 Hello everyone, my name is Sarah Miller and I am our Director of Partnerships here at the Patient Safety Movement Foundation and today we're really excited to kick off Patient Safety Awareness Week with our very first webinar of the week called Patient Safety Past, Present, and Future. Next slide please. Perfect. So I'll just really quickly go through the learning objectives for today. The first learning objective is examine the outcomes of the past 20 years of global health care safety improvement efforts on patient harm. The second is recognize why patient safety is so important and the impact preventable medical harm has on patients and families. The third is identify the typical patient safety gaps in most health care organizations. The fourth, summarize what general public patients and families can do to eliminate harm and finally commit to zero preventable harm and death in health care. So we're also really excited to announce that we will be offering continuing education credit for board certified patient advocates for today's live webinar and we'll provide a little bit more information about the CE process at the end of today's presentation. And this next slide just shows that our panelists and speakers have no financial disclosures to provide so again we'll provide more information at the end about the process of receiving your CE. So before we introduce our panelists I did want to provide a few housekeeping items. We will have a 15 minute question and answer session at the very end of this presentation so if throughout the webinar you have any questions that you'd like our panelists to answer there is a Q&A section at the very bottom of the Zoom tab. You can just hover over it and submit your question and I will be monitoring those and we'll have a chance to at the end ask the questions to any of the panelists to get those questions answered. If for some reason we don't get to your question we will be sending these questions to our panelists after the live webinar and we will be sure to send your responses out to ensure that everyone's questions are answered. So at that said again very excited to welcome our two panelists we have Helen Haskell the president of Mothers Against Medical Air and then we have our very own Donna Crofzer Chief Clinical Officer here at the Patient Safety Movement Foundation. So to kick us off Helen do you mind introducing yourself? Hello I'm Helen Haskell I hope I know a lot of you already. I've been a patient safety advocate for about 20 years and I've been involved with the Patient Safety Movement Foundation from the time that began really in 2013, 2012 and 2013 and I work with a number of different organizations, Mothers Against Medical Air, Consumers Advancing Patient Safety, Patient Safety Action Network and of course Patient Safety Movement Foundation and I am very happy to be here. Hi everybody I'm Donna Crofzer I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. I've been a nurse for a little over 30 years now and I saw I've been a bedside nurse I have been a hospital administrator I've been a consultant and I've also been a family member and a patient on the other side of the bed so I really understand how you know all of the quality and safety issues that we have in healthcare from a 360 degree lens and I also have been working in the quality and safety space for the past 20 years so been at the Patient Safety Movement Foundation for a little over a year now and really excited to be here today as a panelist. Thanks Sarah. Well thank you Donna. Donna Helen very excited to have you guys on this call today and with that said I think Helen we'll we'll pass it over to you. Okay so I will start by talking about the problem. So the problem is that preventable medical harm remains a leading cause of death in the United States and across the world. There's no standard mechanism for tracking deaths due to medical error which means that all current statistics are estimates rather than counts. In the U.S. we have several estimates that more than 200,000 people die each year making medical error the third leading cause of death after heart disease and cancer. If you include delayed effects and less obvious errors like misdiagnosis it's probably much higher. Globally medical error is estimated to be the 14th leading cause of death killing more people than HIV, tuberculosis, and malaria combined. In some parts of the world harm from medical error is calculated to cause as much mortality as the leading diseases in those regions. COVID-19 has surpassed medical error as a leading cause of death this year but the pandemic has shown a spotlight on the systemic safety issues in health care today. These can no longer be ignored. Next slide please Donna. The global economic impact is estimated to be billions in the U.S. a lot. Conservative estimate is about 20 billion. The global economic impact is even larger. The OECD has calculated that 15% or more of hospital expenditures and activities in the 13 OECD countries can be attributed to treating safety barriers. This again is probably a conservative figure and doesn't take into account the ripple effects of things like lost productivity and added cost for the victims and for those who must leave the workforce to care about. Next slide please Donna. So patient safety isn't a new discussion. There were occasional articles on patient harm going back to the 1960s but it's been about 30 years since the quality and safety movement as we know it was really born. Harvard pediatric surgeon Mission Lee pictured here is thought of as the father now the grandfather of patient safety. Dr. Lee fired a shot across the bow of the medical frigate so to speak with a 1994 article called error in medicine in which he estimated that around 180,000 people die each year due to the Medicare. He was the one who came up with the famous jumbo jet analogy equating medical harm to the toe we would have if three jumbo jets crashed every two days. Dr. Lee had made a study of safety science in other industries and in his