclosure to patient/familyLitigation concerns emergeHow do I document?What happens next?Who can I talk to?Will I lose my job/license?“I knew we needed to be careful what we said- but it might have been helpful to talk to someone else but I had no one…I didn’t know who to talk to”“When I came back to work, no one really talked to me about it or said anything…the process took forever…that was frustratingObserve for silent sufferingIdentify all key persons involved in eventInterview key personsCreate clarity about what happenedBegin creating a picture of “why it happened”Stage 5Obtaining Emotional First AidCaregiver seeks personal and professional supportGetting and receiving supportWhy did I respond in this manner?What is wrong with me?Do I need help?Where can I turn to for help?“There was no one I could tell – not even my husband. All I could say was that I had a horrible day. I could only say ‘I had a patient die today’”Check in and ensure WE CARE for YOU team is involved is activated and caregiver is getting supportOffer support to caregiver family as indicatedStage 6Moving On(One of 3 paths chosen)Dropping OutTransfer to another unit or facilityConsider quittingDeep feeling of inadequacySurvivingCoping but still having intrusive thoughtsPersistent sadness – trying to learn from the event“Hanging in there…”ThrivingMaintain work/life balanceGain insight and perspectiveMake something positive out of the eventDoes not base entire practice on one eventIs this the profession I should be in?Can I handle this kind of work?“It affected me greatly and made me question my abilities…..I moved to another service unit. I think a fresh start was good for me”How could I have prevented this from happening?Why do I still feel so bad/guilty?“I made a mistake that caused a bad patient outcome but I haven’t figured out how to forgive myself…it’s impossible to let go…’What can I do to improve patient safety?What can I learn from this?How can I help others who go through it?“I was questioning myself over and over again….but then I thought – ‘I had had this experience that has made me a better person. It really did – it gave me a deeper insight’”Provide ongoing supportSupport caregiver if they are seeking another role in the organization.Provide ongoing supportMaintain open dialogue and availabilityProvide ongoing supportSupport caregiver in making a difference in the futureEncourage staff input and feedback on making improvements in care processes or care mon “Second Victim” Responses and Symptoms (according to UMHS)Worries and Fears:PatientIs the patient/family ok?What have they been told?How did they respond?SelfWill I be fired? (Nursing and allied health caregivers)Will I be sued? (Medical staff)Will I lose my license? (all professional groups)PeersWhat will my colleagues think?Will I ever be trusted again?Will I still be a respected member of my team?Next StepsWho will contact me to talk about this?If legal issues come up, when will I know? How will I hear about it?What do I need to do?Who can I stay connected to for support?Common PhrasesI had a sickening realization of what happenedI don’t deserve to be a doctorThis will change the way I come to work from now onThis has been a career-changing eventI came to work today to help someone – not to hurt themThis even shook me to my core. I will never be the sameSigns and Symptoms of distressThese are normal reactions to an abnormal and unanticipated patient event or outcome.PhysicalSleep disturbancesDifficulty concentratingEating disturbancesHeadacheFatigueNausea or vomitingDiarrheaRapid heart rate or breathing rateMuscle tensionPsychologicalIsolationFrustrationFearsAnger and irritabilityDiscomfort when returning to workDepressionExtreme sadnessSelf-doubtFlashbacksFeeling numb or detachedSee Appendix D for Stress Reaction symptoms and suggested strategies commonly understood and used by Critical Incident Stress Management (CISM) -trained facilitators (who are the Tier 2 support layer for WE CARE for YOU.(placeholder for results from KHN results from baseline survey/assessment of caregivers)Following the research, UMHS developed a comprehensive approach with a system-level oversight team, a support/response team of special trained coaches at each facility, peer supporters, a referral system, formal team training, and a group debriefing component. The KHN WE CARE for YOU component of CANDOR provides a similar approach. The following is a general graphic display of the dimensions of support.Scott’s 3-Tier Support approach (as it appears in the CANDOR Toolkit from AHRQ):WE CARE for YOU infrastructure:Local facility steering team ---comprised of representatives from the 3 Tiers of support, an executive champion, and Risk Management – provides continuity from the KHN CARING through CANDOR process. NOTE: The peer supporter (whether in the department or Tier 2 response) should practice within their training and provide active listening and support - remembering that this is not counseling, solving another’s problems, advising another what to do, interrogating, judging or questioning, or imposing one’s own beliefs on the affected caregiver. This is about hearing the caregiver’s story, giving an empathic response or supportive silence and focusing on their feelings and reactions. Tier 1 Made up of local support from Leaders/Managers and peers – coworkers. Educational classes are offered for leaders and selected staff from targeted departments that covers basic emotional first aid, words/actions that convey compassion and support, case scenarios and role playing. In the research, Tier 1 support provided what was needed more than 50% of the time for affected caregivers.Leaders:Connect with clinical staff involved as soon as possible and regularlyReaffirm confidence in affected staffConsider calling in flex staffKeep affected staff informed of next stepsAssure that Tier 2 support is activated as neededLocal peers – colleagues:“Be there” for your colleague. Focus on their feelings.Practice empathic active listening without judgment or advice – use Communication recommendations in this manual and the Called to Care booklet.Ask how you can helpDon’t ask specific details about the patient eventTier 2Trained peer supporters – trained in CISM – make up the 24/7 on call “coaches” – who provide caregiver assessment, emotional first aid, and ongoing crisis intervention and support 1:1 and/or in group diffusing/debriefing. All support and conversations are confidential and are focused on the well-being of the caregiver – not the facts of the event case. Risk Management resources as needed.In general, CISM skills cover:Introduction: The peer coach initiates the conversation, explains the nature and goals of this supportExploration: The peer coach helps the affected caregiver express their emotions, and empathically asks questions about their current physical and emotional rmation: The peer coach normalizes the caregiver’s experience through sharing information related to possible impact, precautions, and self-care strategies and resources. Contact information for 24/7 support is given.Follow-up: The peer coach share’s a plan for checking-in with the caregiver regularly and determines if additional referral resources are needed. NOTE: It is imperative that if team/group “debriefing” sessions are planned, that two Tier 2 coaches are present.Tier 3Expedited referral network – Employee Assistance; Clinical Psychologist or personal counselor; Chaplains. Tier 3 support acknowledges that occasionally, there are limits to peer support and the caregiver will benefit from highly skilled and specialized support.