 Good morning, everybody, and welcome to our December webinar. I am Donna Crosser, Chief Clinical Officer here at the Patient Safety Movement Foundation. And today, we're going to talk about sustaining change, something that health care professionals across the world are concerned about being able to do a little bit better, and how to prevent your hard-won efforts from failing. So we have a fabulous program today. We're going to be examining the current challenges and sustaining improvements that everybody shares. We're going to compare and contrast opportunities for education versus for communication and how you can leverage both of those to sustain your improvements. And then also, we'll discuss how to set up the frontline workers for success so that they can help to sustain improvement initiatives. As always, we're going to be providing continuing education credit from MedStar Health to nurses, pharmacists, and physicians. Respiratory therapists can also, in most cases, claim this credit. And so if you are looking for this type of credit, please do be on the lookout for an email from MedStar Health that you should receive this email within the next week. Sometimes it does take five to seven days, but usually a little bit sooner than that. And as soon as you complete the evaluation, you'll receive that credit from MedStar. Healthcare executives are also eligible for this credit through the American College of Healthcare Executives. You can just log that into your portal on the ACHE website. Certified Professionals in Patient Safety will receive a certificate from the Patient Safety Movement Foundation. And Board Certified Patient Advocates will also receive a certificate from us after this event. Again, please give us about at least a week to get that done. And here you can see that none of the speakers and none of the planning committee has any conflicts to disclose. So as always, we welcome your comments and your questions. Please, if you have comments that you want to make, use the chat function. If you have specific questions that you'd like to ask, use the Q&A. We may or may not answer them as we're going through the program today, but we will save 15 minutes at the end for questions and answers to discuss anything that we didn't get to. Sometimes we don't get to everything. So anything that we don't get to today will make sure that we answer electronically. And we will post that along with this recording on YouTube. We're going to be using a product called Slido today because we want your interaction. We want to ask some questions and know what's going on in your world. So please do help us with this. Join Slido. You can do this on your phone. Just take your phone. Take a picture of that QR code. It'll take you right to Slido so that you can answer the question that's on the screen. Or you can go to slido.com and enter the number 464125. We will repeat those instructions again when we get to the first question. But for now, I am very excited to be able to introduce our moderator today. Chrissy Blackburn is our moderator today. She's the principal advisor for patient and family engagement at University Hospital's Health System in Cleveland, Ohio. She's also the mother of a child with complex care needs. So she has very much able to speak to both sides of the health care coin here. So Chrissy, welcome. Thank you so much for moderating this panel. And I'd love for you to tell us a little bit about yourself. Thank you so much, Donna. And thank you, everyone, who's joining us today. It's always an honor to partner and work with Patient Safety Movement Foundation and all of their efforts to improve patient safety. As Donna said, I'm principal advisor for patient and family engagement at University Hospital's Health System. I've been in my role for about almost eight years. But I've been in the role of patient advocacy work for 14 years as well. Mother to my daughter, Lily, who successfully had her one-year transplant anniversary last Thursday. So that's very exciting. So in my role, I really, this work found me. I did not find it. Like most mothers that have children with medical complexities, we dive in. And are really some of the best patient advocates that want to partner and work with health care teams. My position does sit within our quality institute. So I'm savvy around quality improvement work, what needs to be done, and the difficulties of sustaining that work. But without further ado, I would like to introduce our esteemed panelists today. Kristen Miller, who is the senior scientific director of MedStar Health National Center for Human Factors and Health Care. Also the associate professor of emergency medicine, Georgetown University School of Medicine and affiliate faculty, Georgetown Medical Center Innovation Center with Biomedical Informatics. Wow, Kristen, that is a mouthful. And I would like to pass it on to her to tell a little bit about herself and then I'll introduce the rest of the panelists. Great, thank you, Chrissy. Good morning, everyone. Yeah, so my role as scientific director at the Human Factor Center at MedStar primarily focused on research. My own research portfolio, which is health IT, decision-making, public health, health IT policy, but then responsible for our overarching research portfolio as a center. And so lots of exciting work happening across the spectrum of human factors, things like safety surveillance, built environment, data science, informatics, lots of exciting projects that I can speak to. And then lots of teaching as well. So I teach in the Georgetown Executive Masters in clinical quality safety and leadership. And also as part of ICBI, there's a masters of informatics and data science. And so really making sure the next level leaders or current leaders understand this human factors engineering approach. And I think really relevant to this talk today about sustainability, which can be quite challenging. So excited to be here and look forward to the panel. Thank you. Thank you, Kristen. That's a true love of human experience, human factors and math all rolled into one. Next, I'd like to introduce Joyce Alamno, who is the President and CEO of Health Corps, also President of Health