 All right, well, it is 8.30 here in sunny California. Welcome everybody to our webinar on candor. This is part two. I am Donna Prosser. I am the Chief Clinical Officer here at the Patient Safety Movement Foundation. We did a webinar on candor back in January, and it was so well received that we decided that we needed to do more. So this will be part two. Next month we'll be presenting part three. And so today what we'll be focusing on are understanding the AHRQ Candor Toolkit and talking about the gap analysis process and how to do that and who do we have to engage and who are all of the people that really need to be involved and the skills that need to be involved. We'll also examine a particular experience from Samaritan Health Services and we'll talk about the lessons learned and the challenges that everybody can anticipate in implementing candor. And so here you can see that all of the planning committee members and all of the speakers today have no complex of interest to disclose. For continuing credit information, as always, we're going to be offering continuing education credit through MedStar Health for nurses, pharmacists, and physicians. This activity is only available to those who are here today on the live webinar. So if you're watching this on our YouTube channel, my apologies, we can't offer CE credit for that. If you are a physician, a nurse, or a pharmacist, then if you registered and told us that that was your role, you will get an email from MedStar Health within the next few days. And you'll have to log into their cloud CME system in order to receive your CE. And one thing I forgot to mention, if you are a respiratory therapist in many cases, your local board will accept nursing credit for that. So you will also, if you registered as a respiratory therapist, looking for nursing credit, you'll also get that email from MedStar. We are also offering ACHE credit, CPPS and BCPA credit. For those of you who are looking for ACHE credit, all you need to do is just log that information into your ACHE account. We will send you a certificate if you are looking for CPPS or BCPA credit. And if you are looking for CPHQ credit, NEHQ will document your attendance on their end. We are going to be using a program today called Slido. It's a great program where we can poll the audience and get some great information from you. So if you have a chance right now, go ahead and log into slido.com using this number. Or you can use the QR code that you see here. You'll have another opportunity to log in when we start the polling questions. So no worries if you don't get to it right now. And I'm very excited today to introduce our moderator, Martin Hatley. Marty is the Co-Director of the MedStar Institute for Quality and Safety. He's also a member of the board here at the Patient Safety Human Foundation. And one of our most favorite volunteers, we're always happy to have Marty here. So I'm going to turn it over to Marty so he can introduce the rest of our panelists. Thanks, Marty. You're welcome, Donna. Thank you. And I'm excited to be here too. So I've been looking forward to this panel and I know it's going to be a great program that we offer today. As Donna mentioned, this is the second in our series on Candor. The first one was an overview. This is the middle part of the trilogy. This is really about helping your organization assess its readiness for Candor. And then the next one, which will be next month, was really about implementing and sustaining. So assessment is a huge portion of the readiness challenge or opportunity. And we've got a great panel today, just in order of the faces that you see. My close friend and colleague, Tim McDonald, is here. Tim is really the architect of the Ketter Toolkit. He did a lot of the research that went into the demonstration projects that produced the Toolkit. He's probably the most experienced person that I know in terms of helping organizations implement Candor. So, Tim, we're just delighted to have you with us again today. Amy? It's great to be here, Marty, and also with our other panelists as well, who are pretty amazing in this domain as well. They are. They are. Amy, I just met you, but I know congratulations are in order. You're the head of patient safety at Samaritan Health Services and I know you just got your doctorate. And that involved working Candor. So welcome and congratulations. Thank you. Thanks for having me. And Julie McCoy is a farm dean of JD from the Providence system. She's been working with Tim and with me in the past, doing Candor gap analyses, which we'll talk about today. And Julie, it's just great to work with you today and great to see you again. We haven't crossed pounds in a year or so, so that's fantastic. Next slide, please. So good to be here, Marty. Thanks. Yeah, welcome. So this is going to be our first poll and we just like to get a sense of who you are. You have a sense of who we are. So Slato.com, it's a very easy thing to use. Open it up on your phone if you could just sort of plug in your answers to the question, what is your role in the organization? This is real time polling. So a lot of safety and quality people here today. We have a fair amount from leadership and from risk and legal. So people are able to and if they have multiple roles. So we're seeing more than 100% because people are having multiple roles. Okay, we have a good sample with a with a large representation for safety and quality. Okay, let's move forward to the next slide. So, Tim, we have, you know, covered in an earlier event what Candor is, but let's just do a quick recap. Why Candor? Why is it so important and why is it so important at this point in time in the history of the patient safety movement in this country? Oh, well, thanks Marty. Yeah, so just going over again, the whole goal of Candor is to shatter the wall of silence, Marty, as you know that Rosemary Gibson speaks about in her book. But the wall of silence extends beyond just the wall between us on the care delivery side, patients, families and the loved ones. It's also within the teams, within each other. And so part of this shattering the wall of silence really involves a major culture change because we know culture eats strategy for breakfast. And, you know, at the next slide, you know, what you're going to see is with the goal here is that when things happen, when harm occurs, as we'll advance to the next slide, it's just really important to think about this comprehensive approach. And as you can see there, it's principled, it's comprehensive, it's systematic, and it's empathic. And it was, again, developed