 Good morning everybody and welcome to our October webinar. I can't believe it's already October. I am Donna Prosser. I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. Today we're talking about creating a person centered culture of safety and why it's so hard after all of these years of working on this. So today we have some broad objectives that we're going to be talking about. We're going to define the term of what is person centered culture of safety, talk about how that relates to high reliability, talk about what we've done over the last 25 years to improve that, and then talk about what's happening right now, especially with the impact that COVID has had. And then as always we are going to try to give you some best practice recommendations about how you can improve a patient centered culture of safety in your organization. So as always, we will be providing continuing education credit for nurses, pharmacists and physicians through MedStar Health. We will receive an email from MedStar if you have registered as a physician, a nurse or a pharmacist looking for that credit. If you are a respiratory therapist, check with your local organization, you'll be able to find out whether or not you can use this credit towards your requirements. So you'll receive an email from MedStar Health directing you how to obtain that CE credit. We also will provide CE credit for healthcare executives, certified professionals in patient safety, board certified patient advocates and certified professionals in healthcare quality. For ACHE, go ahead and log in that information into your own account. If you're looking for certificate from the Patient Safety Movement Foundation, if you're looking for CPPS or BCPA credit, and if you're looking for CPHQ credit, then we will send that information to NACU and they will document it for you. As you can see on this slide, none of our presenters today and nobody on our planning committee has any financial disclosures to report. And just like all of the other webinars that we do, please do ask questions. You can utilize the chat function if you'd like to make some comments or ask questions in the Q&A. We do have 15 minutes reserved at the end for questions, but we may answer them as we go depending on how the conversation is going. I would like to go ahead and introduce our esteemed panelists today. We're really excited to be joined by Anthony Staines. Anthony is the Patient Safety Program Director for a Regional Federation of Hospitals in Switzerland. We also have Abdelayla Alhousali. He is currently the CEO of Nordiacs Diagnostics and Discovery, but was also the former director general of the Saudi Patient Safety Center, which is a WHO collaborating center in Saudi Arabia. And then we have Joanne Shelby Klein. Joanne is a nurse, a director, a writer. She is also a patient advocate and currently is the Patient Clinical Site Liaison for link two trials in the United States. So I'd like for each of our panelists to just tell a little bit about yourselves. I'm going to stop sharing my screen so that everybody can see your faces. And so let's go ahead and start with Agelayla. Tell everybody a little bit about your background. Hi everyone, I think I should say good day because we have global audience. My name is Abdelayla Alhousali. I'm a transplant and hepatobiliary surgeon, both American and Canadian board certified. And as Donna mentioned, I was the founding director general of the Saudi Patient Safety Center, which is a WHO collaborating center in patient safety. Last year also during the G20 presidency, I helped introduce patient safety on the G20 agenda, which continues to be on the G20 agenda during the Italian presidency. So, you know, I continue to be very much passionate about patient safety and involved in different settings, both nationally and globally, and I'm very happy to be here. Well, welcome. We're so excited for you to join us today. Anthony, you want to tell us a little bit about your background. Thank you Donna. Well, I've been for 10 years a CEO of hospitals in Switzerland. And then I went back to studies and did the PhD with research on quality improvement programs in hospitals. And the first question was, do quality improvement programs in hospitals lead to improved outcomes for patients. And I fell in love with quality and safety for for healthcare, and I've stayed in that field for the last, the past 15 years now. Wonderful. Well, welcome and thank you for joining us as well. And Joanne, tell us a little bit about your background. Greetings, everyone. I am Joanne Shelby Klein. I'm from Pittsburgh, Pennsylvania. I have been a registered nurse for over 37 years. And I'm very passionate about patient safety. One of the lessons I learned in nursing school was safety first. And I've adopted that as a lifestyle as a nurse. It was a course of my career I've worked 21 years with renal patients. This is a hands on dialysis nurse and as an educator. I also worked with multiple sclerosis patients. I love doing nurse writing and developing patient education and staff education materials. I'm also a very passionate patient advocate, not only for my husband who has high functioning autism, but for many relatives and currently members of the St. Peter and St. Paul Ukrainian Orthodox church where I hope to start a faith community nurse program and focus on person centered safety. One of the things that I enjoy is doing quality assurance and CQI, just learning and growing as a nurse as a patient. I am a cancer survivor. And use that experience to look at things from the patient perspective, because I've learned things good and bad. And I hope that I can share those experiences not only today, also in the future, the patient safety movement foundation. So welcome, Joanne. Well, I'm going to start by asking all three of our panelists to, you