 All right, well, good morning everybody. It's nine o'clock, right on the nose. We're gonna go ahead and get started. I am Donna Prosser and the Chief Clinical Officer here at the Patient Safety Movement Foundation. And we are so excited today to bring you a webinar talking about improving patient safety using CANDOR. So we're gonna go ahead and get started here. As always, our monthly webinars carry one continuing education credit hour for nurses, pharmacists, and physicians through MedStar Health. If you designated yourself as either a nurse, a physician, or a pharmacist in the registration, you should receive an email from MedStar Health within the next week with an evaluation form and instructions on how you can collect your CE credit. The CE credit is only available for live webinars. We will be recording this session. It will be available on our YouTube website later on today or tomorrow. But only those who are here today will be eligible for that CE credit. As you can see here, none of our speakers and none of our planning committee members have any financial disclosures to report. And so I would like to turn it over to Dr. Dave Mayer, who is our CEO here at the Patient Safety Movement Foundation. And he will be moderating this session today. So welcome Dave. Thanks, Donna. It's great to be here and welcome to the Patient Safety Movement's Educational Webinar Series. This webinar series focuses on important concepts and issues related to the safety of not only patients, but healthcare workers in the safety arena and healthcare arena. Today's discussion will be on CANDR, which stands for Communication and Optimal Resolution After Preventable Medical Harm Occurs. Before we start, I would like to send our best wishes to Jack Gentry, who unfortunately will not be with us on the panel today. Jack has been dealing with some health issues and we all send him our prayers for a speedy recovery. As you will see later in the program, Jack and Teresa, his wife have been very active in promoting CANDR across the country and will share a video that will demonstrate some of their passion around this topic. We have a great panel for you today. Steve Burroughs will kick it off after I finish some introductory comments followed by Tom Gallagher, then Carol Hemmengarn and then Marty Hatley will take us home before we open it up to some questions and comments from the audience. Each of the panelists has got a great CV, but I'll let them introduce themselves. So what is CANDR? I like to say CANDR is a comprehensive patient safety improvement program that has helped hospitals across the country reduce their preventable medical harm events. But you will also hear from this webinar that CANDR has so many secondary benefits that come from a culture that embraces open and honest communication after harm is incurred. Unfortunately, preventable medical harm still occurs in too many hospitals, put what Rosemary Gibson called a wall of silence up, as she noted in her book of the same title. In the medical malpractice community, that is known as deny and defend. Let's deny that the care was bad, even if the error was obvious, and let's defend it as hard as we can, even though we know an error led to the preventable harm. The CANDR program is based on work done by pioneers like Rick Boothman while he was at University of Michigan, Tim McDonald while at the University of Illinois, Larry Smith at MedStar and a number of others, including Tom Gallagher, who we're delighted to have on our panel today with us. These efforts led President Obama in 2009 to put $25 million into demonstration grant research around an open and honest program related to medical harm. That was followed up a number of years later by an AHRQ, an agency for healthcare research and quality action to task order, which allowed the piloting, creation, and finally the rollout of the CANDR toolkit, which is available to everybody in the public. MedStar Health, Dignity Health, and Christiana care hospitals were actively involved in that important development work. So I'll stop here and let the panel take it over, but we have a video clip, a short one, we'd like to start off with. So, Donna, did you play that video for us? Sure will. This is the call that started it all. Mom fell and I can't keep her hip. The ambulance is on the way. When my mom went into the hospital for a routine partial hip replacement. He knew something was wrong. The neurologist told us, mom is in a coma and now it's brutally clear. I need a lawyer. We have not even began to recognize the country's third leading cause of death, medical care gone wrong. The medical profession needs to be accountable for the errors. These are our costs, $421,000. Meds, health insurance, taxes, all roads lead to the insurance company. Their whole plan is to drag this out as long as they can. You're a lawyer, am I correct? No, I'm a comedy director. This is taking over our lives. Problems in health care continue to be endemic. We're not learning from our mistakes. Something has to change, so this doesn't keep happening to people. Apologies. Dave, would you like to introduce or have the panelists introduce themselves a bit? Oh, you're muted, Dave. Yeah, thanks, David. That would be great. Let's start with Steve as he will kick off our presentations before we get into Q&A. All right. My name's Steve Burroughs. I'm the writer and director of the HBO documentary Bleed Out. Thank you so much for being here today and thanks to the candidate folks for playing our HBO trailer. Basically, the film is about when my mom went in for a routine partial hip replacement, came out in a coma with permanent brain damage and our world just kind of stopped. And I'm here today to support these incredible speakers, but also give my point of view on when something goes wrong, what does this deny and defend and look and feel like for patients and families like ours? And I can tell you that in our case, with my mom certainly as it's depicted in the film Bleed Out over 10 years, we experienced this insidious deny and defend tactic twice, once medically, and then all over again legally. And I would actually like to add the word today, we could delay, delay, defend and deny with regards to the truth and what happened when we were trying to figure out what happened, we experienced this