by the Agency for Healthcare Research and Quality over the course of the grants that began in 2019 and moved on until the Candor toolkit was released in May of 2016. And as you'll see again with the next slide, there's many domains to Candor that are really important to know and understand about. And when you do the readiness assessment, as we're going to talk about where Amy and Julie are going to talk about how we go in and we really take the pulse of the organization and see where they are, it is looking at, are they able to identify harm events that require this comprehensive approach and able to activate their system where two things happen, actually three things happen simultaneously. It's kind of like the aviation go team where with number three there, that response and disclosure, it's communication with patients and families, but it also peers support. And then with number four, you can see they're also beginning to do your human factors-based event review. Marty, I think in COVID-19, it's demonstrating now more than ever the need for this sort of empathic communication that needs to happen. Patients and families have just been horribly affected by COVID-19 and the entire continuum of healthcare from the outpatient area all the way through acute care and even into senior living as well. It's just a big deal. And we also know burnout has been huge. The numbers, I think, suggest 85 to 90 percent of members of the clinical team are now experiencing significant burnout. And so having this process in place that can support the team is also super important. Now more than anything we've ever seen, Marty, in the evolution of healthcare, at least since I've been involved, since beginning my journey in healthcare in 1979. And then of course, with the event review, learning from it, and then ultimately leading to are we able to resolve these cases, even though we know in patients and families cases that it's never really fully resolved, but how do we get to that last conversation? So when we do our assessment, these are some of the kind of domains we really want to think about, Marty, as we go forward. Thanks, Tim. And I'm glad you brought up the issue of burnout because this is the official flow diagram, by the way, from the candor toolkit that, and whenever I look at this, Tim, I wonder where the care for the caregiver component is, because it's been such an important part of not only attracting interest of healthcare systems, but also getting the engagement that we need to get. I think you've told me it's that little circle of the middle. I mean, that it's a continuous process and care for the caregiver is throughout this flow diagram. Yeah, Marty, and I agree. And in fact, what I've done, Marty, when we do these, and I've done it a lot with Samaritan, is you see what the word disclosure is. We've actually removed the word disclosure, and we have communication in there. And that communication, Marty, is intended to reflect the communication to patients and families and loved ones, but also the care for the caregiver. And the circle in the middle is, as you learn more, you share more with patients and families, but also as you learn more, you identify members of the team who may have been affected by these events. So yeah, we're constantly making changes and modifying and improving the flow. Okay. Okay, thanks, Tim, for that overview of candor and for just kind of the reminder that this is still a living toolkit, and we'll see that as we get into how Samaritan implemented so it's a fantastic toolkit. You have the link in the slide before, but I think every system that we've worked with has modified it to some degree or tweaked it or customized it, which brings us to you, Amy. So welcome, Amy, again. And will you tell us, can we move to the next slide, Donna? So, Amy, when we were prepping, oh, here's the modules. Here's one more slide on the candor toolkit just to quickly give you a sense of what's in it. So we gave you the flowchart, but there are a number of modules. It's at hrq.gov-cander. And what we're going to really focus on today is the gap analysis and implementation planning, because it is really important. We'll get into, the gap analysis tells you, frankly, whether you're ready to this, whether you've done the work that released, but I just set you up for success. It will help you evaluate that. So let's move on to the next slide and to Amy. So Amy, when we were chatting, I think I'm getting to know each other a little bit in preparation for this. You mentioned that it was really mission values and vision that drove your organization's interest in candor. Can you say a little bit more about that? Sure. Thanks, Marty. We as a health system were introduced to candor through our insurance broker. So that set the stage, I think, for the acceptance of the program as a means to resolve claims and proactively talk to patients. Our health system acknowledged that if our insurance broker feels this is important and a valid approach, then it's something that we could embrace. But before we could get there, we really needed to take some time as a health system to reorient. We were in and still are in a transitional state. We were just approaching a transition of our president and CEO. And our new president came on and said, this is a fantastic opportunity for us to talk to our patients, proactively for us to support our clinicians and the rest of our team. We need to prioritize, though, aligning our five hospitals are at the time 80 clinics and set a path for our mission vision and values. So we took about a year across the health system to learn these 17 words so that everybody could articulate and align with them. And this truly set the stage for us as we were getting ready to embark on our candor work. And now as we're looking at high reliability. Amy, when we talked before to you, I'm going to just underscore something you mentioned. You mentioned the importance of leadership, and it was new leadership that really emphasized this. Can you say a little bit more? Why don't you tell us who they are? Who was your new president? And why was this so important to him or her? Our new president, yeah, is Doug Boyson. Internally, we joke about WWDV, what would Doug do? Because he is, for me at least, a strong ethical barometer, which I think is extraordinarily beneficial to us as a health system to have such a fantastic leader. We were also in the process of transitioning out a lot of folks who had a more traditional approach to resolving patient harm events. And so adopt and we'll get into some of the information that