article he introduced the idea that we still that still guides us that we should focus on faulty systems as the underlying cause of most medical harm. Next slide please Donna. Also in the 1990s there were two large studies in New York, Colorado and Utah showing significant rates of harm and death from medical error. Most of this kind of early work remained hidden in the medical literature until the 1999 Institute of Medicine report to errors humans reported the now well-known figure of 44 through 98,000 deaths a year on medical error. These numbers came from those New York and Colorado Utah states which had been undertaken to find answers about malpractice litigation. They only included cases that would have been likely to prevail in a court of law which is a relatively high bar so as shocking as these numbers were at the time again they were thought likely to be underestimates. To errors human was followed in 2001 by a second item in the court called crossing quality chasm which laid out a roadmap for improvement focusing on six aims to make care safe effective patients that are timely efficient and equitable. These are now called the steep aims S-T-E-E-E-P three E's to make them easier to remember. Next slide please Donna. So this was when I dropped into the picture between the two IOM reports. This smiling boy is my son Louis who died at the age of 15 from a medication error following elective surgery in a major teaching hospital. Louis was a vibrant healthy boy and did not have to die. What killed him was the defective system that Lucian Leed had spoken to six years earlier. He died from what's called failure to rescue that is a failure to escalate care because of cumbersome slow moving systems that are not designed to deal with emergencies. When Louis died I entered almost by accident into the other patient safety movement. The movement run by patients who suffered serious medical harm and were focused on the idea of consumer action and patient-centered care. Because the patient safety movement as a whole was small we were all interconnected at some level and the S-T-E-E-E-E-P principles of the second IOM report came from a major patient organization the Picker Institute which was dedicated to elevating the patient voice and focusing care on the patient. Another focal point for patients at the time was Rosemary Gibson's book Wall of Silence in which she gathered patient stories and emphasized the culture of secrecy that continued and still continues to enable patient harm. Rosemary helped bring together a community of people focused on solutions for the patient and her work inspired a number of health care leaders like David Mayer of the Patient Safety Movement Foundation. Next slide please Donna. Following the two IOM reports from my perspective as a patient things did not get better. In fact they seem to get worse with infection especially seeming to run rampant as medicine expanded with few controls and in place. Then in 2004 the Institute for Health Care Improvement launched the first of its big patient safety campaigns the Save a Hundred Thousand Lives campaign which pulled together stakeholders from all parts of health care to implement a menu of patient basic patient safety measures. This was a turning point. It was followed rapidly by other initiatives that had been in the work since the IOM reports. Consumer Union Stop Hospital Infections campaign resulted in a number of state laws around disclosing hospital infections and ultimately in national reporting of infections and other hospital acquired conditions. IHI style improvement collaboratives and disease focus registries became part of the discourse under prodding from the Obama administration. Electronic medical records were finally implemented in a system that had remained paper long after everything else had been computerized. Patient surveys like HCAPs finally gave patients an organized way of providing feedback about what they were seeing and how they were being treated. The Affordable Care Act of 2010 and other legislation included a number of patient safety provisions that are still unrolling. Just next month this is not on the list. Patients are supposed to be granted free access to their medical records as they are being created. Next slide please. So there's been a lot of work in patient safety. The problem is at least in my opinion that medicine has changed faster than patient safety solutions have and that we still do not have a good handle on what's actually happening. In 2010 the Office of the Inspector General published a report in which it examined the medical records of every Medicare patient in the country on a single day in 2008. They found a 27% rate of medical harm adding up to an estimated annual medical error death rate of 180,000 among U.S. Medicare beneficiaries alone. This is one of three reports published in 2010 and 2011 that showed high rates of harm in hospitalized patients. One in Colorado and Utah showed circa 33% rate of harm. One in North Carolina showed about an 18% rate of harm with no change over six years. All these studies used data from 2008 and earlier. Later reports like the James and McCary studies that I mentioned earlier do on these reports to project national rates of harms but we do not have any large-scale data that dates after 2008 which means we simply do not have a systematic way of knowing what the effect of our considerable later interventions has been. What we do know anecdotally is that harm continues to occur. What we don't have is the patterns and trends on a large scale that could help us address it in a more rational way and on that curing up I'm going to turn the virtual microphone over to Donna to talk about some of these solutions. So thank you for your for your attention. Donna? Thanks Alan. Appreciate it. Everybody if you have any questions please pop them into the Q&A we're going to we'll get to the Q&A section at the end and I think we'll have plenty of time for questions so keep them coming for us. Thanks Alan for for you know taking us