** See the WE CARE for YOU policy and protocol in Appendix E. EVENT INVESTIGATION AND ANALYSIS“The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue” ~Dan Norman, cognitive scientist and usability engineer(Most content taken from the CANDOR Toolkit)To the patient/family: “We want to assure you that we will carefully be reviewing what happened and keep you informed all along the way”The sole objective of the event investigation and analysis of an adverse event or near miss is the prevention of future adverse events. This process should not be used to assign blame or liability. In many hospitals across the country, many of the recommendations that come from root cause analysis of adverse events focus on re-education, re-training, disciplinary action, or the creation of new policies. However, safety science shows that these types of strategies do not consistently lead to sustained improvements in the quality and safety care delivered to patients. Why?Diverts attention away from factors in the system (other than the individual) that might have contributed to or caused the event.Focusing blame on a particular individual does not prevent other individuals from making the same error. The focus on individual blame creates a culture where staff fear punishment and may try to hide adverse events, unsafe conditions, and near misses rather than reporting the hazards to help improve the system.The Key Elements of an Event Reporting System:Supports a rapid response to harm events. Obtain staff and providers’ feedback post-event. Obtain patient and family feedback post-event. Allows for immediate, anonymous, and/or confidential reporting and input from frontline staff and providers. Provides potential protection of event analysis from discovery. Provides immediate and ongoing feedback to reporters. Protects patients from future harm events. Sources for Event Reporting:Robust Event Reporting Outcomes:Caregiver support ?Patient and family engagement and support ?Continuous organizational learning ?Innovative solutions ?Improved culture of safety The system approach recognizes that all adverse events have multiple contributing factors, many of which are outside of an individual’s control. The CANDOR approach utilizes the Just Culture principles and model: Normal error and at-risk behaviors are treated in a non-punitive, supportive, and protected manner. The event review focuses on uncovering latent hazards or contributing factors that increase pressure or constrain performance.At-risk behaviors should be “coached” and supported – that is, reviewers or peer leaders remind and educate the provider that their practice may lead to an adverse event. This is also an opportunity to improves processes, procedures, design and the environment.Reckless behaviors are always unacceptable, very rare, and not tolerated, regardless of tenure, status, or position.Principles of an Event ReviewLearning about system vulnerabilities before they occur is critical. Event Reviews include all of the following guiding principles;All information is protected under the organization’s bylaws and policies governing peer review and patient safety.Quick response and review is essential. Details are lost quickly in memory. Include a review of the site of the event.Follow all organizational confidentiality guidelinesTrained event reviewers are essential to gain an understanding of the system as a whole and to conduct in-depth cognitive interviews with knowledgeable parties.Interviews are conducted individually, typically with one or two members of the review team. Larger numbers of interviewers are less likely to facilitate full transparency about the adverse event.Those being interviewed should not be accompanied by their supervisor. This helps to ensure the interviewee will relax and remember the experience, and not be as likely to withhold any information about workflow patterns or processes for fear he or she may be punished if protocol was not followed.It may be helpful to get feedback from those familiar with the usual work processes before talking with the individual who participated in the adverse event.The organization’s leadership provide attention, support, and resourcesThe patient and family are involved in the interview process.A fair and accountable culture should be emphasized with interviewees. The goal is fact-finding – not fault-finding. The following is a general CANOR recommended Event Review process. (See CARING through CANDOR Policy and Protocol)**The trend currently is to move away from “root cause analysis” language- to “event investigation and analysis,” with a focus on “contributing factors” rather than “root cause” (since there is rarely one root cause), and to provide immediate response to events along with a tightened timeline for event reviews. This CANDOR component focuses on a systematic approach to robust gathering of information before the first analysis meeting, and encourages two other meetings: Confirmation and Consensus, and Solutions.Preliminary ReviewAt the recognition of an unexpected patient out outcome, any clinician, leader, or caregiver an activate the CANDOR process. The CANDOR Response team is mobilized which includes specially trained communication coaches who will support the clinicians who have conversations with patient and family/representative. The Response Team also includes the primary event reviewer who is usually the Risk manager. The initial activation also includes the care for the caregiver (WE CARE for YOU) team who will focus on supporting the impact of te event on the clinician/caregiver.A preliminary review will ensue which should occur within hours of the event and should take place at the event location. The preliminary review:Identifies and addresses the immediate needs of the patient and familyEnsures the immediate needs of the caregivers are being metObtains all time-sensitive information (e.g. rhythm strips, equipment and devices…)Initiate’s a patient bill-hold as indicatedBegins to identify individuals who will be part of a “core team” for this case going forward.Seeks facts, not faultAvoids hindsight biasEmphasizes an understanding of each person’s perspective at the timeIdentifying the Core TeamThe core team should be established by the primary preliminary reviewer. At a minimum, this team should include the primary reviewer, executive sponsor, and administrative support. The type of event, the preliminary review, and other information gathered will help guide the selection of additional members which could include those who are knowledgeable about the context of work or are in a position to effect the final solution, such as risk management, safety leaders, clinical leaders and physicians from impacted areas, department chairs, patient and/or family, or member of the patient/family advisory council. Based on the preliminary event report, the c ore team will also bring in subject experts in the organization for guidance such as: Biomed Engineering; Plant Operations; Information Technology; Human Factors or other system/process experts; Pharmacy; and more…In-Depth ReviewThe In Depth-Review process begins within 72 hours of the adverse event and is hallmarked by interviews conducted with individuals involved in the event. The bulk of time and effort of the entire event review process should occur during the in-depth analysis. Confidentiality is critical throughout the interview process. Interviews should be conducted in person, with not more than two reviewers present with the individual. Essential interviews will start with key stakeholders – those who know the processes, supervisors, those who interact with the process, and those involved directly or indirectly with the event.Every effort is made to understand the context of the adverse event (all observations) and all processes, reviewing all pertinent records, and developing a chronological timeline that lead up to the actual event. These steps do not have to be sequential and are most effective when conducted iterativelyLeaders should support the involved caregiver’s understanding that the goal of the interview is to gain accurate knowledge of the details of the event without blaming the individual. It is essential that the caregivers feel comfortable sharing openly as this will help them recall the event accurately. The interview questions are an opportunity to focus on system factors.Questions should cover: Aspects of the organization (e.g., staffing, policies, and procedures) Technology involved (e.g., any usability issues, downtime, individual knowledge gaps) Interactions with equipment (e.g., beds, pumps, other equipment) Physical environment (e.g. time of day, day of week, temperature, light or dark, room layout, noise) Supervision (e.g., leadership or management involvement/resources or lack thereof)Teamwork (e.g., how long has this team worked together, and do they have thoughts about strengths or weaknesses of this team?) Communication (e.g., were there barriers to communication?) The task itself (e.g., how frequently is this task conducted? Were staff adequately trained? What is the normal way it is done? Were there deviations? Why?) Any unusual aspects of the patient (e.g., unexpected patient complications, conditions. How would they describe their interaction with the patient? Any other aspects or concerns?) This is not a comprehensive list, but it serves as a starting point. Outputs from the In-Depth Review Analysis:Pertinent interview quotes and notesPreliminary findings (patient’s current condition/needs; caregiver needs, etc)Detailed review timeline (working conditions, processes, people, environment, and pertinent interview perspectives and finding)Copies of objective data (medical records, EMR audit trail, paging records, labs, imaging reports, and all other time stamped audits)A visual model of what the event review believes are the contributing factors (to be processed and discussed at the consensus meeting)The completed questions and checklist in Appendix D of the CANDOR toolkit – or similar process The in-depth investigation should yield a very coherent story of the event. This information is the starting point in determining the contributing factors.