 Good morning everybody and welcome to another webinar here at the patient safety movement foundation. I am Donna Prosser. I'm the chief clinical officer here and today we are talking about a hot topic right now. And that is the topic of burnout and how can we reduce burnout and healthcare. What are some strategies that clinicians and leaders can employ to to deal with this very significant problem that we have. We are objectives today are very straightforward. We're going to talk about some of the root causes of burnout and healthcare and how to recognize those signs in yourself and in your colleagues. But most importantly talking about ways that we can mitigate that burnout at both an individual and an organizational level. As always we're going to provide continuing education credit for nurses, pharmacists and physicians through our our partner MedStar health respiratory therapist may also be eligible for this depending on your state. So if you are interested in collecting this CE you will receive a an email from MedStar directing you what you need to do within the next five to seven days to to obtain that CE. We will also for this webinar be providing continuing education credit for healthcare executives. If you want that then please just log this event into your ACHE account certified professional professionals and patient safety will receive a certificate from the patient safety movement foundation as well as board certified patient advocates. And then for a certified professionals and healthcare quality, your attendance will be documented by NHQ we will let them know that you attended today. As you can see here on this slide none of the planners or the participants in this webinar have any disclosures to report. Now we want this to be interactive so so get your phones out or open a new browser on your computer, you can go to slido.com and type in the number 383 753, or you can use your cell phone and just take a picture of the QR code that you see on the screen right now. And that'll get you into the program or polling software because we're going to be asking you some some questions during this session. We as always we you know in keeping this interactive we want your comments on chat your questions in the Q&A, we will have 15 minutes of question and answer at the end. Just one more reminder to please log on to Slido right now because in just a few minutes we're going to ask our very first polling question. So now it is, it is my pleasure to introduce our moderator, Vanda Vaden Bates. Vanda is is a medical safety advocate but she's also the CEO of 10th Dot so she has a lot of a wonderful organizational experience. She's also a member of the board of directors here at the patient safety movement foundation and participates in in so many wonderful things with us and we are always love to have Vanda moderate our session so welcome Vanda I'll have you now introduce the rest of our panelists. Thank you Donna and thank you to the committee members who have helped us come here today and please forgive me everyone. I am developing a little bit of a cold it is not coven tested. But you might find me just a little bit raspy today. I will begin by saying that in 2012 my husband died from a preventable medical error, and that is how I come to even understanding the issues that are presented within the medical systems today, and that burnout is particularly one of those issues that has been drawn near and dear to me because it relates very much to the work in my career, but also because having spent 12 days in the hospital with my husband before he died. It was very evident to me where there was a resourced clinician physician nurse or staff member within that hospital system, and where there was an resourced when the, when there seemed to be an exhausted person attempting to move past their boundaries. It isn't our human nature to push past our boundaries, and there are plenty of upsides we go to the moon because we, we push past the limits of our thinking and our, and our perceived capacities. When systems begin to press against our limits, repetitively that impacts safety in our medical system, and it impacts it for those who are delivering care those are receiving care and those who are supporting care. Joining us today are professionals within healthcare who have particularly paid attention to and are drawing our intervention strategies toward that, which will help improve burnout in the medical systems. I'm going to be introducing Kim Baker, who has a Masters of Science in Nursing, and is a behavioral health programmatic nurse specialist at the University of Pittsburgh Medical Center Presbyterian Hospital Kim thank you for joining us today. Oscar San Roman Orosco is an MD in the institution of applied global public health initiative at University at Otanimo de Cantero in Mexico, and Colonel Lewis stout is also has his Masters of Science in Nursing, and is a retired Colonel from the US Army Nurse Corps is a chief as a chief nursing officer at Madigan Army Medical Center, and when I thank the three panelists for being here today and bringing to this audience both those who are here present live in this conversation as well as those who will be watching us and watching this webinar later. Your expertise matters a lot for this audience but also in the institutions that you serve and have served. Oscar, I will begin by focusing on something that you created. We're going to present. Actually, first of all, let me ask a quick polling question I'm sorry I'm jumping ahead just a little bit Donna would you pull up that polling question, and we'll ask the audience here to weigh in on what the legislative measures, or interventions or strategies, have you witnessed with regard to burnout. This is an open ended, open ended question that we would invite you to respond to, and that polling question will stay open so if nothing's coming to you immediately or you're still wanting to get up to speed on the slido.com and putting that number 383753 in, then just know that it will remain open for you to until we ask the next polling question which will be quite some time from now, and I see some responses from the committee time off recognition of valiant efforts time away from work self care, resigning from affecting job positions I know we are seeing a lot of that today. That is an act of a response to what I would think of as unreasonable circumstances or expectations of our human capacity. So keep keep putting those responses in there. I will continue to look at them and Donna will pass along anything in the chat that she thinks might be important for myself and the panelists to note. And next I