know, briefly define for us. What do you think we mean when we say person centered culture of safety and how does such a culture drive reliability and healthcare I'll start with Adela. So let me start with that with a quote by Aristotle, you know, whenever I talk about patient safety, which is, he said, our problem is not that we aim too high and miss but our problem that we aim to law and head. So I think when it comes to patient safety. The goal should be zero harm. And, and if we if we're looking at the person centered culture of safety. And Donna mentioned the high reliability organizations and aviation is a good industry that everyone uses and it's probably the worst safest industry. In 2019, there were around 39 million flights throughout the globe. And even though many of us in healthcare take for granted that 10% of patients will be harm. The aviation industry has a different way of looking at things and in that year, if they only, you know, have taken not not 10% not 1% but 0.1% of harm that would have been acceptable to them we would have ended up with almost 40,000 airplane crashes. But you know, thankfully that never happened that it would never happen in the aviation industry just because you know the culture of safety in that industry is way up there, I think we're still here and the question is how can we move it up in that direction. So last year during the G20 presidency. I presented five main areas where I think are the kind of the causes for persistent implementation gaps so even though that we know what to do, which is kind of, we've done a very good job bridging the knowledge gap. In the last 20 years of the global patient safety movement, I believe there's still a lot of work to be done to bridge the implementation gap. So one was the culture of safety itself and it, you know, whenever you think of culture of safety think about the leadership within the healthcare facilities organizations at different levels of you know not just the C suite but also mid managers and and and even unit managers. Do they come to work every day thinking that the safety of patients the safety of the staff the safety of organization is the number one priority. I think that is a very important question. I think the view safety as religion, I think we're far away from that vision when it comes to healthcare. Another important part is advocacy. You know just compare the global climate change movement with the global patient safety movement and you'll you'll you'll get a sense of where things are just ask 10 persons of you know people around you. You heard of the global climate change. I've done that in my own family have asked my mother asked my, you know, siblings have asked my kids, three different generations. Every one of them heard about the global climate change do the same and ask him about the patient safety and then you will see that delta so I think there's a lot that we need to do and you know such webinars and the work patient safety days and others are actually good good platforms but I think we need to have talk about safety on on a on a daily basis on a regular basis. You know the third is the human factors engineering and ergonomics higher liability industries actually have integrated that into their day to day workings. You know there's lots to be done. The fourth one is the information asymmetry. So, the gap between the knowledge that we clinicians have and the patients and family is big I think, unless we work on bridging that gap, we're going to have a persistent safety challenges so I think empowering patients empowering families and empowering communities is a way to go. And finally, not having a common, you know, taxonomy and classification of harm. So for us to have platforms and shared learnings, we need to be using the same language we need to be calling an apple and apple and orange and orange and sometimes, even within the same hospital maybe within the same department. We have different ways of calling these harms and that would make it very difficult to actually share the learnings and make sure that we're proactive rather than being reactive so these were the five reasons that you know I presented last year that one in the G 20 I believe they continue to be the same. And we need to address every one of them if we really want to move towards, you know, zero harm. Thank you. That's great. That's great well absolutely we're going to have to summarize those five points for everybody and make sure that we have that available as a resource for after the on the notes on YouTube so thank you so much for that. Anthony, how about you, what do you think we mean by a person centered culture of safety and how does it drive reliability. Well, I think Abdullah has made a very good selection and it's difficult to add to things but I would say one thing that I would add is the awareness that we are in the high risk industry. I think that's something important and I don't see that awareness everywhere I should see it around me. So that's one thing. And also to the word culture that Abdullah used, I would perhaps add the, the keyword of a just culture by which I mean a blame free environment where there is transparency about errors about address events and where there is a focus on learning from these events rather than blaming people. I think that's something very important. Perhaps one keyword I could add also is teamwork. And I'm when I mean teamwork I mean teamwork across professions across disciplines across ranks in the hierarchy. So that's something I think is important. And perhaps I would add one comment to the person centered aspect. I think Abdullah has already mentioned engaging patients and families. So I would perhaps add the idea of seeing safety through the patient's eyes. It has happened to me, I was organizing a large event, and I had a patient on the