Retirement and Tourism, also known as Heart Alliance of the Philippines. Joyce, please tell us a little bit more about yourself. Hi, good morning to all of you and good evening from the Philippines. It's past midnight for us here in the Far East as they call it. And it's really an honor for me to be with this really dynamic ladies from the US. Thank you so much for the invitation. What I do here, Kristen and Christine, is that I am currently heading this organization called Health Corps Academy. And what we do is that we try to educate our healthcare providers in order for them to comply with the international standards of accreditation like JCI, the Joint Commission, Accreditation Canada, NABH and so on and so forth. And for the last, I'd say what, 15 years of my life, I've been trying to spearhead the globalization of healthcare in this part of the world. I've headed the development of medical tourism program in the Philippines, also called Health and Wellness Tourism and also the requirement tourism. Right now I'm also teaching in foreign service and also strategic marketing. So those are some of the things I do here in the Philippines and happy to be here with all of you. Thank you so much, Joyce. We're so glad to have you here. And last but definitely not least, like to introduce Christine Luzernas, who is the Regional Director of Infection Prevention and Control at the HEROES program at Kaiser Permanente. So next slide please. We're going to jump into our first Slido question and just a reminder on how to do that is you can join at Slido.com using the 464125 or you can use the QR code with your phone's camera to join today. So our first question to everyone is what types of initiatives are you currently prioritizing in your organization? You may select all that apply and then please just take a couple minutes to run through and answer those questions. Thank you. So it looks like our top priorities are workplace safety and wellness related initiatives which actually comes at no surprise during the COVID pandemic right now. Also in second place, we see specific clinical initiatives such as sexist falls, et cetera. Also not a big surprise. I know that falls just on an international rate is a very high priority due to some of those staffing related initiatives which came in force. And I honestly am very happy to see that there's some prioritization there with patient and family engagement related activities and initiatives as well. Thank you so much for sharing your answers. And I think what we're going to do now is we're going to dive into the first panel question. So we'll go to Kristen first and really answering why do our current approaches to sustainment fall short? Sure, yeah, I think this is such a great topic and one that maybe we're hesitant to talk about because everyone's so excited about the actual work, right, all of these new interventions and new approaches. But I think we can all be honest here that this stuff is really hard. Implementation to start is really hard, whether it's some innovative app that we think is going to improve decision making or simple changes in workflow or getting someone to use a checklist, whatever it is that implementation is hard, scaling it can be really challenging. But I think sustaining any of these interventions is probably the hardest piece of this. I think that happens for a number of reasons. We maybe you're working on something that's a funded project. And so your focus is to get something deployed and evaluate it. And then you sort of walk away from whatever that project is or you sit on a root cause analysis panel, you come up with lots of different solutions. And then you find out none of them were ever implemented. That might be a different webinar, not about sustainability, but about actual deployment of this stuff. So I think there are lots of competing priorities. Everyone would agree. There's lots of excitement when you first deploy something. And then over time, if it's not integrated into workflow, if you don't have buy-in from stakeholders, if you haven't thought about the technical components for sustainability, then the stuff just isn't gonna last. And so excited today for us to talk about some of the opportunities here, whether it's a robust evaluation that continues over time, whether it's discussions with the right stakeholders at the table to begin with, to make sure that what you're developing is gonna have some longevity and not run into any sort of technical or socio-technical challenges. And I think we'll talk more a little later about the actual design of something coming from this human factors lens. To me, that's the most important part is, there's energy and there's excitement, but what's the actual thing that you're deploying and what's the likelihood that that's gonna be sustained? So I think lots of challenges here that lead to this lack of sustainment and sort of across the board, lots of different things that we could talk about technically, culturally, socio-technically, lots of different contributing factors. Kristen, thank you so much. It looks like we have Christine back who is next on the question. Christine, were you able to join us via audio? Can you hear me? Yes, wonderful. So, Christine, we were just talking about why do our current approaches to sustainment fail? And I know you were gonna start talking about the overburdenness of staff and health systems. Right, well, first of all, I'm sorry for the technology issues I'm having this morning. And I wanna thank you first of all for having me today and for hosting this conversation, which is very important, always been important and had taken on a new challenge because of what's going on in the world. So, yeah, so I think the number one feedback we get from frontline managers and frontline staff when we introduce another improvement idea or another initiative is that, well, here comes another one. And I think part of the reason why we get that response is because we bring in the frontline manager and the frontline staff quite late in the game. So, I think I'm sure later on we will talk about how we will inspire and promote sustainability. And one of the very important elements is that