** Some organizations choose to involve patents/families in some manner in the Event Analysis process. By doing this, the organization demonstrates its commitment to taking every step to ensure a similar event will not happen again. This has been shown to be a key desire of patients/families who have experienced an unanticipated event.Confirmation and Consensus MeetingThe confirmation and consensus meeting is an opportunity for the core team and event stakeholders to understand the event. This meeting should NOT be a review of the event. Stakeholders may include: risk manager, safety leader, quality leaders, clinical leaders from impacted areas, content experts, department chairs, and patient and family members.All attendees of this meeting should receive the detailed review timeline before the meeting and prepare questions. The goal of the meeting is to confirm contributing factors (found in the in-depth investigation), to build consensus around the factors, and to consider early action steps.The reviewer will go through the timeline and pertinent findings The reviewer will refer to the visual model. The reviewer will then share the CANDOR tool which explores completed contributing factors. Finally, the group will confirm each causal factor. The factors are the focus of the Solutions meeting.The Solutions meeting is then scheduled within 2-3 weeks of the Consensus meeting.Solutions MeetingThe solutions meeting purpose is to develop targeted solutions and strategies related to contributing factors to the event, to determine the appropriate measurement strategies, and to create a plan and assign responsibilities for deliverables. This meeting is NOT a reinvestigation of the event. Attendees will be the core team, stakeholders involved and impacted by the event and those who will implement the change in process and front line staff. Solutions/strategies should focus on the most critical contributing factors of the event, determined during the confirmation and consensus meeting. It is important to remember that a solution will require a change in a process and there may be some resistance. Consider all areas that will be impacted by the change, identify the time, communication plan, and resources needed to accomplish the change. Stakeholders that will be making decisions and driving the change should be present.For each critical contributing factor determined in the Confirmation and Consensus Meeting, solutions are explored, responsibility is given to appropriate individuals, and measurement strategies are finalized. Evaluation StrategiesIt will be critical to evaluate the strength of each solution (measured in effectiveness and sustainability). Create a way to measure and track their effectiveness.Each proposed solution should be evaluated for both effectiveness and sustainability.Solutions cannot be evaluated as effective if a measurement tool is not available. The core team is responsible for developing the measurement strategies. Remember that once implemented, a solution could actually have negative unintended consequences – and the measurement strategy can help reveal this.Schedule 30-60-90 day follow-up meetings to evaluate solutionsAfter the Solutions Meeting, all documentation should be finalizedEnsure that all improvements made to care delivery or care processes is communicated and disseminated to the organization.REMEMBER for every conversation with patient/family:What are the goals of the interaction?What emotions do you anticipate and how will you name and validate them?What are you going to tell the patient/family?Who should be present for the conversation?Who will provide emotional first aid during the conversation?What questions do you anticipate?What answers will you give?How will you follow up?**When describing to patients and families what took place after Event Analysis has concluded – use visual aids as much as possible (picture of the hearts and vessels, the lungs, - equipment – whatever fits for the event, etc)DOCUMENTATIONConsult with Risk Management for guidanceAll known facts and information should be shared with patient and family in person – and NOT in MyChart or other electronic means.Consult with Risk Management before any other form of communication is utilized with patients/families other than direct in person conversations.Only factual information should be documented in the medical recordInclude who was present in the conversationInclude what was discussed and all questions asked and answered“Empathy and support provided” is always appropriate to documentDo NOT reference: “event report”, “Incident report,” “Risk Management notified”, “root cause analysis,” peer review”, “confidential” or “privileged information”, or disciplinary actions. Do NOT speculate, assume, assign blame, or record premature conclusionsIf no patient injury obvious, you may document “no apparent injury”Differentiate between “reported” and “observed” informationDocument teaching or instructions providedIf patient’s primary language is not English, document appropriate translation was provided(place holder for screen shots of EPIC and MIDAS)What goes in MIDAS?All information per KHN policies and guidelines, and procedures which pertain to unanticipated patient events for quality improvement and peer review purposesCapture of all subsequent information regarding the event analysis and investigation, consensus and solutions related to the review.Important: Any notes taken during conversations with patient and family should be for the purpose of following up on questions or needs. Personal notes regarding impressions or opinions regarding the discussion or participants is NOT appropriate.Electronic RecordingIt is not appropriate for caregivers or leaders to record or video discussions with patients and families without their knowledge or consent.Patients and families have the right to record disclosure conversations and it is not appropriate for the caregivers to tell them they may not, however, the caregiver has the right to decline being recorded and if the caregiver is uncomfortable with being recorded, they should discuss this with Risk Management BEFORE beginning or continuing the conversation with patient/family.Notify Risk Management if the patient or family has recorded the conversations.RESOLUTIONAll decisions regarding compensation must be vetted through and approved by Chief Legal Counsel, KHN Legal Services before any offer of compensation is made. Any and all offers of compensation are only to be made by Patent Relations or Chief Legal Counsel, KHN Legal Services. Do follow through with general Service Recovery according to policy as indicatedDo NOT commit to compensation without proper authority. Do NOT however, ignore comments or requests for compensation - simply let patient and family know that you are not the one to best answer that question but you will find the right person who can talk with them. Avoid being defensive or argumentative. Make sure to inform patient/family of improvements/changes made to care delivery or care processes through the event analysis and because of their input.When adverse patient events occur, the patient and their family are hurting, may be feeling helpless, and are looking for answers.Resolution is the act of solving a problem, dispute, or contentious matter. A CANDOR Resolution is comprised of the actions associated with addressing the needs or issues of the patient, families, and staff following a CANDOR event. The overall aim in Resolution is as far as possible is to restore relationships and re-establish patient/family trust through:Apology as indicated. Show empathy and remorse. Own errors if pensation if appropriate Organizational commitment to improvementThe first step of the Resolution component is to apologize for the adverse event. This apology is a regretful acknowledgement of the event by the care provider and/or the organization. The