Medical Error & Patient Advocacy – How Can We Have More Candor?

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1st Talk Compliance features guest Kathleen W. McNicholas, MD, JD, CHC, CCEP, Consultant and Patient Advocate with Medical Legal Patient Advocacy Inc., on the topic of “Medical Error & Patient Advocacy – How Can We Have More Candor?” Kathleen joins our host, Catherine Short to review medical error and provide an approach to harmed patients. The CANDOR program of Communication and Optimal Resolution will be explained. CANDOR is well established and has been successfully adopted by many medical centers.

Catherine Short:  0:04

Welcome, and let’s 1st Talk Compliance. I’m Catherine Short, Manager of Virtual Education at First Healthcare Compliance. Thanks for tuning in. This show is brought to you by First Healthcare Compliance as part of our commitment to provide high quality, complimentary educational resources. We help create confidence among compliance professionals throughout the United States. Please show your support by taking a moment to provide a review on Google, Facebook, or iTunes. You can also follow us on Instagram, Twitter, and subscribe to our YouTube channel.


On today’s episode, we are speaking with Kathleen W McNicholas, MD, JD, CHC, CCEP. Consultant and Patient Advocate with Medical Legal Patient Advocacy Inc, on the topic of medical error, CANDOR, and patient advocacy. We will review medical error and provide an approach to harmed patient. The CANDOR program of communication and optimal resolution will be explained. CANDOR is a well-established program and has been successfully adopted by many medical centers. With CANDOR in place, patients may benefit from the use of the principles and the help of a Board-certified Patient Advocate.


Before we begin, I would like to mention at First Healthcare Compliance, we strive to serve as a trusted resource for compliance professionals and every month we celebrate their hard work and dedication with our Compliance Super Ninja recognition. For this episode, we’re spotlighting Super Ninja Julie Garcia, Business Office Manager at Coastal Vascular Center. Julie says “Coastal Vascular Center has three office locations and yet the whole group works as a team. They all respond well to the compliance updates and changes. I’m fortunate to have such a close-knit caring group of professionals to work with every day”. Congratulations, Julie, our team is honored to have the privilege of working with you.


So hello, Kathleen, thank you so much for joining me today on first talk compliance.


Kathleen W McNicholas:  2:22

Thank you, Catherine. It’s a great pleasure.


Catherine Short  2:25 

So what skill set is required to be a board-certified patient advocate?


Kathleen W McNicholas: 2:32

We have to have real competence, proven competence, in our field, in mine its surgery, relationships to get us credibility. It also is important to have humility. With my career and my background, I got a healthy dose of humility. I feel that I’m fairly competent to do that, but it’s an ethical relationship and it’s a pleasure for me to be able to extend my career and service.


Catherine Short:  3:02

What made you become a Board-certified Patient Advocate?


Kathleen W McNicholas:  3:06

That’s a very interesting background story. I had a very special friend, I was part of his family essentially, and he had a very bad outcome, due to a medical error. I was involved in that in the late 1990s and saw the anguish and the suffering that the family went through. And a little quote that I’ve used from René Leriche: “Every surgeon has a small cemetery, and they go there frequently to pray”. I think that really was the impetus in my case, to a lot of my changes in my career and transitions. When I saw that happen, I thought that there had to be a way, a better way. I’ve subsequently spent a lot of time in that cemetery thinking about what we could do differently, to make M’s death not in vain and to make it really a pivotal point in at least my career. It was happening at the same time that the medical errors, medical liability was becoming a big issue and I just kind of got caught, thankfully, in a great wave. When my career as a cardiac surgeon ended, I continued as a surgeon, but just didn’t operate, which is an unusual surgeon. I then was able to do patient safety and leadership and work in performance improvement at an excellent institution and learned a lot about patient safety risk management.


I had spent some time in my transition. I found that I was pretty boring, didn’t have a hobby, and thought I’d go to law school. A couple other things happened to me which I kind of put in the background, but law school was pretty eventful, and not because of my experience in law, but I had a myocardial infarction in 2002 followed by stents 2003 I had a coronary artery bypass grafting. I retired from cardiac surgery in 2008. This experience with my friend, son and my friend really prompted me to become more involved in patient safety. I’d also met Tim McDonald, who started the CANDOR program in the University of Illinois, and it all kind of just came together. When I saw something called board certification and patient advocacy, I thought that was perfect. I really enjoy patient work. I still enjoy patients.


Catherine Short:  5:34

This next question has to do with CANDOR, which is all capitalized. Could you explain to our listeners what the program of CANDOR is, and then what concept support CANDOR and healthcare and who has ownership with this.