bringing in those who are doing the work as part of the improvement project from the very beginning, from the design of it all the way to the implementation and of course, sustaining the work. In that way, they were brought into the whole idea from the very beginning and we are listening to the actual problems that they are experiencing because it's their work that we are improving. And that will help with decreasing the feeling of being overburdened or just being put upon. Thank you, Christine. And just in my own personal efforts around patient family engagement and how we try to involve patients and families in our quality initiatives and process improvement sort of on the back end just like you're talking about with, oh, oops, we forgot to include the nurse manager or the associate nurse manager or even the staff and providers. And a lot of what we try to do is look at how we can piggyback or jump on to the end of other initiatives that are going on. So when we talk about fall risks, falls is very tricky because there's so many different pathways and processes that we try to look at and how to help people prevent themselves from falling but self-pride and ego happens with patients. They think they can do it and they get up right to the bathroom. Unfortunately, that happened. So when we talk about that overburden and thinking about how we include the other stakeholders, are there different ways? And, Christine, please feel free to jump in here too that we can really hardwire piggybacking on to other initiatives that we're working on a specific project so that we're not doing the overburdening of the staff. Right, Chrissy, I'll start and I'm sure Christina will jump in. Well, I can only think of our own efforts and my organization where we have really tried hard to engage the frontline from the very beginning. And what we know from the very start is to create kind of the conditions to allow that. And one of the things we've done is including the frontline leaders, both formal and informal into this structure which in our organization, we're calling heroes. And they are part of the conversation, they're part of that group and they are the ones that are identifying the problems in their environment and escalating the issues up to their managers and then thinking of solutions. So, and the role of that bigger group is to not only listen to the problems that are being brought to them but also making sure that they are coordinating and prioritizing so that not three groups are working on the same problem but bringing the three groups together and working on that one problem and then spreading it out. And I think that's what you're speaking to when you talked about coordinating the work of the frontline. So that's one key strategy that we've done is we've created this clinical work groups that consist of frontline managers, nurses, physicians and subject matter experts and then they bring it up to the bigger group so that they can talk about the work that they're doing and also ask for resources and perhaps connect with others doing the same work. Oh, Kristine, I think we lost your audio. I was on mute. Was there anything else to add? Yeah, I mean, I think Kristine hit the main actionable item right away, which is you're designing this for someone and they need to be at the table and I think as engineers, we're really guilty of that of coming to the table and saying, here I built this thing for you and that person saying, well, but that's not what I wanted. There's nothing to do with what the actual problem is. So I think having those stakeholders there and then as we think about actionable solutions, I would say the second piece is making sure it's not just that stakeholder, but it's everyone else and who's gonna be impacted down the line. So you're rolling out some new initiative for, I don't know, screening for palliative care or financial hardship or suicide risk or whatever it is. There's the people that are doing the screening, you get them on board, you get that part implemented and sustained, but who else is going to be impacted, right? Do you have enough resources to have that financial hardship conversation or to do the palliative care consult and then who else is impacted? So the IT folks that are building the screening tool, what do we need to know from their perspective? Maybe there's EHR changes that happen all the time that are gonna impact this process down the road or a number of other parties' leadership and patience. And I think really this thoughtful approach at the very beginning to think about how you're gonna design something so that it has that longevity. And I think we're gonna talk about what sustainability is to because that's a really important part of this conversation. Am I doing something because we're at the peak of COVID and I need to improve screening and then we can sort of roll back the initiative a little bit or am I doing something that I need to sustain forever? And I think those considerations are really important too. What's sort of the end goal and the timeline of the implementation as we think about how robust we need to build the architecture around it to make sure that it's sustained. Yeah, and I really like how you said that moving from the doing for to doing with. And I know when we talk about patient family engagement we say that all the time, we're not doing two, we're not doing four, we're not doing with, but we need to include our providers and our staff into that same statement as well so that we are meeting the needs and we really are truly understanding the problem and not seeing just what the data is but what are the actual operational steps and the barriers that they face too. Thank you so much. We're gonna move on to the next panelist question which is Kristen, thank you. Christine, what does effective sustainment look like? Yes, so we had been thinking about sustainability for quite a long time, formally for the past three years. And what we found is that we talk about sustainability a lot but it turns out that we think about it differently. So I think from the very beginning we've started quality improvement. We've always expected sustainability to be part of the conversation but