we learned in our gap analysis. But I would say we had some folks on my team and in the health system who chose to retire early or leave because of the direction we were going. With Candor specifically. But some of those transitions really set us up to be able to adopt this. I don't think that we would have been in a place, I know we wouldn't have, been in a place to adopt Candor as a process in 2016, 2017 when we learned about Candor. We really had to wait and be intentional in talking to Tim and we'll talk about some of the findings of other adoptions as to why we weren't ready. Great. Marty, if I could, I just want to follow up on Amy said about Doug. They're going to see later on the attendees is the paper you and I wrote about lessons learned. It's now up to probably 500 hospitals we've worked with. I have yet to find a leader like Doug in any of those other hundreds of hospitals. He really is an extraordinary servant leader. He attended so much of not just the gap analysis, but even the training about how do we empathically communicate. So I just want to highlight again what an extraordinary person he is and how valuable it is to have somebody like that at the helm when you're taking this journey. That's fantastic, Tim. Amy, you're lucky to have a CEO like that. But Tim, I would also say that on the candor implementations I've worked on with you, we've found extraordinary leadership being just a key ingredient pretty much every hospital where it's worked. Amy, quickly before we move on, what did you, when you learned about the gap analysis process, what did you hope to get out of it? I mean, what were your objectives in getting out of it? Getting something out of it? That's a great question. So I, at the time, was actually a clinical risk manager and my manager, Chi-Hui, who is now our Enterprise Risk Director. Both were introduced to candor at the same time and we were both very new to risk management and had since transitioned into patient safety and risk. And because we were so new in it, we knew this was where we wanted to go. We didn't know how to get there and we didn't know, we thought we were, we had a good handle on the organization and what our needs were, but we wanted that confirmation. We wanted to know what we needed to do as a team to engage our leadership, to engage our healthcare team members. So we truly, when we looked at the gap analysis, wanted to know, are we ready? Where are our opportunities? What are our weaknesses? How can we make some changes to ensure that we're ready? Fantastic, thanks. Okay, let's go on to the next slide. This is just a timeline that you've given us, Amy. I know this will be of interest to some of our participants. Can you walk us through quickly? If you spoke into it a little bit already, but what was the timeline for implementation? I would say we're still in implementation. So if there's anything I can offer to those folks who are considering adopting Candor or a CRP is stick with it. Know that this is a long fall labor of love. We learned about it in September of 2017 and talking to Doug in January is when he transitioned to the CEO and president. We knew we weren't ready, but he had it on his radar. We took that time in most of 2018 to prep for it. And so we actually had Tim present by the video at the time it was a novel process for Tim to present. I believe it was June 22nd, which was the date his granddaughter was born. No, true, Amy. He took some time away from that wonderful occasion to talk to our executive leadership and help them understand what this meant for Samaritan and the benefits of it. But our executive leadership gave us the permission to go to Honor Health to observe training there so that we knew as a team what to expect. That was our first introduction to empathic communication training and Julie was actually there with us. And then it took us almost two years to get to the gap analysis process from the time that we were first introduced. And another seven months, six months until we did our first candor training. What you don't see after January 20th is the pandemic and everything else that came with it. So we prioritized actually our care for the caregiver portion of the program. Chihue, the Enterprise Risk Officer, is responsible for that. We put some of the other work on fold, but felt like the care for the caregiver piece had to happen as soon as possible. Knowing what we now know about clinician burnout. We're still in the implementation phase right now. Okay. So fair enough. And it's interesting to hear you say that because I think we're always surprised by how much care for the caregiver pops up as a crucial portion of this. Again, it's not in the flow diagram, but it seems to be just part of the crucial fabric of candor wherever I've seen it. Okay. Let's move to the next slide. And Amy, can you tell us who facilitated? You did a gap analysis in every one of your hospitals. Who facilitated that process? You're looking at them. Julie and Tim facilitated. We actually did our process a little bit different than some other organizations. We were on the heels of a consultant group coming in and optimizing our operations, which was, and I'm sure Tim and Julie will talk about this traumatic for some of our teams. And so we knew that sending folks in to interview with another consultant could be triggering. And I don't say that lightly. So we had to spend in that probably July 2015 until that point building relationships with our healthcare team members. That was a big priority for our team. In that time, we had previously been known as the deny defend delay group that really embraced siloing and not sharing information. And so we had spent a lot of time developing relationships. And we knew that the teams were having some burnout from consultants. So our team actually participated with Tim and Julie, encouraging folks to be honest, telling them this is a safe space and really introducing the reason behind why Julie and Tim were there. Okay, great. And so Julie and Tim facilitated, but your team attended some of the facilitated sessions. Is that correct? We attended all of them. Okay. So you were listening in as it was happening. Okay, good. And this slide is just a sort of a quick peek at what's in the gap analysis facilitators guide, which is one of the HRQ tools. And it's got several different resources that it draws on in terms of structuring the gap analysis. Tim, I don't know if you want to say anything or Julie want to say anything quickly about this before we move on to the next slide. Well, while we really did build out the