Kathleen W McNicholas:  5:52

CANDOR is an acronym for Communication and Optimal Resolution. This is a process that was started in the early 2000s. It was led by Richard Boothman at the University of Michigan and Tim McDonald from University of Illinois, Chicago. AHRQ threw a big grant in their way to pilot this program, and to make a toolkit so we could share. The important thing in medicine is you don’t have to do everything yourself that other people can do some things and form a toolkit, and you do things uniformly. So CANDOR was instituted. CANDOR is an amazingly good process in a response to harm caused by medical error. So this has to be recognized, reported, and really intense review and then after a review, and a consensus decides that this is appropriate, there was harm caused by medical error, resolution comes about. Resolution can be monetary, it can be of course, waiving the fees because you don’t want to charge for useless service and certainly medical error will be considered useless service. You don’t want to go down that rabbit hole. So if you want to look at that in hold the bills, hold future bills. Then some families want to be part of the process in that at University of Illinois has been worked into it and they have a wonderful patient, advocacy group that goes with them. It is difficult, it’s a heavy lift. It’s a big process, it works well when it works well. What I have done is taken the large caps and made them small caps, just to get the usual word candor. The whole process is geared towards finding resolution for families and finding it in a timely fashion. You don’t want to go through a four-year legal process, which is the alternative. If you can’t accept and you don’t understand and you need to find information, you go to the next best source, which is the legal process, you get experts, then you have a battle of experts. Then if you get a settlement well, that’s pretty disappointing, too because that’s a shallow victory.


Catherine Short:  8:23

Okay, so how are ethics of medicine, patient safety and patient advocacy aligned?


Kathleen W McNicholas:  8:31

The ethics of medicine are the basic ethics do good, and that we learned in kindergarten before, do no evil, do no harm. Then justice, be fair. The other thing is autonomy: treat patients with respect, respect their decisions, respect their positions, respect where they are, their status. That’s pretty easy. Medical practice came along, and we kind of amplified them and changed them. Patient safety ethics are also very, very interesting and I think focus on something that I focused a lot on and was able to develop programs and work around things. It’s pretty intuitive, but it’s also pretty powerful. You have that vigilance. I had a brief career as a pilot.  I won’t say it was very successful. I didn’t crash but I came close and I did have a problem finding airports, but you have to be vigilant. You have to look out for what could happen. Mindfulness is something I wish I had a little more of, and we all have to kind of block out the other things and be mindful. Compliance, I mean, I thought we were compliant just because we were doing well and doing things the way we thought was correct and there was a whole body of information there, of law and compliance. Compliance is key to making the ship run and have a commonality. The biggest part really and the part that appeals to me is humility. Humility is really difficult. I should say resilience too but nobody did tack [INAUDIBLE] because we really do come and go with our patients. People asked me how I remember my patients and I asked them how you could forget them. The most important thing in CANDOR is communication and optimal resolution. Therefore, the acronym CANDOR.


Catherine Short: 10:26

Can you describe in four words, the basic skills required for patient advocacy?


Kathleen W McNicholas:  10:33

You have to have empathy of the patients and the patient’s families. I had my own little experience on the opposite side of the sternal retractor when I had my bypass surgery. That’s something that people have, some people have naturally, some people acquire, and some people have it amplified.


You have to have trust. If you can’t trust someone, you can’t work with them. I think trust is a very important thing to have, and to have the ability to develop and to nurture.


You have to have credibility. Got to have been there, you’ve got to have walked in the shoes. I tried to arm myself pretty well. I considered law a hobby but that was five years of intense study and as I told everybody that asked me what I did, I told them I was a technician. When they told me what hard days I had, I said, well, did anyone die? And they said, No, I said you had a good day.


And then humility. I’m not the most humble person in the world, though I certainly should be and I tried to be and it should come naturally, but I think that’s an important quality. I would say in short, it would be empathy, trust, credibility, and humility and integrity would go in there too. You have to be a solid person on solid ground.


Catherine Short:  11:53

Right. I agree. So you pursued a legal education. What impact did your career in medicine have on you pursuing a legal education?


Kathleen W McNicholas: 12:07

It was would be very difficult, I could imagine, if I lived long enough to practice medicine at the intensity that I did. So I was looking for a hobby. I went to law school thinking it would be a casual experience, it was anything but. I had to go to law school and actually finish it. I love the body of knowledge I got. I did not become a lawyer. I do not want to become a lawyer, I don’t want to practice law, but I love the theory and I love the way lawyers think.


Catherine Short:  12:36

Well, what impact did your experience with law have on your career then as a patient advocate?