incredible delay of the proceedings for as long as possible, particularly the legal proceedings. They would defend their position to the death and they would deny any wrongdoing at all costs whatsoever. There's a sequence actually in our film where I actually recorded all of the depositions at trial, all of the doctors and all the caregivers that were in our case. And there's a sequence where they don't recall, they're asked questions about what happened and they don't recall. I don't recall, I don't recall. It's as if having this routine surgery patient falling into a coma happens every day for these folks, completely forgettable event, I don't recall. It still irks me to no end when we screen that portion of the film. What does delay, defend and deny look and feel like to us? Certainly in our case, in our experience, it feels like 10 years, literally a decade. When this happened back in 2009 to my mother, my mom came out cognitively and physically disabled due to permanent brain damage. She lost her home, her car, her independence. She had saved 50 years of her life savings and that was gone in less than three years of pain for the injuries inflicted upon her. And for those of you who don't know, my mom actually lost her life last year as well due to these injuries. And then it has this ripple effect as well for our family. And in our case, in caring for my mother for those 10 years and in seeking justice for her, we went through a seven year litigation. My family, my wife and I in particular, we lost our jobs, we lost our careers, we lost our income, we lost our health insurance and we recently lost our house. And I don't say that as what was me. I say that as a cautionary tale to let people know that this is not pretty, this is brutal. And it's all because of the, there was no accountability or transparency or apology or ownership or any restitution at any point in this entire situation with my mother even to this day. And one of the things I think Dave might talk about this a little later, but the concept of intentional harm versus unintentional harm. We all know that that first harm, whatever happens, is never intentional. No doctor or nurse gets up and says, hey, I think I'm gonna go cut off the wrong leg today. That doesn't happen. But it's the second and the third and the fourth harms that in our case, certainly the lies and the deceit and the cover up. We had falsification of records and surgery. These are intentional acts. And I say this truly in my humble opinion, these harms are the most devastating harms for families like ours. The ones that cause the most long-term pain and suffering. This is damage that in our case has not gone away medically, physically, emotionally. So we know that when something goes wrong in medicine, whether it's medical malpractice or negligence or mistakes or adverse events or preventable mishapses, whatever you wanna call it. And we all know that not all negligence is medical malpractice. We know not all mistakes are negligence. But when something goes wrong, there's this moment of truth. You know, I've seen it, I've talked to now thousands of people who have been in our shoes that I didn't even know existed. And when something goes wrong for these doctors and nurses and hospitals, there's this moment of truth. What are you gonna do? Are you gonna do the right thing or are you not gonna do the right thing? And a lot of it depends on the culture of the hospital. A lot of it depends on the individual. But if you don't do the right thing, I can promise you that that event causes this caustic, destructive ripple effect that continues to just like expand and expand and it helps nobody. It doesn't help the families. It doesn't help the patients. It doesn't help the doctors and nurses and by the way, their families. I think about this all the time. You know, the doctors were involved in my case. They have families and children and grandchildren too. Everyone was traumatized by this. Nobody learns anything. No healing occurs. It's like this disease that just keeps feeding on itself. Nothing's better. Or if you're like the Jack Gentry story, which you'll see in a little bit, this can be a life-affirming, life-changing event that really helps injured patients and their families and the doctors and the nurses and the hospitals that are all affiliated with this. Lessons can be learned. Healthcare gets better just because you do the right thing. You just are honest about it. You know, we're all human beings. We all make mistakes. It happens in the medical community. Mistakes are going to happen. I think the big question that Bleedout asks, I didn't even realize, it took me years to even figure out what my movie was about. But in the end, I think it's about what happens when mistakes are made. You know, what are you going to do? And the great Jack Gentry, I'm sorry you can't be here today, I saw him a year ago and he told me that my mom's story and Jack's story are opposite sides of the same coin. And you folks are going to have to tell me which one works better. Our experience is delayed, denying, defend, works short-term for one side. And long-term, it slowly eats away at both sides. This shouldn't be a us or them thing. It should be a we thing. And I thank God for Candor. And I'm so grateful to be here today. Thank you. Thanks, Steve, for sharing that story. And we got to know your mother before she did pass away. And the legacy you are leaving for her and you and Margot, your wife, is just amazing. And for those of you who haven't seen that HBO award-winning documentary film, you have to watch it. It really describes what we're trying to accomplish here, not only in this webinar, but through the great work you'll hear of others on the panel today. So I'd like to turn it over now to Tom Gallagher. Tom is professor and associate chair at the Department of Medicine, as well as the professor in the Department of Biotics and Humanities at the University of Wisconsin. Tom has led more scholarly work on Candor and communication optimal resolution-type programs than anyone I have ever met. His ongoing contributions to this area continue to raise the importance of open and honest communication after medical harm. And Tom, it's an honor to have you with us today. Dave, thank you so much. And it's great to be with everybody. I