The health care industry does everything possible to mitigate errors, yet mistakes can happen. That's why CommonSpirit Health has worked to adopt an organizational culture of transparency that allows its employees to feel comfortable reporting errors when they occur. In this “Safety Speaks” conversation, CommonSpirit Health's Beth Miller, system director, patient safety-performance improvement, and Austin Peterson, system director, patient harm prevention, discuss how safety transparency benefits both patients and providers, and how a CommonSpirit Health toolkit can help organizations lead the way in error reporting and patient safety. 

Tom Haederle

Hospital and health system care teams provide amazing care to countless patients every minute of every day. But they are human and mistakes do happen. No one pretends otherwise. If an error is discovered, it's important that anyone feel comfortable reporting it and sharing that information with a patient as well. Sometimes saying sorry the right way makes all the difference.

Tom Haederle

Tom Haederle

Her two guests from CommonSpirit are Beth Miller, system director for patient safety performance improvement, and Austin Peterson, system director, patient harm prevention.

Joy Lewis

CommonSpirit Team, Beth and Austin, thank you so much for being here with me today and welcome to Safety Speaks. I really am looking forward to exploring this topic of CANDOR and how accessible it is as we think about advancing equitable care, and I think we should start really just with setting the stage. I think CANDOR is familiar to those folks who work in the quality improvement and patient safety space.

Joy Lewis

It's familiar language to them. But others of our listeners may be wondering what exactly is CANDOR, which stands for Communication and Optimal Resolution Approach. So can you just elaborate on what exactly CANDOR is. Let's pitch that to you, Austin.

Austin Peterson

Sure. I'd be more than happy to. So there's a couple of different ways to pronounce CANDOR. Some people might call it a SCRP or communication resolution program.

Austin Peterson

We just adopted the agency for Health Care, Research and Quality and Language of CANDOR, as you alluded, is a communication and optimal resolution program. And really, it's a patient safety program to help health care organizations respond transparently and effectively to adverse events when they reach our patients. The key components of it is really emphasizing early communication, providing a thorough event review, utilizing RCA squared, and providing resolution.

Austin Peterson

And this whole program is about fostering trust, not just with our patients and families, but also with our staff members if they make a mistake that leads to a potential CANDOR event. And the ultimate goal is to try to make what's right that we can with our patients and families but also improve our health care system so it doesn't happen to anyone else.

Austin Peterson

And I'd just like to take a moment and start by saying I'd be remiss by not acknowledging some key individuals in our industry who has developed this transparency movement of communicating events to our patients and families. And the list I'm going to say is not exhaustive, and I apologize in advance for missing anyone critical. But our work at CommonSpirit Health has been built on many others, such as Dr. Lucian Lee. Dr. Tim McDonald and Rick Boothman with their Seven Pillars, and Dr. Tom Gallagher and his studies advocating that patients and families value compassionate communication and an honest apology post error.

Austin Peterson

And also our patient advocates who keep us honest in the health care industry. But I want to shift again to discuss the agency for Health Care, Research and Quality, who developed CANDOR with some key individuals within our organization, Linda Ubaldi and Dr. Morelli at Dignity Health and also Barbara Pelletreau, who ensured CANDOR was successfully adopted across all Dignity Health and now CommonSpirit Health before her retirement. As a health care organization that collaborated with AHRQ, and they have contributed to the creation and the refinement of the CANDOR toolkit that is open access and free for everyone to adopt. The collaboration of all, providing insights and feedback based on our experiences with our patient safety leaders and

Austin Peterson

communication practices. And it really helped shape the toolkit's content and implementation strategies that exist today.

Joy Lewis

Well, thank you so much for that context. And I would imagine CANDOR is something we can all get behind, because what you just outlined for listeners is really a level of humility that the health care system brings to the patient care experience and really focusing on being transparent and learning and improving, and to all of that and really creating an environment of trust.

Joy Lewis

So can you go a little bit further and talk a little bit more about how you implemented the CANDOR approach inside and across such a large system?

Austin Peterson

You know, with any large projects such as this, it really needs to be led by our executive leaders who say that this is the right thing to do and get behind it, to push all of us in that direction.