will move over to you, Oscar, and ask you if you wouldn't mind, Donna's going to share a systems map that you created and I do want to preface this by saying that this is not a complete map. One of the great things that I admire so much about the patient safety movement foundation is that they are particularly skilled at at starting and managing and perpetuating collaborations that bring a number of perspectives together on particular issues. And Oscar I know you've used this tool to look at other problems in healthcare systems issues. And I would just like for you to very quickly show us what you've created here and then I have a question with regard to how that relates to burnout. Thank you everyone. It's a pleasure. First of all, good morning to everyone. It's a pleasure to be here and an honor. And yeah, well, basically systems thinking has been born in the past recent years. There's some thing that it's starting to evolve and helping us to look things differently. Like a lot, there's a lot of literature there. But basically the idea is to point that in every system that is alive, that is, it's continuously changing and many factors are affecting one to another A plus B is not equal C is what this is what it can mean. So this is the idea of the system, what I tried to point out here, it was that we have two main factors in the middle, the middle we have burnout in healthcare. There is like a bubble in which all the different factors if you put more air in one bubble is going to impact the the other bowl and so on and so on. That's why there are different color codes and stuff. But the idea is that you have personal factors, an environmental factor so she'll associate all factors around it. And that's basically a point of showing this. Thank you. Thank you, Oscar. And I am wondering if you might want to draw our attention to maybe one or two that you see in this very early map. Again, this is, this is a tool that could be used and I would even recommend that maybe the patient safety movement can work with you and some of the individuals who are attending here today to really pull this map apart but are there one or two here that you think might be levers that would cross over many different populations across across this global across this global issue. For sure. The idea, three very important things that we can highlight here like the first, the one that you mentioned it's this leverage point in which you will see that a lot of arrows connect or when you start building it and you start drawing it. Like, like you mentioned it that's very important to mention this is obviously my perspective on a colleague's perspective that help me here to say, oh, you should put this just put this. But the idea of the systems map and system thinking is the more you know of a system, the more you know the system, the better the understanding will be so in here this is we have a mental health if you can see like in the middle of the human figure. There's a lot of arrows there. Mental health, if we start influencing mental health we can start obviously influence and reduce burnout in healthcare and how that's that could be one of the leverage points in which we already know that. But the idea also here is to find a another kind of things that are for example the feedback loops or the unintended consequences sometimes when you start acting in some place, you will impact the other one and so on and so on. And same with the feedback loops when you start acting in just starting drawing working in interventions and mental health to obviously reduce burnout in healthcare but you can also influence the family situation you can also influence the mindfulness, which is also related with the mental health of the person. So that from the personal perspective and from the environmental perspective, you can see, for example, the leadership style of them, of the leaders in the, in the field of what the bosses, how are they're giving the workload to their to their staff, the bureaucratic tasks, the political situation influencing them and the educational system and the healthcare system. So the idea here and this is how I'd like to wrap up a little bit this with these three very brief a strategy way to look at the different strategy is to start to open and look at all the different small factors that we think they don't act or they don't influence, but if you start adding them up, they will start impacting something. So here you have a, like I mentioned, mental health, and it will, if you start seeing all the different things around mental health, it's a whole work. If you start looking at there, same thing. Thank you, Oscar. And I am wondering if you might want to draw our attention to maybe one or two that you see in this very early map. Again, this is, this is a tool that could be used and I would even recommend that maybe the patient safety movement foundation work with you and some of the individuals who are attending here today to really pull this map apart. But are there one or two here that you think might be levers that would cross over many different populations across across this global across this global issue. Yeah, for sure. The idea tree tree very important things that we can highlight here like the first the one that you mentioned it's this leverage point in which you will see that a lot of arrows connect or when you start building it and you start drawing it. And like, like you mentioned it that's very important to mention this is obviously my perspective on colleagues perspective that help me here to say, Oh, you should put this, you just put this. But the idea of the systems map and systems thinking is the more you know of a system, the more you know the system, the better the understanding will be. So, in here, this is we have a mental health if you can see like in the middle of the human figure, there's a lot of arrows there. Mental health, if we start influencing mental health we can start obviously influence and reduce burnout in healthcare and how that's that could be one of the leverage points in which we already know that. But the idea also here is to find a another kind of things that are, for example, the feedback loops or the unintended consequences sometimes when you start acting in someplace, you will impact the other one and so on and so on. And same with the feedback loops when you start acting in just starting drawing working in interventions and mental health to obviously reduce a burnout in healthcare but you can also influence the family situation you can also influence the mindfulness, which is also related with the mental health of the person. So that from the personal