 Okay, good morning everyone. Welcome to another healthy simulation com webinar in our webinar series So excited to be participating in this week's health care simulation week 2020 as well. We also have World Patient Safety Day, which is this Thursday, September 17th every year organized by the World Health Organization and supported by a lot of our media partners like the patient safety movement foundation As well as ISQ UA and other nonprofit organizations in the health care simulation space So a lot of awesome activity taking place So excited to have with us a dawn up Proser who is the chief clinical officer of the patient safety movement foundation So Dr. Proser has been in the health care industry for more than 30 years and is currently the the CCO if you will The patient safety movement foundation a wonderful organization that's doing some really amazing work in the patient safety space She spent the first 15 years of her career at the bedside and Transitioned into administration after a personal experience helped her to understand just how fragmented and unsafe patient safety can be so That's really awesome here. I'm sure there's going to be some really important kind of insights here game from someone who has seen Both sides of the equation when it comes to the health care process and Prior to joining the patient safety movement foundation Donna worked as a health care consultant helping organizations across the United States to improve quality and safety increase patient engagement and reduce clinician burnout and so You know, she's also served as a chief nursing officer to improve Clinical practice across multiple health care systems So really excited to have you with us here today Donna to provide us with this presentation Safe and reliable care how the patient safety movement can help. I know there's some really exciting developments this week both for the patient safety Day health care simulation week, but also with what patient safety movement foundation is announcing this week So really excited to have you and to learn more Great, well, thank you so much for having me. I'm excited to be here Absolutely, so we'll just go ahead and get started right in this presentation folks if you're in the live stream, please feel free to Ask questions there or in the application for zoom I'll be following along and then we will get those questions asked and With that Donna, thank you for your presentation Thank you. All right. Well, um, you know as as Lance mentioned I have been in this space for a very long period of time I'm really excited to be now with the patient safety movement foundation. We are We're a network of very passionate people around the world who are looking to improve patient safety Because we know that we have a huge problem Both here in the United States and across the world We know that hundreds of thousands of people die every year because of preventable medical error now What that number is it really kind of depends on on which article you read There are estimates of anywhere from two hundred thousand to four hundred thousand people dying every year in the US alone And and the millions are harmed. We know Who may not necessarily die because of their medical error, but have life You know life-lasting results as because of it. So so we know that this is a huge problem in And we've been and we've been talking about this for a really long period of time The estimated economic impact is tremendous. We know that we spend billions of Dollars annually in the US alone as a result of these medical errors So, you know, it's definitely something that we have to improve But I want to show you one of the reasons, you know Actually the reason why we exist here at the patient safety movement foundation So a quick five minute video just to kind of Set the tone for why we're here and and what we do why we do what we do Don't it doesn't sound like we've got audio there. So it's Oldest child we have two children He was really a live wire. He was a very lively boy. He was also quite brilliant He was one of the most highly intelligent people I've ever known and he learned a lot He knew a lot of things more than far more than most adults So he had this sort of wide and varied knowledge and he also had a wicked sense of humor. So he was So other children really enjoyed him. He was just a fun kid He had a condition called Pectosexcovatum Which is a condition in which the breastbone doesn't really grow straight. It's just it's a cosmetic condition We saw an article in Our local newspaper talking about this safe minimally invasive New surgery and we ended up taking our son for Pectosexcovatum And Lewis came out of surgery and we thought we've made it through that About three days after surgery Suddenly had this excruciating pain and his upper abdomen He was prescribed a drug called Catorlactorto, which is Insane pain reliever like aspirin He developed a perforated ulcer because he was probably hydrated at the same time and no one Noticed he declined for 30 hours and they dismissed it as Constipation by the next morning He had no blood pressure. He had Sky-high pulse rate. He lost 2.8 liters of blood for a child's size. I think he had had about four liters all together, you know, I watched the The color drain out of his lips. It was just like water going down in the glass and they turn the same color as his skin Just all the all the pink left his lips, it's really hard to even imagine Seeing something like that Yeah, he said to me it's it's going black and he Went to cardiac arrest Yeah, I ran out of the room. I thought he was having a seizure. I ran out of the room looking for help these down residents and nurses We're just astonished and they worked on him for about an hour and a half before they gave up They never could bring him around losing Lewis has been Devastated I started mothers against medical error and we came back from From the hospital the first thing we did was the legislation the Lewis Blackburn Act So one of the things that we have tried to work on is Full disclosure informed consent transparency Badges labeling of people because we had been misled about who was a resident and who was a doctor and Rapid response having an emergency number For people to call and allowing people to call their doctors as well. So those were four things that had come directly from our case that You know that we had seen that we thought we could fix with legislation Lewis was monitored but It kept alarming and they would keep setting it lower and lower and Finally they had it down at 85 and he had still kept alarming. So they turned it off Every patient deserves continuous monitoring you you never know That's going to happen particularly with the best operative patients Lewis is