board of the organization of that patient safety conference. And the patient said but what do you mean by patient safety. And so we discussed it was preventing harm in in healthcare. And the patient said, yes but what do you mean by harm. And the patient said, well, of course, a physical harm, etc. And the patient said, well, but it's much more than just preventing physical harm. Isn't it also psychological safety. Isn't it preventing disrespect to patient does not belong to harm. And the patient said, I'm coming to your event, only if you define harm as including disrespect to the patients. I would say I had not seen it as I'm a professional healthcare professional myself. I hadn't seen it that way up to then. And so it was quite revealing and it extended my definition and my understanding of patient safety culture. And that's what I mean by person centered patient safety culture, seeing it through the patient's eyes. Thank you. That's great points. Joanne, how about you. There's a great point Anthony about looking at things through the patient's eyes, because as a patient who was also in our end, they see things from a slightly different perspective. And my husband, I think of others that I have talked to, don't realize the little things that can be that we would consider harm to them, see as a norm. I think asking the patient and the family members, what safety. We need from us to help them to feel safe and secure. One of the first things that I learned with safety first. I also learned as a part of that, all of us as human beings are composed of our biological and physical health. Our psychological health, our social health and our spiritual health, we all blend together and with us clinicians and as patients that influences how we view things. And from a patient perspective, maybe no physical harm was done to the patient. But what about the psychological harm of getting a cancer diagnosis, or a chronic disease diagnosis, or suddenly being told that rituals and the faith practices that you normally follow, you no longer can, because it would cause physical harm down the road and we need to take all of that into consideration. I've always been a firm believer, every one of us, whether we are a housekeeper security guard, registered nurse nursing assistant physician therapists that we have a responsibility every day when we set foot in our job and dealing with our patients. We need to remember that we make the biggest difference and it all starts with us. If we believe that we're going to go in and no harm in any of those areas today. We make a difference one person at a time. And I think that's a really big thing to remember. And some of that comes from being diligent and being observant, looking at our environment and listening to the patient, not only with our ears, with our eyes, what is their body language telling us so something, maybe we're missing that we can address. Therefore, as diligent caregivers and diligent patients, we can prevent something bad from happening. And that's how I look at things and my perspective changed when I became a patient. And I realized that I had to take an action part in my health care, asking the questions and saying the things that were important to me. And my goals were slightly different. Maybe what doctors go for doctors goals were just to keep me alive. My goals were not to just be alive, to be able to practice and continue the things that I needed to do for myself and how do we mesh those things together. And I think that's a big issue that we can address. And I think it starts at the training level, whether you are in nursing school medical school, you can teach that and help students to learn that so that they can help teach it in turn to the patient. It's a big challenge. If we take it one small bite, one person at a time, we can do it. I think that's a great, great thought, Joanne, and kind of segue into my next question because, you know, we've been talking about this for a really long time. I mean, you talked about the aviation industry. I mean, 25 years ago, we talked about, you know, we started comparing healthcare to aviation and started talking about having a culture of safety. Why do you think we haven't fixed it yet after all this time. I think, I don't think it's for lack of trying. I believe A, that the mindset has to change. And let me build on what Joanne just mentioned about eating it, you know, in small bites. So the saying how do you eat an elephant, one one bite at a time. So if this zero harm is the big elephant. We continue to have in some of these small circles discussions about the question of whether zero harm is achievable or not and I think this is not helpful, because, again, all the hard reliability industries. Know that, you know, zero harm is not ever going to be, you know, done completely. You will always have some incidents in all these different industries, but they have managed to really drive the safety in their industries in a way that we did not. So I think the mindset is that is something that that has to change. And I believe we, you know, we can't, we can do it alone for that for the past 25 years, you know, and many years we've we've we thought that we could do it alone as the care healthcare providers. And I believe we have to be humble enough to know that this can only be done in a in a co produced way. So if we and and and you know Anthony mentioned the patient talking about you know what what do you mean by harm and imagine at the beginning of every admission or at the beginning of every encounter even at the at the outpatient setting. If we tell the patient who's going to have a hip replacement that hey listen this is let's let's work on making sure that we work together to make sure that your journey through the hospital is a safe one. And we would write down, you know, these are