we haven't really formalized what the definition means. We've shared words, we think we have shared vision but the truth is we have not explicitly defined what sustainability is. And then what we found is that in literature that is exactly the problem. There is no standard definition of what sustainability is especially in the context of quality or healthcare improvement. And that's part of the problem. Now, some people think that, okay, that's fine because that allows for flexibility but in the longer term it makes it difficult to create kind of a evidence-based or an operational paradigm because you don't have a standard definition to look to and it's hard to benchmark what you're doing against others because the other problem is it's not measurable. So given the lack of like formal definition there are many definitions but there's no one definition. It's very important from the very beginning when you're designing a project that you define what sustainability means. So at least your own group or your own organization has a very defined vision of what sustainability means for the project. So for us, for instance, I mean it's a very simple definition which means that we would like to maintain the improvement that we've made the processes that made the improvement possible and then we've set the criteria of what that's gonna look like, you know that we have set perhaps a group perhaps we've defined like an accountability structure and there are definitive roles for every single person in that structure. And then we have identified how we would measure the improvement and we would monitor it and how can problems be escalated and what we would do if there's a drift which we're gonna talk about later or there's like a degradation of the improvement. And yeah, so we've defined what sustainability is we've defined what the structures are that would support it and also the workflow around that is what we think sustainment would look like. And another thing too is that and this one is still a work in progress is that sustainability for us does not mean that you're consistently meeting a target, for instance whether it's SEDF or CLABSI what it means is that you have a structure behind that that could address, right? When your performance in CAUTI or SEDF or what have your falls had degraded, what do you do? That to us is the definition of sustainment. Christine, thank you so much and really hitting it right on the head that definition of sustainability really can throw us as far as finding what that structure is and what that process is. And looking at at the end of the day we are all in healthcare because we want to help we want to help people and patients and families as I like to say and many of my other national colleagues are one of the most underutilized resources in healthcare and it's not that not every patient wants to be involved and when we look at things like patient activation measures and point of care and how a patient or family caregiver is owning the health for themselves or a loved one it's really just tapping into those patients and really getting some of that allotative and quantitative data on what it is that they need as well and really when it comes down to the patient experience it's doing what you said that you were going to do in providing that input and that structure and many on this call as far as the panels and our attendees know CMS have developed that three tiered level of patient family engagement at point of care, policy and protocol and in governance levels because of patients and families we have an expertise whether it's our experiences that we carry with us through the healthcare system or our professional backgrounds as well that can offer input and that co-design in the sustainment process and really when we look at it for those outcomes and what the patients want it's the consistency in care, it's the delivery of care and at their own meeting them where they are as far as being engaged and involved in that process. So we're going to move on to another slide that will talk to patient and family engagement and what we really want to know is how is your organization involving patients and family members? So one, our organization utilizes our patient and family advisory councils and quality initiatives. Our organization invites patient and family advisors to participate on specific QI and patient experience project teams and committees. Our organization needs further education on how to build and utilize PFACs or inviting patients and families and quality improvement work or your organization does not have PFACs or does not involve patient or family members in projects. So it looks like about 46% are involving their patient and family advisory councils and quality initiatives and I just think off the top of my head where are they in the process when you begin? Are they involved in the very beginning? I can tell you just from some of my own experiences that the organization will roll out a project then they'll take it to the PFAC for feedback and input and they find that they're starting at square one again and redoing an entire brochure or something else within a process around QI. So really involving them in the very, very beginning is critically important. It also looks like about 31% do invite patient and family advisors to be part of their quality improvement teams and committees. Very happy to see that. And that about a quarter of you would like more information on how to build and utilize the PFACs. This is something that I have done for many, many years with many of my national colleagues and for those that do not involve PFACs or patient and family advisors maybe rolling in where the barriers are to that. You know, why is that, is it cultural? Is it training? Is it onboarding? Is it resources, et cetera? So thank you so much for answering those questions and we are going to head into our last question for the panel. So Kristen, we'll start with you. What are actionable interventions for effective sustainment? Sure, real quick, I wanna address the comment you just made, because I think about engaging patients and families because I think where people miss the mark is meaningful engagement. And