love the Midwest. We spent about 10 years there. I'm actually at the other UW, the University of Washington. And hopefully my Husky background reminds folks of where we are in Seattle. And thank you so much, Steve, for sharing just a really horrible experience for you and your family and your mom. You're right that this culture of delay and deny and defend when mistakes happen just exacerbates the suffering of patients and families. But it also is, I think the number one reason that we've struggled to improve the quality and safety of healthcare, because when something goes wrong, we're not open, we're not honest, we're not learning. On the next slide, we depict even for organizations and clinicians who really want to be open and honest, they struggle with how to do this. Here's a doctor who's decided to come out of the operating room and takes the musical approach, singing, listen up, my fine people, I'll sing you a song about a brave neurosurgeon who done something wrong. Well, this is not the approach we would recommend that you take, but it just shows how awkward and uncomfortable these conversations can be. And if we don't train clinicians to handle them effectively, it just takes a bad situation and makes it so much worse. Well, you've heard about candor. Candor is an example, a type of communication and resolution program. What's a communication and resolution program? On the next slide, we describe the different elements. And this is if I send you a chat on the webinar and ask you what's a communication and resolution program, here's the answer. They're principled, they're comprehensive, they're systematic programs for both preventing and responding to harm events. And they have multiple elements, early incident reporting, open and ongoing communication with the patient and family, really thoughtful event analysis and quality improvement. For those harm events where an error or system failure has occurred, making a proactive offer of financial compensation rather than forcing patients and families to go through the court system, care for the caregiver is critical and patient and family involvement throughout. And all of these elements need to be hardwired to work effectively together. A lot of organizations have each of these pieces, but they don't use them systematically each and every time there's a harm event and they don't use the whole model and the pieces don't work well together. The benefits of an effective communication and resolution program are described on the next slide and they're multiple. First and foremost, this is about supporting patients and families who have been harmed by their care, provides empathic and ongoing communication, connections to learning. In our research, we know that this is just critical to patients and families that they'll be learning and financial and non-financial resolution, but it's also something that supports clinicians and others at the organization having been involved in high harm events myself as a clinician. I can tell you most often we just put our heads down and move on to the next patient. It's not helpful for the clinicians. I doubt you would wanna be the next patient that we rounded on, but ultimately communication and resolution programs are really about driving a culture of accountability and learning at an organization, thereby improving patient, family and clinician trust and in the aggregate, there's a happy secondary benefit of reducing medical legal expenses, but those organizations that use a CRP primarily as a risk or claims management tool are not likely to reap all of the benefits. I've been pleased to contribute to a growing evidence base around communication and resolution programs and that's summarized on the next slide. You can see that it's clear that CRPs contain the key elements that patients and families expect in the response to harm, both quantitative, qualitative as well as anecdotal, information supports that claim. CRPs can improve medical legal expenses and don't worsen them. That's clear from a variety of studies. Qualitative research suggests that these promote patient and family trust, they support clinicians, they enhance quality and they drive a culture of healthcare accountability. And we, as the evidence base grows, I am confident there will be quantitative researchers to support that claim as well. And one of the reasons I'm so optimistic about the field, on the next slide, we highlight this is work that's not only being taken up by healthcare organizations, but multiple liability insurers who as Steve mentioned is are often the ones behind the denying defend mentality or are recognizing, this is a key way to move forward. The beta healthcare group, a large liability insurer in California that we work with has an outstanding CRP called HEART. It's a very rigorous and systematic process, Constellation Mutual, a liability insurer in the Midwest recently launched a communication and resolution program they call HEAL. These are just two examples of the insurers really coming to the table and wanting to be supportive and constructive partners in this work. So when you look across the field, on the next slide, what we see is that uptake of communication and resolution programs is increasing dramatically. We estimate between four and 500 healthcare organizations and insurers have a CRP or are working in this direction, which is great. But the big challenge that the field is experiencing is one of inconsistent implementation, using this sometimes and not others, using this approach some elements, but not the whole approach for an individual case. And the reason that this inconsistent implementation is so toxic is that it just gives fuel to the skeptics who thinks these are really kind of claims management programs dressed up in patient-centered rhetoric. So to really meet the patient and family-centered objective that drives a CRP, we need to use, learn how to implement them much, much more systematically. Well, on the next slide, I highlight how at times, the deny, delay, defend response is an intentional conscious choice, but there's also a lot of subconscious, unintended action at play here when something goes wrong. Cause think about times when you've been involved in something going wrong. We all have this normal human tendency to want to keep