a prime example. He was a Perfectly healthy child, which is why no one believed that he could possibly have anything wrong with them So you need a an objective observer like a monitor Thank you for indulging me and that you know keep in mind When we talk about how many hundreds of thousands of people die every year because of medical error There are faces just like Lewis behind every single one of those those names, you know, and and Helen Haskell has been a Voice in the industry for many years ever since Lewis passed away Because patient safety is not a new conversation We've been talking about this for quite a long period of time as a matter of fact if you look in the literature It was really in the 1960s that we began looking at you know, how medical error occurs and But it really didn't the movement didn't really take off until the early 1990s And so we had pioneers like Lucian Leap at that time who estimated in 1984 that a hundred and eighty thousand people die every year because of medical error and He was one of the first people to equate that to three jumbo jets crashing out of the sky every day Suggesting that we need to look at our systems not at individual mistakes As a root cause for solving some of these medical errors But again, you know Lucian talked about this in 1994 that if if three jumbo jets were crashing out of the sky every two days There would be a public uproar And the aviation industry would be expected to explain themselves Um, but you know, it's a little bit different in in healthcare. So, you know Lucian and a lot of his other The other initial founders of the quality and safety movement were doing a lot of great work But the general public hadn't really heard a whole lot about it until 1999 Now in 1999 the Institute of Medicine released its its landmark report to Aries Human This is the one that said between 44,000 and 98,000 people die every year because of preventable preventable medical error Now the difference here is that this actually got leaked to the press So all of a sudden it got the notice of the general public and of the end of the united states government So but it's important to remember too that that particular report was only looking at errors of commission In other words, if we omitted A treatment that ended up in in serious and serious harm. It wasn't counted as one of those errors So we know that even in that report that that estimate was likely quite low And then in 2001 they the Institute of Medicine followed up with a Blueprint of sorts, you know a roadmap for us to say all right. It's the 21st century. We have to be different We need to make care safe effective patient centered timely efficient and equitable So that ushered in a decade of change those of you who have been in the quality and safety space for a long time Know what i'm talking about that, you know for the the first decade of the 21st century We did a lot of work. There was so much more focus on performance improvement in hospitals And you know, we started learning all kinds of different terminology and lean methodology and six sigma and using using different terms like damaic and pdsa The institute for health care improvement. They they had the 100 000 lives campaign Which was followed by the five million lives campaign trying to You know to do whatever we can to improve those those processes so that we can reduce medical error um Suddenly reporting data on a public basis became quite the thing You know, so we started sharing our core measures online with with the government And and of course this led to a desire to no longer hide the information that we have You know, there's no longer proprietary information how to take care of patients safely We began sharing this learning using collaboratives with each other uh disease specific certifications became quite the thing In in in that period of time because it became important that we improve quality and safety outcomes of those particular Areas where we knew that reimbursement was really going to be significant. So a lot of us began having oncology cardiology and and and cardiac disease specific certifications so that we could maximize our outcomes in those areas We also began implementing electronic health medical health records or electronic medical records in an effort to improve coordination and collaboration And then h-cap scores they started in 2005 in other areas of the world We also started tracking patient satisfaction scores And then at the end of the decade, of course, we had in 2010 the patient protection and affordable care act Here in the united states This is the first time that an organization's financial outcomes were tied to their those publicly reported Metrics that we had been talking about for a couple of years But then here we were back in 2010 In the office of the inspector general looked at medicare beneficiaries and found that we were still looking at 180,000 people dying every year because of preventable medical error So at the end of Of that first decade of of trying our founder Joe Chiani said there has to be something that we can do There has to be a way that we can we can help make this better And so he founded the patient safety movement back in 2012 You know with with the very ambitious goal of eliminating preventable deaths in hospitals by 2020 And in 2013 we developed the first of what we called our actionable patient safety solution Or apps and what these are is a An evidence-based summary of all of the best practice guidelines that are out there And they're they're available for free on our website for any hospital to download And one of the things that Joe was very famous for talking about was saying we can no longer hope for zero We have to plan for zero and we can only do that if we're doing it together And so he invited everyone that was passionate about improving patient safety to come together in a global network And in our network, we invite patients and families hospitals and healthcare systems partners from all different organizations that are that are interested in healthcare healthcare technology companies and and legislators as well So our patient and family advocates are absolutely the heart and soul of what we do and why we do it You know you heard the story from Helen you you can find on our website any number of stories like that to To help to remind us of why we're we're doing this very important work Because every one of us at some point is going to either be a patient or Or have somebody that we love be a patient From 2012 to 2020 we we had four more than 4,700 hospitals who committed to patient safety with us And together we tracked that by implementing new improvements like the ones that we talk about in our apps These hospitals saved over 366,000 