I'm sure, Chrissy, you can talk about this or put a patient on that thing or make sure there's a patient involved. But how are we actually engaging the patient? What's the expectation of them? And this is something I'm obviously passionate about because I think it's the same with human factors, it's the same with health equity, it's the same with patient engagement where there's this like pixie dust sprinkle of, oh no, I had a patient at the table, but what were you asking them? And how did that actually improve the initiative? And it's not an afterthought. Like you said, it's designing with, right? It's at the very beginning, it's not bringing a brochure and saying, does this look good? Like I want your sign off, but meaningful collaboration, I think, from the beginning. But that's not the question you asked me, sorry. So what effective sustainment, again, I'm gonna focus on like going back to the beginning of the design because I think that's the critical part that's gonna lead to sustainability or not. Donna, if you wouldn't mind pulling up that hierarchy of control slide, because I think as we were talking about this idea of designing for sustainment, I immediately thought about all of the work in the engineering field where we think about strength of action and this idea of hierarchy of controls. And when we do physical things, a new construction build or I remove the hazard, there's some sort of foreseen function. We know that these are the most effective controls, but also that they're the most sustainable. So Donna, if you go to the next slide, this is sort of engineering world, but this has been moved into a healthcare framework. And many of you, I'm sure are familiar with this, lots of places where you can find this, but thinking about what we call weak actions, which really are just foundational, you need training and education, you need new policies, but those things alone are not going to be effective and they're not going to be sustained either. Asking people to remember to do something that human vigilance is always going to fail. And then you think about intermediate actions and stronger actions. Are we making software modifications? Is it not just a policy, but some deep simulation training that people are going to remember for a long time, introducing a new cognitive aid or a checklist, and then these really strong things. So again, the foreseen functions, simplifying and completely changing processes, architectural changes, that these are really the most effective and the most sustainable, but I also recognize there's huge trade-offs. We can't just physically redesign everything with new construction. It's very expensive, it takes a long time, you need lots of buy-in, there's competing priorities, but to really think about what your intervention is and where it falls on this. And then, sorry, one more slide, Donna, there's some work that our center has done led by Zac Keddinger and Terry Fairbanks a few years back where they actually mapped these different actions and then looked at sustainability over time and thinking about adverse events that had happened and solutions that were put in place and saw a lot of the same things that we had seen in the literature, but actually in practice. So that these built environment improved processes, the sustainability was higher there, IT structure, the stuff that's really hard, I think institutional change, cultural change. Are we thinking about the well-being of providers and not about production pressure? These are the things, if you're able to make that change, those are the things that are sustained. So all that to say, I think it starts in the beginning, the design of the intervention, the effectiveness and complexity of it is directly tied to the sustainability that you're gonna see in actual practice. Thank you, Kristin. Joy, we'll move to you as far as commenting as well. So the question was, what are actionable interventions for effective sustainment? All right, sorry about that. Okay, Alba, I can of course give a full lecture on sustainability, but for the sake of, for the interest in the interest of time, I can probably just share with you one slide for us to easily remember as a takeaway regarding sustainability and we can easily remember it as a four-letter word, which is step. And that is to always monitor the implementation of whatever programs and plans that we have set in the beginning, because the question of sustainability is always how to make sure that we deliver with consistency in the future, looking at always at the long-term, how to make sure or ensure that the entire team will really deliver from beginning until the end. And so what for me is most important is to have some tools or monitoring tools that we can easily remember every time. And I would call it as a step. First is to always remember or monitor the status of our patient and always patient being at the center of the core of our services. And considering always the status of the patient with all the plan of care, the medications and the vital signs. And second is to make sure that we are always taking care of our team members, so that's letter T, to always make sure that our workers are not overburdened and that they have the right skills in delivering proper service. They're not stressed out, especially nowadays, we are in the pandemic. Of course, we have to always consider their mental health and their safety. The other thing that we should consider in order for us to make sure that we can sustain the programs and the plans that we had set is that we should always monitor and look at the status of our environment. So when we talk about environment, this involves the facilities, the administrative information. Of course, our staffing, our triaging, our equipment, our inventory and so on and so forth. And the last one will be the letter P which stands for progress toward goal. We have to make sure that we monitor how we are progressing in terms of the achievement of our goal, the status of our team's patients, the goals that we have established as a team, what are the tasks or the actions that we had set and if we are really able to fulfill them and always to check whether the