Kathleen W McNicholas:  12:44

My experience of law was really an academic experience. It was important for me to be with people who were pursuing that line of work and to see how they think and to read the cases, to see how they were judged, to critique them, to apply my knowledge- there were a couple really pivotal cases, one I was involved with. It was not a malpractice, but it was a court judgment on a Christian Science child. It’s a life of service, I really want to be useful and I’m trying. My heart is to continue to appreciate the fact that my health had declined, and I have an excellent cardiologist that rescued me. So I’ve got a new lease on life that I’m trying to enjoy, that I am enjoying.


Catherine Short:  13:32

Wonderful! So if you’re just tuning in, you’re listening to 1st Talk Compliance brought to you by First Healthcare Compliance as part of our commitment to provide high quality complimentary educational resources, we help create confidence among compliance professionals throughout the United States. My guest today is Kathleen W, McNicholas MD, JD, CHC, CCEP, Consultant, and Patient Advocate with Medical Legal Patient Advocacy, Inc, on the topic of medical error, CANDOR, and patient advocacy.

Please show your support by taking a few minutes to provide a review of First Healthcare Compliance on Google or Facebook. You can also follow us on other social media.

So Kathleen, what was your contribution to patient safety?


Kathleen W McNicholas:  14:25

I co-lead the CANDOR program at a major local institution, which is an outstanding institution and I think that has to be the highlight. I also worked on Just Culture, which is a new way of approaching error in dealing with individuals and the choices they make. I had a lot of interest in working with people after events because I think that’s the hardest time for them and that’s the time when they really lose confidence in themselves and the suffering is unbearable. I set up a program of post event debriefs, which we held at variable times during the day, as soon as we could, after the event and with the support of absolutely tremendous Patient Safety Department. We could do this, we invite all people that were involved in the event that we knew of, and it was really a very diverse group of people and people would know that they alone were not responsible, which at the beginning, they all thought they were, and this was not punitive. In the old days, we had a very simple system, it was ABC assess, blame and crucify. This is the polar opposite of that, where you take the wisdom of the group, and you support them. The fact that they’re supportive makes them realize that they are really valued professionals, that they see a safety problem, they will be the ones to report it. The reporting system has outstanding, near misses, good catches, crash events, and try to learn from them. I really enjoy looking at problems and seeing how people fix it and getting other people’s perspectives. I hope that answered your question.


Catherine Short:  16:06

Yes. I have a question about something called Human Factors, capital H, capital F. So can you explain what that means? Human Factors? And then what has been the contribution of Human Factors to patient safety.


Kathleen W McNicholas:  16:23

I wouldn’t even begin to assess the contribution. It is huge. And when you’re blessed as the institution where I worked at, a value Institute, and they had a whole section of people who were experts in Human Factors, they would come and look at a problem to say, what made it so simple for that accident to happen? What made it so not avoidable that you fall into that trap? How can we improve this? How can we change it? Their minds, it was a psychology but it goes back to Deming in trying to figure out why bad things happen. When you get a group of people and somebody that’s a specialist in Human Factors, they can cut through what you are all looking at and show you what the defect was, or what the potential harm was, that was laying there behind the scenes that allowed this to happen. How the drain got stuffed up it wouldn’t work, how the door to the bathroom had a handle that if you pushed it, it would just release and you could have [INAUDIBLE]. We looked at [INAUDIBLE], we looked at all major events and we could see how these things happen. The labeling, the storage, the tall man letter labeling, there were so many fantastic things.


This group of people is sitting there trying to help us to make it harder to make an error, and easier to do that right. I think that is a talent and that’s a science that has incredible application and it’s one that you don’t think of normally. Here when I’d always insist that we’d get somebody from Human Factors, people would think that was a little silly and a little out of the field. Why could they help? But they could help because they could cut through, they have a different way of thinking and a different way of looking and it’s all of us how we look at the problem and how we come up with solutions or improvements.


Catherine Short:  18:22

So Human Factors is how humans are influencing errors. Something happened by accident and this seems to be happening over and over again because humans are doing the same thing over and over again. And how can we fix this, that kind of thing?


Kathleen W McNicholas:  18:38

It’s a latent defect that makes it easy to do it wrong. We want to put a layer of prevention. If somebody notices a small defect in what we’re doing, how we’re thinking, and it gets people in the operating room to announce their names to say who they are, they speak, you hear their voice. If something goes wrong, they could speak up and say, excuse me, I want to double check this, or I have a question. That’s listened to, and that comes from aviation, and the read backs, there’s so many things that Human Factors professionals can tell us, if you put this in your system, you will improve the performance. It’s small things but then you get to communicate it and you amplify, you magnify the value of patient safety experts. The meetings we have with the people who have really devoted a lot of their time and education to getting it right is just overwhelmingly beneficial. It’s great. I’m enthusiastic about it because it’s how we’re getting to the safety culture and it is a culture of safety. You have to understand that an error could be catastrophic. Therefore the vigilance, therefore the mindfulness, therefore the compliance, therefore be humble and admit to yourself ‘I can make an error’. If it’s going to happen one out of 1000 times, it’s going to happen to someone. Someone’s going to be that one out of 1000 and you want to prevent that.