perspective and from the environmental perspective, you can see, for example, the leadership style of them, of the leaders in the, in the field of the bosses, how are they're giving the workload to their to their staff, the bureaucratic task, what's the political situation influencing them and the educational system and the healthcare system. So the idea here and and this is how I'd like to wrap up a little bit this with these three very brief. A strategy way to look at a different strategy is to start to open and look at all the different small factors that we think they don't act or they don't influence, but if you start adding them up, they will start impacting something. So here you have a, like I mentioned, mental health, and it will, if you start seeing all the different things around mental health, it's a whole work, if you start looking at there, same thing. Thank you. Thank you very much for that. Kim, Colonel Stout, what do you see as some of the organizational drivers of burnout Oscar points to some of those on the systems map. What do you see in in your organizations and in your experience. I think that first the recognition that healthcare has really become a business and recognizing that shift from the patient to the customer and the focus of that and the association with the not only the staff at the bedside and the treating providers, but also from an organizational level. That societal shift of customer has really, I think, driven much of the burnout that we see, especially at the bedside I am in an inpatient I work in the inpatient setting and we certainly see that societal shift impacting and the organization has to support it. I mean, we recognize that, you know, it is healthcare has become a business and we have to treat it as such. And sometimes that takes the patient focus away and puts it more toward that customer element. Yeah, I can see that. I think one of the issues that I see with an organization is the redundancy of workload that's pushed out to the clinicians, often tasks are added but it's rare that tasks are taken away so organizations have certain requirements or they're interpreted as certain requirements, and those are passed to the clinician for each health care visit. You know, as we say, requirements to check certain boxes, and it just, it's compounded, and it's just adding to the complexity, and it's actually taking time away from our clinical visit. So that's always a distractor. I think that Kim I'm really interested in that focus on business, the business model that has now, you know, we almost feel like it's a must like that is a requirement. And given that then what are some of the barriers for administrators to address burnout. And recognizing that we're set at best, really that workload, right, recognizing that we cannot give as administrators as leaders 100% all the time to every single topic that we have to address. And recognizing the own our own institutional barriers that redundancy the record we find from an administrative perspective, which I know also, you know, and comedy is the clinical perspective, the barriers and we see just with the record when it comes to workload of administration I think what we see is not only can we not give 100% but then are those that are surrounded by us our patients see we're not giving 100% they see our attempts to multitask. And those attempts to multitask usually result in one one task, not being fulfilled completely. So the requirements requirements to the customer aspect or hcap scores work by balance, all those things are, are in our minds from an administrative perspective that we ask our employees to check their feelings at the time clock and we just know that simply. It's possible. So, yeah. I mean, you make an interesting point there that I think is important for us to keep in mind when we're looking at this issue and that is that burnout is it doesn't stop based on role, whether you are a nurse or a physician or a person who is managing the health and wellbeing and the cleanliness of a system, or an administrator. No one is immune from burnout, and the system itself is is something that can contribute to that at an individual human level. I'll ask you the same question but I'll focus on a different part of the equation. When you look at physician burnout. What are some of the barriers for physicians and addressing burnout specifically. One of the things that I see is, you know, as I mentioned just a addition of administrative tasks, you know we have professionals expertise in every single area, you know they've spent years honing their craft becoming experts at what they do, and then oftentimes there's bureaucratic requirements that are just laid on them. Without the organization taking the time to really do a review and say what is this really the responsibility of a clinician. This is something that the clinician should be spending their time doing as opposed to administrative personnel so do we have the right mix of personnel in each work area. And that takes time you know for the organization but it's important and it needs to be balanced so the administrative point of view with the clinician point of view, you know oftentimes policies written are not received, so they don't have the same consequence of the intention. And so you need to balance that you know we can put all policies in place but if they're not realistic, then they're not helpful to the organization, and they're confusing. And that just leads to again distraction and just increases the stress and the burnout. And one of our audience members points to something that relates to that, and then in not putting the policies in place and not doing some of the things that we know could help change the culture, create systems that are actually supportive of individuals who are writing in their roles, what will happen instead is there is a mindset and a language set that focuses on more of the blame and shame Sarah thank you for that comment because I think it is really difficult and I will say that as I was preparing to create this panel today. I noticed my own mindset of what I would call of you wanting to like pull myself up by the bootstraps, some of those, some of those internal messages that I have had since the time I can remember being a human that is about pushing myself past my, my perceived breaking point, going further than I think I can. And while there is a time and a place for that, when there is a repeated expectation around that, and then on top of that, a language and a framing that there's something wrong with the human because they're not able to. I read a number of evidence based research and, you know, documents