plan or the program that we had set in the beginning is still appropriate. So I think these are some of the tools that I can impart to everyone when they do or try to sustain a program or a project for that matter. Thank you so much, Joyce. And to Christine, how do you identify when an initiative begins to flip and why does flipping happen and how do you correct it and prevent it? Thank you. Yeah, well, first of all, I just wanna say too, just listening to Joyce, I think she gave us kind of the sustainability and action at the frontline level with her staff. And then with Kristen too, she just gave us the rundown of sustainability elements like in the cliff notes. I don't know if people still know what cliff notes are, but I felt like that's what she had given us. So yeah, so drift or degradation. So obviously we're obsessed with data, right? I mean, pretty much after the project has been implemented, what we do is we look at data constantly, we watch that dot every day and every time it goes down or goes in the direction we don't want, we literally throw everything in and start doing action planning, outreaching. I mean, that is our trigger. We are triggered by the dot. So I said earlier that the most important piece of a sustainability approach or framework is that being able to monitor the data. But the other piece to that is knowing what to do when the data shows you something. And the number one thing is not to panic, right? Not to throw everything and all let's start a project because, you know, our CDEF had gone up like last month. So being very clear about what the triggers would be to trigger an action and what the actions would be. And I have said in the beginning that sustainability does not mean perfection. That doesn't mean that you will achieve your target all the time that it will always be zero because we're dealing with humans, right? We're dealing with change. This is the pandemic and it's changed everywhere and for everybody. So there would be the ups and downs in the data and the performance. So the important thing to do is to be able to detect that number one and to know what to do after. And if we are truly sustained, there would be support structures in the medical centers and in our system to be able to respond to that, to bring in the right people to the table and have a conversation. What have you found out? What did you do? Did you do a drill down, which everybody does? And what is it that you've done? And maybe it is just like, you know, we have new people and we have not trained them well enough or there is a new test or perhaps we're getting a different kind of patients. But the important thing is knowing that what could be the factors that led to degradation. So in our organization, I mean, just like everyone else, you know, we watch data from the regional level and the local folks are doing the same thing. And when we have met our trigger, then we would do an outreach or we would reach out to the leaders and ask them what's going on. It's very rare that we would start over and which we've done by the way with CDEF because it had become very critical. But for the most part, it's just conversation. This is what we found. We just need to do a reset and have training and education usually which is a very easy intervention or there's nothing to be found and that is fine too. And we'll watch next month again. So for me, the most important piece is having a detection system and having the support structure to respond to what you're detecting and including those people who are doing the work when you're doing the respond day. Thank you so much. And I think that, you know, this sort of rolls into the next couple of questions that we talked about and I'll open it to all three of you to answer is, you know, Christy, I think you really just described what that evaluation looks like and going back to that definition of sustainability but also looking at the accountability and what role do leaders have in sustaining initiatives on the front line. And in addition to that, Christy, you also mentioned education and what are the ways to optimize education and when it's being delivered and that communication as well, you know, as far as that interrupting staff, providing multiple learning modalities. So I will open that to any one of you to answer. We have a couple of minutes before our Q and A. Maybe I can take that question, Christy, about education and communication because there was a question earlier as to whether which one should be considered in terms of sustainability. But I believe that both education and communication should always come together and believe all of you will agree with me on that. But the question is which one comes first? And I believe in the case of healthcare, in most cases, it really requires technical skills and come with it. And it is important that in healthcare need to be learned. It is not something that you can just acquire through experience. When we are dealing with lives, there is no trial and error. Everything has to be exact, precise, science, and evidence-based. And as what we have always talked about and as what we have been advocating here in patient services, there should be zero harm. And so I believe this is one industry in which we can never afford to make any mistake or defect, just like in manufacturing or in other industries. And since we are all living organisms and viruses and bacteria are very much alive too, such as what we are going through right now in this COVID-19 pandemic, I believe we need to keep learning and studying in order for our health. And I believe that and studying in order for us to be able to adapt and prevent any harm from happening. And now we also hear many of our healthcare professionals being overburdened, they're tired, they're burned out. And so nobody can really complain that they are not doing their best. But the question is, is it enough that we are doing our best? I really remember this quality guru, Edwards Deming, saying that it is not enough that we do our best. First, you must learn and know the right thing to do. And then we do our best. And so once we have educated or we have been educated on what is the right thing to do, and