through the the background and the history of patient safety. You know and as Ellen mentioned you know it's not for lack of trying that we haven't fixed this problem yet and so last year at the Patient Safety Movement Foundation we said you know gosh why is this? Why is it that we've been working so hard and what is it that we can do to improve this problem in the future? And so we thought you know the first thing that we want to do is get a pulse of where the public sits on this. Does the general public even understand how much of a problem patient safety is? Because our premise was you know we're never going to fix patient safety if the public doesn't demand it and the public isn't going to demand it if they don't know that it's a problem. So and as you can see here on this slide last April when we surveyed in this case we surveyed those in our network which is the the purple color there and then those in the United States just in the general public. We're repeating the survey again this year and we're hoping to have more international representation moving forward but you can see that nearly 91% of the folks that we called indicated that they'd heard either nothing or very little about medical error in in their region so so we know that this is a huge focus area for us. There's also you know a lot of reasons as Helen alluded to why we haven't fixed this yet in in hospitals and other healthcare organizations. You know again not for lack of trying I've been one of those administrators that has worked really really hard over the last two decades. You know none of us got into medicine for any other reason except that we want to help people we want to make people better and so you know so we've we've tried things like you know like performance improvement you know that became a real big thing in in the 90s and the 2000s but what we did essentially was we created this what I like to call a patchwork quilt of improvement because the right hand didn't necessarily know what the left hand was improving and so you know and and those teams were really focusing mostly on process change not necessarily culture change in the organization. We also in healthcare tend to focus on on blame we we look for somebody that we can blame for making a mistake we're always looking at individual behavior rather than examining systems and processes and for that reason the front line is often afraid to speak up and they're you know they don't always want to to mention when they've made a mistake because they don't want to be blamed we've talked about patient centered care for a very long time in healthcare we know that we have to have patients as part of their their healthcare team but care today remains clinician centered more than patient centered in general and and some of the reasons for that is that the care environment has become so incredibly complex it's really a lot harder now to take care of patients than it was 20 years ago and part of that is because care coordination is lacking across the continuum there is no one person who really oversees in a patient's entire journey throughout the continuum now there might be you know navigators in orthopedic or oncology or cardiac programs that are very specifically focused on care coordination for that particular disease process but in general across the entire care of a patient about patients continuum there is no one person who's really overseeing all of that. Another reason why we haven't fixed this yet is because performance improvement is a lot harder than we ever anticipated it to be. Sustaining change is really really hard because we're dealing with you know healthcare which and a lot of a lot of healthcare organizations are struggling financially and you know there's a lot of change there's a lot of new physicians and new nurses and travel nurses and and and various individuals that are coming and going all of the time so it's a lot harder than we thought to be able to sustain this and do this well. And then finally I think the most important lesson that we've learned over the last 20 years is that culture change is really hard it takes a long time we can't just go and say hey start being patient-centered because you know a lot of folks think they're being patient-centered when they're not and so and so that culture change that mindset change takes a really really long time. So here at the Patient Safety Movement Foundation you know our vision is zero preventable harm and death by 2030. So how are we going to do that? How are we going to get to the place where where there is no longer preventable harm or death in any healthcare organization? Well we believe that the only way to do that is to require that every healthcare organization becomes what we call a high reliability organization. Now a high reliability organization is is one that has operated for a very long period of time without having an error. So the you know if you think about nuclear power as Helen mentioned the aviation industry the oil and gas industry those organizations are anticipating errors. They're looking ahead to see what can they do to prevent the error from happening in the first place. In medicine we wait until an error occurs and then we go do a deep dive and a root cause analysis and say I wonder why that happened and I wonder if we can prevent that from happening again. So we need to just change our mindset a little bit from the get go in order to become a high reliability organization. The other thing that we advocate here at the Patient Safety Movement Foundation that organizations do is that we stop focusing so much on the population specific improvements that we've been doing over the last 20 years and focus more right now on creating a foundation for safe and reliable care. So you know what we've seen a lot happen in organizations is you know maybe there's a team that's working to improve your success or falls or pressure ulcers or you know or unintended extubations any number of safety issues we have a team that's working on it we have you know a lot