Acknowledgments

The Communication and Optimal Resolution (CANDOR) process was funded by AHRQ and is based on input from experts, key stakeholders, and lessons learned from the agency's $25 million Patient Safety and Medical Liability (PSML) Grant Initiative launched in 2009, the largest Federal investment in research to test promising model programs to improve patient safety and reduce medical liability claims. AHRQ commissioned the Health Research & Educational Trust, in partnership with the American Hospital Association, to develop a customizable toolkit for national distribution to guide hospitals in implementing a communication and resolution process in their institutions. These services were provided under contract #HHSA290201000025I.

This groundbreaking initiative was made possible by the many individuals and organizations that joined together to advance the implementation of a transparent and just response to those who have been injured due to an adverse event. This approach, known as the CANDOR process, represents a synthesis of best practices in the field, as informed by those most affected, including patients and families themselves.

Specifically, we thank:

The National Project Team, which consisted of many partners and subject matter experts who participated in designing, training, and implementing CANDOR:

• Health Research and Educational Trust
  • Barbara Edson, R.N., M.B.A., M.H.A.
  • Stephen Hines, Ph.D., Th.M., M.Div.
  • David G. Schulke
  • Marie Cleary-Fishman, B.S.N., M.S., M.B.A.
  • Shannon Woodford, M.P.H.
  • Dawn Herman, R.N., B.S.N, M.B.A.
  • Mary "Sue" Collier, M.S.N., R.N.
  • Anna Wojcik, M.P.H
     
• Expert Faculty led the design and teaching of the CANDOR curriculum, guided the synthesis of draft tools, and/or provided ongoing strategic counsel on the CANDOR Process:
  • Sarah Armstrong, J.D., M.S.N., Affiliate Assistant Professor, University of Washington School of Nursing
  • Sigall K. Bell, M.D., Director of Patient Safety and Quality Initiatives, Institute of Professionalism and Ethical Practice, Beth Israel Deaconess Medical Center, Harvard Medical School
  • Richard C. Boothman, J.D., Executive Director, Clinical Safety and Chief Risk Officer, University of Michigan Health System
  • Nikki M. Centomani, R.N., B.S.N., ARM, formerly with the University of Illinois-Chicago and now Director, Office of Patient Safety and Risk Management, Loyola University Medical Center
  • Rollin J. "Terry" Fairbanks, M.D., Director of the National Center for Human Factors in Healthcare and director of the Simulation Training & Education Laboratory at MedStar Health
  • Heather L. Farley, M.D., Emergency Department Physician, Christiana Care
  • Thomas H. Gallagher, M.D., Professor in the Department of Medicine and the Department of Bioethics and Humanities at the University of Washington
  • Seth A. Krevat, M.D., Assistant Vice President for Safety, MedStar Health
  • Bruce L. Lambert, Ph.D., formerly with the University of Illinois-Chicago and now Professor in School of Communication and Medical Social Sciences, Northwestern University
  • Timothy B. McDonald, M.D., J.D., formerly with University of Illinois Chicago and now Director, Center for Open and Honest Communication, MedStar Institute for Quality and Safety
  • Susan D. Scott, Ph.D., R.N., Manager of Patient Safety and Risk Management, University of Missouri
  • Kelly M. Smith, Ph.D., Scientific Director, Quality & Safety Research, MedStar Health Research Institute
  • Andrew A. White, M.D., Associate Professor, Department of Medicine and Interim Director, Hospital Medicine Service, University of Washington Medical Center
     
• Contributors of tools from successful programs and AHRQ's PSML demonstration grantees, which were synthesized, tested, and adapted to align with the overarching CANDOR toolkit. Sources include:
  • George Mason University
  • Harvard School of Public Health
  • Medically Induced Trauma Support Services (MITSS)
  • MedStar Health
  • Project Patient Care
  • University of Illinois at Chicago
  • University of Michigan
  • University of Missouri
  • University of Washington
     
