Relevant Literature
Our CANDOR Coalition is equipped with the latest information related to collaborative resolution. Please refer to these resources to stay abreast of our journey to improve patient outcomes.
Localio A, Lawthers A, Brennan T, et al. Relation between Malpractice Claims and Adverse Events Due to Negligence-Results of the Harvard Medical Practice Study III. New England Journal of Medicine. 1991; 325:245-251
DOI: 10.1056/NEJM199107253250405
“Medical-malpractice litigation infrequently compensates patients injured by medical negligence and rarely identifies, and holds providers accountable for, substandard care.”
“The chance that an injury caused by medical negligence would result in litigation was 1.53 percent.”
“Ninety-eight percent (weighted rate) of all adverse events due to negligence in our study did not result in malpractice claims.”
Gallegos, Alicia. Frivolous Lawsuits: Still a Big Threat to Doctors? Medscape Medical News October 28, 2020.
"Nonmeritorious claims still occur relatively frequently today, according to data from the Medical Professional Liability Association's Data Sharing Project. Of about 18,000 liability claims reported from 2016 to 2018, 65% were dropped, withdrawn, or dismissed [without payment]. Of the 6% of claims that went before a jury, more than 85% resulted in a verdict for the defendant, the researchers found.”
Studdert D, Mello M, Gawande A, et al. Claims, Errors, and Compensation Payments in Medical Malpractice Litigation. New England Journal of Medicine. 2006; 354:2024-2033 DOI: 10.1056/NEJMsa054479
“The average time between injury and resolution was five years, and one in three claims took six years or more to resolve.”
It was difficult for patients and their attorneys to learn of events before the initiation of a lawsuit. Much could only be learned during the litigation discovery process.
“Although the number of claims without merit that resulted in compensation was fairly small, the converse form of inaccuracy—claims associated with error and injury that did not result in compensation —was substantially more common.”
In cases that went to trial, the patient/plaintiff won only 21 percent of the time.
“For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts).” Thus, the patient got less than one-half of the funds committed to the claim.”
“A higher-value target for reform than discouraging claims that do not belong in the system would be streamlining the processing of claims that do belong.”
Seabury S, Chandra A, Lakdawalla D & Jena A. On Average, Physicians Spend Nearly 11 Percent of Their 40-Year Careers With An Open, Unresolved Claim. HEALTH AFFAIRS 32, NO. 1 (2013): 111–119
“The average claim was not resolved until 43 months after the incident.”
The average physician practicing for 40 years is estimated to spend 50.7 months with an open claim.
Han S, Shanafelt TD, Sinsky CA, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Ann Intern Med. 2019;170:784–790. [Epub ahead of print 28 May 2019]. doi: https://doi.org/10.7326/M18-1422
“Approximately $4.6 billion a year related to physician turnover and reduced productivity is attributable to physician burnout in the United States.”
“At an organizational level, the annual cost attributable to burnout in the base-case model was estimated at $7600 per physician.”
Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open. 2015.; 5:e006687. doi: 10.1136/bmjopen-2014-006687
Physicians who had “recently received a [patient, hospital, or Medical Board] complaint were 77% more likely to suffer from moderate to severe depression than those who have never had a complaint.”
“Doctors were 3.78 times more likely to report the presence of suicidal thoughts while going through a current or recent complaint compared to doctors who had no complaints.”
Physicians having been through the complaint process were more likely to practice defensive medicine (i.e. ordering unnecessary tests, avoiding riskier procedures or declining to accept high-risk patients).
Twenty percent of the physicians surveyed believed that their particular hospital-initiated complaint actions were the result of a “dysfunctional culture” with the action having been in retaliation for their having “raised clinical or managerial concerns.”
When asked how to improve the process, the physicians surveyed indicated that the process should be “transparent.”
Anderson P. Physicians Experience Highest Suicide Rate of Any Profession. Medscape May 7, 2018.
It is estimated that every day in the United States a physician dies by suicide.
The rate of physician suicide is more than twice that of the general population.
Charles SC. Coping with a medical malpractice suit. West J Med 2001; 174: 55–58. (Updated article).
Charles SC, Psykoty CE, Nelson A. Physicians on trial: self-reported reactions to malpractice trials. West J Med 1988;148:358-360. (Older article).
"More than 95% of physicians react to being sued by experiencing periods of emotional distress during all or portions of the lengthy process of litigation."
“[T]his study showed no significant differences in symptoms between physicians who won and those who lost their trials…."
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West CP, Dyrbye LN, Sinsky C, et al. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open. 2020;3(7):e209385. doi:10.1001/jamanetworkopen.2020.9385
“Although maintaining and strengthening resilience is important, physicians are not generally resilience-deficient and burnout rates are substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.”
Boothman R. CANDOR: The Antidote to Deny and Defend? Health Serv Res. 2016 Dec; 51(Suppl 3): 2487–2490. Published online 2016 Nov 28. doi: 10.1111/1475-6773.12626
“Elementally, CANDOR is a deliberate strategy intent on normalizing honesty, transparency, and accountability.”
“As such, health care leaders must see their organization’s response to injured patients, not as an exclusive province of lawyers and risk managers, but first and foremost as integral to their clinical responsibility. They must insist on an honest and transparent response to patients harmed in their organization, not just because it is a moral and ethical imperative, but because honesty serves a true culture of safety that is indispensable to their organization’s core mission.”