that are really framed through the lens of, of language that's around us humans not being enough to be able to do that. And not, for example, like if I wanted to fly or take a train or drive my car from here to California. If my vehicle runs out of gas, I do not blame the car, I do not blame the gas tank. And so I do hope that one of the things that that this webinar will do and that the work that those who are here present today can do is to help change the model of our thinking around this. But with that in mind, I want to ask a question about these ingrained systems that are, that are complex there are economic drivers insurance there's an opaque payment structures pressures to increase productivity while reducing costs, it, it all appears to me sometimes as being unfixable untenable. And I am aware that inroads are being made by organizations such as the ones that the panelists here today serve. I would like to hear from each of you if we could about what you're seeing that are actually driving changes to better align performance expectations with true human capacity. Kim, would you like to start. Sure, I have to just going back to what you said previously. I think it is also important to recognize that as leaders often we will praise an individual for pushing themselves too far. You did a great job working that fourth 12 hours shift this week or, you know, commending them for saying over three hours to chart instead of saying, What can we do to ensure that you're getting out of here on time and not having to work additional So I definitely think that is from when we talk to the administrative and the organizational, you know, contribute contribution. That's one of those things. But to those complexities and what we can do to drive some realistic expect is to set realistic expectations. I think we don't do that anymore as as it is healthcare. I think that the expectation and again going back to that societal shift the expectation is that as page as a patient that every individual need will be met. Exactly when you expect it to be met. And I think the providers also have that same expectation that their expectation is to do that to meet that every need in that moment and just immediately from the beginning setting a realistic expectation to the to the patient to the caregiver we know you can't do all of these things at the exact same time. We use the aid it you know really just setting a duration I think that that's very important. So I'm just making patients know I will get you within this timeframe. However, or letting staff dog at you within this time frame we will meet this often, but really sticking to those durations but not setting an unrealistic duration when you're doing so. I'm just making sure you're really explaining to not only your, maybe your subordinate or your patient or the patient explained to the nurse, just not only explaining you know, this is what I expect, but also this is how, how I expect it to be completed. And I don't do the best job of that in healthcare. Oscar, what's your perspective on that. What are medical professionals and what can people do to help drive change that really better aligns performance expectations with human capacity. And what I what I would say is to go back to where where where the system is was like was born or where are the basis and where are we sitting at, because if we want to to change that part, or that like last part of the tree, if we could say see like a tree in a metaphor, let's look at the roots of the of those problems usually here in Mexico happens a lot that a root of the problem is the since education system, because how residents are in charge of what the medical that doctors in in base or on duty have to make. So you're giving some students more tasks than they actually need to be shared. And that's because of a here, here I key system that needs to be changed. So here, what I also, we need to look at this, go back, look at the root and start changing the root from the problem because if we start just like a tree cutting just the branches and starting to fix the tree will still keep growing but we need to go to the to the basic of the problem. Thank you I appreciate that perspective. Colonel Stout. I think where I found the organization to be most effective in making change is having a collaborative discussion. As you know we've alluded to several times you between executives administrators and clinicians, there can be a disconnect in what the workload truly is. And you know, I think we've said it were just adding, you know, I'm just adding one thing, but it's being added to already a very long list of tasks that have been interpreted from different organizations or, you know, certifying bodies or the organization itself as being requirements without actually understanding or measuring the amount of time that's required to meet those tasks. And you know whether it's the electronic health record is what should be looked at is you know the number of keystrokes required you know how long does it take to get in and out of each patient record. That takes an amount of time and the patient see that it was already said, the patient see the distraction they see the amount of time required. The clinicians hurrying to get through the task of having to see the patient so that they can do their documentation, or doing their documentation while they're seeing the patient. And you're not not truly focused to having the ability to truly focus on the patient which is leading to burnout, you know our clinicians want to spend their time, you know with with the patient that's what they're there for that's what they've trained for. And that's truly the satisfaction of the profession. And we get mired down in a lot of the administrative tasks so we can sit down and really walk through that and then identify redundancy identify those areas that are you know being documented in multiple places or getting done by multiple people in different areas. You know we when we can eliminate certain parts, not only do we become more efficient but we're more likely to have proper documentation, because often you miss it in one place but you know because it's done in three other places. And then somebody measures it and say it's not being done well it is being done it's just being documented somewhere else. Listen to you Colonel stat I think about you know that let's let systems do what systems do best and let people do what people do best and right now it feels like there's this convoluted attempt to cross those boundaries and not really honor the both the the assets and the benefits that come from from those from individuals as well as from