questions, Marty, based on the NQFSA practices related to one, two, four, five, seven, and eight, which are the ones you see there, the leadership, the culture, identification, mitigation, risks, and hazards, all the questions that go into that really do emanate from NQF and how you go about and assessing the organization to do that. And then we also asked questions around the high reliability domains of culture, performance improvement and leadership. And that's how we built out the guide. And then we'll talk later about how it then flows to the creation of the report that goes to leadership. Okay, let's go on to the next slide. So, Julie, I haven't really invited you into this conversation as much yet, but can you just say a little bit about the approach? As one of the facilitators, how did you just approach doing these interviews with different stakeholder audiences in the organization? Sure, thanks, Marty. As Marty mentioned, just my name's Julie McCoy and I'm a practicing pharmacy manager and an attorney and my focus is in health law. I was lucky enough to be in the right place at the right time in September of 2019, like Amy mentioned on their timeline. Tim was getting ready to do this gap analysis with Samaritan and he had to be in person for a keynote speech on the day, on one of the days of the gap analysis. So he asked me to come and take his place that day. And so it was just a significant learning experience for me and I'm thankful for that. And so I was this neutral person coming in and thrilled to have Amy and her team present for the sessions and they just soaked it up and really, really listened. They never once tried to defend someone's statement when we asked a lot of questions, a lot of questions and tried to take those AHRQ tools and modify them to meet the needs of this analysis. So it was not a quick rapid fire checklist of questions to mark the box non-compliant, partially compliant, fully compliant, but rather it was to really get to the cultural readiness for candor and that happened through these open conversations with facilitated groups. So we asked the questions that we modified from AHRQ tools like Tim mentioned, modified these questions to hit those domains. And what we really tried to do is bring out the stories, the candid conversations, the frank and honest team vulnerabilities, frankly the burnout, the trauma that people were experiencing try to bring that out and get that from those teams. And so it's groups of four to 10 members and without their direct reports in the same session. So they felt I think it was a safe place to discuss what they were proud of and also where they thought opportunities existed. And we also mentioned both as we started each session that the information would be kept confidential and not shared with the other groups just in case they were worried about that as well. So how did you manage that, Julie, given that you had Amy and her team sitting in? So the direct reports weren't there, but senior leadership was. How did that safe space get created? That's a great question and a point, Marty. I was really amazed because the previous gap analysis that I was able to see, Marty, with you and Tim, the risk and patient safety and quality teams, they might introduce the group, but then they kind of left and did their own thing and came back between sessions and had their own session. But with Amy's team being present, it was really clear that they were working behind the scenes or something. You could tell something had been going on behind the scenes and I didn't have all this history when I came in that Amy's just talked about, but they trusted each other. You could tell there was this enormous trust between, gosh, the eight different facilitated groups we had. They knew Amy and her team already. Like they had this relationship. It was hard to describe, but they just were able to function together and still have open conversations. And Marty, if I could clarify a little bit because a question came up in the Q&A. So the way it's set up, just like Julie described, is that there was a lot of trust already with Amy and her team in all of these groups. They all trusted her and the team. The key part though is nobody's boss was in the room. And that is the key to setting up the stakeholder meetings. No one's boss is in the room. And on the confidentiality part, which is in the Q&A, is that the thought was no comment would be ascribed to an individual person. There would always be, it would be more general themes that we were trying to get telling them we are going to communicate the general comments we're getting back to Amy and the leadership, but no individual's name would be listed at all related to any of the sessions we did, Marty. So I just wanted to say that now to clarify the question again that was asked in the Q&A. Great. Thanks, Tim. Let's move on to the next slide. So here is the group of people it looks like that you targeted to do these sessions with. Why was this group chosen? And again, Julie, you've kind of mentioned this, but there was about four to eight people in a session. Roughly four to 10 members per session. Thank goodness Amy and her team scheduled those ahead of time. People just showed up to the room. And we started with introductions and just went through the group. We had family medicine physicians, CEO, VP of ops. We had frontline clinical from pharmacy, from nursing, from respiratory therapy, sleep center, imaging, volunteers and chaplains. And they were all in strategically paced groups that was already planned for me just to kind of get through each of those groups with our questions. And we had hospitalists and surgeons and managers and directors too. Great. What about communications? Where did they fit in here? The communications people. Are they under managers and directors? You know, the managers and directors group was a very interesting group because they had just come, if I remember correctly, from this meeting with the consultants. And I would ask Amy if there were, if communications was in that group, but they started off, they had just literally just come from another meeting about, I think some recommendations to cut back a little bit. And so they were really fired up in a concentration way. And so it was a little bit of more of a challenge to kind of break through on that group. But I think that's probably where the communications team was. I'll ask Amy about that. Amy, do you want to jump in? So maybe I need some clarification, Marty. Are you looking for how we communicated to these teams or a communications team specifically? I'm