Austin Peterson

Again, that was led by Barbara Pelletreau and Dr. Robert Weaver. Initially because we were smaller at Dignity Health, we had the opportunity of providing these two-day workshops where key leaders of the hospital would be our chief nurse, chief medical officer, quality directors, patient safety leaders. Our claim leads who get together and they learn about the principles and foundations of CANDOR while also practicing that empathetic communication.

Austin Peterson

Austin Peterson

But it's really hard pulling our leaders away for that long of a time when they need to be with our frontline staff and our patients and our families. So we've revolutionized what we do, and now we provide this in a learning management system and four self-paced modules that all of our leaders go through. And we say all of the leaders, if you're in the leadership capacity, we recommend that you go through CANDOR.

Austin Peterson

That is completed by having a live practicum where Beth and I reinforce the training with experiential learning. And we've also rolled out an advanced CANDOR series where we include many unique scenarios that our leaders come across. And as you alluded to, we've trained a lot of people. To date, our organization - we've trained over 1,300 leaders, including our physicians. And we're continuing to push to ensure that everyone receives this training.

Joy Lewis

That's massive.

Joy Lewis

You're really doing this work at scale.

Joy Lewis

And it's really interesting how you've evolved your approach pre-Covid and post-Covid. But at the end of the day, it sounds like transformational leadership is what's really needed to move the needle here. So talk about that transformation. How has the CANDOR training program transformed your organization's approach to patient safety and equity? Beth, can you elaborate on that?

Beth Miller

I love that question, Joy, and I think it's an important one. But I think to try to sum it up is that CANDOR's success really ultimately relies upon robust event reporting. You know, people have to feel free and comfortable to report safety events, you know, quickly and often in order for those things to get escalated. And then for the CANDOR program to effectively be implemented and launched, and for all of those pieces to start to come together.

Beth Miller

So really, our organizational culture plays a big part in the ability to achieve any of this. You know, we have to know about events in order to then act. And, CommonSpirit has invested heavily in establishing psychological safety in order to make it easier and then safer for teams to speak up and report. And I feel like this is where CANDOR really impacts equity internally within our organization, is that psychological safety really seeks to ensure that everyone feels safe and comfortable speaking up, regardless of their role, regardless of their department and where they sit and within the organization.

Beth Miller

And so we feel like it's been an important aspect of equity internally as we work with our teams to try to help improve internal communication. But then obviously it also does affect our patients as well.

Joy Lewis

Right. But you've done a really good job it sounds like of having your workforce, each member of your workforce, regardless of where they sit inside the organization, to see themselves as a health equity influencer, if you will. We always talk about how culture eats strategy all day, right? All the time. So you've also invested in creating that culture of safety where people feel comfortable speaking up.

Joy Lewis

I imagine you're tracking and leveraging data and analytics to really inform and drive your actions in this space. What tools -dashboards, scorecards? What are your mechanisms for tracking progress and outcomes?

Beth Miller

Great question. And again I would say we're using all of those things. We're using various reports, dashboards, we've customized and again invested heavily in all of our different analytic tools to make sure that we're using what we have available to us. But then layering on that CANDOR lens to see how the things that we're currently measuring, we can then also include specific elements of CANDOR in those measurement principles.

Beth Miller

And so we do - we use a ton of various scorecards, dashboards that we develop internally in connection with our event reporting system, so that that way we can make sure that data is shared appropriately with various stakeholders at different levels in the organization. You know, with an organization as large as ours, data sharing amongst the different layers, you know, can be quite a challenge.

Beth Miller

But we've spent a lot of time with our teams developing those specific things so that it can be shared effectively, but also in a more simple fashion, so it's a little easier to understand. Data is a powerful tool, but it's only as effective as someone can understand it. And so we spent a lot of time making sure that it's displayed and presented in a way that's easy to digest.

Beth Miller

So then people know how to act upon it.

Joy Lewis

Can you share a little bit more about the different audiences that you're reporting out to it? Does it go all the way up to the board? Are you sharing this information with community leaders, community stakeholders, internally, who are your target audience?