lives during that period of time Some of our hospitals we called five star hospitals because they committed to every single one of our apps to To improve all of those different populations in their organizations We had more than 90 partners that joined us to to help And and to formally state on our website exactly what it is that they're going to do to improve patient safety We also talked with technology companies because healthcare technology companies Very often in the past we're collecting a lot of patient data But then charging organizations to share that data with them We have more than 90 hospitals who have signed an open data pledge and committed to not charging For the patient data that they're collecting on their devices And of course policymakers we um, you know, Joe Joe knows a lot of people And so we were able to to create a network a global network that included some of the the most well known politicians in the world And as you can see our network expands across the globe we are we have more than 60 countries who have partnerships with us So after all of this time after 18 years of working with the patient safety movement foundation and after more than 20 years of dedicated effort By healthcare professionals everywhere. Where are we? Well, obviously we did not achieve our our goal of zero harm by 2020 Because millions continue to die every year And if anything this COVID-19 pandemic has highlighted that patient safety still remains a huge problem for us Especially for our health workers And it's one of the things that we are focusing on this world patient safety day on thursday September 17th with the world health organization is both health worker safety and patient safety because you can't have one without the other So why haven't we fixed this? Why have we been working so many years and so hard? And and we still haven't gotten to the point where we have safe and reliable healthcare systems Well, the first is just the it's just our culture. It's the way that we look at how people make mistakes We in healthcare, um, you know, we have a very hierarchical system a very paternalistic system Where you know, we don't we do not tolerate people making mistakes. And so Rather than identifying systems and processes people are looking for who it is that we need to blame Which then makes people afraid to speak up and to admit when they have made an error We also have been talking for a really long time about the importance of patient-centered care But really in reality our care is pretty clinician centered It's it's focused on the needs the needs and the efficiency of clinicians rather than those individualized needs of every patient And in the meantime over the last 30 years as we've been working to improve quality and safety Our care environment has become more and more complex as patients become sicker and sicker And because we have been working so hard to improve quality and safety All of those processes that we've been put into place over time have made almost a patchwork quilt of improvement That's made it really hard for the frontline to um to simplify care processes When we look at patient care, we you know, we we know that we have gaps in in the way that patients are Cared for across the continuum care coordination is is something that is very hard for Organizations to do because there is no one person who follows the patient across their entire Care journey from the beginning to the end. And so we need, you know, we we we definitely are lacking processes That helped you improve coordination and collaboration We've even though we've been working very hard on improvement and um, and you know There's those of us who have been in in health care for a really long time Know a lot more about performance improvement now than we did 20 years ago But that improvement has often been implemented in silos So, you know, I like to say the right hand doesn't know what the left hand is improving and that has also created confusion in some organizations And sustainability is much harder than any of us realized, you know, we you know in the beginning We're like, oh, we can fix that process. That's easy. Yes We will change that process to do x y and z we put it into place and then all of a sudden here We are six months later and nobody's following x y and z anymore And then we scratch our heads and wonder why so And then the reason why is because it's really really hard to do And and and in the midst of all of this Most health care organizations today are struggling financially I mean with the exception of our for-profit hospitals and our very large systems that have A good deal of money, you know, most of our smaller health care organizations are not that flesh And so there isn't a lot of excess cash Around to dedicate towards improving quality and safety Another problem is that the public is generally not aware that this is a huge problem Now if the patient safety movement foundation a few months back We pulled a thousand folks in the public and compared them their answers to those in our Our network in the community that that knows that patient safety is a problem But 91 of the public for that repulse said that they'd heard either very little or nothing About medical error and and they're in their region or their state So this is a huge a huge reason why I think if people if if 91 of the public knew How much of a problem patient safety was they would be demanding answers So what do we do? How do we how do we improve this? Well, the patient safety movement, we're still planning for zero that we just because we didn't get there yet Doesn't mean that we are not going to continue to strive for zero So this year in 2020 we renewed our mission and vision and now our new vision is zero preventable deaths by 2030 Um, and but we have expanded our mission. We are no longer focusing just on hospitals We're looking at healthcare across the continuum and also not just focusing on death But we want to eliminate all harm from preventable medical error And so we have nine strategic aims for how it is that we want to get we're we're going to get there as I mentioned prioritizing our patients being at the center is one of is a core value for us here at the patient safety movement foundation And you know, we we know that we have to promote transparency and we have to get everybody Involved in improving this problem We have a strategic plan that is focusing on number one improving our impact We are a nonprofit organization. We rely on on donations And so that is a huge issue for us if we want to continue to help to help folks for free Then we need the funding to do so as I mentioned We need to generate awareness out there in the in the world so that people know that patient safety is a problem