wondering if you brought in your communications and marketing people, how you were going to talk about CANDR, not only internally, but externally. Okay, yes. We, outside of our GAAP analysis, actually we, when we first decided to embark on our CANDR work, we were assigned a project manager who was both project management and marketing. So her job duties were 50-50. And so she has been working with us on this since the beginning, which I would say is extraordinarily important for us. That's okay, good. Okay, let's move on to the next slide. I mean, we're running a, I'm loving the conversation. Please keep the questions coming into the chat room. And here, I think we just started trying to get at what you learned, or this is sort of more of the approach too. Tim, why don't you jump in here? I see the magic wand here. I've worked with you in the magic wand. Are these some of the questions that you asked and what you brought during the events? Sure, Marty. So we developed this methodology over the years of our grant to do this. Every single session begins with share with us where you get your greatest joy in your job. And then we get into a lot of the domain and the open-ended questions that Julie described about, tell us about the culture of the organization. Are you comfortable speaking up when you see unsafe situations? Tell us about event reporting and the system for reporting events and how they responded to. And take us through a case that you may have been involved in, really open in and trying to get to all those different domains we talked about. And then every single session we tried to finish with, if you had a magic wand and you could change anything in the organization to bring you more joy, what would that be? And that was the standard methodology, Marty, in all of these sessions. So when we were done, we had hundreds and hundreds of joy comments and magic wand comments to turn around and put together for leadership Amy, Chee Hoi, and the others that were there. So, but I'll let Julie talk more about the tears we would see, some of the responses when in this safe space, people felt really comfortable sharing what it is that they wanted to share. I was just amazed, Tim, at the things people would share and just, it was emotional sometimes. I think, you know, a few examples of the things people shared for having joy at work was getting patients through a tough time, collaborating with the team, to be with people in a place of peace, telling stories with patients, empowering people, helping others to see the mission and vision, and they enjoyed lots of fresh energy, statements like that, and just stories that they told. It was really impressive. And I think building on that question about joy, what brings you joy at work, started the conversation with the questions we were going to ask, came from a place of joy, like that joyful buzz is what got the meeting started and opened it up. Then you could ask questions about how involved are patients and families in the committees that you sit in on, and what happens when there's unacceptable behavior and what kinds of root cause analysis have you been involved in, and it just opened them up to being more conversational about that. I mean, we talk so much in this work about head-to-heart connection and I think starting with that joy, what brings you joy at work helps helps just establish that as this is a place to talk about that. Let's move on to the next slide. I'd like to kind of move forward here. Tim, one of the things, I wanted you to speak to this, although Amy and Julie, welcome to jump in as well, but I know one of the key audiences to get engaged is the medical staff. I know that's often a challenge for organizations. These are actually quotes from another presentation that you and I have done together with another client about the kinds of things we hear from physicians. Do you want to just speak to the importance of the medical staff in this process? Well, as you'll see and even in the lessons learned, Marty, and we're talking about it is, one of the keys to success is making sure you have medical staff knowledge and information about the process, but also some buy-in. And you don't need it from everybody to start. You need a few champions, but what we've learned meeting with the medical staff has been particularly in COVID-19, how badly they want the care for the caregiver or peer support program, and how badly they want help in having these very difficult conversations with patients and families. There's this idea of moral injury that many of us in healthcare suffer when we're not put in a position to be able to share what we know about what has happened with these patients and families. We know it leads to physician suicide. We know it leads to nursing suicide. So now more than ever, Marty, that's what we're hearing from them. And if you really want to get your medical staff engaged, it is letting them know that this program has a huge upside for them as well as the patients and families that we've talked about. Fantastic. I mean, I don't know if you want to copy on this. I mean, I wasn't at your, I wasn't part of your sessions, but I know when I've seen Tim and Julie work elsewhere, there's often just sort of a hesitance or a reluctance or a lack of trust the medical staff brings to this that you've got to kind of get through. Was that true for you or not? Yes. We knew that was going to be a barrier and it was great to work with Tim early on and he shared with us some of the learnings from the first 200 hospitals which we'll talk a little bit about before it got published. So we knew what to expect and we knew that clinicians were going to be a challenge to get them to embrace this process. So we started early on talking to our clinician colleagues sharing with them what our vision is for how we approach patient harm, engaging them with Tim and having him come talk to them and present. We actually had a very challenging patient harm event that ended up being non-preventable harm but it was so complex that Tim came on site and helped us with this process and talking to the family and demonstrated the value of Candor before we had even really educated on it. So trying to demonstrate all the way through to our clinician colleagues that we mean this and this is what we value this is what's in our policy but we want you to engage with us to have planned conversations that this is a principled and comprehensive approach. Amy I'm glad you brought that up because if you think about the timeline there's going to be events that happen as you're rolling this out and