uncomfortable information to ourselves and rationalize and minimize. It doesn't come naturally because organizations send all sorts of mixed messages. We want you to tell the patient and family what happened, but don't say that. And the nervous clinicians isn't sure what to do. The status quo and inertia show down the progress. There are some cases which are clear cut errors, but lots of cases that involve gray areas. And then until the release of the candor toolkit and more tool development, there really haven't been a lot of tools and resources out there that help organizations know, well, what exactly are we supposed to do? How well are we currently doing and what can we do to improve? And the next slide just sort of highlights again how this inconsistent implementation impacts patients and families. And this is a silly cartoon of the false apology card. Organizations saying, well, we'll apologize to the patient. And they say, I'm sorry you feel that way. I'm sorry you experienced this problem. I'm sorry that you got mad, right? There are all sorts of ways that organizations can say, well, I apologized and really not meet the needs of patients and families. So how do we do this consistently? On the next slide, we highlight all of the work that's going on in three domains that are really critical to consistent high-fidelity CRP implementation. We need tools and metrics to help organizations know how are we doing with our CRP process. We need standard work that's been designed and launched. And then we need to apply implementation and process improvement tools to the CRP process. Actually, in some respects, this should come naturally because at many organizations, CRP implementation lives largely in the quality and safety space where they're used to using these tools for everything but their CRP. And we hope that that will change. So one of the examples of ways that the field is working to change is highlighted on the next slide, an action network that we are standing up in partnership with our colleagues in Boston at Ariadne Labs and with the Institute for Healthcare Improvement. It will help organizations design and implement a variety of new tools and measures, use a variety of digital platforms to help them and really bring together organizations that are wanting to learn and improve in this area. So in summary, the deny and delay and defend approach that caused such horrible damage to Steve and his family is not the way we should be approaching harm events and mistakes in healthcare. Communication and resolution programs are the comprehensive, principled and systematic programs for both preventing and responding to harm events. The increased uptake is great but the inconsistent implementation is concerning. And we look forward to working with as many of you as possible on rolling out the tools, the measures, the standard work, the other strategies to make sure each and every time harm events happen, this is the approach that's taken. Thanks so much and I look forward to the comments of the rest of the panelists. Thanks, Tom. Are you sure I can't get you to University of Wisconsin? What a great place, great institution and I came from, as you know, Washington University was where I was previously so that just maximized everybody's confusion. Well, I see you have dubbed and my mental model wants to go to my oldest daughter's alma mater in Wisconsin. So my apologies, but I know you're there. Okay, next panelist, we're excited to introduce Carol Hemmelgarn. She will humbly tell you she is a patient safety advocate and leave the rest out. But I could tell you Carol is a patient safety communication and ethics specialist. She is an instructor and curricular development advisor for not only MedStar and Georgetown's universities, executive masters in quality and safety leadership, but also at the University of Illinois in Chicago, master's program in quality and safety leadership. And she has really been instrumental in helping lead the creation of candor legislation in her home state of Colorado. So Carol, we welcome you to the panel. Thank you. Many people ask patient advocates, family members, why we get involved in this work. And it's not because we want, the theme that you will hear from any harmed patient or family member is that we wanna make sure what happened to us in our loved ones doesn't happen to anyone else. And if you go and you look at the literature, there's four things that patients and families want after harm. The first is tell us what happened. And when we say that, it's not what you all as providers and organizations feel comfortable telling us or think we ought to know, it's what we wanna know. The second one is take responsibility. You see, we carry this immense guilt and burden that we did not do enough to protect ourselves as patients or our loved ones. The third is what I believe are the two most powerful words in the English language. I'm sorry. Apologize, as Tom said, but apologize sincerely because if you're not, it's just another intentional harm. And the fourth one is tell us how you're gonna fix the problem. We need to know that what happened to us, our loved ones, wasn't taken in vain. But there's a fifth one that is not talked a lot about in the literature. And that is involving patients and families and how to fix these problems. And that's what I really wanna focus on today is that Tom talked about, what can organization and providers do, but what is the role of patients and families in this space? You've been sitting here looking at the picture of my nine-year-old daughter, Alyssa. Alyssa died because of multiple medical errors and it took the organization where she died three years, seven months and 28 days to have the first honest conversation with me. And how do I know all those days? Cause every morning I got up and I walked into her empty bedroom and I started my day by apologizing to her for not being a better mother and protecting her. This is no way to treat patients and families after harm. I still don't have answers to what happened to my daughter and I probably never will. And she is the passion that drives me to do this work. One of the things I've learned is that grief and gratitude can coexist. And that's what we have to understand when it comes to transparency and disclosure and honest