the top five 10 things to to to look after and and this is what we will do to make sure that you are safe. And this is what we want you and your family because you know at certain points in the care the patient is not going to be as much contributing. I think if we look at the patient and the family unit you know look at the patient and the loved ones as one unit. I believe we can we can really be proactive because this is what would be with the aviation industry does and with the higher liability industry. I believe they do. If the harm happens at step 10, you know they intervene at step one to unfortunately in health care we intervene at step nine sometimes at step 11 and 12 after after the facts. It's kind of reactive, but we can do some simple interventions to be to be proactive, but part of also, you know, transforming safety and health care is not to look at it as a kind of a, you know, kind of an independent from from from the perspective of the whole ecosystem so for the longest time we thought that you know safety of patients are kind of, you know, in a way a zero sum game, and where if we focus on the safety of patients, sometimes this happens to the detriment of the staff and you know we have the second victim phenomenon and everything and the and the and the burn. The burnout that happens in health care. But if we decide to go in a co production strategy where we would say that the safety as a whole in health care means that the safety of patients is interdependent on the safety of health care workers and vice versa, and do it in a in a way that that we empower the patients and families. I believe that would take us to the person centered care because it's not even about just patients because if you if we're, and this is why I love your title and of the webinar because throughout the care continuum we move away from just this kind of episodic way of looking at care, rather than this the health, the whole care continuum, you know so you're talking about primary care you're talking about home care. And throughout this, you know if we empower the individuals if we empower the patient and families I think we can we can do it so co production I believe should be a big part of our strategic initiatives moving forward. You're absolutely right. I think, you know we definitely I love what you said about how, you know, we're looking at this at safety at step eight or step nine, and certainly not at the beginning. Anthony, you know that you're over a group of hospitals you probably deal with hospital administrators all the time. What's your perspective on this why why do you think that that we still haven't hardwired this and health care organizations from a leadership perspective. I have the feeling that there is a challenge with having the right expectations. And I mean, by that there is probably some kind, at least what I see around me is also some governance problem. What I see is boards of directors who are quite preoccupied with dealing with the budget in one meeting, and then the accounts in the next meeting and then it goes back to the budget and back to the accounts. Sometimes they discuss an architectural project, but I don't see quality of care and patient safety and person centered care, as much as I would like on the agenda. I see that many hospital CEOs that are evaluated on patient safety. I see them evaluated on occupancy rates on the balanced budgets and things like that. I've been in the position of being a CEO of hospitals for 10 years, and I had quite a number of pressures I was facing but not as much pressure on patient safety and person centered care as I probably should have. And so, of course, as a CEO you allocate your energy your time on things that you are assessed on that you are evaluated on so I think there is a need to shift the focus in in governance on showing that it's important but to do that. We have to build understanding within the boards of directors about the safety issue like I teach patient safety and quality of care for board members of boards of trustees. And five weeks before the seminar, we do online survey and we asked the board members. What is the proportion of patients that get harmed in your health care institutions in your understanding, and we provide them answers in a logarithmic scale that means one in a million or one in 100,000 one in 10,000 one in 1,000 one in 100 and one in 10. The answer is one in 10, quite a number of people answer one in 100,000 or one in one million. So if you believe that it's one in 100,000. What why should you discuss that at a board meeting, but it's fits one in 10, then it's absolutely urgent and key that it's discussed at a board meeting. There's still some basic understanding and that drives expectations and it, in my view it sometimes creates a flawed system, whether the incentives are not where they really should be. Wow, that's a really great point and I, you know, I wonder, I wonder how many folks on the on the call could take that back to their organizations and ask what people's perceptions are. It goes back to what Abdelayla was saying before about how the general public doesn't really even understand how how significant this problem is. So what are your thoughts from a patient perspective from it. Why do you think that it hasn't taken hold you mentioned before to that, you know, patients sometimes just have an expectation that this is, you know, it happens and as bill said and bill Adam said in our, in our chat that there's an attitude and healthcare things just happen so get over it you know we call them complications we call them side effects. Why is, why do patients tolerate that. Oh, you're on mute, you're on mute. Sorry about that. They were mowing, they were mowing the lawn outside so I muted myself. One of the things that I see from a patient perspective as well as a nursing