We'll work with legislators to see what we can do to To improve transparency and aligned incentives through legislation Our partnerships are still very important to us We want to increase the number of hospitals that are making commitments and continue to increase the number of partners that are joining us in this effort And then finally providing solutions those actionable solutions that organizations need to truly improve And so what we what we really need is to help organizations to become these highly high reliability organizations We've been talking about this for 20 years and quality and safety as well Back in 1990 curling roberts Had this definition that hro's high reliably organizations are are those organizations that have been able to operate nearly error-free for very long periods of time Again, this is not something that That we can claim in health care And I think it's really interesting that we that this has been optional up until this point And and so a goal for us at the patient safety movement foundation is to help organizations to make this no longer optional We have to improve the reliability and the safety of the care that we provide Now one thing that we have We have come to find out over the last 20 years Is that if we want to improve the population specific care that we've been focusing on For example in oncology and cardiology In sepsis if we want to improve those population specific components of care Then we've got to have a solid foundation from from which to practice in the past We relied on champions to get us To to develop improvement in those areas So for example in oncology perhaps there was one particular oncologist who was championing a cause to improve processes and quality in that particular program and Those those changes may sustain because those individuals are there to champion the cause But when those individuals leave that's when we see difficulty with sustaining And that's why we're suggesting that we need these three components To make sure that our Improvement is not relying on these champions and these heroes that we have in healthcare We need a person centered culture of safety a holistic continuous improvement framework And an effective model for sustainment in order for any change to to continue And so what I mean by this is you know in organizations that have a true person centered culture of safety Those organizations make sure that safety is is a priority for every person that enters the organization And so here i'm not just talking about patients and families I'm also talking about every clinician every administrator Visiting physicians vendors visitors everybody that's coming into the facility We need to be looking and and focusing on the patient or the safety of every one of those persons And then of course that also means patient centeredness and patient centered care We have to engage our patients and families and improvement activities We need to ask them is is the care that we think that we are providing Actually what you're receiving And then creating those care systems that are well coordinated and individualized for our patients is critical Now in order to do this, we have to hardwire transparency Respect and trust throughout the organization from the front line to the boardroom and everywhere in between If there are nurses who are afraid to speak up And and to and to challenge a physician in a respectful manner in the organization Then that's a culture a culture change that has to happen before any improvement is really going to be able to take place Organizations need to in as well as being transparent across the organization be transparent With individuals when errors occur There is a program called candor through the a h a h r q that walks organizations through How do you discuss errors with patients and families in an open and honest way? And then finally adopted just culture approach How do we know whether or not the reason why an error occurred was because of an individual mistake or because of a system or process Issue Generally speaking, it's a system or process issue and we need to get to the root cause of it We should leap said back in the 90s that the single greatest Impediment to error prevention and prevention and medicine is that we punish people for making mistakes Everybody makes mistakes and we have to identify when those human errors occur Now this the second core component of having this solid foundation for safe and reliable care is a holistic Improvement framework and what do I mean by that? I mean that we are approaching continuous improvement as an entire organization from a system approach So we don't have pockets of improvement happening throughout the organization and every department didn't choose their own way Of figuring out how that improvement will happen. You think about how many different types of vocabulary We now have in organizations those of us that were trained as clinicians were trained on the scientific method And the nursing process as problem-solving methods But then we met engineers and lean improvement specialists that brought in pdsa and pdca and jamaic and six sigma And now we have all of these different acronyms and all of these different ways of saying the same thing And that is very confusing to people Words mean a lot and we have to be very consistent about the way we talk about improvement across the organization and all of the improvement work needs to be Coordinated and at a singular level because you know, all of these improvement teams regardless of where they're working Are competing for the same resources to make their projects happening. They're competing for Informatics for the informatics department to build something into the electronic health record Or to build something into a policy or to create a form or to create An educational module for the team so that they know what the changes are And so all of this effort needs to be coordinated across the organization so that we are not competing for each other's attention and resources And then looking at our data and and the integrity of our data If if uh, if we're not using technology to maximize our efforts with with managing data Then we're probably missing a lot of things and there's still organizations today where where Where where our metrics are are hand calculated in some cases So we need to maximize the use of technology to collect data to validate data But then also to share the information about how all of that that works together Leaders should be able to see how the improvement in one area is also impacting the improvement in another area And so so using that data to provide information in the terms of of charts and graphs to leaders is very important I mean you need to make sure that