of effort that is put into creating this change and usually that change is really successful because there are what we call champions those healthcare heroes who really really care about about that particular patient population and want to make a difference and maybe we see change in you know in a short period of time but very often it doesn't last and it's not sustained because those champions leave they move on to another project you know or something along those lines and without that foundation in place then that work then begins to crumble because it's person dependent improvement and not really something that was was baked into the culture and so here at the Patient Safety Movement you know we've really changed our focus with our commitment model with healthcare organizations and we're asking healthcare organizations now not just hospitals all healthcare organizations across the entire continuum outpatient and inpatient to commit to creating three critical components to create that foundation for safe and reliable care that is a person-centered culture of safety a holistic continuous improvement framework and an effective model for sustainment so what do we mean what do we mean by all of that well a person-centered culture of safety means that that organization is focused on the safety of every person in the organization this is not just patients and families but doctors and nurses and visitors and vendors and everybody else that is in that organization one thing that the pandemic has taught us is we cannot have patient safety without health worker safety and so it so everybody in the whole organization needs to have patients say or everybody's safety as top of mind and then we need care systems that are patient-centered as part of that person-centered culture you know that means that our care systems are well coordinated and that they're individualized patients should go into the hospital and get a care plan that works for them not one that is just a blanket care plan for anybody with their particular diagnosis or disease process and in order to to really have effective patient-centered care we have to include the patient and the family as an equal member of the care team and engage them in improvement activities there should be a patient or family member on every improvement team in in the organization because they're the ones and they don't have to necessarily be on every meeting you know to and spend a lot of time but at a minimum there needs to be some effort from every improvement team to understand the perspective of the patient and the family the other thing that has to be done as part of this work is to hardwire transparency and respect and trust you know in order for the community to to have faith in their hospitals and their health care systems you know they need to trust that if something goes wrong that that there's going to be openness that that the administration is going to practice what we call candor and and and openly discuss the errors with patients and families make it so that you know the the the front line is not afraid to step up that they they respect each other enough to be transparent about the the errors that are happening and then of course we need to not not blame people for for making those individual mistakes and so organizations should use what we call a just culture approach to determine whether or not you know whether or not people should be blamed versus the system and a just culture you know this is a program that provides an algorithm that helps leaders to walk through a particular event that occurred and decide was this human error in which case we have to figure out how to make sure that prevent that error from ever happening again was this reckless behavior or i'm sorry at-risk behavior where maybe somebody stepped outside the bounds of what we expected them to do but there was a really good reason why that happened maybe they didn't have the right PPE or they were short staffed that day or there are several reasons why that occurred and we need to examine that and again not blame the individual but fix the system and then finally if we decide that no no this was reckless behavior this never should have happened in the first place well then we address that in a very different manner so um so that is what the just culture is all about and you know Helen talked about Lucian Leep earlier he said once that the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes and that is probably the number one thing that we have to address in healthcare the second critical component of a foundation for safe and reliable care is creating a holistic continuous improvement framework now i remember back in the 80s and 90s you know when i was a young nurse a student nurse and a young nurse and you know whenever joint commission would come they would want to know what is our performance improvement framework and we had it on the back of our badge like nobody really knew what the letters meant and it usually spelled something like a word like improved and each letter meant something but we didn't really know what the letters meant we just knew it was an acronym for something and but we've been talking about continuous improvement for a really long time in in healthcare and the problem is again that we don't always apply that in a holistic manner across the entire organization and so maybe you have three different teams working on three different problems all using a different approach maybe one person is using a pdsa approach and another team is using a damaic approach because that's the way they learned how to do it and somebody else is applying lean and six sigma to their to their project planning and so that is very confusing for staff it's really really hard to get people to be good at performance improvement when we throw a lot of acronyms and names at them that are confusing so that is you know it's the first thing that we recommend is that you know there's that that that framework is holistic and consistent across the organization and