systems, but also not really honoring the limitations of those as well, and setting our systems up to do so well. I want to acknowledge a couple of really important comments that are made in the chat here. Thank you Maureen Melody and Terry, Susan. So, Alyssa Donna, could you put up again that map the systems map that Oscar presented there's a request to see that again and I think it would be interesting to see that or to let the audience see it again. Before we continue on, there's, there's something that is really nagging at me and that is, and it is not something that the current panelists have expertise in so I just want to acknowledge that. One of the things that the patient safety movement foundation is really looking at the education system and looking at governance systems to help support and mitigate some of the stressors that are are being seen within the systems of healthcare throughout. And so I don't, although we're not focusing on that today in this webinar. If you take a look at some of the broader webinars that the patient safety movement foundation as well as other organizations have been presenting over the last couple of years. You will find that there are a number of intervention strategies that are being promoted and carefully looked upon to help address both burnout but also some of the repercussions from burnout like attrition, etc. Thank you for showing that Donna. Let's go to a question. A question for the audience and that is, where is your organization focusing efforts to mitigate burnout. And again, this is an open ended question. And I would invite you to take a look at the screen. And let's just look at what some of the organizations that are represented here today by this audience are doing to help mitigate burnout. We have a lot of communications with employees. Yes, COVID has resulted in efforts to fall flat just treading water. I, I hear that I see that. I also think it's important for us to note that burnout is not stopping at the doors of our healthcare systems. We support a number of patients who are working or, you know, in relationship with long term healthcare issues, and in some case, terminal situations, and the burnout is very real there as well. This is not something that is limited to those who are delivering care, administrating care, supporting care. It is also being felt, witnessed, and is having a strong influence on those who are receiving care. I just, is it possible for you to scroll a little bit on that organizations trying to give time off, which is, of course, complicated by the short staff ratios, one of the statistics I saw recently in New York and I think this is several months old over 2,000 nurses, there was fewer, 2,000 fewer nurses in one particular healthcare system in upper state New York over the period of, since COVID had started and I think that was about a year old. Thank you Donna and thank you for your continued comments. This poll will stay open if you want to continue to respond to that. Thank you very much for doing so. Let's come back to the panelists. I'll go down a little bit. In terms of prevention, the day-to-day interventions and long term solutions. I'll call on you Oscar to first start us out by talking a little bit about what you think some of the major prevention strategies can be to mitigate burnout in healthcare What's the globe? Let's keep in mind here that we're not just talking about the systems that this group of panelists are familiar with, but this global concern. I think it's very important this last part that you mentioned that is across the globe that the system doesn't apply just for us, but it's different for anyone. So I think number one will be to analyze and personalize your system. The system map strategy is something that everyone can do, that you can start looking at all the different perspectives and be there, be in your system, live it and know every little part that is going on. And administrator usually needs to go to the field to see how the January is doing, how the physician is doing, how everyone in the field and the task that is a day-to-day so that they can have a grasp of what's happening there. And second, having this in mind and what's going on will try to begin to change and take the risk to go for interventions, evidence-based, the patient safety movement has a lot of interventions that can be related and can apply to their system and adapt them based on what you build and where you create it. And mindfulness being mindful that this is a problem, that this can be prevented and this can be acted. It's something that we should keep in mind and clinicians and also hospital leaders can must have in mind, this draw the map, point their map and see where are the issues and see where are the leverage points, where are the feedback loops, where are the unintended consequences of doing X, Y or C. I think that's the best prevention strategy, one size doesn't fit all, they must do it by each one. Oscar, a couple of things that you said in there that I think I would like to put some highlight on and it came up from one of our audience members today is that there's often a great distance between the individuals who are designing and implementing the procedures, the policies, you know, shaping those systems. There's often a great distance between what they're doing and the patient care, the direct care. So one of the things that occurs to me is what might we be able to do more of to help people have more direct experience with that day to day care. And that Kim will turn to you. Let's, let's hear from you about what you think would be the highlights of preventative, but on the day to day, not on the preventive I'm sorry but on the interventions with regard to the day to day care and mitigating burnout. I think that, you know, it's important to recognize that we often give our patients times where they are not disturbed right when they have times when we will not pass meds times we won't do vitals we allow them sleep holidays, and that's important for their healing. But we don't do that for ourselves. And I think that as administrators as employees we have to advocate for those holidays ourselves, even if it's one day and I as a former director really enjoy the idea of the no call day. This is the day that even if the place is on fire your best friend isn't going to text you to say oh my gosh, can you believe this happened, right just that one day, even a month, when an employee has a chance to just not have to be concerned with work, because we know with technology we're all so connected every day to everything that's happening. I think of mine is on maternity leave, but she knows