then we start communicating, echoing the right thing to be done, and then work at it towards achieving whatever goal or plans that we have. So I think education should come first, knowing the right thing to do, and then we communicate to our team members or within our network and the community. Thank you so much. It really is, is it the chicken or the egg as far as that education and communication? I know, Kristen, you were gonna talk a little bit further about evaluation, please go ahead. Thank you. Yeah, and I love that. What did you say, Joyce? There's no trial and error when it comes to patient lives. A good takeaway. I wanted to add a little bit to what Christine said, which I think was so spot on about the evaluation and not panicking and how much we love data. I think where I see people fail, two things. One, we don't look at anything. And then we come back a year later and say, why aren't you doing this thing that I thought you were still doing? Or we look at the wrong data. So just wanna talk about the evaluation and thinking about this mixed methods, really robust evaluation. Because when people, I think what people tend to do is focus on that main patient outcome. So there's all these things that you put in place and then we're looking at mortality or infection rates. And that's so far removed from the actual intervention that people are missing everything that's happening in between. So we like to look at preference and performance, look at clinical outcomes, but also structure and process outcomes. So can you do a quick survey or an interview of the people that are involved in the intervention and say, how is this going for you? We started this thing six months ago. Is it still what you wanted? Can we think about this iterative design? Can we make any improvements for you? What are all the other data points that you wanna capture? Is it adoption or usage of something? If you had, I do a lot of clinical decision support tools, you rolled something out, are people following the recommendations that were given? So not just using it, but using it in the way that you expected them to. Are there cost issues? Should you be talking to IT to see if there's an economic burden or if this thing that you built, you didn't realize now requires lots of maintenance and that might impact the sustainability. So I would say as much as you can throw a lot of evaluation components around something, qualitative pieces, quantitative pieces, process, structure, everything to really understand if something is slipping, but then even on the positive sides, you've sustained something for so long. Why? What is it that people like about it? And then you can use that, I think to inform other initiatives as well. But to not focus on just that one infection rate or whatever that final endpoint is, even if that's the goal of what you're doing, but what's happening along that process. Kristen, thank you so much. And to all of our panelists, thank you. I mean, we really just demonstrated that healthcare is complex. And when it goes into quality improvement and performance improvement initiatives, it gets even more complex. And really having the appropriate stakeholders, the appropriate evaluations, the appropriate support in place to sustain is really critical. And even jumping on to some of those other initiatives that we may have going on in our healthcare organizations. We do have a few questions that came in through our Q&A box. So the first one we have is, how relevant is assessing organizational readiness for change? Yeah, I can start with that, Chrissy, because that is exactly the first step that we've done when we started working on our sustainability in our organization. And we found that we didn't know how to tell if the organization or the facility, in our case, is ready to take on the improvement that had been put in place as part of their standard work. So we looked far and wide to see if there was any tool out there or any framework that we could use to help us understand whether or not the facilities and the leaders and the people in it are ready to take on this project, right? That is no longer a project, because it's done, we've implemented it, we're now having success. Now, it's all yours to maintain. And it turns out, and we've known this, that that's not enough. So we have developed a tool that we have based actually from the frameworks that IHI had developed on sustaining improvement and put together a facility and leadership readiness assessment tool. And in it, we've added, we've included probes and elements that we expect based on evidence and literature, what a successful leadership should look like. You mentioned, what is the role of leadership and sustainability? Well, a lot, they have a lot and very important role in sustainability and what should be present in the units? What is the role of the nurses, the physicians, the frontline managers, the directors? We've included all of that in the stool and we have set it out to specific leadership in our facilities and asked them, granted it was self-reporting, self-reporting and assessing themselves on these elements and giving it as a demonstration. So yes, you have to develop some sort of assessment methodology to assess the readiness of the medical centers or the facilities or what have you. Otherwise, what would usually happen is that the improvement that you have built up and worked so hard for would just go to waste, which is the theme of this webinar. So it's important to understand where they're at and what kind of support they need. And it's important to have something above them to be able to support and detect when they need that help. So yes, readiness tool is very important. Thank you so much, Christine. Yeah, you have to see where your culture is at and where everyone is in order to really start implementing and moving things forward. As I asked the next question, I do encourage our attendees to put any other questions they might have into the Q&A box. But the next question I have is change episodic or continuous or vis-a-vis sustaining change? Kristen or Joyce? Yeah, I mean, I think it depends on the initiative, right, like there's always change and some that we