making sure that that work is coordinated to the singular source what happens is that organizations are out there making so many different changes that they cannot figure out you know what the other teams are doing and so then they're all competing for the same resources and that becomes inefficient again as i mentioned before patients and families their voice should always be very very clear in across all of the improvement work that we're doing in an organization and that one single consistent source whether it's a person or a department or a committee of some kind should be able to see how that patient voice is interwoven across all of that improvement work and then finally utilizing technology to do a better job at looking at our data we uh you know Helen talked about how we don't really know how many people die every year of medical error we don't know how many people are harmed every year because of medical error and that is mostly because we just don't collect the data the way that we need to and you know we we we've got a lot better in the last 20 years but we still have a long way to go to maximize the use of technology to make sure that we are addressing problems in the right way based on on on truth and data and then you know another thing that i think that you know the general public doesn't really understand so well is sometimes it's really hard for the frontline to know what's expected of them and to know what to do we rely a lot on memory and medicine you know i rely heavily on the way i was trained and so you know if you have somebody who's been a clinician for five years 10 years and 20 years they all might have a different frame of mind based on when they trained and so the so organizations you know there is no lack of policy and procedure manuals in most health care organizations but the problem is there's so much information that people just can't keep it straight i remember in one hospital system that i worked in we counted the number of policies and procedures that we had just so that we could get an idea of how hard is it for the frontline to really have a good understanding of their expectations we had more than 6500 documents across this hospital system policies and procedures so you know it's it's no wonder that people weren't necessarily following the policies and procedures because there were too many to keep track of so and so we recommend that the patient safety movement foundation that that organizations really take a hard look at at their at all of those documents that guide practice and make it really easy for the frontline to know what to do we call this the six p's of clinical practice improvement and and and we work with hospitals health care systems to to improve these and make them easier to understand and for not just for patients for for clinicians but also for patients and families and then finally we help hospitals and health care systems to improve um sustainment over time um you know human beings do this work we are human beings taking care of other human beings so it is a very different industry than nuclear power aviation but no less um you know no less risky in terms of of patient safety so we just have to remember that we have to change the conditions under which human beings work if we really want to change the human condition and so so um we work with hospitals to help them to um to organize their their improvement work and to create those more effective learning systems across the the organization and so so the the question the real question then is you know what can you do well as a you know as a concerned citizen um first of all make sure that you know what your organizational scores are um you know look at the leapfrog scores and the hospital compare scores if you are here in the united states and and and and see what you know what the safety record is for your health care organization ask them ask when when you're there ask them do you have a continuous improvement framework or do you have a person centered culture of safety um you help us to advocate for national and regional patient safety boards we don't know what this would look like yet there's some some work out there being led by the Jewish health care foundation to create a patient safety authority um very similar to the patient safety to the um the national transportation safety board and so um you know again we're we're not going to fix this problem unless the general public helps us to demand that this happens um and so if we had some kind of regional oversight then we would be able to determine if an error occurred did it occur because an organization doesn't have those foundations those three critical components in place or did it did they do everything that they could to try to keep patient safe and the error occurred anyway that's really where we need to get to you now is understanding um you know the the gaps in in um and the root causes of some of these errors so having some kind of of national patient safety board would would certainly assist in that effort again supporting other legislation that makes patient safety data more transparent is is really important you know there's there's um organizations are um are surveyed on a regular basis especially here in the united states um you know there are crediting bodies that that will um will come in and do a survey and determine whether or not an organization is safe and then provide a report for that for that organization and there are some people who believe that that needs to be transparent hospitals will tell you they paid for that consulting report and it shouldn't be transparent um but you know we're however it is that we that we do this we need to make it so that when you know if a death occurred because of medical error that's captured somehow on um on a death certificate that you know if there are errors in a hospital that occur if that adverse events occur that that information is very clear to the people who seek care there as well as all of the things that an organization is doing about it