every single day what's happening in this institution because our friends are texting her right so just recognizing that that time is necessary away from the bedside, same as it is patients. I think from a day to day perspective, just immediately recognizing what bad events occur and intervening not just recognizing that but immediately having intervention. And then there's an immediate response by a team of specialists I've seen in the chat multiple people referencing mental health. These are individuals who are trained in that crisis response that deploy to the unit, maybe be a telephone person physically to the unit, but they engage with everyone that's involved in that situation if it was a bad code the bedside nurse, potentially that that you know feels that maybe they didn't do something right. The family member that just lost a loved one really individualizing that intervention to each individual that was impacted by that negative event. And also really just being collaborative from a day to day perspective, if we are not collaborative and that I know that everyone said it across the way but really from the physician to the nurse to the patient we all have to be engaged in the treatment plan. And if we're not all engaged in that treatment plan, then we don't have as much success, right so if we all agree to a treatment plan, or at least recognize and acknowledge that this is the treatment plan that's set. There's a lower expectation of going beyond that. So as a, as a healthcare provider, recognizing that a medication, we know our men's are doing every certain, you know, every four hours or whatever it may be. But have making sure that the patient understands that to writing it on their whiteboard so that they understand the expectations really being clear and collaborative having the physician explain this is why the medication is ordered every four hours, etc. I think that that collaboration is really critical. And then also when addressing those behaviors that are really high risk, those one, we all have patients that. And we sometimes ourselves demonstrate really high risk behaviors and making sure that we are working collaboratively with our team to approach those and to address them. And then finally, from a day to day just really addressing moral injury. I think that not only our healthcare workers are faced with moral injury, but our patients are directly impacted by it as well. If the staff that is caring for a patient is struggling with a decision that is being made for that patient by that patient on behalf of the medical team. If we're struggling from a moral and ethical perspective. It's important that we address that and that we do so in a manner that's not objectifying that distress of recognizing and it's something that we all experience. There's so much in there Kim and I want to emphasize that Donna and Olivia and Isabel who are sort of the foundation of this webinar today are taking resources like what you've mentioned and and what other panelists and they have also at their disposal, and they're making a resource list together for the audience here today and for those who will be listening later so if you didn't catch all of the, all of the references that came made there, just know that we will have a resource list for you. A few years ago, long before COVID and the pandemic circumstances exacerbated burnout so strongly. I had the great fortune of working with a healthcare system in the Salt Lake City area with a leader who knew to give a lot of time and understanding with several nursing teams and a pilot program or we started to scope out a pilot program and one of the, one of the key results of our thing was almost a six month discovery process is that just like you just said Kim, every single patient has their own treatment plan. There are different individuals, their needs are unique, and you cannot subscribe a general plan to all patients, and yet we do try to, to subscribe, prescribe rather for individuals within our healthcare systems around burnout, burnout circumstances. And so I think it's really important for us to remember that and it certainly came up in that discovery process with the healthcare system in Salt Lake City is that if we give processes to individuals to create what they know resources to them so that they have the agency to safely care for themselves and their patients or their systems that they are designing. We stand a much better chance of creating environments that are conducive for thriving and are safe in the delivery of care. That individualization cannot be underscored strongly enough in my opinion, and we do trend we trend toward generalizations on matters that certainly there are things that we can learn like the systems map that Oscar put together that will help us see where to put those levers in place. But that does not replace the individual care treatment for each individual so thank you for emphasizing that. Colonel Stout, let's hear from you about more of a long term view, especially since you are now a retired colonel from the US Army. What's your perspective as you start to look back but also to look forward into more of a long term intervention strategy. I think that's a, you know, very complex question depends on the organization for, you know what, what the priority is, but that has to be narrowed down. You know there's just, you know, increasing priorities and everything seems like it's, it's emergency and it really takes an effort to focus on that and decide what's really going to have the most effect. As I mentioned before, you know it's very helpful for an organization to take the time to review their staffing model. As we call it a bottom up review, looking at each individual area by itself and looking at their workload, looking at the measurement of tasks and seeing if the right mix of staffing personnel are on hand we have the right mix of professionals and administrative staff is, you know, what's the reliance on automation is that really helpful in some areas you know we add an automated tool, thinking that it's, you know, just this great savior where actually it's just adding an additional barrier. You know there's, and sometimes an over reliance on something being electronic or automated, where a piece of paper has always worked, and will continue to work. You know we, when that electronic system fails then you know organizations can struggle to complete tasks because they become so reliant on it. One of the things that I think has been successful at organizations I know there are some organizations that do this is, you know we, most organizations will do exit interviews with individuals as