communications. So I want you all on the call to understand where do patients and families fit in this work? Well, we usually start by sharing our stories because that's a way to bring awareness to the problems. But then many of us start to realize we can also teach that we can take our skillset and share about why communication is important and transparency. And then many move on to education where the story becomes less and less and it's more about organizations understanding more bias and perception and cognitive diagnoses play in to these errors. Oftentimes then people realize that they wanna get involved in committees, sepsis committees, adverse drug events, patient safety committees. Then many move up to the board level or do work with like the collaborative. I'm fortunate to be on the collaborative board with Tom and realize that I can have a bigger impact at a larger scale. Then many jump into policy. As Dave mentioned, I happen to live in Colorado and Copic is the liability insurance tier for many and for many other states and they reached out to me when they started to want to build legislation, candid legislation like Iowa did and they wanted to make sure the patient and family voice was as represented as the provider voice. And we got legislation passed. Is it perfect? Absolutely not. But our goal is to make those conversations better and easier to have. And it's that the next state and the next state build upon it and make it better. It has been 20 years since the IOM report and there have been some great things done in healthcare but there's been a lot that hasn't been covered. And one of the main reasons is patients and families have the most skin in the game and we're only have a seat at the table some of the time. If we want healthcare to be more reliable, innovative and safer, patients and families have to have a seat at the table 24 seven, seven days a week and we have to have a name tag because it was once said by so many people, nothing about us without us. The catalyst for change in healthcare is patients and families. Marty, I'll turn it over to you. Thanks Carol and hello everybody. If we could go to the next slide. Oh, we're gonna do Jack now. So this is the case study that Steve mentioned earlier of candor in action. The patient here is Jack Gentry whose face you see here, we're about to see a clip and you'll see his story. Jack experienced a harm event at MedStar Hospital. MedStar as Dave mentioned was one of the organizations that was involved very early in implementing candor and so the infrastructure was there, the leadership was there, they were ready to go and here's the story. I lived an active life with backpacking and camping with my wife and my children. I played a lot of sports and coached baseball for 11 years. I joined the police department in 1975 and the last 17 years of my 37 year career I spent with the SWAT team. I've always used to preach to my guys and SWAT that it's an adapt and overcome. In the summer of 2013, I began to experience a shooting pain in my right arm. Dr. Torilani recommended surgery and he explained that there were two ways to do it. One was to fuse the desk but there was a second method was relatively new but he had done it successfully and that was to replace one desk with an artificial desk and then fuse the second desk. While I was sitting there waiting, the attendant asked me to go to a back room and take the phone with me and I was thinking, oh, he's finished, he just wants to tell me that they're done and he's moving on and instead it turned out that he said things weren't going very well. One of the instruments that he was using malfunction and struck my spinal cord, I learned that I was paralyzed from the neck down. Dr. Torilani did come out and sat down and talked to me and explained to me what was going on. He went way beyond apologizing. I could tell for him it was very hard because he had known Jack for a while. I had always been a fighter and I told him, I said, let's get the show on the road. Let's figure out what we're gonna do and get it started. I don't remember exactly when I got the call from the risk manager who's on site at the local hospital but when he called me the question was, how do we deal with this? What should we do? When you work in an organization where the directive is to do the right thing, the answers are really easy. Tell them basically anything they need is what we're here to give them. We have to support them. I was shocked personally that the hospital did say something happened on our watch. We wanna be responsible for it and we wanna help you in any way we can. I went in the hospital as a patient and then I became a victim and that's not right. As a victim, the early intervention allows the victim slash patient to get on with their life a little quicker. If we're there in the very beginning, we can make sure they have home health aid. They have somebody in the house to take care of. They may have attendance if they need to. Somebody to take care of their needs. In the old traditional way, I'm just looking at picking up the pieces after everything's been broken. In the new way, we're looking at taking those pieces and making sure they're melded together to get the patient the best outcome possible. MedStar did it all. They did emotional support. They did physical support and they did monetary support. I think all of those things together are what's gonna make it a success. It was one less thing I had to worry about. It allowed me to concentrate on getting better. That just made life a lot easier for me. I didn't really introduce myself before. I am Marty Hatley and I serve as the co-director of the MedStar Institute for Quality and Safety. I also serve as the CEO of an organization in Chicago called Project Patient Care that's done a lot of work with CMS on patient safety and candor. So, Tom mentioned already just the speed in which candor is being taken up in the country. And it's happening in different areas and different markets, if you will. So for example, in California, there are large systems and the university system. And smaller hospitals that are almost creating the market. He mentioned beta healthcare. You see their banner in the lower right-hand part of this slide. I mean, they gave premium discounts to physicians and hospitals and hospital