it's easier for the frontline to know what to do So you think about think about all of the information that the frontline needs to be able to take care of patients When you're creating simulations and your educational opportunities You probably know exactly what i'm talking about here, right there's and it depends on who The the team was that came up with the processes for this particular diagnosis or or or or department so there are It could be that there are policies or procedures or protocols or order sets or maybe it's a memo or somebody Somebody just posted a word document on you know in the bathroom so that everybody could see it There's a million places where the clinicians need to look to be able to find out what it is that they need to do And part of this continuous improvement framework needs to be having a clear process For touching every single one of these documents and making sure that they are very clear and easy to follow and easy to find And then sustaining You know again, it's the bane of every healthcare administrator's existence. How do we make this improvement effort stick? So again, I suggest that we look at integration of all of our efforts across the organization If if the frontline has 16 different computer based modules that they have to do every year and two different Skills spheres that they have to go to and all of these other different in services and such If they're just going through the motions to get those things off of their list Then you can imagine how these things are not going to sustain this behavior is not going to change over time so look critically at What is it that you're doing in terms of communication versus education because they're two very different things If if you want to communicate something make sure that you have very creative networks That have multiple opportunities to get information to to people across your organization And then if you truly are going to be doing education again Make sure that your education department understands all of the efforts that are happening out there with education So that they don't so that there isn't a frontline clinicians someplace who may be getting Who may have three different modules that have conflicting information in them because three different people wrote those modules Focus on Leadership development organizations that are highly reliable know that leadership development is critical And that also means looking at their workload Do they have the time that they need to be able to effectively hold their frontline? Accountable and to effectively lead improvement. Do they have those skills? So so focus on on on leadership development there And then of course understand the impact of of human factors Everybody in the organization needs to understand what that means, you know, what what it how do human people behave? And what is how does that impact change management regardless of how it is how it is occurring? So as james reason said we cannot change the human condition But we can change the conditions under which humans work And that's what we advocate for here at the patient safety movement foundation We cannot continue to do things the way we've been doing them for the last 20 years And expect to get a different result We have to change the way we are looking at quality and safety improvement moving forward And we are here to help organizations to improve All of our resources are free We have many networking opportunities that we used to have but in the face of covid those are now virtual But on our website, you can see we have patient stories to engage and get people interested There are plenty of blogs and articles and videos and webinars As far as we're concerned, we have two very distinct Audiences we have patients and families in the general public who may not Have this speak the same language as the the healthcare professionals that we do And then we also have have our clinicians and our administrators and we have resources for them to improve care and in hospitals and healthcare organizations We have a couple of very great pages on covid 19 resources. So excellent resources there for you We've expanded our actionable patient safety solutions and i'm going to talk more about that in just a moment We also have two mobile applications. One is called patient aider, which is patient education Information and and also our patient safety solutions is our our apps blueprints that are are available on On a mobile app in addition to being able to download online And you can access all of this again for free under patient safety movement dot org Again our expanded actionable patient safety solutions include blueprints Yeah, no worries one quick question from Diego Donna Is the patient safety uh movement foundation focused on patient safety primarily in the united states Or does it have international resources and support and kind of what's going on internationally for the organization too No, that's a really great question. Um, yes, we are a global organization And um, we are based here in the united states, but our focus is improving Is improving globally and so um, we are also in the process of Creating a Spanish library of all of our actionable patient safety solutions as well Awesome. Thank you so much Great So our actionable patient safety solutions include three different components There are what we call apps blueprints that used to be that that uh, that evidence-based summary that we that I that we've always had of But that now includes a few more things now it has a clinical workflow and a performance improvement Or a performance improvement plan and each of those blueprints We are about halfway through updating all of our apps to include these by the end of the year We will have incorporated them into all of our apps Our educational resources we now have available on our library on our Educational library that's on our website and you can find All of these resources there and what we've just started offering Effective now for anybody that is in our network is free virtual coaching So if you're if you're a healthcare organization that doesn't have the endless funds to hire very expensive quality and safety consultants To come and help you with performance improvement. Let us know we're we're here to help you with that as well Um, and so there's many things many things that you can do to get involved with us I think the most important thing is that we all have make a commitment to a personal shift in awareness Those of us who are in healthcare You know, we we need to be aware of the patient safety issues that we have and to And to make a commitment that we're going to change the way that we focus on on healthcare moving forward Help us to build momentum for patient safety