expect and some that we don't, like a new pandemic that happens. I mean, I think it sort of goes back to the original idea of sustainability and is this something, is this a moment in time sort of change or is this something that you're gonna change for forever? I don't know if I'm answering the question, but all of these considerations are really important. And so again, when you're thinking about the design of something to really think is this something, I'm gonna be continuous improvement. I'm gonna check on this new intervention every month for the next few years or is this something where we need to really focus for sort of three months and then we can move on to the next thing? Folks are so excited about deploying this new thing or making change and not really thinking about some of these more foundational theoretical kind of concepts. Chrissy, can I just add something to that? That is my favorite question. To me, sustainability, change is always present. And sustainability doesn't mean no change. It's not static. Sustainability to me is not an outcome. It is a constant process that starts from the very beginning and there's no end to it. As Joy said, you're dealing with people, right? They always percent change you. Things are changing right now. So change may be episodic in terms of how you respond to it, but there's always change constantly happening. So what's important is to create a culture that is able to continually improve, adapt and learn, as Joy said, about the learning. So sustainability means you're able to detect the changes and you know what to do with it and knowing that that's always going to be present and nothing is static. So being flexible, not being perfect, but being flexible and being able to learn so that you can adapt. So that to me is what sustainability is. Change is always going to be there. Yes, and I think this question has come through very loud and clear as far as open leaders support that sustainment. So for some of our leaders that are removed from units or clinical areas, what can they do to ensure that those offers and sustainment is happening? Joy, would you like to take that question? Yeah, Chrissy, I think there's one word that really, I think hit me and reminded me in all this discussions today and in order for us to sustain any project or program, I believe being able to adapt, adaptability is very important and tenacity at the same time. And in all of this leadership takes on the biggest chunk of the job, I would say, because it is the leaders that will set the tone. They will say what are the correct things to do, the right things to do, but at the same time, they need managers. We all know that leaders managers are not identical, but they have to come together in order for us to, in order for our team to have a high performance. Leaders will say the correct things to do, but the managers will be the ones who will help us in leading the past and in making the operational plans and the strategic plans. So I think this is really the time when, especially during this pandemic, that leaders should come down from their boardroom, but really come down and meet the people and talk to people and make sure that everything is in order. You know, this is the time that leaders will need to develop the trust and the transparency also for the people to understand what's going on and what's happening. So I think at this time during the pandemic, it's difficult to think about sustainability right now. It's really survival. I would say for many of the organizations, but then after survival, we must learn to cope and we must make sure that we will be able to stand all these challenges in the future. For us now, there's a problem of sustainability. Why is that so? Because a lot of our health workers are migrating and leaving their country. So really that's a big problem for us on sustainability if we have a lack of human resources to really sustain and keep the operations together. So right now, what we're really doing is to make sure that there's constant education and training because we don't know when this health workers will leave us. It can be next month, it can be next week. So it really has to keep going, training, really empowering them, equipping them and for the leaders to be really on the ground to see what's happening. Thank you so much, Joy. So we have just one final comment before we have to wrap up today and I just wanna thank everyone. And that was from one of our attendees. Someone famously said that with reference to performance improvement that change is the only constant and that really is true. So thank you again to everyone in our attendees for being here today. And I will turn over the closure of the webinar to Donna. Thank you all so much. What a fabulous, fabulous discussion. Somebody commented that this was a very inspirational talk and it absolutely was. Especially these days, as Joyce mentioned, in these days of the pandemic. I do just want to reinforce again for anybody who might have joined late that we are providing continuing education credit for anybody who joined the live webinar. So nurses, physicians and pharmacists will get an email from MedStar Health if you registered that way. If you are looking for ACHE credit, you can just log that right into your account on the ACHE website for certified professionals in patient safety and for board certified patient advocates. If you registered indicating that you are looking for that kind of credit, we will be sending you a certificate from the Patient Safety Movement Foundation. So thank you everybody for joining. Every month we provide these webinars free of charge and we'd love for you to support us in that endeavor and be able to continue to offer these for free. So if you're interested in supporting us, please do visit our website at patient.sm.webinar-donations. We will be sharing this presentation with you and all of the resources that everybody spoke about today. So you can always find the link directly here afterwards. So again, thank you to our panelists, to Chrissy for doing a fabulous moderating session today and to everybody out there who joined us. Have a wonderful day and a wonderful weekend, everybody.