systems that would go through candor training or what they call beta training. They've read a heart program, which is a version of CRP that they've branded themselves. And so that market has really taken off and it's spreading. And it's spreading as the evidence accumulates that this does not cost more to hospitals and it permits them to do a lot of healing and a lot of things that not only take care of their patients and sort of earn the trust of their patients by respecting them and being honest and transparent with them, but it also takes care of their caregiver. So it's exciting to see that. He also talked about the liability insurers in other places stepping up and mentioned consolation. But the other one to note is Copic in Colorado. Copic was involved in supporting candor type programs, CRP type programs in Colorado and in Iowa. Both of those states now have legislation passed that create kind of a safe space or a safer space for conversations that happen in the immediate aftermath of a catastrophic event to go forward in a space of trust where you don't have to worry about what is said in those conversations, whether you're the plaintiff or the defendant, potential defendant I should say, coming back to bite you in a court of law. And we've heard from both family members and patients and providers that they're just nervous about having those conversations unless they have some assurance that it's not gonna be used against them later. So seeing the liability insurers step up in that way is really significant I think and we're seeing more and more. The liability insurers were just not at all on board three or four years ago, it's a sign of change. The other thing that I think is a major dynamic is what Carol spoke about. And that is the engagement of patients and families in this work being part of the training. Carol herself has been just instrumental here. You see it's not a great picture of you Carol but in the lower left hand slide you see Carol presenting to a group of residents and people in Colorado. Carol does a terrific amount of training as Dave mentioned. In the upper left hand corner in the sort of top left hand side you see Bob and Bob Malizzo. I mean, they were so prolific out on the circuit talking about the importance of this to their family that I bet many people on this phone call have heard them speak before. The picture at the top with the little cursor in the middle is Bob, Barb and Tim McDonald who in many ways has been the thought leader for all of us in this work presenting at CMS in 2011 and that went viral. I mean, that went everywhere. They had so many invitations to come and be part of motivation and not just motivation but creating the space of empathy where we can have, we can understand each other's sides and each other's positions in this as we go forward. I also wanted to point out the picture in the middle that's Jack's wife Teresa. You saw her a little bit in the last video but we were presenting on a system in Minnesota, a small system in rural Minnesota that felt that candor was really needed for their culture because they had had some events that just were completely traumatizing to the system. Jack and Teresa came out to speak and of course had to visit the Mary Tyler Moore statue of Minneapolis and just kind of toss our hats in the air to celebrate the fact that we were transforming. The other picture I wanna point out here is just to the left of that, at least on my screen and that is a presentation that we did at Visiant at their major conference in 2019. And you see Jack and Teresa there along with Visiant leaders. At that presentation, which was very condensed in time, Jack said, it took me a lot to get out here because it's not easy for Jack to fly. If I reached one person in this audience today I would have done my job and I'm happy to say we've heard from people later who said I walked away from that talk and came back to my organization thinking differently, thinking about my job differently, thinking about my organization's mission differently. So there's a lot of vectors that are in place now really driving this forward, including the kind of research that Tom is and metric development that Tom's collaborative is doing that just keeps generating the evidence that this paradigm shift is not only the right thing to do but the better thing to do from a number of different points of view, cost savings, earning trust, being the organization that you wanna be and treating your patients the way you'd wanna be treated if you were a patient. And it's interesting to see how candor will be impacted by COVID because we suddenly have a lot of providers who are now patients themselves. So we're thinking about patient safety really is this place of empathy. I'll stop there, but that's kind of my contribution to where we're going from here. It's great to see this momentum. Thanks Marty, appreciate you sharing now all those great stories. I don't know if many people on the call realized that Marty Hatley was there 25 years ago. I mean, before the IOM report, he and two others organized the first Annenberg Center on Patient Safety that got national publicity and really started this movement. So Marty, thank you for your 25 years of supporting patients and family members. We've got a lot of great questions that have come in. I've been watching the chat room also. Thank you for your comments. But I think the first question I'll give the time because it relates to in the candor, reporting requirements and mechanisms. Our hospitals required to report to the National Practitioner Data Bank, ordered their state medical boards when they see maybe something egregious that happened and caused harm. So there's a lot that federal and state regulators can do to support the advancement of communication and resolution program. And Marty mentioned two of the states, Colorado and Iowa which have passed enabling legislation. There's enabling legislation in Massachusetts and then Oregon also has state legislation around their early intervention program. And that type of work is great but there are some policy barriers at both the federal and the state level that I think slow this work down. One is the requirement around reporting to the National Practitioner Data Bank. The National Practitioner Data Bank requires reporting