by joining the movement If you can if you can join on behalf of your organization, great If not join join yourself and and there's plenty of ways that you can get involved Help us to plan for change not just hope for change If you again if you can You know, if you have the ability in your organization, then you know Talk to whomever you can and you're in your institution to help them commit to zero harm We're looking to help legislation for various Activities including patient safety boards. We'd love to see just like we have a national Transportation safety board mediation. We'd love to see something like that in countries to to be able to Examine when patient errors occur And then donate please we are a nonprofit organization So please donate so we can continue to help patients families clinicians and administrators But the free resources that we have If you are a in the position that you can make a commitment on behalf of your organization Then please do so those organizations who make a commitment to establishing a safe And reliable care foundation are eligible for free coaching If your organization has not made a formal commitment We are still here to help you at a nominal fee for our coaching But um, you know, if if you commit to sharing your serious safety event and near miss event data with us next year Then then this coaching is free And then of course Thursday is our Big day world patient safety day. We have an event just And so do most quality and safety organizations across the world Our event begins at five o'clock p.m. Eastern Standard Time on Thursday, September 17th It's about a three-hour event that'll be live streamed on youtube. We would love to see you there Um, this also is free. So please rsvp and unite for safe care um on our website So, uh, awesome, that's everything I have for you today. I assume there must be some questions. I can answer Yes, absolutely one from the audience here Do you think that having so many different organizations involved in patient safety in the united states works against patient safety in the u.s I guess that's in relation to They're just being a lot of different groups. I know ihi for example, I believe acquired or kind of merged with the patients npsf Right and yeah, and so yeah, I guess what do you think about the different groups and organizations? Is that hindering us in any way? No, I think um, I think it's a great Illustration of how improvement has happened over the last 20 years, right? I think in 1999 when I know I know I along with a lot of other people said, oh my gosh You've got to be kidding me. We had no idea that this was such a problem And so we just started fixing we just started saying what can we do? What can we do? What can we do? So I think we're all moving in the right direction I think there are some things that some of us offer that others don't and we are now learning how We can work collaboratively there There's been a lot of effort On on the part of many of the organizations to join forces So you'll notice that our event on thursday is co-sponsored by is quack As well as leapfrog group. We also work very closely with The national association of health care quality and on wednesday We are co convening with them at their annual event so that we can have They're dedicating one whole day of their annual Conference to patient safety and we're working with them on that content So I think I think you're going to see a lot more of that collaboration among patient safety organizations moving forward That's fantastic. And I know that for example They're in the simulation world There's groups like the global network for simulation health care that are working to kind of Be a think tank for the The various organizations in the space and so I think you know the more the merrier in terms of expanding these conversations and each group has You know its own kind of focus and capabilities and strengths in terms of Ways to engage and support the community one of which I think is so unique for the patient's eating Foundation and if you wouldn't mind me going just a few slides backed on up to talk a little bit more about this Coaching program. What is the commitment that is necessary? in terms of you know Being able to gain access to that coaching and then what does that coaching itself entail in terms of the support that these Groups can start to kind of rely on the patient's eating movement for in terms of the support Absolutely. Well, um, so in order to now we'll we'll provide the coaching again to anybody And if you think about, you know, what you would get from an ordinarily ordinary consulting firm We would help organizations to and I'll actually go back here so you can see my list here So the first thing that we need to do is is help with an assessment of what your current state is Help you analyze your data and look at your current processes. We um, or I would in my Back in my consulting days. I would come to your organization and we would map out current state and things like that We can't do that in a pandemic, but we have figured out how we're going to do this virtually and help you To map out that current state identify where your gaps are and then prioritize what it is that you need to do to To meet your goals that that your organization has determined Most organizations have so much to fix that it's not going to happen all at once so we're going to help you To to put a process in place for performance improvement for now for those things that are important to you But mostly also help your teams to learn how to do this performance improvement So that you can continue to apply that to your strategic plan over time Now in order to get this for free all we ask is that organizations make a commitment to zero harm What that means is that your ceo and your senior leaders have said Yep, we agree that having a person-centered culture of safety a holistic continuous improvement framework and an effective model for Sustainment are a priority for us moving forward And we are going to do everything that we can to improve that foundation so that we can reduce our Our events of harm All they have to share with us are their serious safety events and their near-miss events for the year And because what we want to be able to show people is that with With a focus on on on establishing this foundation Organizations are able to make a true a true difference And what we should see is that serious safety events go down and near-miss events go up over time Right and so for the it seems like those organizations that want to be forward facing towards the patient safety concept and road map That want to or are already committed to these types of outcomes And that are willing to go a little into a kind of slightly more uncharted