they become opportunities to sort of walk the talk. Okay let's move on to the next slide. Thanks Tim, thanks Amy. Okay this is really probably what you went in with sort of a structure about what you wanted to get but the question I want to use this slide to trigger is what did Samaritan learn? You know if you had to summarize Amy I'm going to turn to you first. What did you get out of this that was really helpful to you to decide to move forward? So we we shared some broad strokes like a one pager with our management teams at each of our sites specific to their site and the first thing that we listed and what we learned in our gap analysis is that we're ready. We identified we absolutely have opportunities we're still working on some of those opportunities right now but we are ready we were ready at the time to embark on on our hand or work. We also learned that we are open to having difficult conversations with patients and it's not that we don't know what to say but that we don't know how to say it. We needed that that training on how to be empathic how to have planned communication with our patients and even our colleagues and we also learned that we need a structured process of how we respond and we're still working on that now as COVID winds down and we're starting to embrace some of our high reliability work intertwining those. We have lots of strengths opportunities and weaknesses that I'd be happy to share as well but those were the main tenets. Amy can you also say I mean how you reported this out to senior management and what their reaction was? Absolutely we worked with Tim because we were involved in a lot of the all of the sessions and the gap analysis we were able to write insights and clarification to some of the report out language that meant something to us that maybe didn't didn't resonate with Tim and so we worked with him I think we had a two hour long session of a report out with all of our senior executives across the health system. We did have some findings that were specific to certain areas that we felt needed further discussion with our executive leadership in a private setting not necessarily beneficial to the whole but needed to be addressed and then we took that information we did a road show we went to all of our sites and shared a more meaningful amount of information to our managers gave them information to then share with their employees as well so it was a cascading communication approach which is one of our processes now within the health system. And how did you give feedback to the people who participated? I mean Julie and Tim and you have told us that there was emotional content that came out and some very heartfelt things what kind of feedback did you give them about how how their investment of time and energy and comments were going to be used? That's a really great question real time we thanked them obviously during the sessions followed up with all of them afterwards individually I wish I had in retrospect a better answer for how we got specific information to them regarding our findings I wish looking back we had taken the time to share that one pager of here's what we learned and thank you so much for your time I could do it again I would differently but we did communicate with them afterwards just our level of appreciation especially for those who were extraordinarily vulnerable Okay And Marty if I could add Amy the other part that happened that was beautiful was when we came back to do the training most of the people who came to the training had also been in the facilitated sessions and so we would always begin every session Marty with Amy and Cheehoi talking about here's where we were you know here's what we found out and here's where we're going so it was kind of neat to actually do it almost face to face in a lot of these trainings Okay so and Sandy did ask a quick question I can jump on here right now so we actually Sandy in the arc gap analysis toolkit brought in some of the questions that we do ask on the HRO domain domains but we modified it even further so after the arc toolkit came out the candor toolkit came out we added even more questions around those domains and it's based on that article Marty as you know by Chasen and Loeb who talked about ways you can actually go into these organizations and see where they are so we created a bit of a hybrid Sandra about how you can go about doing that so that's the quick answer to that question that just got posed Okay good we are going to have some time for Q&A too so keep the questions coming to Tim and Amy and Julie and we're going to move forward now to come out of the kind of Samaritan experience thanks so much Amy for sharing as much as you did it was I think it's going to be really really helpful to our attendees and just I'm going to ask Tim and maybe Julie you start first compared to the other gap analysis you've done for other organizations how was Samaritan similar how was Samaritan different I mean what was unique or what did you learn or what thoughts do you have about how it compared to others one was the discussion that we just we just already mentioned about Amy and their team coming to the sessions that was great there was so much hope in the future with their new leadership at Samaritan that was a common theme that they couldn't say they knew exactly every time the mission and vision and where they were going but they they trusted their new leadership and they would come right out and say they were super excited about that so that was really impressive some other gap analyses that we've done seemed to happen kind of right after a big traumatic event and so sometimes the common themes revolved around the trauma from that there were still some mentions of caregivers experiencing trauma in this session as well but it was more hopeful it was more of new leadership hope something good is coming kind of from this gap analysis so the the common themes there and I think too a lot of the similar themes came out about wishing for provider mentorship that peer support so I'm really glad to hear that Amy in their team chose to go with that first if they had to kind of pause on other things that that peer support is something they needed and common but something they needed and then wanting you know facilities for patients with mental health challenges chemical impairment and they actually talked to about wanting more time to implement mindfulness resources which is another theme that we saw in some of the other gap analyses is they get a lot of information about being mindful and peer support resources but they don't