• The Evaluation Team guided the evaluation of the pilot project and development of measures for ongoing hospital monitoring and improvement of their CANDOR process implementation:
  • Michelle M. Mello, J.D., Ph.D., formerly with Harvard University and now Professor of Law, Stanford Law School and Professor of Health Research and Policy, Stanford University School of Medicine
  • Lorens A. Helmchen, Ph.D., formerly with George Mason University and now Associate Professor of Health Policy and Management in the Milken Institute of Public Health at George Washington University
     
• Patient advocates provided patient and family member perspectives while advising the national project team at every phase of CANDOR development, including during tool synthesis, training, and stakeholder events:
  • Rosemary Gibson
  • Helen Haskell
  • Carole Hemmelgarn
  • Sherri Loeb

Key stakeholders were engaged to develop the CANDOR model, its implementation structure, and toolkit design:

• Pilot Hospital and Health Systems:
  • Christiana Care, Newark, Delaware (Stephan Pearlman, M.D.; Kathleen McNicholas, M.D.; Brenda Pierce, J.D.; Michele Campbell, R.N.; and Susan Perna, R.N.)
  • Dignity Health, Sacramento, California (Linda Ubaldi, R.N. and John Morelli, M.D.)
  • Medstar Health (Washington, D.C., and Maryland) (Kelly Smith, Ph.D.)
     
• Patients and Family Members:
  • Martin J. Hatlie, J.D., President & CEO, Project Patient Care
     
• Medical Professional Liability Association:
  • Brian K. Atchison, President & CEO, PIAA
     
• Technical Expert Panel:
  • Richard C. Boothman, J.D., Executive Director, Clinical Safety and Chief Risk Officer, University of Michigan Health System
  • Jeffrey N. Catalano, J.D., Partner, Todd & Weld LLP
  • Robin Diamond, J.D., M.S.N., Chief Patient Safety Officer, The Doctors Company
  • Jeffrey F. Driver, J.D., M.B.A., CEO of The Risk Authority Stanford and Chief Risk Officer of Stanford Health Care and Stanford Children’s Health
  • Gerald B. Hickson, M.D., Senior Vice President for Quality, Safety and Risk Prevention, Assistant Vice Chancellor for Health Affairs, and Joseph C. Ross Chair in Medical Education and Administration, Vanderbilt University
  • Alan Lembitz, M.D., Chief Medical Officer, COPIC
  • David E. Longnecker, M.D., Director, Association of American Medical Colleges (AAMC), and the Robert D. Dripps Professor Emeritus of Anesthesiology and Critical Care at the University of Pennsylvania
  • Robert and Barbara Malizzo, Patient Advocates
  • Shawna J. Perry, M.D., Director for Patient Safety Systems Engineering, Virginia Commonwealth University Health Systems, and Associate Professor and Associate Chair for the Department of Emergency Medicine
  • Andrea R. Price, M.H.A., formerly President & CEO, Mercy—Northern Region
  • Gordon D. Schiff, M.D., Associate Director of Brigham and Women’s Center for Patient Safety Research and Practice, and Associate Professor of Medicine, Harvard Medical School
  • Pat Schou, Executive Director, Illinois Critical Access Hospital Network (ICAHN)
  • Susan D. Scott, Ph.D., Manager of Patient Safety and Risk Management, University of Missouri

Video production was provided by:

• Contrast Creative (Cary, North Carolina)
• Pacific Standard Television (Portland, Oregon)

Primary AHRQ Staff: Richard Kronick (former director), Sharon Arnold, James Battles (retired and former Project Officer), Kathryn  Reback, Irim Azam, Karen Migdail, and Karen Carp.

Additional AHRQ Contributors:Jeff Brady, Erin  Grace, Farah Englert, Corey Mackison, Chris Heidenrich, Phil Dunn, Nathan Stone, and Phil Kreutzer.