purpose for this apology is to begin to re-establish trust with the patient and the patient’s family. A CANDOR event apology should consist of the following components:Taking responsibility—This is not admitting guilt, but rather admitting that an adverse event occurred while the patient was under your care or in your organization. Showing remorse— This is a time for the transformational skills of empathy, presence, and listening. When speaking with the patient and/or family, it is important to show your honest emotions and feelings, and allow them to see how this event has affected you. There is also a difference in just saying the words “I’m sorry” and really saying the words with empathy.Making restitution—In the initial disclosure of the adverse event, caregivers need to be careful not to promise things to patients and families. When the conversation turns to resolution AFTER the event analysis has been completed, the organization should know whether the standard of care has been met or not, and whether it plans to financially compensate the patient/family or make other offers to help the patient/family feel whole again.Be genuine, humble, and respectfully ask questions of patient and family that draw out their true needs and then seek to fill those needs. Do what they cannot do for themselves. Don’t assume knowledge of what kind of help they want or need.Patients want to hear from their care providers and/or the organization – an explanation of what happened, a heartfelt and sincere apology as indicated, and an assurance that every effort is made to prevent a recurrence of the event for someone else.. If this is not done well, it can lead to a loss of trust from the patient/family.This component of CANDOR can lead to financial settlement or support, but might not always lead to resolution of all issues related to the adverse event. The literature is clear that the patient and family are more likely to pursue legal action if the caregiver or organization act with the “deny and defend” approach, however, litigation is not always the patient/family’s first preference after an adverse event. Not every adverse event warrants compensation and not every patient/family wants financial compensation. However, patients and families want to feel they are part of the improvement process. A multidisciplinary team convenes to make decisions about compensation and can include representation from internal Legal services, Risk Management, Finance, Clinical leaders, and Executives.Resolution is not a one-time occurrence and can be revisited throughout the CANDOR process. ORGANIZATIONAL LEARNING AND SUSTAINABILITYOrganizational learning is a process that involves intentionally and systematically applying gained knowledge for the purpose of improving processes, relationships, and the culture of safety and patient-centeredness. The goal is to create a culture of inquiry, transparency, and dialogue where people are safe to share openly and respectfully.The characteristics of a learning organization are supported through the implementation of the CANDOR process. After the resolution of a CANDOR event, information is fed into an organization’s performance improvement metrics, which allows for improvement of CANDOR processes, and prevention of similar harm events in the future. The Implementation Team Lead and other Team Leads help build and promote a shared vision of organizational learning that can challenge the way “we’ve always done it.” CANDOR process leaders are able to support continuous learning from the CANDOR process and from the outcomes of CANDOR events. Sustainability occurs after an organization has made significant changes to improve and performance holds over time. One of the more well-known and accepted change models is John Kotter’s 8 Steps of Change Model. Kotter’s Step 7 is “Don’t let up—be relentless.” This step involves using the knowledge and the momentum from short-term wins to align an organization’s systems and policies with the new vision and to train a workforce to fulfill the vision. This stage also developing strategies to maneuver around obstacles and barriers that may threaten the change effort. ?Kotter’s Step 8 is “Create a new culture.” This step involves making the desired changes routine and apart from daily life in the facility. During this stage, leaders assure transparency in data surrounding the change effort to support continuous evaluation and modification of the change.Sustainability occurs when processes, outcomes, ideas, beliefs, principles, or values underlying an initiative continue beyond the implementation phase of a project. Sustainability can also be described as “when new ways of working and improved outcomes become the norm.” A process which has been integrated into the organizational culture is more likely to continue to produce a specific quality improvement or long-term outcome. ?The Institute for Healthcare Improvement (IHI) identified six common elements of sustainability. These elements include:Supportive management structuresStructures to “foolproof” changeRobust and transparent feedback systemShared sense of systems to be improvedA culture of improvement and engaged staffFormal programs to prepare people to learn and apply new skills The six elements of sustainability can be found in the CANDOR process and toolkit resources. ?Supportive management structure—The CANDOR process components that represent a supportive management structure constitute the CANDOR Team Structure. ?Structures to “foolproof” change—These are system design elements that ensure all elements of the CANDOR process are being followed. These may include a checklist to follow after an event. ?Robust, transparent feedback systems—The CANDOR process components that correspond with transparent feedback systems are Response and Disclosure and Event Analysis.?Shared sense of the systems to be improved—The entire CANDOR process fosters a culture of improvement around the response to unexpected patient harm events. This desire to improve should be shared among the organization as well as the patient and family. ?Culture of improvement and a deeply engaged staff—The Care for the Caregiver program and the engagement of staff, patients, and family members represent significant efforts to promote deep engagement on the part of all stakeholders. ?Formal programs to prepare people to learn and apply new skills—The CANDOR process educational resources are designed to build capacity among clinicians, staff, patients, and family members and to equip staff to lead effective program implementation. The overall CANDOR process facilitates an environment of trust, which supports sustainment of program goals. To Plan for Sustainability:Build the organizational structure to support the 5-step CANDOR process.Plan early to sustain the work.Engage senior leaders and risk managers.Ensure buy-in from frontline staff.Build a measurement system and a robust transparent feedback system to monitor performanceDevelop a sustainability plan that includes identification of barriers and solutionsEmpower caregivers and engage leaders; identify and develop champions for CANDORPromote a Just CultureEngage caregivers with stories that move the heart and stir toward excellenceProvide ongoing education and trainingManage resistance and remove barriersHave patients and families sit on quality and safety councils and share their stories in targeted meetingsCelebrate and broadcast successesAPPENDIX A. AcknowledgementsWith gratitude, we acknowledge the support of KHN executive leaders in their pursuit of excellence and in cultivating a caring culture. We particular thank Jarrod McNaughton, president of Kettering Medical Center and Executive Vice-President for Kettering Health Network, who started the conversation and vision that has become our CARING through CANDOR passion.We acknowledge our Physician leaders, medical staff and residents; our Nursing leaders and nursing staff, Quality, Risk, and Legal leaders, and all KHN caregivers who give their best every day to create safe passage for our patients and their families.To our patients and their families – you are why we do this very sacred work. Our hearts are deeply grieved when you experience an adverse event or unexpected outcome and we promise to follow best practices and do all we can to maintain your trust; to care for you physically, mentally, emotionally, and spiritually; and to partner with you in continually improving our care delivery.A special thank you to Dr. Tim McDonald, our primary consultant, coach, and friend. Your passion