they choose to leave an organization. And they will, you know, ask them their questions get their feedback, and some organizations will actually do stay interviews. And I think that's can be very helpful is to take the time to sit with employees that choose to stay and find out specific reasons. Are there certain initiatives, is there certain drivers that really keep them there keep them with the organization and when you find those and we say we exploit them. We offer those opportunities, more globally to other individuals. I think one thing that would be helpful as a global health care community is a formal publication of rights and responsibilities for the health care provider. I know it exists in certain areas it's been written to, and in some level but I, in my opinion I don't have never seen it, you know, globally promoted or produced that we actually publicize that there are, you know, the patient rights and responsibilities that I think are more highly seen and talked about, but I think there's, there's some benefit for the health care providers certainly during these times to be recognized, and to set that expectation with our with our patients, you know, in those health care contexts, they, we seem to have also you know patient population it's under stress they're they're frustrated, and they come in and they are seem to be increasing the hostile or have demands, you know, what they believe is required of the medical community to provide to them, without really allowing for the health care team to identify what the issue is, and what the best resource would be for for that patient. I think there's really a need to go back to that collaborative patient interaction where the health care provider can sit with their patient and determine their needs and explain to them. What I feel is truly will be in their best interest for the optimal patient outcomes. There's a lot in there. Thank you, all three of you for sort of looking at the, you know, the prevention strategies the day to day and the long term. I will add one that I would say I would maybe put it in the near term category and that is paring up the education with the, with the delivery of care. And also, there is a, there has been so much change and I think it was Nancy or Terry who brought this in the chat that a lot of individuals come into their clinical or you know their medical delivery of care, because they came in to actually deliver care, not deliver administrative tasks. And I do, I do understand that there is often a mismatch in the way in which individuals are being prepared, and then actually what happens when they get that first job and they start to work with individuals who came in 1020 30 years are very different circumstances. It also it strikes me as really interesting occasionally when I hear people talk about the reasons people go into health care. And I think we often limit our thinking about people going into health care because they are compassionate and want to deliver care and certainly that is in large part that is true. But also these are career choices. These are living and these are financial choices that individuals make and so making sure that we align the intentions of the individual and what the reasons that they are going into the fields that they are going to in with what they will actually be doing day to day in their work. We have one question from our audience. I'm going to start to turn toward our audience questions here and so I will invite everyone to use the Q&A area to add that and these are questions that will pose to Colonel Stout, Oscar and Kim. The first one comes from Dharmak Nimana and I apologize if I'm not saying your name correctly. She asks or they ask, can we create key performance indicators or KPIs for burnout purposes. How might we do that. What would the details of that meet. What would the details of that look like. Kim, are you seeing some efforts to put some KPIs with regard to KPR in place at your hospital system. Not specifically, however, I can speak from a general perspective and when we talk to measuring burnout, we are doing a lot of work currently around the workplace violence and the worker on workplace violence and we're developing those indicators to measure that. I believe that those indicators very closely aligned with burnout, because we know that the two are very close that there's a close relationship between the two, but I can't say that we're using anything specific I don't know it. Father of the other panelists can speak specifically to that. Thank you. Oscar, Colonel Stout either if you have something to contribute for that question. I think there's a lot of belief in the organization that they are that they are measuring burnout that they have effective tools for that but I'm not sure that we do. I think, you know, we find those things that we feel we can objectively measure. And, you know, we're trying to measure a lot of things that are very subjective. So, you know, there's, I saw a reference in the chat, you know, for being counters. You know those resource personnel that think that, you know, here we have this tool here's we're measuring this is this is really a reflection of it, but it's so it's so diverse I think it can be very difficult to truly measure burnout in individuals. And as he has been mentioned before, you know, when it's also affecting you. So our, you know, administrators are under an extreme amount of pressure, and you often feel strange to be effective, you know, without having taken the time to do our, you know, own personal resiliency, as well so that we can remain effective for our personnel. So I was assigned to the US Army burn center for several years and I was doing burn flight missions for a number of years and you know the workload just increased and increased and you know I found myself doing you know back to back missions overseas. And, you know, I thought, you know, okay this is my job this is this is what I do. And it actually took, you know, somebody to come in and stand there in front of me and good military fashion order me to leave to go home. And to point out to me very distinctly that I was not being as effective as I thought I was. So I thought just being there and continuing to do the task was the expectation, the requirement. And clearly, I, I could do it. And I was not, again, being effective like like I thought that I was at the time and that needed to be pointed out to me as well. And the person who who brought that to your attention and in a way that you were able to hear it. I wish there was more of that I think we could use more of that today. Oscar any comments on that before I move to the