um you know again think about you know the aviation industry or the nuclear power industry if there is an accident that occurs the entire world knows about it whereas in health care accidents are occurring every single day and nobody knows um we also need to look at you know supporting legislation that aligns financial incentives it is right now not um it is it is it is not necessarily in an organization's best financial interest to do this work of creating this foundation for safe and reliable care because it is really hard it does take a lot of manpower and initially it is slow going and it feels like you're spending more money than you are saving initially and over time over time as you have more quality and safe processes then financial stability will occur but that is a hard that's a hard sell to an executive who's being held to financial uh goals for one year at a time so we need to align those financial incentives so that the needs of the and the the um the the the desires of the patient and the family are aligned with the desires of the clinicians and the administrators and then finally the last thing that i can say is you know again be an active member of your own care team make you know make uh you know make yourself um knowledgeable about your disease process ask questions um and um and you know when you're choosing your physician in the very beginning ask them how do you feel about about a patient about patients being involved in their care i do that when i when i choose a new physician i make sure that they are very clear from the outset that i direct i'm the coordinator of my own care in conjunction with them as part of my care team so um so uh you know i would say that is probably the most important thing that you can do for you and your loved ones is to get involved and to be that coordinator of care because that's just not something that is is part of our reality right now in healthcare so um so with that i have nothing else to add so i'm going to pass it back over to sarah great thank you so much we again really appreciate your insight um just a reminder for those of you that are on the live webinar we are offering continuing educational credit so for board certified patient advocates um you will receive a certificate so please note that the CE may take about five to seven days to process but if you have any questions feel free to email clinical at patient safety movement dot org and we will address your questions appropriately um so with that said i will go ahead and lead us into the q&a session we we have a little bit more than 15 minutes so um if you guys again have any questions for our panelists please pop them in the chat we only have a few um so with that said i will go ahead and start it looks like we have two comments and one question so i will address the comments um from our very own marty hatley um excellent overview helen i'd add that there are more recent data sources also from the iog about death from preventable harm in non-hospital settings for example in nursing homes and sitem is developing data from liability claims about harm in ambulatory setting isn't it time for us to look beyond hospitals to other settings um i didn't know if either of you donna or helen wanted to address that comment well i'd love to uh so i think um yes ambulatory care is sort of a black hole we have um the the big malpractice insurers specifically crico the harvard medical insurer has got a lot of data that they have really mined um on diagnostic issues in particular because they saw diagnosis as um is one of the major causes of of malpractice claims so the malpractice insurers have an interest in in reducing um medical harm right that it reduces their payouts um and they they can do a particularly good good job at that um oig does lots of reports about um harm in all sorts of different places tremendous amount of information in their reports the problem is i think that you know none of these are global none of them are comprehensive so it's great to have a database looking at diagnosis or surgery um which what i'd like to see is something that really puts all that together ambulatory nursing homes um hospitals um outpatient surgery everything and um you know and look at the whole picture where the harm is occurring because you're so right marty that most care is moving out of hospitals you know even operations that it makes you cringe to think about are being done on outpatient basis and um we don't have a handle on that we don't know even the infection rates in these ambulatory surgery centers um so you know something it's sort of in the state where hospitals were when when we began this journey and um so we need to get a handle on it globally and you know we have a lot of solutions we need to have a global way to apply them as well so you can see that i'm a big picture sort of gal and you know that's what i'm looking for so donna i don't know you have something to add no no i agree 100 we definitely need to expand our our our overview into the outpatient setting i definitely something that is a a goal for us here at the patient safety movement we started on that journey to expand beyond the hospital walls in 2020 but we're really gonna focus even more in 2021 yeah you know we started on hospitals because they're easy right they're already pretty regulated um you know that you can they're centralized you can get data from hospitals and you can tell hospitals what to do much more easily than lots of little practices but you know we have the means of sort of coordinating things now but that we didn't have 20 years ago yeah i think i think we we started with the low hanging fruit right now we said what's the easiest thing that we can go after and we did a lot of great things with the low hanging fruit but now you know we pretty much picked it all so now the hard work begins right great um the next question i think is um directed more for dana but so dana regarding punishment any thoughts on how we get past providers conflating being held accountable for