for the sacred work of creating safe passage for patients and their families in your own medical practice is admirable. Yet, you have taken on the additional “call” to guide others toward excellence through your CANDOR leadership. We are grateful and better for your collaboration with us. APPENDIX B. KHN CARING through CANDOR PolicyPR-KHNCommunication and Optimal Resolution (CANDOR) PolicyPage 1 of ___PURPOSE:The purpose of this policy is to provide structure and guidelines for a principled and comprehensive response through communication and disclosure of unanticipated or adverse medical outcomes.POLICY:Kettering Health Network (KHN) is committed to doing all we can to prevent avoidable mistakes and improve patient care. KHN is also dedicated to promoting timely and transparent communication to our patients, their families and/or representatives regarding outcomes of care, including when an outcome is unanticipated or adverse. Through a principled and coordinated effort of communication and support to our patients, families, representatives, and caregivers that integrates human factors and system analysis while applying Just Culture principles, KHN strives to continuously improve the health and safety of patients and the quality of health care provided to our community.DEFINITIONS: CANDOR Event: A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial) to a patient. These events trigger the CANDOR process even when a cause for the event is not yet known. CANDOR Response Team: Specially trained communication coaches available 24/7 who support the clinicians who respond and communicate with patients and families. The CANDOR Response Team also helps activate the Care for the Caregiver Team. (See Care for the Caregiver protocol).CANDOR Communication: The early and ongoing conveying to a patient, their relative and/or their representative of known information surrounding an unanticipated or adverse outcome.Empathy: An immediate and sincere expression of caring, support, and sympathy. It is appropriate and expected at all times by everyone in our organization.Harm: Temporary or permanent deformity, impairment, or loss of use of a bodily function or organ system requiring medical intervention which may include monitoring the patient’s condition, change in therapy, or active medical or surgical treatment. Harm also includes death of a patient that results from medical care provided or not provided rather than their underlying disease process or health.Unanticipated Outcome: The outcome of a medical treatment or procedure that differs from an expected result. An unanticipated outcome does not imply medical error, medical negligence, or substandard care. An unanticipated outcome may or may not result in harm to a patient. An unanticipated outcome may be a CANDOR event.Adverse Event: An event caused by medical care provided (an act of commission) or not provided (an act of omission) to a patient rather than their underlying disease that results in harm to the patient. An adverse event does not imply medical error, medical negligence, or substandard care. An adverse event may be a CANDOR event.Serious Reportable Event: A serious reportable event (SRE) such as the following may be a CANDOR event, subject to review and determination by the CANDOR Response Team. These follow the definitions as per the National Quality Forum and can be obtained from the Patient Safety Manager or Quality Director: Surgical or Invasive Procedure eventProduct or Device eventsPatient Protection eventsCare Management eventsEnvironmental eventsRadiologic eventPotential Criminal eventsSerious Patient Safety Event: A serious patient safety event may be a CANDOR event, subject to review and determination by the CANDOR Response Team. These include events in categories E through I of the National Coordinating Council for Medication Error Reporting and Prevention. These definitions can be obtained from the Patient Safety Manager or Quality Director.Relative: A patient’s spouse, parent, grandparent, stepfather, stepmother, child, grandchild, brother, sister, half-brother, half-sister, or spouse's parents. The term includes said relationships that are created as a result of adoption. In addition, "relative" includes any person who has a family-type relationship with a patient.Representative: A legal guardian, attorney, person designated to make decisions on behalf of a patient under a medical power of attorney, or any person recognized in law or custom as a patient's agent. Event Analysis: A standardized structure and systematic review process for reviewing patient harm events for the purpose of understanding all contributing factors and arriving at effective and sustainable solutions.Resolution: The action of solving a problem, dispute, or matter by addressing the needs and concerns of patients, families, representatives and caregivers.CANDOR PROCESS:Identification of a CANDOR event: A CANDOR event involves an unanticipated outcome, adverse event, serious reportable event, or a serious patient safety event resulting in patient harm. The CANDOR response process is triggered even when a cause for the event is not yet known. The CANDOR approach is not a one-time response, but an ongoing process. The occurrence of a CANDOR event triggers the CANDOR Response Team and the process is activated which includes the components of: Communication, Care for the Caregiver, Event Analysis, and Resolution. The CANDOR Response Team, which is on call 24/7, is activated by notification from the attending physician, department manager, or nursing supervisor. The CANDOR Response Team supports the patient, their relative(s) and/or representative(s), as well as the attending physician and/or other clinicians involved with the response and communication.Response and Initial Communication. It is important to understand that CANDOR Communication is a process and will likely be ongoing. While an initial conversation with the patient, relative(s) or representative(s) will occur as soon as practical, the communication about cause and plans to prevent reoccurrence will typically not occur until after the Event Investigation and Analysis has been completed –- usually 30 days or more after the event occurred. The CANDOR Response Team is activated as soon as possible to support the physicians and other care providers who will provide the initial and ongoing communication with patient and family/representatives. The response team will also help assess how best to meet the needs of the patient, their relative(s), and/or representative(s) prior to the initial communication with the patient and family. The communication should be made utilizing clear and understandable terminology to a lay person and should be factual and objective. Care for the Caregiver: This process is part of the Communication component of CANDOR and provides peer support and a specially trained response team to assess and support the impact of the patient harm event on caregivers.Event Investigation and Analysis: This component begins with the reporting of the CANDOR event and continues until all the information is gathered, analyzed, and a plan is developed to prevent the outcome or event from reoccurring, if possible. Resolution: After effectively implementing the first four components of the CANDOR process, the organization can begin implementing the Resolution process. During Resolution, the organization will apply what has been learned to potentially improve patient safety and prevent similar unanticipated or adverse outcomes from recurring. During Resolution, the organization will also determine how to appropriately address resolving the CANDOR event, which may include a component of compensation. Patient Relations shall coordinate service recovery efforts with the input and assistance of KHN Legal Services and KHN Risk Management. All decisions regarding compensation must be vetted through and approved by Chief Legal Counsel, KHN Legal Services before any offer of compensation is made. COMMUNICATION WITH AND SUPPORT FOR THE PATIENT, RELATIVE OR REPRESENTATIVE Who will attend the CANDOR Communication with patient and family/representative? In addition to the attending physician or a designee, the clinician should preferably be accompanied by a member of the CANDOR Response Team and/or a representative of Patient Relations. When appropriate other members of leadership and/or a chaplain may attend.Who will lead the CANDOR Communication? It is the responsibility of the attending physician or a designee to assure communication of a CANDOR event with the