perspective is that there's not enough education to the general public about safety and how important safety is and how if you are creating your staff and your patients and family members who come to the hospital and creating a culture of safety where harm does not happen in the long run it saves you money. It saves you resources in the form of lawsuits in the form of lost time in the form of time spent with patient. I'll give you an example in my own personal life was in a nursing facility skilled nursing facility for rehab. And I rolled out of bed while asleep. I laid on the floor for over 30 minutes before anyone found me and heard me yelling. One of the things that concerned me about that is that no one had informed me what to do if the call bell wasn't within my reach. How could I get a hold of someone. There was no one rounding and coming in and taking a look, see what was going on in the middle of the night. And was no education the staff was not prepared, try to lift a 200 pound woman off of the floor to safely get them back into bed. Fortunately as a nurse. It was able to fix the problem for them. Not all patients can do that. And I think we need to educate all of ourselves, lowest level, whether it's in the hospital a facility. And with the patients out how we can be safer and prevent things. One of the things a lot of nurses get frustrated about is the patient satisfaction surveys. They're done here in the United States. And one of the questions that should be there that isn't is how safe did you feel during your hospitalization. Did you feel safe. If you did, why did you feel safe. And if you didn't, why not. And blame is also a problem. When someone, when a bad incident happens in the hospital, someone gets a wrong medication, or a medication gets missed a treatment gets missed. There's automatically blame put on the person. We need to look at the system. We need to look at what's going on. How many patients did that staff member have care for how critical were they. What was going on in the environment was that patient able to give their name and their birthday to make sure that they were the correct patient was that patient able to reach a call bell. We need to look at that, not blame the individuals, but look at the system and the cause of the fact over the last 40 years in healthcare. They have noticed a huge change here in the United States. And that our patients are sicker when they come in the hospital, getting discharged sooner. And there is a decrease in staffing. We're not utilizing all of the nurses, nurses aid, maybe bringing licensed practical nurses back into the case mix would help as well. Because then you have people who can educate and can observe notice things. Another thing that I think would be great is if we could get more registered nurses and positions on board of directors and board of trustees, because they are frontline workers, and they understand what the individual patients and staff are doing and letting their voices be heard and pointing out. Sometimes it's more cost effective to prevent, and it is to actually have to deal with the consequences with physically, monetarily, emotionally. What frightens me is years ago they talked about a nursing staff shorted. And it's going to impact those of us who were in the baby boomer and later generations, because there's not be enough staff there to help. We're seeing it come to light, the light of coven. We're seeing a lot of nurses and doctors who are walking away. We're seeing shortages everywhere. And we need to get a mindset on focusing on correcting all of those because as you correct shortages, and you've had enough people in place with good training. It will correct itself and unfortunately, instead of it in better without works. If we had another hour I could tell you about the concepts that we learned years ago, aren't hot day for new nurses coming out and new doctors. And that's something we really, really, really need to think about in driving the culture of safety and reliability. We also need to remember culture of safety patients talk people in the community talk about hospitals. And you can sit in any restaurant or social hour in a church or social gathering and you'll hear somebody say I will never go to that hospital, because man they don't do a good job. That hospital thinks they're doing a good job, you don't see the reality of what patients are seeing. And there's that disconnect somehow. We've got to think outside the box and figure out how to put it together. That's great. Well, you guys have given us all so many ideas already about what we can do to fix this. I'm delay like you have a question now I know a lot of times I talked to clinicians and they, you know, their opinion is that they don't really want to involve patients and families in their care. They perceive that, you know, their, their role is, is there to be the advisor to be the driver of care. You know, what do we need to do to change that mindset. Yeah, such a great question. And unfortunately, there is this misconception amongst clinicians and specifically amongst physicians, you know, like myself, that, you know, patients should stay in their lane, you know, you should just be a patient, you know, we will tell you what to do. I think there's a little bit of arrogance there there's a little bit of lack of understanding of how the safety works. And I believe this has to change, and it's going to create a lot of, you know, interesting conversations some some discomfort. And it starts with an empowered patients coming, you know, to, to the, to the clinic and empowered patients coming to the, you know, to be admitted. I believe, you know, just, just to give some practical solutions. We should start seeing patients in boards. And so, you know, the whole saying of safety from from from the board to the