preventable harm with punishment or blame um yeah i think you know again it goes back to that just culture um and you know if if an organization whether it's a doctor's office or a nursing home or a hospital um you know they they need to take a look at how they are right now um uh dealing with events that occur and applying that algorithm can certainly help to make it really easy for leaders to to come to that decision about about the root cause of an error so um so i can tell you in um in the state of north carolina actually the north carolina board of nursing adopted the just culture algorithm as part of their disciplinary process and asked every leader in the state if for any event that happened with a nurse to go through the just culture algorithm and report that to the board of nursing because they recognize that a lot of times you know we we might we might say ooh that was reckless behavior you really shouldn't work here anymore so we fire somebody because of their behavior and then they go to the hospital down the street and they continue their bad behavior down the street so um and so the the board of nursing actually got involved with that which was um very very helpful it taught leaders across the state how to apply the just culture algorithm and it also helped us to address on a state level those few individuals who truly are reckless that don't need to be taking care of patients at all great thank you donna um the next one is more of a comment um so the comment says i am of the opinion that different qi methodology fit better than others for different issues slash problems i understand the need for congruence but i don't think we should be limited to one for example lean versus ihi both have their own places as to others um donna do you want to address that comment yeah yeah so i guess what i mean all the tools need to be applied based on the the particular um project at hand right i guess what i'm talking about there is the framework in in terms of the the documents that right that the forms that people have to fill out in your organization um the you know the the the acronyms that they have to memorize so think about the end user if i am if i am a committee member and i belong to three different committees and there's three different frameworks being used in those committees i'm going to get really confused about performance improvement right and at the end of the day whether we're talking about pdsa or damaic or you know the nursing process or anything it's really all the same problem solving methodology um and so that's what i'm suggesting is that organizations choose that high level methodology but in terms of what specific tools they use to address root causes and and such then they definitely um it should be able to to apply the tool based on the need great thank you donna um and i can combine these next two questions so how does one become board certified as a patient advocate and are there any training programs for patient safety advocates either of you are welcome to answer that one i suspect that some of the people on our call can answer this better than we can yes there is the there's a a board certification and i think there are training programs i don't know if somebody could share in the chat or that is there audio enables here or not for attendees maybe not for now but yeah in the chat the answer to that question because um i'm actually not that clear it's been a long time since i've been directly involved with that okay yeah there are a couple of different folks out there that do some training um you know there's the um the alliance for professional healthcare advocates a pha is available um and um and then the um the patient certification um board is i'm sorry patient advocate certification board um is the one that provides that um the board certified patient advocate credential and they also have great resources as well perfect yeah and if anyone on the call today knows of any other um you know trainings feel free to pop that into the chat so that everyone can view that i do see people having conversations in here so that's great um so the next question of new rns practicing on their own very quickly after graduation and limited clinical training they now receive donna do you have any comments on that i'm sorry you you broke up for just a second could you say that one more time yes um is there any discussion of new rns practicing on their own very quickly after graduation and the limited clinical training they now receive uh well yes that's and that's a concern i think for all clinicians there's so much information that people have to learn in school these days that they can't possibly learn at all and so it is crucial especially for nurses that organizations have a solid orientation and you know residency plan for them so that they can learn all of those skills the problem is that how a lot of hospitals perceive that they can't afford that and they and they don't necessarily recognize the the patient safety implications there so i think it is absolutely necessary that organizations have a residency for nurses physicians have a residency when they graduate they cannot you know cannot function as a independent physician until they go through an internship and a residency and i think nurses should have some some form of that as well so and here at the patient safety movement we're happy to help organizations figure out how to to make that happen in your hospital great thank you donna um so this next question i might rephrase it a little bit just because we we recently just launched our new commitment model in September so we don't have a a ton of improvement projects around this but the question is donna how do you sustain patients engagement in hospital projects but i guess i'll rephrase that to say how do you plan to sustain patients engagement in hospital projects um i think you know again it comes back to how we think about including people so i um you know a lot of times when we say we want to include x person in this project people here