next question. I would just like to add that maybe measuring a burnout would be like how bad is too bad, or getting into the zone of. Okay, this is bad but not too bad and starting to, to play with that thin line and because sometimes the leaders think if I can if I can handle that workload, they can, or they must, because that's a run is a wrong way of thinking because usually you're not living with them. So I think what we need more its empathy with the with the other staff, and instead of measuring and how bad this is, is, is too bad, or, or, or they can do this but they not is just start to be more mindful of the situation and more empathic with all your coworkers and your, your people working below next and over. And so all three of you have have identified one of the barriers that is at an individual level and that is that one of the impacts of burnout is our perception might be skewed, we might actually feel like our capacity or that we rally to continue, and we forget that that can have consequences with regard to safety with regard to our own safety with regard to the other individuals in our, in our personal systems that are impacted by our behaviors as well. And so what can we put in place to help bring that into awareness in such a way and I, and I do think that that little lens itself to the, the predeterminations that we make the agreements the operational agreements that we make. And so it starts within our teams, within our organization within our households within our networks to say okay, when this happens, I'm going to raise the flag, and this is what we are predetermining to do as a result of that versus waiting for that moment when we are under stress or in a state of burnout to try to make hard, difficult decisions. I'll call on Susan Hunter's question for you next and then we'll start to move toward closure here. And maybe I'll just ask you, Kim, do you see efforts in your system that are addressing that conundrum of sending people home when it is necessary, and managing that alongside the staffing shortages I know that you can see is particularly focusing on this with some of the work that Tim in many years doing. Would you speak to that just briefly and then I'll start to move us toward close for this webinar. So if I understand that just so I want to be sorry that I understand the question there, what the work that we're doing to get our patients safely transition to the community. No, I'm so sorry. I'm actually managing the shortages the staffing shortages. But also, making sure that people get sent home when they are at the staff is sent home. They're not overburdened. Yeah, sorry. I apologize. Yes, one of. So, obviously, the nursing shortage and I can speak to that directly. The nursing shortage has impacted every center of the world. So we do know that this is our global impact currently, what our institution has done and we did mention to me so I will mention specifically what we have done at our institution is developed an internal staffing agency so we develop a an agency within where nurses can commit to traveling anywhere within our system, specifically, and they are paid a higher rate, they are paid, you know, near that travel rates, and they will commit to any facility so really is improving our staffing system greatly. We just we initially anticipated that many of our own individual staffs would shift into this position, but instead what we found was we brought a lot of those individuals back that initially had left our institution, people that love the institution that left for whatever reason that opportunity to travel that are now having that opportunity, still working within the healthcare system. And that is just monumental when we consider some of the, the efforts that institutions are taking to retain their staff. In regards to sending our individuals home, making sure that our leadership, I can't speak high enough to the leadership at my institution for everyone from our director of nursing picking up shifts on a Sunday to help ensure that the staff have a day off to, you know, our medical directors working in the emergency department seeing patients triage in patients. It's just the the work has been so collaborative and we talked about that right that that importance of collaboration so between the internal staffing agency and really seeing leadership step into those roles and assist in every way possible. We're, I think art we're going to see an immense on our attention. Thank you, Kim. I'm sorry to interrupt you and I wish we had time for all of the questions but I'm going to turn it back over to Donna conclude to conclude the webinar today. Thank you, Colonel stout Kim Oscar and for everyone who attended the broadcast today and who will be listening later. We could probably spend days on this topic and I hope that this will just be the beginning of the conversation through the foundation today. Donna. Thank you, Vonda and thank you to all of the panelists what a fabulous discussion today. Vonda is absolutely right. I think we could, we can talk about this, you know, for days. So, thank you all to the, to the attendees today. Thank you for your interactive chats and questions. We will be answering any questions that we didn't get to afterwards and we'll post those on our YouTube page. And of course I just want to reinforce that if you want continuing education for this then you will receive a email from MedStar if you are a nurse physician pharmacist or respiratory therapist who indicated that you wanted that credit for health care executives or certified professionals in patient safety, or for health care executives log into your a CHG account for certified professionals and patient safety or board certified patient advocates will get a certificate from us, and log your, your attendance if you are looking for CPHQ credit here at the patient safety movement we try to provide all of this learning for free so we would love for your support in this if there's any amount that you can donate please do visit our website, donate $5 $10 and it'll can, it'll help us to continue to offer this fabulous content free of charge. Please do visit our YouTube page afterwards will let everybody know when that's up there. We post all of our videos all of our webinars on our YouTube page afterwards, and in the description you'll see all of the resources that we have talked about today. So, thank you again to everybody for, for joining us today, Fonda as always best moderator we, we love when you come in and and lead our discussion so, and thank you to Kimberly Oscar and the lease it was just lovely to have you today so everybody have a wonderful day.