Target Audience

CMOs, CNOs, key people involved in root cause analysis (RCAs) or event reviews.

Series OVERVIEW

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.

Workshop Description

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.

Learning Objectives

• 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.

Agenda

PROGRAM NOTES

Dress for the conference is business casual. Layered clothing is recommended for your comfort.

HANDOUT INFORMATION

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.

Resources

• 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

Speakers

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.

Disclosures

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