Candor Training Series: Event Reporting and Review
Other Candor Workshops
CMOs, CNOs, key people involved in root cause analysis (RCAs) or event reviews.
The intent of the summer Candor training series is to familiarize network hospitals with the early disclosure process, Communication and Optimal Resolution (Candor). Candor is a powerful tool that works to maintain relationships with patients and families after an adverse event through immediate and frequent communication. It provides care for the caregiver and creates a culture of learning and process improvement throughout the facility.
Through this training series Iowa Healthcare Collaborative, Iowa Medical Society, Iowa Hospital Association and MedStar Institute for Quality and Safety will guide hospitals through the various elements of the Candor process and provide the tools needed for effective implementation at their facility.
During this interactive and experiential workshop attendees will use actual de-identified cases of medical harm to work through the processes of event reporting and event review in a way that is consistent with the principled, comprehensive and systematic approach to patient harm. This will include the application of human-factored engineering concepts and the process of cognitive interviewing. Finally, all of the information learned from the review will serve as the basis for the development of sustainable change and prevention of future harm.
- Describe the fair and accountable approach to the review of unexpected harm events in healthcare.
- Explain the need to apply human-factored engineering concepts to event review.
- Discuss ways to conduct basic cognitive interviews of staff involved in unexpected events.
- Identify sustainable process re-designs and improvements will a high likelihood of being effective and sustainable.
|8 am||Welcome, Introduction and Reflection|
|8:15 am||Background on Traditional Root Cause Analyses (RCA) and the Need to Improve|
|8:45 am||Introduction to RCA Squared Concepts, Including Cognitive Interviewing and Patient Involvement|
|9:30 am||Review of the MegaCase with Mock Medical Record|
|10:15 am||Cognitive Interview and Learning|
|12:30 pm||Putting Pieces of the Event Review Together|
|1 pm||Just Culture in the Context of Event Review|
|1:45 pm||The Solutions Meeting: Identifying Sustainable Changes and Plan for Patient and Family Discussion|
|3 pm||Operational Questions and Lessons Learned|
Dress for the conference is business casual. Layered clothing is recommended for your comfort.
These are paperless workshops. You will be notified via email when the handouts are available online, with a direct link to access the files. Paper copies of handouts will not be available onsite at the conference.
- AHRQ Building the Business Case for Candor Worksheet
- AHRQ Gap Analysis Process
- AHRQ Candor Event Checklist
- AHRQ System-Focused Event Investigation and Analysis Guide
- AHRQ Communication Assessment Guide
- AHRQ Disclosure Checklist
- AHRQ Care for the Caregiver Implementation Guide
Kelley M. Baker, MA, is program director for quality and safety research in the MedStar Institute for Quality & Safety. She is a human-factors engineer with significant experience leading human-factors reviews of serious safety events, hazards and near misses in MedStar Health’s ten hospitals and ambulatory care facilities. These reviews include observations and interviews to identify human-factors issues and develop actionable recommendations for effective, sustainable solutions to reduce medical error and improve patient safety. Her work focuses on patient safety, her experience includes patient safety and patient engagement research, as well as medical device usability evaluations. Baker is currently the program director for MedStar’s task order with the Agency for Healthcare Research and Quality to develop a Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families.
Lt Col Steven L. Coffee is joint manpower analyst, Directorate of Manpower and Personnel, Office of the Chairman Joint Chiefs of Staff in the United States Air Force. In this capacity, Colonel Coffee advises the Director, Manpower and Personnel Directorate on all joint manpower requirements determination matters supporting nine United Combatant Command Commanders and the Chairman of the Joint Chiefs of Staff. Colonel Coffee graduated from Morehouse College in Atlanta, GA and George Washington University in Washington, DC. He entered the Air Force in 2001 through the Tennessee State University Reserve Officer Training Corps. Colonel Coffee is a charter member and first community chair of the Medstar Georgetown Patient and Family Advisory Council for Quality and Safety and assists in patient advocacy for the Medstar Health System and the Partnership for Patients.
Timothy McDonald, MD, JD, is president for the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety and a professor of law at Loyola University – Chicago. Dr. McDonald is a physician-attorney whose research has focused on the principled approach to patient harm with an emphasis on reporting of patient safety events, the use of simulation and human-factors analysis and providing open and honest communication following harm events. His federally funded research has focused on these domains and their impact on improving the quality of care while mitigating medical liability and other legal-related issues.
Relevant to the content of this educational activity, the following individuals have no conflict of interests with commercial interest companies to disclose.
- Kelley M. Baker, MA, Speaker
- Jennifer Brockman, Planning Committee Member
- Kate Carpenter, Planning Committee Member
- Lt Col Steven L. Coffee, Speaker
- Martin Hatlie, Planning Committee Member
- Timothy McDonald, MD, JD, Speaker
- Dennis Tibben, Planning Committee Member
A parking ramp is located behind the IMS building with entrances on both East 6th Street and East Walnut. Please feel free to park in the ramp. When entering take a ticket, parking validation tickets will be available at the workshop to cover the cost of parking in the ramp.
A discounted rate is being offered at the following hotels to IHC event attendees on a “non-last room” availability, meaning that there are times when this rate will not be available to book due to high demand in the area so it is important to book early if you think you may need arrangements. When calling, please ask for the Iowa Hospital Association (IHA) rate and reference the corporate ID.
Staybridge Suites Des Moines Downtown
Corporate Rate: $129 per night + taxes
Corporate ID #: 786828419
Embassy Suites Des Moines Downtown
Corporate Rate: $139 per night + taxes
Corporate ID #: 560001333
Continuing Education Credit
- DO: Des Moines University (DMU) is accredited by the American Osteopathic Association (AOA) to provide osteopathic continuing medical education for physicians. DMU designates this program for a maximum of 6.75 AOA Category 2-A credits and will report CME and specialty credits commensurate with the extent of the physician’s participation in this activity.
- MD: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Iowa Medical Society (IMS) through the joint providership of Des Moines University (DMU) and the Iowa Healthcare Collaborative. DMU is accredited by IMS to provide continuing medical education for physicians. DMU designates this live activity for a maximum of 6.75 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- Other Health Professionals: This live activity is designated for 6.75 AMA PRA Category 1 Credit(s)TM.
No commercial interest company provided financial support for this continuing education activity.
Everyone in a position to control the content of this educational activity will disclose to the CME provider and to attendees all relevant financial relationships with any commercial interest. They will also disclose if any pharmaceuticals or medical procedures and devices discussed are investigational or unapproved for use by the U.S. Food and Drug Administration (FDA). Determination of educational content and the selection of speakers is the responsibility of the activity director. Firms providing financial support did not have input in these areas. The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. The content of each presentation does not necessarily reflect the views of Des Moines University.
- 6.75 AOA Category 2A
- 6.75 AMA PRA Category 1 Credits™
- 6.75 CE Contact Hours
IHC reserves the right to cancel the conference due to insufficient enrollment, in which case pre-registered participants will be notified and full refunds provided.
IHC does not discriminate in its educational programs on the basis of race, religion, color, sex or handicap. IHC wishes to ensure no individual with a disability is excluded, denied services or segregated or otherwise treated differently than other individuals because of the absence of auxiliary aids and services. If you need any of the auxiliary aids or services identified in the Americans with Disabilities Act in order to attend this conference, please call 515-283-9330 or write to the Department of Education at IHC.