have time to actually implement that so those themes came out too as we had seen before but I think the hope was the big thing yeah and to add Marty what really really for me set a lot of us Samaritan sort of work the whole the whole service the whole the whole system was just eye-opening for me one of the questions you know we like to ask is around are you encountering are you recognizing issues related to diversity and inclusion you know issues around language preference and gender identity and things like that and Samaritan was one of the first organizations that was grappling right away and looking for solutions around issues around transgender patients it was so heartwarming to see an organization so embrace where we need to go in health care it was it was remarkable for me to be involved in that and Amy I don't know if you want to speak to that but you know I constantly come back to you because of the cutting edge stuff that you do you know particularly in this area it's just amazing well thank you I don't know that I have anything specific to say you know other than transgender human rights as well as you know every every type of person and and I I you know we've struggled with racism and implicit bias not just with transgender patients you know we have embraced demonstrating same-sex relationships as well we just feel like it's very important for our colleagues to see representation of themselves or of people that are different from them and feeding them exactly the same as you would want your your family member yourself to be treated okay well kudos to you Amy for being in the forefront of such a positive approach okay we are we are now kind of closing in on time Tim the article I just showed Don can we go back to the last slide just quickly this is an article Tim and I wrote with a number of other colleagues a couple of years ago after lessons learned from 200 hospitals is clearly more now including the Samaritan group but Tim I'm going to just show the quick findings here you've already mentioned next slide please Donna some of the things that we found were really important in those first 200 hospitals that really were that you had done and I highlighted the importance of C-suite engagement board of directors support here because you know I know from reading writing this article with you that you know organizations fail if they don't take that into attention you've also mentioned diversity is there anything else here that you would like to really emphasize as crucial to the gap analysis well the other part is as you can see there and even Julie brought this up as well is that it really is important to get a sense of how much you're getting patient and family involvement and the review of the events and the process improvement part that's another part where we see it being absolutely critical the other thing I'd like to say to this that's also critical and Amy I'd like to have you comment is going to be we got a question in the in the Q&A about could you get a little more specific about your engagement because this is one of the lessons learned is you need your liability carriers on board can you speak a little bit more about your broker and then the carrier and how you actually are insured because it's a great question that comes up a lot that is a great question and thanks for asking it's one that I think provides a lot of context we are self insured we have a captive we work with Gallagher so John Walpole I don't know that he's on but he's the one that connected us to Tim so thank you John we we got connected to Tim through John and then we had a few a few cases where it was difficult for our defense council to rack their brains around what we wanted to do we had two that I can think of off the top of my head but I think there's more events where we had a really delayed disclosure and I used disclosure intentionally because we told them stuff that they didn't know and some of them we needed our reinsurers on board for and so it took us I not overestimating probably 50 to 100 man hours to plan for some of these conversations with our broker our defense council our reinsurers Tim engaged with us to make sure that we're doing it truly in a principled fashion but ultimately with the patient in their family and our team members at the heart of it yeah so what I'm hearing Amy is that as this gap analysis process was going on you were also having conversations kind of spinning out of the issues that were coming out of it that you needed to do to kind of get your audiences on board did you bring in your external counsel into the gap analysis process formally you know I don't know that we did now that I think about it and I think that would be a great idea we prepped them we had a lot of conversations with them we invited them to our training sessions as well connected with Tim in this the process pretty early on and again you know we had this long so in the long timeline of our implementation and so as we had cases come up that warranted honest conversations with patients we were able to really learn the candor process with Tim I mean it was it was a one and then one and then one I grew a lot last few years in our learning and understanding of candor okay well and Julie you can probably speak a little bit too we are improving our engagement with attorneys I mean your group as well that you're involved in this is a really critical question Marty Julie do you want to comment on that as well with you and some of your colleagues I've spoken to I agree I think the big the big learning we've had in and I'm part of a partner in a law firm and we we met with Tim and we met with John Walpole and Marty you might be next if you're willing but we just want to learn maybe more about what individuals want to know and so we've been planning and working through some educational sessions and so learning more about that and how the process works and what people want to know about so for us it's just learning from these experiences about you know what kind of questions come up and what would people want to know more about so that's what we're working on fantastic one other thing I wanted to mention which is really important so we are self-insured but we have a lot of clinicians that work at our health system that are insured by private insurance companies and that has been hard for us that is a real challenge and barrier when we look at resolving patient harm early and we want to do the hand or process and the insurance company of the co-defendant if you will is not on that same page so we've had a lot of conversations with our