word. So we should start having patients, not just, you know, having the optics of it having a patient representative coming in to the board every now and then we should have a patient representative who's not a clinician, who represents you know that the the population that the hospital taking the agenda for for for patients forward, you know, trying to empower them to ask of us the the tough questions. I think we should redefine safety and in two different ways we should redefine it, because safety now is defined as the absence of harm. But that's a kind of a one size fits all definition and I don't think it helps the patient who's being admitted today to the hospital, it doesn't help the patient who's actually being wheeled into the emergency room as we speak. I think the definition should be personalized for every individual coming in contact with the with the with the healthcare system. So how can we work together but but it needs to be personalized, and it needs to be co produced. So we, I think we've learned enough now that there's no way that we can do it alone as as providers, and I think we have to have the humility to say that. And we have to show the solutions of how we can co produce this I think one of the most important things is to empower patients and families to speak up. When you look at many of the Sentinel events, you know, there was someone within the vicinity who realized that there was something going wrong, but they were not empowered to speak up. And it you know sometimes it's a junior team member that is not empowered to speak up. It's a new nurse who kind of joined in, who was intimidated by the by the attending. You know, I think Sheila here mentioned that the nurse patient ratio and Joanne talked about it. And this is a very, very important aspect that also can connect the, the two safeties, you know, together. So, recently we decided patient safety center I continue to go to say we because I've been in the center for for a long time. There was a white paper about the patient. Sorry, the nurse patient ratios. And this was that there was also a work that we've done with ICN and I presented in 2019 during the ICN conference and I believe what is happening in the in this staff staffing ratios and specifically nurses and midwives because they represent more than 50% of the health is something that really needs to, you know, we have we have to have, we have to basically, you know, sound the alarm about pushing nurses into kind of taking more and more patients without having the, you know, the time or the way of looking after them. You know, just to look at aviation again aviation has something called the minimum equipment list so any airplane anywhere in the world that are commercial flights, the airplane does not take off. If that minimum equipment list is not ticked. Why don't we have minimum equipment list in sorry minimum safety list within our units. So why are we pushing staff and and and again I would say nurses it's usually that the offenders is us physicians kind of pushing nurses to to actually take more and more ratios rather than starting you know closing beds and saying that is the maximum ratio, you really have to have a very good reason to take up more patients with the same stuff. Because, again, this this would kind of disconnect the safety, because what we will do, we're actually putting that nurse into more risk so when we're compromising his or her safety. We're not in the name of we're trying to actually increase the care of patients but we know that actually both safety suffer. I'm calling I'm speaking about them as the two safeties but I think we have to connect them together as one safety. So so that the patients, the nurse patient ratio is something extremely important, but but I believe one one thing that we really need to do is is to really put the safety agenda at the level of the board. And we really have to hold the board and the entire organization accountable because what happens is you know the analogy of the blunt end sharp sharp end. So what happens at the sharp end that the same nurse who was actually pushed to take up more patients when he or she makes an error. Who will fire her the the board, you know that the CEO of the hospital. So people at the top who did not create this the environment for for safe practice so so I think that that accountability matrix has to be connected and the next the board or the CEO or, you know, department head wants to fire someone or for for a safety event. He or she should look in the mirror and know that they're as culpable if not more accountable for whatever happened as the individual at the sharp end. Well, it looks like Sheila life that's giving you some some great applause here so and Christie is as well. So I think that's, that's very well said I'm a nurse myself I've been a nurse for 31 years and when I look at nurse staffing. It's the same today as it was 31 years ago, and the number of things that nurses have to do now are is far far different so so very very well said. Anthony, this is these are our fabulous recommendations. You know, so, you know, Adela said close beds if you don't have enough staff so you know I'm sure that you as a previous hospital administrator probably knows how that would go over and organizations so how do we actually make that happen in hospitals. What do we have to do differently in administration. I would argue that perhaps the model or the vision that we have needs to be questioned further. I mean, the image of patient centeredness, I think has been very helpful to move away from paternal paternalistic care, top down care professionals telling the patient what to do and I'm glad that there has been the model of patient centeredness. But on the other hand, that idea of patient centeredness suggests the image of a circle where the professionals