Gallagher T, Mello M, Sage W et al. Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions. Health Affairs, 2018. Nov; 37: 11 1845-1852.
“Over time, the CRP [communication-and-resolution program] field converged around a single set of practices: transparency (early reporting of adverse events and open communication with patients and families); quality improvement; emotional support for patients, families, and clinicians; and proactive offers of financial compensation when the harm was caused by unreasonable care.”
“Going forward, there are strong arguments for viewing CRPs as essential components of high-quality, ethical medical care rather than as alternative dispute resolution processes that compete with civil litigation.”
Institute of Medicine, 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.
“Health care services is a complex and technological industry prone to accidents…. When large systems fail, it is due to multiple faults that occur together. One of the greatest contributors to accidents in any industry, including health care, is human error. However, saying that an accident is due to human error is not the same as assigning blame because most human errors are induced by system failures.” (pg. 65).
“Errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur. Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer.” (pg. 49).
“Improving patient safety requires fixing the system, not fixing the blame.” (pg. 179).
“The primary objective of systems design ought to be to make it difficult for accidents and errors to occur and to minimize damage if they do occur.” (pg. 58).
“There is a need to enhance knowledge and tools to improve safety and break down legal and cultural barriers that impede safety improvement.” (pg. 4).
McMichael B, Van Horn RL, & Viscusi WK. “Sorry” Is Never Enough; How State Apology Laws Fail to Reduce Medical Malpractice Liability Risk. Stanford Law Review. Feb 2019 Vol 71 Issue 2 pp 341-409.
“Overall, our findings indicate that on balance, apology laws increase rather than limit medical malpractice liability risk. **** For physicians who are not surgeons, the net effect of apology laws is to increase, rather than decrease the likelihood of a claim that results in litigation, the amount of damages associated with the claim, and the cost to the insurer of defending the claim.”
“Given the failure of apology laws to achieve their intended effects on malpractice litigation, states may be well-advised to take one of two paths with respect to apology laws in the future: (1) repeal these laws or (2) rehabilitate them.”
“If state lawmakers remain committed to the goals of apology laws but want a more effective means of accomplishing them, they may turn to hospital-specific apology programs [such as CANDOR] that provide physicians with training on the effective utilization of apologies…. Multiple studies have confirmed that these programs can effectively reduce both the incidence and severity of malpractice claims.”
Kachalia A. Improving Patient Safety through Transparency. New England Journal of Medicine, 2013; 369:1677-1679 DOI: 10.1056/NEJMp1303960
“Transparency - especially when things go wrong - is increasingly considered necessary to improving the quality of health care. By being candid with both patients and clinicians, health care organizations can promote their leaders’ accountability for safer systems, better engage clinicians in improvement efforts and engender greater patient trust.”
Sage W, Gallagher T, Armstrong S, Cohn J, McDonald T, Gale J, Woodward A, Mello M.. How Policy Makers Can Smooth the Way for Communication-And-Resolution Programs. Health Aff (Millwood). 2014 Jan;33(1):11-9. doi: 10.1377/hlthaff.2013.0930.
“Communication-and-resolution programs [CRPs] follow a simple plan: Tell patients and their families what happened, try to put things right, and improve safety for the future.”
“CRPs timely, proactive approach is very different from the ‘deny and defend’ mentality that is common among hospitals facing malpractice claims.”
“Published data suggest that such practices lowered the number of malpractice claims, accelerated settlements, reduced legal expenses, and allowed hospitals to redirect resources toward safety improvement.”
“Policy makers can help this promising approach succeed by creating a maximally supportive legal and regulatory environment.”
LeCraw, F. et al. Changes in liability claims, costs, and resolution times following the introduction of a
communication-and-resolution program in Tennessee, Journal Patient Safety and Risk Management 2018 Vol 23(1) 13-18.
“Collaborative communication resolution program [CRP] implemented at Erlanger had a reduced time interval to resolve events and lower defense and total liability costs.”
“The improved liability outcomes and the total of 43% of events with medical error resolved by apology alone, even though 60% of these patients had legal representation, may encourage physicians to support CRP.”
“[M]any patients only want an apology, explanation of reason for the adverse outcome, and change in the hospital system to prevent the error from occurring to others. These results support survey findings by Hiskson et al that showed the desire for financial compensation accounted for only 25% of cases that were litigated.”
Kachalia, A. et al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program, Annals of Internal Medicine 2010 Vol 153 No 4 213-221.
“In this analysis of changes in liability claims and costs with the introduction of comprehensive disclosure-with-offer program at the UMHS (University of Michigan Health System), we detected a reduced rate of claims, primarily driven by a decrease in the number of lawsuits; lower liability costs; and shorter time to resolution after the program was started.“
“After implementation, mean legal expenses for UMHS decreased by about 61%.”
“Not only can the shorter time to resolution translate to lower legal expenses for patients, many plaintiff attorneys now take cases on an hourly basis (as opposed to the more expensive contingency basis) in claims in which the UHMS has admitted error.”
Lambert, B. et al. The “Seven Pillars” Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes, Health Services Research 51: 6, Part II (December 2016)
“A communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting clinically and financially significant changes in a large set of core medical liability process and outcome measures.”
“Claims were less common, settlement costs and legal fees and expenses went down, both overall and on a per claims basis.”
“Annual contributions to the self-insurance fund declined dramatically, and the self-insurance fund moved from a $30 million deficit to a $40 million surplus.”