executive leadership team and our attorneys and insurance brokers about that process and it's usually each individual case I know that's been an issue before and maybe in our next candor webinar we should talk to him about how to bring the insurers together in some kind of a discussion to help them get on the same page yeah and in the Q&A Marty candor just brought up a phenomenal point on that so let me just share now and Marty I just talked to you about this earlier this morning and I want to bring Amy into that group that we've talked about but we have a group that's called the partners in communication we now Amy have 18 carriers for the independent providers who have joined this group to talk about how do we when harm occurs collaborate together where the self-insured organization is able to communicate and collaborate with the providers of the independent you know non-employed docs or other people there and we've made a ton of progress we actually have now a written agreement that we've created that we're trying to get people to sign on with I'd love you to be part of that Amy and Kendra that's how we're going to go here and we do even have in Colorado we have some members of Copic and others Marty who have joined and been part of this group so really exciting I think we need to think about the next webinar or even one after that to get to this because Amy has just articulated one of the most critical things that needs to happen going forward in organizations spot on and Julie you'd probably agree as well with your law firm on that Julie, Tim, Amy we are closing in the time at the end of our time today so thanks so much Donald just quickly to the next slide there's a bunch of research and tools that we have assembled for you these don't all go to GAP analysis they go to just the ROI in general but they could be important to get leadership on board so we've got examples of this we also have an example of a GAP analysis that's been de-identified that Tim shared with us if you'd like to see that just check out the resources and thank you for all the questions that we've got Donald, we want to do one last poll here in our last couple of minutes so again bring up your Slido how useful was this discussion in helping you understand the candor GAP analysis I learned what I wanted to know was one choice I still have questions I'd like to see more events about candor okay we have a nice group there still answers coming in still have questions I'm not surprised by that I mean we've sessions like this raise questions because this is hard work I mean as you know part of the timeline issue you have Amy is just you know it's it's hard to get people on the same page especially for something that says dramatic a shift in the traditional approach to risk that this represents yeah I very much like high reliability this is a marathon maybe more like an iron man it takes it takes dedication and commitment and that's one of the learnings and the article that you highlighted is truly not understanding how much work this takes is one of one of the missteps a lot of organizations take and I would say I didn't realize how much it was going to take and feel very fortunate that our executive leadership all the way up to Doug have prioritized this is as something for our health system yeah Amy if you could there's still one question I didn't quite bring up to you if you can just share a little bit how are you now really beginning to engage patients and families and loved ones in event reviews or getting their perspective on what has happened that was one question that was again buried in the Q and A if you could you could jump on that very quickly very quickly we aren't doing it consistently because we don't have a consistent root cause analysis process that's coming that's part of our our higher liability work so in the next few months we will have that consistent across the system I have engaged families in the conversation I think of one in particular where we would not have learned all of the information we needed to be able to identify what exactly happened to this patient and when we went back and did a full review and in January for our higher liability work we found 19 opportunities that would have prevented this patient's death and we would not have learned all of those opportunities holes in the Swiss cheese if you will if we hadn't have talked with the family and engaged with them and we did embrace the candor process with them and their attorney one of their attorney is similarly that we've partnered with on a couple of candor cases and I think he's going to be a strong advocate for the process moving forward thank you Amy thank you Tim thank you Julie I will just say we'll respond more in the email that there are where organizations have a PFAC structure they've they've engaged them in the in the gap analysis process and learned a lot too Donna over to you we're right at time I know but you have some some closing remarks thank you so much Marty what a fabulous moderator you are and thank you Amy, Julie and Tim this has been such a great session as you saw in the slide a poll that we just did there's still lots of questions so please everybody do come back for part three that will be next month I'm sure we will continue to identify more learning needs that we will we will definitely work on creating new sessions to meet any questions that we did not answer during this session we will we will be posting that along with all of the other links that I post I put in the chat that will be on our YouTube page so we'll get the panelists to answer some of those questions and writing and have that posted as soon as we can again just very quickly if you are interested in getting CE for this for nurses pharmacists and physicians you will receive an email from MedStar Health and you'll need to complete the evaluation in order to get that for ACHE please log your information into your account for CPPS and BCPA you'll receive a certificate from the Patient Safety Women Foundation within the next five to seven days and for CPHQ and AHQ will take care of of documenting your attendance here today so again thank you everybody for joining this is such a fabulous topic and such a fabulous panel and we really appreciate having you all here today Julie thank you thank you to the Patient Safety Movement Foundation thank you so much and Amy thank you so much for sharing your organization's experience I mean it it will be really helpful to others and Julie your expertise was just great thank you thank you so much bye everybody yeah all right bye everyone bye