are all of the professions etc and the patient is in the middle. And it seems a little bit like a team doing things for the patient that is in the middle of the circle. And I wonder if now we don't need to move away for this idea of we're a circle doing things for the patient to the patient is within the circle is part of the team. Team steps says the patient is part of the team the Montreal model says the patient is patient partnership, which suggests the patient is in the circle, and things are done with the patient rather than for the patient. And so I think that's, that's, it's been done already it's not a new idea but I think we have some of us has a little bit being trapped by this idea of patient centeredness, which means, yes the patient in the center but we shouldn't consider just doing for the patients with the patient it's the idea I think of co production of co design, and that's something we need to work on much more. And that kind of leads into a question that Christy Hughes asked in the Q&A about how you know how do we get to that place from a patient perspective Joanne. I wonder if you can answer Christy's question about you know how does the average patient know how to demand that to be part of the team as as Anthony was mentioning. You're on mute again. I apologize. I think it begins with educating and empowering the patient and telling them you're an important part of the team that is taking care of you. Do not be afraid to speak up. Speak up to the a speak up to the nurse, speak up to the doctor and say I have questions. When I was training patients to do their own dialysis at home. I used to tell patients that the only one question was the question you failed to ask. Because I think we need to remember that patients do have questions, and they do have concern, it might not meet clinicians agenda. But they ask it to give us perspective and opportunities and it gets back to allowing them having a sign. In a patient's room and in the hallways of the hospital is, don't be afraid to ask speak up. You have a voice. Don't be afraid to use it. And encouraging them and saying great question. I'm really glad you asked that or, you know what I never really thought about things that way. And letting it be a teachable moment between the patient and the staff because sometimes patient can teach staff things. They didn't know. I'll use an example again from my own life. I had a home house nurse here yesterday dealing with one of my wounds. And she didn't know how to hold the end of tape under so that she wasn't wasting tape and having trouble wasting time to get the tape torn open and I said, let me show you a trick. This is what to do this is how you do it. She went, Oh my gosh, it's so simple and I didn't think of it. The patient teach me a nurse of 20 some years, years ago, a Manny's jar is great for getting rid of insulin syringe. It's simple. It's basic. We learn from each other and needing more of those teachable moments. Those teachable moments can happen when you have good staff ratios. And when you think outside the box, maybe it can begin at home, you have a patient you're seeing in the office they're having surgery. You want to prepare them for surgery and you send them to standard video and give them the reading material one problem patient can only access the video once a week at the library. The patient is not able to read or is blind and the material is not written in in Braille, or they have no one to read it to them. Think outside the box about retired nurses retired doctors, retired physicians assistants who might want to work at home, or a decent rage, call that patient and talk to them on the phone. And interact them and provide the information and build a rapport. And it starts with that thinking outside the box and building and collaborating together as a team. And I know it frustrates my physicians when I do that. I get involved and I say well I did this or I know this and I understand that. I said you're not looking at it from my shoes. And we need to sometimes put ourselves in that patients shoes and brings up a point, a little off topic about harm and preventing. I learned something new that do the Americans with Disabilities Act. A patient who is in a wheelchair who cannot make a transfer to the bed or to the exam table. As the right, we have a higher lift used lift them on to that exam table. So that they get a thorough exam and things don't miss and we all know, but doing a thorough exam is an important part of preventing harm. Thinking outside the box and including people with disabilities and their advocates and their advocacy groups. And utilize them as resources to help educate us as staff and educate each other as patients. And I know that's so well said Joanne and and I, we do only have just a few minutes left so very, very briefly. I just want to review the continuing education credit information and then I've got two more questions I'd like to try to squeeze in before the before we finish the program. Again, if you are a nurse physician or pharmacist you'll receive an email from MedStar health about what you need to do for continuing education. You will receive a certificate from us if it's for CPS or BCPA. Otherwise, you can either log it yourself or CP or NHQ will log it for you. And then if, you know, we always provide all of our educational content for free. We don't want for cost to be a barrier to improving patient safety anywhere so you know if if you are interested in helping us as a nonprofit to be able to continue to do that, then please visit our website and and you can donate there to help us continue to keep this content free. Abdelayla I have a quick question from Krista. Krista and I actually did talk about this not that long ago. She had a patient family member who did speak up who did ask questions who wanted to be