territory in terms of releasing those records and getting them out there um Are those things identified with regards to individuals and actual moments of Of error or is it more about like system-wide issues that are being reported? Yeah, we don't want any I patient, uh, you know associated data. We just want global numbers So we just want to be you know, if if there were an organization who said we would love to have free coaching from you Then we would say excellent. Let's find out what you where you're at right now What's your baseline for serious safety events and near-misses? And then give us that number again at the end of the year so that we can help to show improvement That's all we are interested in and I think yeah, right So so making it so that we're not getting the nitty-gritty but rather looking at the bigger picture here and trying to start making some kind of uh, larger Brushstrokes in terms of an understanding of what's going on with that particular institution so that we can use that And correlate it with not only the work that you all are offering in terms of the support But also to better understand the metrics of what's going on in this space It does sound like a lot of the terminologies That you that you've been utilizing donna relate back to the aviation industry And the way that it handles Near-miss events or or errors, right? We've had recently the two Boeing 737 max Crashes that led to an international shutdown within a month of the use of that plane, right? And so I think in that space. We've got things like the ntsb We have things like the the faa. We have international um commitments to Or standards with regards to communication through crm and you know just quite frankly like even a baseline common language utilizing english for all ground control Or or radio-based discussions right between various agencies. Do you think that We are in the long run Trying to utilize some of those same tactics that have worked so well in aviation and and translate them into The healthcare space and and does that even work and and obviously there's some differences What do you think those differences are? How do you think we overcome them? I know that's a grandiose question, but It's one that I I am so passionate about in terms of understanding Where can we learn from groups that have gone forward and and achieve the goals that we want? And I think that aviation is a perfect place to to do that. Am I okay? Yeah, we agree. We agree 100 percent You know again, if you look at those organizations those those industries that are considered highly reliable You know the nuclear power industry the aviation industry You know space, I mean they can't afford to make mistakes And we can't afford to make mistakes in healthcare either but because We because our product is different because our product is human beings There's almost the sense in healthcare that medical error is just a cost of doing business And so so I think that's what really has to shift We're we're all in agreement that we could learn from those organizations by by using checklists by focusing on you know standardization and and by uh by you know validating That you know by measuring all the time we don't measure all the time in healthcare We measure until we see an improvement and we stop measuring that thing and move on to something else They don't do that in aviation and nuclear power. So there's a lot that we can learn from those organizations We would love to be able to see that we have a national patient safety board similar to the ntsb And that's something that that a lot of patient safety organizations are proponent of We are Years away from something like that. I think Yeah, I agree. It's definitely like a long term discussion another question that's come up here Do you all see that countries with centralized healthcare systems Have better outcomes when it comes to patient safety or these types of initiatives say for example of the uk or australia where we might have more social democracy type government situations In some sense like an nhs or those types of things That's a really great question and the answer is really no. I mean there there are You know some of it depends on the error, right? So in the united states sometimes we have errors that occur because of lack of access because somebody doesn't have insurance And so, you know, perhaps that means they were misdiagnosed Not because of an of an error that occurred with a particular individual but because of their particular insurance situation Now that doesn't happen in those or in those countries that have Universal access to health care. However, we all have the same culture, right? You think about where did where did the culture of medicine come from? over time, you know, we we came out of both the military Complex as well as out of the religious complex. So, you know, perhaps it was the catholic church who was running a hospital Or you know, or it was as I said the military you think about the language that we use in terms of Charge nurse and a chief of staff, right? So no wonder that we have a very paternalistic view in medicine a very top-down view We've also been Been talked that our individual practice is very important and that I as an individual practitioner need to be concerned about The ethics of my care and so we are not necessarily taught that that health care is a team sport so so there's a lot there's a lot to do in the culture of health care in general across the world and in um, you know, just looking looking at those opportunities to change our culture Deep deep down that are what needed to need to happen in order for us to change this Yeah, having done some interviews with folks in the aviation industry who have seen that transition into simulation mandates and black box technologies for recording everything that goes on and all these the crew resource management Communication practices, you know, some of them had suggested it takes a generational shift, right because those pilots that were educators After say world war two, vietnam era they kind of had to learn on the fly in a sense You know pun intended basically whereas, you know, when they started to become instructors They themselves saw the benefit Simulation based technologies and it kind of it's you know Snowballed from there in terms of becoming more prevalent and more powerful in this space And I think that's really important to kind of consider and I think that Is really relevant to everything that you are saying with regards to sharing the statistics It really is a systems wide issue that we need to be looking at right and I think that in health care You know, we've written an article before about how health care really blames the individual and in aviation