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Communication and Optimal Resolution (CANDOR): What It Is and How You Can Participate


I've written about the Communication and Optimal Resolution (CANDOR) process many times since I started this blog in January. The Patient Safety Authority (PSA) chose CANDOR as one of its strategic initiatives because its multifaceted approach has made a positive impact on patients, clinicians, and healthcare organizations; yet, it has not been implemented consistently across the Commonwealth. 

Communication and Optimal Resolution (CANDOR) is a process that health care institutions and practitioners can use to respond in a timely, thorough, and just way when unexpected events cause patient harm. …

A traditional approach when unexpected harm occurs often follows a “deny-and-defend” strategy, providing limited information to patients and families, and avoiding admission of fault. In short, the CANDOR process is a more patient-centered approach that emphasizes early disclosure of adverse events and a more proactive method to achieving an amicable and fair resolution for the patient/family and involved health care providers.1

To encourage open dialogue and disclosure, caregivers are supported since many are emotionally overwhelmed by their part in patient injuries, whether they are preventable (errors) or not.

PSA believes that facilities who embrace this approach will also have a higher likelihood of meeting state-mandated patient safety reporting and disclosure requirements. Pennsylvania is unique in that healthcare facilities are mandated to report all events of unanticipated patient injuries requiring additional healthcare services and near misses to the PSA. Unanticipated injuries requiring additional healthcare services are also reported to the Pennsylvania Department of Health and require written notification to patients and their families.

PSA’s mandate under the Medical Care Availability and Reduction of Error (MCARE) Act is to collect those reports, analyze them, advise healthcare facilities, and issue recommendations for improvement. It also provides ongoing training and guidance to facilities to help them improve event reporting.

MCARE clearly defined PSA’s role as a consultative partner for Pennsylvania healthcare facilities, while enforcement and oversight of the Act’s provisions fall to the Department of Health.

This spring, PSA will begin helping Pennsylvania healthcare facilities implement the CANDOR program to improve patient safety throughout the Commonwealth. Some key steps in the CANDOR process include:

  1. Identification of patient safety events that require a response. I was fortunate when I worked as a patient safety officer (PSO), as it was in a smaller organization that had a great communication network. I knew almost everything that happened in that organization from having close professional relationships with middle management and sitting on every quality and review committee in the hospital. This is not the case in many organizations, especially larger ones.
  2. We’ve discovered that when an event isn’t reported into our system, it is often because the PSO wasn’t aware it occurred. Implementation of a standardized process to identify patient safety events helps to ensure that those events get reported and that the response system is activated.

  3. Response System Activation triggers two steps: Response and Disclosure and Event Investigation and Analysis. Response and Disclosure is multifaceted, and the organization’s culture plays a critical part in how successful this process will be. It includes meeting with the patient and/or family as soon as possible after the event occurred.
  4. Engaging with the patient and/or family provides an opportunity to capture their unique perspective. It also is an opportunity to provide them initial information about what happened, what outcomes might be expected (if known), and how the organization will support them.

    Disclosure is a process, not a one-time event.

    Providing disclosure is not only the right thing to do, but also an MCARE requirement in Pennsylvania—and should be done well. Effective disclosure is a learned process, and PSA will work with facilities to provide this level of training.

    Response is also timely engagement with the caregivers involved in the event. This not only allows the team to provide critical information about what transpired, but also opens a mechanism of support for those caregivers. In my blog last week, I discussed caring for our caregivers. I wrote about it because our first concern after a traumatic event is the patient—as it should be. But we also have an obligation to our caregivers.

    Supporting our caregivers is important for two reasons. First, it is the right thing to do. Attending to the mental health of our colleagues when they have been involved in an error is an ethical obligation an organization has to its staff. An error that reaches a patient is often (not always) the end result of a multisystem failure. Second, by failing to engage with and support our staff, we may never uncover the underlying causes of the event.

    I remember a conversation I had once about laboratory labeling errors. I was relatively new to the facility and trying to understand some events from the previous month. The unit manager told me that, yes, she was aware that they were having a problem and that they fired two individuals because of these errors. I then asked her if they had experienced any of these errors since they terminated the two employees. Her answer was, “Yes.” Discharging those individuals did nothing to understand the underlying issues causing the errors and continued to put patients at risk.

    If we do not encourage open and transparent conversations with caregivers and offer them support, this could also create a subconscious disincentive to report events. See number 1.

    Engaging early on with patients and staff is also paramount to thorough Event Investigation and Analysis. The investigation of the event needs to be timely, comprehensive, and credible, and it needs to identify actions that can be implemented to prevent recurrence.

  5. Resolution is the last step in CANDOR. The first part of this is meeting the ongoing expectations of the patient and family affected by medical errors. This may include medical care, emotional support, and financial compensation.
  6. The second part, and maybe the most important piece of the entire process, is implementing those action items to prevent recurrence.

    If we don’t prevent future errors, then we fail.

    When I experienced a medical error in my family—a delayed cancer diagnosis—and our loved one died, what mattered most to me is how we prevent this from happening to others. It’s one of the reasons the PSA’s work in diagnostic error is so important (and personal) to me, but that is a blog post for another day.

Improving practice so we don’t need to have these conversations with another patient or family is what the art and science of patient safety are all about. It’s why we do what we do. I believe that CANDOR helps on this journey, and I encourage you to join your colleagues in this work.


About this blog

Regina Hoffman serves as the  executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, its award-winning journal.  Ms. Hoffman was recognized by Becker’s Hospital Review as one of the top 50 experts leading patient safety in both 2018 and 2020. This blog serves as a source for her to share her insights in patient safety and leadership with Pennsylvania’s healthcare leaders.



1. https://www.ahrq.gov/patient-safety/capacity/candor/index.html

***​ The views and opinions expressed at or through this blog are the opinions of the author alone and may not reflect the opinions or positions of the Patient Safety Authority or the Commonwealth of Pennsylvania, nor do these views represent in any way medical or legal advice. ​ 

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