when a malpractice claim is paid in response to a written demand and on behalf of a named provider in many states. Also their medical boards have requirements for reporting paid malpractice claims. In theory that might make sense as a signal that there was a quality of care problem or concern about provider competence. But very, very few candor cases actually involve concerns about provider competence and physicians really worry about sort of the black mark of a data bank report or even more so a state board of medicine investigation against them. And so trying to realign some of these reporting requirements with kind of what we understand about patient safety and support for candor programs. I do think would remove a barrier that slows this work down both at the federal and the state level. They're also required to Dave report as you know, action against doctors privileges at hospitals which is I think a strong marker of quality and safety. And I hope that this work over time leads to enhancements in the peer review process because that would be another way that candor related activities could drive quality and safety. And thanks Tom, great points. And yes, you know, when we look at some of the best work done in fair and just culture work whether it's James reasons or others, Sydney Decker always says that the balance in a just culture is supporting the science of safety but also holding those accountable who practice recklessly and put patients at known risk for their own benefits. So it is really that balance and we need to be accountable when those things happen. Another question here, I'd like to reach out to Steve Burroughs for this one. Steven, it's a question related to informed consent. And I know you had a lot of issues that you went through with your mother in regards to a lack of informed consent as well as some of the convents we've had and conversations you and I have had about death certificates being totally void about, you know, preventable medical harm as a cause. Could you address those questions, Steve? Steve, you're muted. Sorry about that. Thanks, Dave. Yeah, there's a whole section in our film Bleed Out about the informed consent thing. My mom came out of a coma, she had permanent cognitive and physical disabilities and she was ruled incompetent and yet this hospital system in Wisconsin had her signing her informed consent for seven years. And I would go into the hospital with her and I would say, is there anything in her chart that says she has an activated power of attorney that she is incompetent and they're like, they couldn't, and I actually filmed all this stuff and this hospital system couldn't, they could not, the right hand did not know what the left hand was doing. And it was shocking because I was all over this thing. And then I started to think about the other people who, you know, what about the other patients that have activated power of attorneys or have had people who need help? There was nothing in the records that my mom actually suffered permanent brain damage at this hospital and was incompetent. It was shocking. And they said they would get on it and they told me that they would do a, what do they call the root cause analysis thing, you know, where they would get to the bottom of it and we're gonna be the thank you for pointing this out. And Steve, we're gonna get to the bottom and we'll get back in two weeks and that was six years ago. Still waiting for the call, not coming. And then the other question, Dave was. And the death certificates being totally void of, you know, preventable medical harm being the cause of death. Right, we just had a unique situation where my mom's the original cause of death that she died a year ago, almost exactly. And her physician put in natural causes and we knew that that wasn't correct. But, you know, you can't fight city hall. And I was so burned out and so sad at the moment but my funeral director of all people decided, no, no, this is not correct. And she took a stand and actually went to the notified the Wisconsin state medical examiner's board and said, you've got to watch bleed out because this is not right. They did, they requisitioned all the records from the hospital and they did something that I'm told is incredibly rare. They literally changed the record of her cause of death from natural causes to accidental death due to complications of hip surgery due to medical error which is, I was told, does not happen. But it happened in our case, thank goodness for a lovely funeral director. I could hug her right now. But it's, yeah, that's a whole nother, it's probably a whole nother film, the informed consent and the death certificate thing. But I'll let somebody else make that. Thanks, Steve. You have a question directed at Carol. Carol, it seems like in certain hospitals the questioner was asking, you have places where they want to embrace candor and the doctors, the nurses want to do the right thing but it's hospital leadership or more often it's risk management that shuts the process down. I'd like to hear your experience and thoughts related to those issues. Yeah, as I was saying, so much of this starts with leadership, you have to have your board of directors, you have to have your leadership that say we're gonna do the right thing. And under that, that has to follow your claims department. It has to follow your legal team. I can tell you in the organization where my daughter died until there was a CEO change, until risk management changed, until legal change, we weren't having any conversations. And so it really is, it's interesting because I know Tracy who posed this question in the work that I've done with Copic. So liability insurer, one of their biggest barriers was their own claims department and having to work with their claims department to say this is what we're doing. This is how we used to do it, but you have to think different. So it has to trickle down and you have to have all the players from the leadership to the mid-level, everyone is aligned that this is the mission and we are going to be honest and transparent and this is what we do as an organization. So you can't have one level doing it and it's not at all levels. And that's where you have to have those checks and balances. So thanks for the question, Tracy. It's not an easy