They blame the system, right? So if there's a if there's an error Something enabled for that error to take place. And so with health care, you have maybe a nurse who made a medication error, but that person was trained educated trained recertified in a process ongoing and somehow we've we've enabled for a system that enables for that mistake to take place right and perhaps it is just this one-off individual, but I feel like a lot of the The outcomes of that is is that there's a lot of blame place on the individual and that makes it harder for health care providers themselves to Be honest and open with regards to errors to be able to On not have the psychological stress of making mistakes and being on point so much that you know, they know that there will be Consequences for their actions that go above and beyond what is You know realistic for a problem that you know, I think came out of the system itself. I remember um one quick note there was this like that there was a um an AED unit that had the charge button the the charge button was Red and the power button was green and so somebody hit green for go and turned off the AED And now the patient has to wait another two minutes for the system to boot off, right? And so in a sense, it's like well, that's a systems issue, right? That's not an individual. We're we're creating an environment of human factors that don't enable for us to have the Greatest degree of success because we're not looking at these things. I think Primarily from that kind of a level as opposed to the individual and how do we keep training the individual? Until they they get whatever is the craziness that's going on any other resources that you would highly recommend I would love to just make note of the book still not safe I'll put a link to it up in the chat room patient safety in the middle managing of american medicine By robert wares who I believe unfortunately passed away North near the end of the book and kathleen suckcliffe who came in and helped to finish the book Really awesome really deep into the conversation of where we are with patient safety right now and what we can do Any other resources donna or books the or other resources we should be taking a look at from your uh perspective There's a ton and then they're all on our website though It just it depends on on you know, obviously on the topic, but um, you know, one thing I will say is that Your audience has a really a really unique opportunity. I think to be involved in patient safety because simulation Helps to it helps to bring so many different concepts into an educational opportunity at the same time and so if there is a way to To improve sustaining through Incorporating education of all of the improvement activities that are happening in an organization. It's through simulation So I would highly recommend that anybody that's out there That is responsible for simulation in an organization Look at how many different opportunities for education your frontline team has And and see what see what you can do. How can you bring simulation to incorporate some You know, at one point I did this I took no lie 10 different educational opportunities And was able to put them together into one simulation So, you know, so whatever you can do to make it easy on the frontline But at the same time to help to show the connection between all of the improvement work That's happening at the same time. I think it's going to go a really long way in patient safety I totally agree. I think it's so important for everyone who really is in engagement simulation Whether they're new or or at any phase with with their integration and their adoption of these technologies and methodologies Keep track of the data. Keep track of what's going on. See what the outcomes are, you know, try to create a plan And we say start with the three things that yeah are the most critical, right? Or that you want every learner to to be ready for Maybe it's the three things that they need to all be ready for really Ready to go and another three things that are rare, but really important to get right, you know And that's where we always kind of recommend folks start but These groups wherever you're at whether it be in your regional hospital area or looking at the patient safety movement foundations kind of Group the leapfrog group isqa There's going to be these resources where you can start to see what are the top areas for medical error to take place You might be able to gain that from your own institution Partnering with schools in the in the nearby area starting to provide for that educational and training resources that will enable for outcomes That can be directly related and I think starting with the stakeholders And as well taking a look at that basic needs assessment and understanding, okay Where are the places where we could create a camp a campaign for? You know engagement or try to secure it in some initial funding to go after one key topic that I think is Maybe in a sense low hanging fruit, but this is so important because it gives you an opportunity to showcase your ROI, right? What is What is the impact that has been created from the work that we're doing? and then that's how you kind of can can gain that additional support for expanding the program once you have a solid win Under your belt in a sense you can kind of utilize that to go for the next heavyweight champion Opportunity of whatever it is that's facing your institution on the next level don't thank you so much for this presentation It's been really eye-opening. There are so many great resources and tools from the patient safety movement You know, I know it's got an annual event normally We've got the virtual one coming up now Folks you really need to participate. There's so many great free resources There's simulation connected up and down throughout the the the group. It's it's mission at schools Between patient safety and simulation are just so online to Donna. Thank you so much any other Questions from anyone in the group right now. I don't see any in the in the two chats Anything you want to leave us with Donna to uh to move us forward at the end here Now just another plug for thursday World patient safety day if you if you can't you know, if you can't join our Our event at five o'clock on thursday, then at the very least Take a picture of yourself support it in some showing in some way support for patient safety and then Share it with you the hashtag unite for safe care Unite for shape uh, safe care. We've got that in the chat room there Awesome, and that's this thursday five p.m. Eastern two p.m. Pacific So hopefully everyone can join us there. Donna. Thank you again so much. Thank you everyone for participating and joining Thank you. I really appreciate it