patient, relative(s) or representative(s) occur in a timely, accurate, and understandable manner. The attending physician or designee will communicate with the CANDOR Response Team prior to the Communication with patient/family to review key CANDOR principles and walk through anticipated questions. The Communication should clearly explain the outcome or event using layman’s terms, and if appropriate, the use of an interpreter. When will the CANDOR Communication disclosure occur? The Communication should be made as soon as reasonably practical after the CANDOR event has been identified and the CANDOR Response Team has been notified. Every effort should be made for timely Response and Communication, preferably within 48 hours after the CANDOR event is identified.What will be Communicated? The initial Communication to the patient, relative(s), or representative(s) will include: empathy for how the patient and family/representative are doing; what is known at the time about the event, reassurance that the CANDOR event will be investigated and that additional information will be provided as it becomes available. The Communication shall include the nature of the outcome or event, the potential impact on the patient’s health (if known), and what, if anything, can be done to mitigate any effect on the health of the patient. It should be conveyed that time and careful analysis will be required to determine the cause of the outcome or event.The Communication will be free of speculation and conjecture and should be free of blame or expressions of fault. Such statements, when all of the facts are not yet known, provide misinformation to the patient, relative(s), or representative(s) and can be a disservice and potentially detrimental to them. Reassurance should be provided that KHN physicians, nurses, and other clinical staff will continue to care for every aspect of the patient’s care, including the management of the CANDOR event. The CANDOR Response and Communication should be accompanied by a sincere offer of appropriate support services such as a social worker, chaplain, patient advocate or member of the CANDOR Response Team. It is always appropriate and expected to express empathy for an unanticipated outcome, adverse outcome, or serious patient safety event.It will be made clear to the patient and family/representative who will stay in contact with them and they should be given access to contact information for their potential use.Documentation of the CANDOR Communication: The Communication –- initial and ongoing - should be documented in the medical record by the attending physician. It is recommended that the documentation include, but not necessarily be limited to, identifying the date, time and location of the Communication, and the name, title (if applicable), and relationship (if applicable) of all individuals present for the Communication. Requests, concerns, questions and the response / reaction of those involved in the discussion should be documented as well. Any use of an interpreter will be MUNICATION WITH AND SUPPORT FOR THE CLINICIAN The Care for the Caregiver (CFC) component of the CANDOR process provides a 24/7 CFC Response Team. The CFC component includes three tiers of support: 1) supervisor/manager, department, and peer support; 2) The CFC response team; and, 3) If needed-, referral to specialized resources such as EAP and/or professional therapies. Referrals to the CFC can be initiated in a number of ways: self-referral by the clinician, initial identification and referral by the CANDOR Response Team, peers, or manager/department referral. The CFC Team will work with the CANDOR Response Team to notify the appropriate leaders of the impacted clinician (e.g. Medical Staff, Nursing). The focus of the CFC Team is on the clinical/caregiver well-being, not on the other elements of, or review of, the CANDOR case. EVENT ANALYSIS AND INVESTIGATIONThe CANDOR event will be subject to systematic analysis and investigation that will utilize Just Culture and human factors principles. Communication is a process and will continue with the patient and family/representative until the investigation and analysis are complete at which time pertinent information will be shared when it is learned. Event Analysis and Investigation may take 30-45 days to complete. RESOLUTIONOpportunities for service recovery shall be identified and addressed. Patient Relations shall coordinate service recovery efforts with the input and assistance of KHN Legal Services and KHN Risk Management. All decisions regarding compensation must be vetted through and approved by Chief Legal Counsel, KHN Legal Services before any offer of compensation is made. Any and all offers of compensation are only to be made by Patent Relations or Chief Legal Counsel, KHN Legal Services.KHN CARING through CANDOR PROTOCOLA CANDOR event involves an unanticipated outcome, adverse event, serious reportable event, or a serious patient safety event resulting in patient harm The CANDOR response process is triggered even when a cause for the event is not yet known. The CANDOR approach is not a one-time response, but an ongoing process(See KHN CANDOR Guidelines Manual for detailed roles and skill guidance)Time FrameResponsibilityActionIDENTIFICATION OF CANDOR EVENTAs soon as possible>Frontline staff or>Manager or>Nursing SupervisorInitial Notifications:__ Attending Physician__ Medical Director of Quality__ Patient Relations / Risk ManagerAssure patient stabilizationRemove and preserve all equipment, devices, medications, monitoring strips, etc. Do not move or remove tubes or lines or turn off/change equipment settings in the patient room unless they pose danger or discomfort to the patient. Contact clinical or biomed engineering for assistancePatient Relations / Risk Manager performs initial review of EMR and enters available date into MIDASDoes the harm event involve an unexpected death, serious injury, or a report of clear error?YES – CANDOR Process – proceed to # 5 belowNO – Follow internal Event Analysis (RCA), skip to # 12 belowCANDOR SYSTEM ACTIVATIONEARLY REVIEWAs soon as possible>Front line staff/>Manager>Nursing Supervisor>CANDOR Team>Risk Manager and designated others5. Activate CANDOR Response Team (coaches)Provide emotional support to patient, family and caregiversActivate Care for the Caregiver Team for initial assessment/support of caregivers impacted by event.Initiate protected event review;__ Assess need to immediate actions based on preliminary event review__ Report preliminary findings to ______________________Identify Executive sponsors for Event Analysis (RCA)__ Initial scan of the environment – understand the “whole” before examining each “part.”__ Collect all time sensitive information__ Review preliminary facts and information known__ Identify potential issues for peer review in accordance with Just Culture principles__ Notify internal legal counsel as appropriate__ Confirm existing known and immediate risks to patient have been mitigated__ Review current communication with patient and family__ Enter all known information in the event reporting system__Subject experts to possibly reach out to:Biomedical engineeringFacilitiesHuman factors or other system safety engineering fieldInformation Technology/SystemsMedical and Surgical SpecialtiesNursingPharmacy__ Maintain contact with patient/family liaison__ Keep targeted leaders informed__ Do NOT determine root and latent causes prior to full Event Analysis__ Identify next steps and set dates for next review meetings__Ensure plans are in place for: ongoing communication with patient/family; care for caregiversRESPOND AND COMMUNICATE“Every hour that goes by without communication with patient and family – is harm”Within 1 hour if possible,And ongoing…>Attending Physician and/or another as appropriate>Nurse Manager>Patient Relations>CANDOR Response Team coaches clinicians who will communicate with patient, family, representativeEarly Communication with patient, family/representativeEstablish a patient/family Liaison**Remember that if able, patient may choose who (family, representative, etc.) is to be present for conversations on their behalf**__ CANDOR response coaches prepare clinicians who will be talking with patient/family__ Confidentiality of patient information is primary__ Recommendations are the goal – not final decisions.__ Who should lead the conversation?__ Are the clinicians ready and capable of doing the communication?__ Is the patient able to participate in the conversation – is the family ready?