Beth Miller

Honestly, it's a bit difficult to answer because we try to customize various reports and information based on that particular audience. So the information, you know, shared with a patient safety quality leader is really going to focus on how they impact the work, versus information shared with, you know, an executive leader is then going to focus, maybe in a slightly different area with relation to how they impact the work.

Beth Miller

So the data does, you know, look a little different depending upon what your role is in the organization. But it all comes from the same place. So it's the same information just presented in a slightly different way depending upon the role.

Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo the AHA’s chief physician executive and a champion of AHA Patient Safety Initiative. AHA’s Patient Safety Initiative is a collaborative data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

Chris DeRienzo, M.D.

We strive to catalyze and connect health care professionals like you across America in your efforts to innovate and improve, and to bolster public trust in hospitals and health systems by helping you share your successes. For more information and to join the 1,500 other hospitals already involved, visit aha.org/patient safety or click on the link in the podcast description. Stay tuned to hear more about the incredible work of members of the HHS Patient Safety Initiative.

Chris DeRienzo, M.D.

Remember, together we can make health care safer for everyone.

Joy Lewis

Once you have those data, the goal of course, is to make the data actionable, right? So can you talk a little bit more about how implementing this CANDOR training program has actually yielded a positive outcome on your patient safety incidences. How are the trend lines shaping up for you? Austin, what do you think about that?

Austin Peterson

So I will say that safety is a moving target.

Austin Peterson

You know, initially we started with the IOM and the 44,098 deaths per year. And then we get better ways of looking at what is a safety event is and we see that the numbers jumped up to 220 to 440,000, which is the third leading cause of death in the United States. You know, so we put in checklists, we put in standardization.

Austin Peterson

We're able to reduce CAUTI, CLABSI, BTEs. That's great but that's only one part of patient care. What else is out there that we can continue to move? So I'm going to say that is a constant moving target as we learn more as we go there.

Austin Peterson

That's a really good point. We never say, you've achieved health equity because there is no endpoint, right?

Joy Lewis

There's this constant journey that you're on, to refine, to iterate, to do better. And so I would imagine when we look at the triad of quality patient safety and health equity, it's kind of that same mantra. You're always working at it. You're always looking to improve and do better. Now that you've really, you know, gotten folks on board, how do you plan to sustain your current efforts and maybe even build on those efforts?

Joy Lewis

So you've got some wins. How are you going to sustain those wins and bring others along?

Beth Miller

I love that question. I think sustainability really of any program is always, always a challenge. Lots of competing priorities. You know, it's obviously a heavy lift to get things going, but it's almost even more difficult to keep it going. But I think that there's some really exciting developments in the health care landscape, you know, especially recently in the last year that will help CANDOR to sustain and then even maybe even be more in the focus in the future.

Beth Miller

You know, one of the things that is top of mind is the patient safety structural measures recently passed by CMS. It directly addresses CANDOR, specifically in domain number four. And so we're excited about that. You know, focus that's being put into play. Because I think it's going to help allow our sites who have had that long standing history of CANDOR to be recognized in a different way for their efforts.

Beth Miller

But it also helps as an organization to help really look at those additional feedback loops that maybe we need to strengthen, which then will help with sustainability. And I also wanted to mention, you know, the AHA's focus on health equity, I also think is a great contributor to helping with sustainability of the program, because the AHA is demonstrating, you know, that this focus and our work and our mission as an organization is relevant, and there's still a lot of work needed in the industry.

Beth Miller

So I think both of those things will really help with sustainability.

Joy Lewis

Yeah, I think you're spot on. They complement each other well. And I do want to recognize CommonSpirit Health for the great deal of work that you've engaged with us around our health equity roadmap, and congratulate you for having all 142 of your eligible hospitals participate with our HETA, or Health Equity Transformation Assessment and continuing to do the great work of doing equity, as I like to say.

Joy Lewis

So I thank you both for joining us today and for sharing your expertise and your on the ground experience in implementing a CANDOR strategy to address patient safety outcomes. Keep up the good work. Thank you for being so dedicated and innovative in your approaches.

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.