that means they have to come to every meeting on Thursday mornings at 10 o'clock and be physically present that is not necessarily the case i think you know the the project lead needs to be able to have a good understanding of who the stakeholders are in their performance improvement project and they also need to um to have a really good handle on the pulse of the patient and the family voice maybe it requires a phone call to them to run something by them to get their input maybe it requires them to be physically present at a meeting so um but you know and it could be anywhere in between so just because they can't physically be present all the time doesn't mean that we don't talk to them and and and get their opinions and their feedback perfect thank you um and then it looks like we have one more question left so again if you guys on the call have any additional questions please pop them in the q and a as i'm moderating that but the last question is how much as can nor reduce medical errors you know i think that's something else we don't know um really all that what's been looked at is how much it reduces claims and satisfaction of those who've been through the program but there is that link between actually the disclosure process and improving patient safety um i think still needs to be more clearly defined and um like everything else we don't know it's something that we have to sort of take on faith for a while because we do know it reduces the stress agreed yeah and and it's you know unfortunately not something that has been as widely adopted as it needs to be um there are still too many organizations who perceive that that uh you know being that open and transparent is a financial risk for the organization so you know so until we get everybody doing it we may not not know the full impact okay um okay so it looks like we actually have another question in the chat um so what is your vision for anticipating safety issues so that we can prevent harm either of you are welcome to answer that one Helen you want to go first but can you say it again i'm sorry i didn't quite of course the question is what is your vision for anticipating safety issues so that we can prevent harm oh well my my vision is the big database in the sky it's the patient safety authority that would be you know able to and we have the ability now with for example global trigger tools tools the ihi global trigger tools you can run them in real time and there are other software programs too and catch things as they're happening um it's certainly possible in any in the institution and and i think it could be possible from outside the institution as well so i think technology is really going to be an answer to a lot of this it just lets us do things that we couldn't do before i think that you know the other question is you still have to have adequate staffing to do what the technology is telling you and to run the technology and that's that's you know that's an issue that is just perpetual in healthcare you know going back to the last century to the century before last staffing issues and i don't know how we address that how you make people staff up yeah i i would have to agree with Helen that you know staffing is definitely a major issue we cannot be you know anticipating errors doing root cause analysis of errors and taking care of people at the same time with the same folks so um so that is definitely an issue i think you know the other thing that we have to remember is that um i think well i'm sorry i i forgot my the thought because i got all i i started thinking about staffing and Helen got me all excited about about a lack of staffing so uh but yeah i think that that is definitely a huge issue yeah well talk about lack of staffing because i think it's i think it's so important and it's often um just sort of tip-toed around in patient safety discussions mm-hmm yeah i agree i agree great so it looks like we do have one more question um so the question and donna we'll start with you for this one um raising patient safety culture among the community needs a lot of effort what is your advice to start spreading the concept i my advice is for everybody on this phone to go on this call to go and talk talk to somebody that you know so at the patient safety movement we have a very ambitious goal that everybody in the world is going to commit to zero everybody so patients families legislators doctors nurses and administrators everybody so um that we need your help with that so please you know share our website share our patient stories um you know invite people to come to webinars we are going to really step up our efforts here at the patient safety movement in fiscal year 21 to improve education for the general public as well as for healthcare organizations on performance improvement and leadership development so um so we'll have lots of information that folks can share thank you donna okay it looks like i was able to address all of the questions in both the chat and the q and a so um with that said i guess i can wait a few more seconds to see if we get any more um but i i do want to address i know a lot of you have asked in the chat if the slides will be available i do want to say you haven't seen my response yes the slides and the live webinar recording will be available following this call on our website and on youtube um and i i'm really excited to see that some of you want to use our slides for training purposes which is exactly what um donna and myself here at the foundation love to see in the future um but with that said i i think we can end today's call if no one has any other questions but donna helen wanted to thank you both so very much for your time and your your really informative webinar and again we look forward to continuing these presentations throughout this week great and i see that michael deho is just uh and and marcia remera i'll said uh happy patient safety awareness week so happy patient safety awareness week to everybody great thank you everyone for joining appreciate your time bye