__ Determine optimal time and setting for conversation; Anticipate patient/family questions __ Introductions; sit down; listen generously with empathy and respect __Assess what they know so far? __ Use effective body-language.__ Input from the patient/family is invited and valued.__ Be attentive to patient/family preference and cultural considerations__ Explain in layperson language: Say you are sorry that this is their experience/that this happened.The facts we know now about what happened and why; Do not speculate or blame or take ownership – the event still needs to be reviewed We will be reviewing and keeping them informedExplain how the patient’s health has been impacted and the resulting treatment planAnswer questionsRecommendations for next steps and follow-up meetingsEnsure they have a contact number and assurance of ongoing support - Identify a liaisonWithin 1 hourAnd ongoing…>CANDOR Care for Caregiver Team>Dept. Manager>Supervisor10. Care for the Caregiver__ Evaluate mental and emotional state of impacted clinicians/staff __ Remove from immediate duties as indicated__ Provide emotional and psychological first aid__ Initiate other resources such as Chaplains/CISM __ Provide EAP information__ Explain next steps in the CANDOR process – event analysis, etc.__ Consider arranging time off from work for clinician(s)/staff__ Plan for continued support as neededEVENT ANALYSIS AND INVESTIGATIONWithin 72 hours of event>Risk/Quality and others trained in cognitive interviewing and knowledgeable of event investigation process/policy processCommence Event Analysis – IN-DEPTH REVIEW Withhold bills or financial requests to patient / family during this timeUpdate leaders as appropriate and timelyPrepare interview strategies, questions based on record review, Event analysis tools, and Cognitive Interviewing skills.Interview physicians and involved staff. Notify program director of Residents to be interviewed__ Close gaps early on immediate safety hazards__Identify organizational policies/procedures that apply – were they followed? Do they adequately address all aspects of the event?__ Determine those involved and timelines; create flowcharts as needed__ Review literature for best practices__ Establish timeline leading up to event__ Capture pertinent interview quotes and themes__ Examine preliminary findings – patient’s current condition/needs; caregiver needs; drawings, photos…)__ Do detailed review of timeline (working conditions, processes, people perspectives, environment, teamwork, communication)__ Obtain copies of objective data (medical records, audit trails, notification records, labs, imaging reports, and all other time-stamped information)__ Begin creating a visual model of the contributing factors to be proposed and discussed at the Solutions and Consensus meetings30+ days post-event>Risk/Quality>Appropriate Executives>Appropriate Clinical Leaders (RCA)>Dept. Chairs >CANDOR Response TeamCONFIRMATION AND CONSENSUS MEETING__ All attendees should receive the detailed review timeline prior to the meeting to prepare questions__ The goal of this meeting is to confirm contributing factors and build consensus around them. __ Share pertinent findings__ Obtain confirmation and consensus on contributing factors__ Consider early key action stepsNo later than 2 weeks after Consensus meeting>Risk/Quality>Appropriate Executives>Dept. Chairs>CANDOR Response Team>All who will be affected by any changes recommended to polices/processes>Senior leaders: Those who will make decision about allocation of resources17. SOLUTIONS MEETING__ Develop targeted solutions and measurement strategies. Solutions should focus on the most critical contributing factors of the event. __ Finalize event review documents__ Plans/timelines for implementing changes to process, procedures and policies as needed__ Is NOT a reinvestigation of the event __ Evaluate the strength of the solution – for effectiveness and sustainability. __ Complete the CANDOR process tool with assigned solutions for each contributing critical factor__Long term goals and ownership for solutions.__Schedule follow-up meetings to evaluate solutions and modify as needed.Report solutions, action plans, and measures to appropriate committees (Patient Safety, etc)Following the Solutions meeting – all documentation should be finalizedDOCUMENTATIONInitial and Ongoing as needed>Risk/Quality>Legal Services>CaregiversDocumentation __ Consult with Patient Relations / Risk Management for guidance__ Document only factual and objective information in the medical record__ Do NOT reference “event report,” “incident report,” “risk management”__ Do NOT speculate, assume, or record premature conclusions; Do NOT assign blame.__ If no injury apparent, document “no injury”__ Differentiate from “reported” and “observed” information__ Document as if the person described will someday read what you have recorded/written__ Document all teaching and instructions provided__ Document those present in conversations__ If patient’s primary language is not English, document that appropriate translation was provided __ Document aggressive patient or family behaviors and the steps taken to manage them.__ Document all questions answered RESOLUTIONMeeting to Develop Compensation Plan:>Clinical providers>Legal Services>Risk/Quality>Senior leaders>Finance as needed>Insurance/Claims as neededMeeting with Patient and Family (with appropriate attendees) AFTER compensation plan developedContinue to focus on needs of patient and family – maintain contact with liason**All decisions regarding compensation must be vetted through and approved by Chief Legal Counsel, KHN Legal Services before any offer of compensation is made. Any and all offers of compensation are only to be made by Patent Relations or Chief Legal Counsel, KHN Legal Services.__ Continue to monitor patient /family needs; maintain contact with between patient/family and liaison.Is there consensus on determination of clear medical error or substandard care?Yes – CANDOR process # 21 belowNo (not substandard care) - Follow internal RCA process and proceed to #26 belowMeeting 1 - Schedule meeting with key clinical providers/stakeholders --Gather all materials created in Event Analysis and from reaching consensus of substandard care and need for apologyDid all stakeholders agree to need to offer apology to patient/family?Yes – CANDOR Process # 22 belowNo (apology not indicated) -- Follow internal RCA process and skip to # 26 belowMeeting 2 – schedule meeting with key clinical providers/stakeholders and executives – this is to affirm support of recommendation to provide an apology for medical error/substandard careWith Legal Services, discuss case findings and provision of apology and discuss process for hand-over to claimsMeeting 3 – prepare for communication and apology – set dates to meet with patient/family/representativesMeeting 4 – helped with patient/family/representatives(s) Communication documented. Share process and prevention improvements made. Commit to continued follow up as needed.Release bills not associated with substandard ANIZATIONAL LEARNING AND SUSTAINABILITYGOAL; CREATE CULTURE OF INQUIRY AND DIALOGUE – PEOPLE FEEL SAFE TO SHARE OPENLY AND WITH RESPECTFUL TRANSPARENCY__ Develop metrics for measuring improvement, financial impact, and indirect impact__ Elements:Supportive management structures and resources – CANDOR Team structure and program executive and physician championsStructures to “foolproof” change – Implementation processes; ongoing “booster” education/trainingsRobust, transparent feedback systems –Reporting; Response and Disclosure; Event AnalysisIdentify/mitigate barriersAlign systems and policies with the visionShared sense of the systems to be improved and monitored – Gap AnalysisCulture of highly engaged staff – Empower frontline staff; Care for Caregiver; connection to Patient Safety and Just CultureCapture compelling storiesEngage patients and families in councils and improvement strategiesFormal programs to prepare people to learn and apply new skills – Engaging all stakeholdersCelebrate, broadcast successesAPPENDIX C. Best Practice Resources:We are deeply grateful to the following organizations for their research, guidance, and ongoing efforts to improve healthcare safety and quality, care and communication:AHRQ (Association of Health Care Research and Quality) – developed the CANDOR toolkit CAI –(Collaborative for Accountability and Improvement) TheCAI@uw.edu IHI – (Institute of Health) – 2011 White paper, “”Respectful Management of Serious Clinical Adverse Events” ASHRM – (American Society for Health