Catherine Short:  20:10

Okay, so here is another difficult question, then what culture is the most important in healthcare?


Kathleen W McNicholas:  20:17

Well, it’s pretty easy. It’s a culture of safety, which is the umbrella culture. All the rest are molded in and become part of the fabric of the patient safety. If you look at it as big quilt, the just culture, the CANDOR program, the care for the caregiver program. If you find a need, you plug it up, and you plug it up safely and it’s under the rubric of the culture of safety. A hospital that has a great culture of safety is a great hospital. Patients are going to understand when you’re doing so much to do things so well.


Catherine Short:  20:51

Well, that leads into another question that I had. Is CANDOR adopted universally? And if it’s not, why is that?


Kathleen W McNicholas:  21:02

It can be because of the intensity. You really need a powerful culture of safety and you need a support group for that, and that’s a patient safety department or section or some group within the hospital. You have to have attorneys within the hospital and outside the hospital in the community, who will agree to this and who don’t just say it’s kerfuffle, which, you know, we had several other terms people throw around, but you have to get the buy in. The industry is important, but the people are more important.


Catherine Short:  21:40

Kathleen, what about care for the caregiver? Do you need a CANDOR program to provide care for caregiver? I know that there’s a lot of need for the caregiver as well.


Kathleen W McNicholas: 21:52

No, you do not. Silent victim is no longer the silent victim. I think hospitals and everyone recognized it. Even talking about my friend and when he had an echocardiogram when he had the EKG, everybody that touched him that knows the outcome is overwhelmed with grief. So I think that everybody’s out there and everybody’s seeking it or nobody goes and wants to admit that they’re weak, or they’re nonprofessional. Well, professionals are the ones that need care. And the professionals are the ones that are giving care. So AHRQ, the same same group that has CANDOR, and the care for the caregiver is another program with another toolkit, but it’s a part that is really beneficial to move in right away and talk with the group, find out who was affected, and open yourself up and have professional people, it appears their colleagues, that can go in find out how the person’s doing and provide more care, suggest or recommend more care if it’s necessary. That syndrome of burnout, you know, this is human being with little parts of their souls being removed, in effect, that you cannot shake it off, you do not take off your ID tag and become a different person when you go home. You carry it with you. Everybody has this little area of their soul and we have to make sure it’s nurtured, it’s healed and it just happened together. We have to look at it as far as the just culture goes, and assure them that we’re humans, things happen. We have to take care of them because they’re absolutely, totally valuable to the institution and their value has to be cared for. It has to be nurtured.


Catherine Short:  23:40

Well, Kathleen, I think we’re just about out of time but I wanted to ask you, do you have some other thoughts or things that you wanted to leave with us today?


Kathleen W McNicholas:  23:48

Oh, yes! We’re all evolving. I think I’ve evolved, and I think that we all have to be open and just look for opportunity, and look to be useful. For patients, there’s always somebody out there and when they’re searching, a patient advocate is a wonderful person to search for. I’ve been a patient advocate all my life and it’s kind of silly, now I have a nonprofit, because I really can’t see burdening people with anything more when they’re already so stressed. It’s really so difficult, but they need to speak and they need to speak with a person and they need to speak with their families and the communication thing is really the key. if he could if they could promote that and make family peace. I tell you that suffering I just can only imagine my friends went through with the loss of the beautiful, beautiful son, it’s overwhelming it really fills that cemetery and there are little plots around it where you see them all sitting in breathing in there, they’re still breathing to this day so you really want to find peace and resolution. That’s why I’ve kind of moved to in my life from the aggressive cardiac surgeon to the patient advocate in a different form just a surgeon who doesn’t operate anymore except in my dreams.


Catherine Short:  25:19

Absolutely. Well, thank you, Kathleen, thank you so much for coming on to 1st Talk Compliance today very, very much appreciate it.


Kathleen W McNicholas:  25:29

Thank you, Catherine. It really was a privilege in the display some of my passion towards this field. And again, I should thank my colleagues who worked very hard with me to make our institutions safer, and really make them places I have tremendous pride in and want to maintain that.


Catherine Short:  25:52

We’re grateful to you. Thank you so much, and thanks to our audience for tuning in to 1st Talk Compliance. You can learn more about our show on the program’s page on and to lend your voice to the conversation on Twitter @1sthcc or #1sttalkcompliance. You can also email me at I’m Catherine Short of First Healthcare Compliance. Remember, compliance is the key to achieving peace of mind!








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