involved and they were dismissed. How do patients and families deal with that? What should their response be? I think basically you need to understand what the mechanics are within that hospital or within that clinic. So if you were dismissed by the primary physician, then you need to look for a way to make your voice heard. You know, so if there's a basically a structured way of complaining, then I would follow that. And it's not about filing a complaint. So when you file a complaint, I hope that you follow up with that and it's not about filing a complaint for the sake of filing a complaint. It is to make sure that this is a very high liability industries would look at this as a kind of a red flag. And I think we should look at this as a red flag because if you had a concern and you were dismissed and thank God as a patient or as a family member, or nothing happened, you know, imagine the number of times that the same concern could have could end up in a major harm or even death of a patient. So don't think about it just for your own safety and for yourself. Think about actually doing it for the greater good. So and I think that would be my the way of dealing with this in a practical way. Great, great. And I do think, you know, I think in general, you know, as human beings, we have to do a better job of communicating to each other, communicating our needs. We are hoping to be able to provide better education for patients and families to learn how to have those difficult conversations that a lot of people, you know, shy away from. I think the last question that we have or Joanne I mean I'm happy for either of you to jump in on this but Anthony you talked about putting how how we put the patient at the center of care. But we often often talk about patient centered care versus person centered care and me on a gas a really great question, you know, there's always this, this question of is it person centered care is it patient centered care. So why do we really define those those roles and and and is it important. Well, in my view. I would more use the term term person centered care because it's not just the patient patient implies often acute care hospital care etc whereas it would be other names in long term facilities or in home care. At least in French we use different words and we don't say patient we say the inhabitant the resident, the user of the system, the beneficiary of the system so it's, it's all of these people and it's often also the loved ones that go together in the concept the family, the loved ones, the helpers etc. So I would use more generic word than patient, but of course the patient is a very important part of all that. And I think that the patient, on some respects, has more information than the professional and more actionable and useful information the patient is an expert on how he or she lives with the disease. And that's something that no professional can provide better than the patient and we should not forget that. Absolutely, and I can see Joanne and Angela Lynn nodding when you said that so. Yes. Person centered care is a great form to use within the face community nursing groups that I belong to we're beginning to use the terminology, health care consumer health consumer, because in reality, we are a consumer as a, as a patient. And we're going to evaluate you as a consumer standpoint. And using it as the health consumer or person centered care individual centered care, realizing in the back of our minds that individual can be a family unit, or a non family unit. There's a blood family unit, a family unit. There's a support family. And that is what patient advocates and liaisons and navigators can become. That is a service part of health care. I think so few people know so little about that. You don't have to be a professional be an advocate. The patient does know their own body best. You know how they manage things at home, family member advocate knows that, other than anyone and I used to tell my patients. And this is a good takeaway point is you know yourself and your body, better than anyone else. And maybe you are that one person that can only take one tile and all, as opposed to two, because taking two knocks you out for a day, and puts you to sleep and makes you non functional. And you have different reaction and being able to say you know what, every time I do this, this happened, because we are all individuals, we're all different, everybody's DNA is different. And we need to remember that the patient is their own expert they may not know what it is. They're trying to describe why it's happening to them. It's happening and getting into the patient's vernacular is very important with all of that and I like person centered care. One of my favorite questions that I die would ask a patient was not. So, what is your problem today. The problem today might be the cat threw up. The real issue that they're having problems with is their blood pressure is high they have a headache and they've had a nosebleed. I always ask them, what, what's going on with you, what what's happening, and that's that you seeking help at this moment, right now. Yeah, from there. That's a really great way to start doing absolutely and I apologize everybody we are out of time you're actually two minutes over so I'm so sorry, as Joanne said we could talk about this for a whole other hour. So thank you all very much for joining us. If you want to learn more about a person centered culture of safety please see our actionable patient safety solutions it's called creating a foundation for safe and reliable care. And, and we will continue to have this conversation because I know that there's lots and lots that we have to do to fix this so thank you Anthony Joanne and Adela and thank you everybody for joining us today we'll see you next time. Thank you very much. Thank you.