care Risk Management) – 2013 Three Monographs – “Disclosure of Unanticipated Events” ashrm@ Massachusetts Coalition for the Prevention of Medical Errors – 2006 – White Paper, “When Things Go Wrong” MACRMI – (Massachusetts Alliance for Communication and Resolution following Medical Injury – Harvard Risk Management FoundationMITSS –( Medically Induced Trauma Support Services) forYOU - University of Missouri Health Care – a peer-support program for caregiversTruog, R, Browning, D, Johnson, J, and Gallagher, T. (2011). Talking with Patients and Families about Medical Error. Johns Hopkins.Special thanks to the following individual experts who have guided and supported us through their published work and coaching:Tim McDonald MD, JD – University of IllinoisThomas Gallager MD- University of WashingtonRick Boothman JD - University of MichiganSusan Scott, RN, MSN – University of Missouri Health Care – forYOU (Care for the Caregiver researcher and director) APPENDIX D. WE CARE FOR YOU POLICYAppendix E. WE CARE FOR YOU PROTOCOL Appendix F. WE CARE for YOU - Caregiver Stress ReactionsCRITICAL INCIDENT STRESS REACTIONSCritical Incident Stress Management (CISM) self care informationA traumatic event is any event that causes unusually strong emotional reactions that have the potential to interfere with the ability to function normally. Even though the event may be over, you may now be experiencing or may experience later, some strong emotional or physical reactions. It is very common, in fact quite normal, for people to experience emotional aftershocks when they have passed through a traumatic event. Sometimes the emotional aftershocks (or stress reactions) appear immediately after the traumatic event. Sometimes they may appear a few hours or a few days later. And, in some cases, weeks or months may pass before the stress reactions appear. The signs and symptoms of stress reaction may last a few days, a few weeks, a few months, or longer, depending on the severity of the traumatic event. The understanding and the support of loved ones usually causes the stress reactions to pass more quickly. Occasionally, the traumatic event is so painful that professional assistance may be necessary. This does not imply craziness or weakness. It simply indicates that the particular event was just too powerful for the person to manage by mon Signs of a Stress Reaction:Your body chills, fatigue/exhaustioninsomnia/sleep disturbancesover/under activitynightmareschange in appetitedigestive problemsnauseafaintingtwitchesvomitingdizzinessweaknesschest painheadacheselevated BPrapid heart ratemuscle tremorsshock symptomsgrinding of teethvisual difficultiesprofuse sweatingdifficulty breathingYour mindlack of concentrationflashbacksdifficulty with decisionsmemory disturbanceamnesiaconfusionpoor problem solvingdisturbed thinkingpoor abstract thinkingchange in alertnessnightmaresuncertaintyhyper vigilancesuspiciousnessintrusive imagesblaming someonenightmaresuncertaintyhyper vigilancesuspiciousintrusive imagesblaming someonepoor attention/decisionspoor concentration/memorydisorientation of time, place or persondifficulty identifying objects or peopleheightened or lowered alertnessincreased or decreased awareness of surroundingsYour feelingsfearguiltemotional numbingover sensitivityanxietydepressionfeeling helplessangerirritabilityfrustrationgriefpanicdenialagitationintense angerapprehensionemotional shockemotional outburstsfeeling overwhelmedloss of emotional controlinappropriate emotional responseYour reactionschange in activitychange in communicationwithdrawalsuspiciousnesshyper-alertnessstartle reflexchange in sexual behavioremotional outburstsscapegoatingpacingantisocial actsinability to restintensified pacingerratic movementschange in speech patternsloss or increase of appetiteincreased alcohol consumptionchange in usual communicationThings to try:Within the first 24-48 hours periods of appropriate physical exercise, alternated with relaxation will alleviate some of the physical reactions.Structure your time; keep busy.You're normal and having normal reactions; don't label yourself crazy.Talk to people; talk is the most healing medicine.Be aware of numbing the pain with overuse of drugs or alcohol, you don't need to complicate this with a substance abuse problem. Drink lots of water to keep up your energy. Remember that Caffeine and alcohol are very dehydratingReach out; people do care.Maintain as normal a schedule/life as possible.Spend time with others who are supportive of you.Help your co-workers as much as possible by sharing feelings and checking out how they are doing.Give yourself permission to feel rotten and to take the time to go easy on yourself..Keep a journal; write your way through those sleepless hours.Do things that feel good to you.Realize those around you are under stress too.Don't make any big life changes.Do make as many daily decisions as possible that will give you a feeling of control over your life, i.e., if someone asks you what you want to eat, answer them even if you're not sure.Get plenty of rest and at least 7-8 hours of sleep at night. Take naps during the day if needed.Don't try to fight reoccurring thoughts, dreams or flashbacks - they are normal and will decrease over time and become less painful.Eat well-balanced and regular meals (even if you don't feel like it).Don’t rule out the care of a professional counselor to help you through it! Especially if you find yourself with prolonged episodes of any of these: continued anxiety or feelings of depression, difficulty sleeping, pulling away from trusted family and friends, or having thoughts of hurting yourself or others. FOR FAMILY AND CLOSE FRIENDS of a Caregiver impacted by a traumatic event:Your loved one has been involved in an emotion-charged event, often known as a critical incident. He/she may be experiencing normal stress responses to such an event (critical incident stress). No one is immune to critical incident stress, regardless of past experiences or years of service. Your loved one may experience critical incident stress at any time during his/her career.Important things to remember about critical incident stress:The signs of critical incident stress are physical, cognitive, emotional and behavioral. Your loved one has received a handout outlining these signs. Please ask him/her to share it with you.Critical incident stress response can occur at the time of the incident, within hours, within days, or even within weeks.Your loved one may experience a variety of signs/symptoms of a stress response or he/she may not experience any of the reactions at this time.Suffering from the effects of critical incident stress is completely normal. Your loved one is not the only one suffering; other personnel shared the event and are probably sharing the reaction.The symptoms will normally subside and disappear in time if you and your loved one do not dwell upon them.All phases of our lives overlap and influence each other: personal, professional, and family. The impact of critical incident stress can be intensified, influenced or mitigated by our own personal, family, and current developmental issues.Encourage, but do NOT pressure, your loved one to talk about the incident and his/her reaction to it. Talk is the best medicine. Your primary "job" is to listen and reassure. Remember that if an event is upsetting to you and your loved one, your children may be affected, also. They may need to talk, too.You may not understand what your loved one is going through at this time, but offer your love and support. Don't be afraid to ask what you can do that he/she would consider helpful.Accept the fact that life will go on: his/hers, yours, and your children. Maintain or return to a normal routine as soon as possible.If the signs of stress your loved one is experiencing do not begin to subside within a few weeks, or if they intensify, consider seeking further assistance.Things to Do: Family and Friends:Listen carefully.Send time with the traumatized person.Offer your assistance and a listening ear if they have not asked for help.Reassure them that they are safe.Help them with everyday tasks like cleaning, cooking, caring for the family, minding children.Give them some private time.Don't take their anger or other feelings personally.Don't tell them that they are "luck it wasn't worse;" a traumatized person is not consoled by those statements. Instead, tell them that you are sorry such an event has occurred and you want to understand and assist them. ................
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