process. Marty, I'd like to get your thoughts on that one too because we've gotten a few questions about, it does start with leadership. And I know a lot of times when you go into an organization, you're doing a readiness assessment or gap analysis with Tim and others when rolling the program out. Could you talk, I know you're on mute, but could you talk and let us know what you've seen as you've gone across the country and dealt with CEOs and the C-suite? Well, we've learned I guess at the most basic level that unless your senior leadership and your governance is in support of this and fully in support of this and not just posing, as Tim would say, not just checking the box and saying, oh yeah, we feel great about Candor or CRP. It's got to walk the talk, it fails. You might implement, but it's not gonna get sustained because your culture isn't gonna believe it's real until you demonstrate, your leadership demonstrates that it's real. What we've seen kind of beyond that basic finding is that when you implement Candor in an organization, it opens up the conversation about the trust issues within the organization. There's still 25 years after moving beyond blame became kind of the first banner cry of the patient safety movement. There's still a truckload of blame that attaches to people in organizations and there's a lot of fear about it. A lot of, I think it's socialized in a number of ways. So the implementation through an assessment process gives people permission to talk about the things that they've done that they might feel weren't the standard of care, but also the things that they've seen other people do that they're afraid to speak up and talk about or the policies that they think don't work or the ways in which people are treated, the bullying that they see or the passive aggressive behaviors. So the Candor process really opens that empathy space which I talked about. Dave, I wanna just comment quickly too on Lisa McGifford's comment too about secrecy being the problem. And I think this is a leadership issue as well. I mean, if you're really gonna implement Candor, you have to make a commitment to be transparent with patients and families. You've gotta tell them everything. There's no hiding there. But when it comes to the different regulatory mechanisms and identifying the people involved in a multimodal failure in an organization, unless there's some better trust that we have in our systems for holding people accountable, I think the strong leaders are saying, you know what, we're gonna tell the patient family everything, but we're not gonna put the names of the nurses and the doctors out in the press or out in other places like that because that will undo everything we're trying to do internally in our culture to create a just culture and a culture of trust. So it's a kind of a nuanced answer to your concern, Lisa, but I really think it needs to be said. I mean, complete transparency with patients and families and then think about your culture and the trust that you want to engender because without trust, Candor and CRP just won't work. Long answer, Dave, sorry to take all the time. No, it's great conversations. Like we've got some great comments in the chat room and tons of questions. It's really exciting to see. I know Irene's been talking about, that advocates need to get involved before harm occurs. And that is such an important concept. You've heard people refer to primary, secondary and tertiary safety. And Candor focuses on tertiary. We need to back the system up so we never have to get into a Candor-like model. Again, if we could move to primary and secondary prevention maneuvers and everything. Yeah, I think we've got time for about one more question and I'll open it up to the whole panel. The question came in specifically, okay, Candor's nice. People are trying to roll it out at different levels. Some have had success. Some are still at the beginning of the journey. Why not legislation? Why not regulations that say everybody needs to come up to this level? And I understand the issues about getting legislation passed, but could you talk about what are next steps that when we finally stop getting this being done for the right reasons, how do we bring everybody up to the same level? Pam, you wanna start first? Well, I would welcome, for example, CMS, including CRP related elements in their conditions of participation. I think that would be a welcome change. But I think because of some of the sort of the nervousness and anxiety and aspects of the medical legal environment that are suboptimal that Marty was referencing, until those can be addressed, I think we will make faster progress encouraging organizations to adopt these voluntarily, developing measures of who's doing a good job and then broadcasting and rewarding people for having high functioning CRPs rather than making this a requirement that organizations could essentially check the box and meet. So I hope it's a little bit of a top down but mostly a bottom up and then celebrating successes approach. I'd like to pile on to Tom with that too. I think regulation is the way to go. I'm thinking about the legislation that was introduced in Maryland that didn't pass despite Jack Gentry and his brothers, in a very vocal advocacy. And it's because the plaintiff's bar essentially said, we're not comfortable having any conversation happen with a family member, even if it's in the middle of an event without us being there. And you can't get a lawyer to the middle of an event or the immediate aftermath of an event when you're trying to open up that level of communication and honesty and trust. So you've got to work through those things. And I think regulation, thoughtful regulations built on some of the metrics that we're seeing is the faster way to implement. I also think leaders really need to be championing this in their communities. I mean, there's things that you can do to grow a culture of trust in a community. I mean, Julie Murath is a great example of that. When she was basically gone after by the Minneapolis Star Tribune because she wouldn't disclose the names of doctors and nurses involved in candor events, she went to the press and she started talking about just culture and what they were trying to inculcate at Children's Hospital in Minneapolis. So you can do some things in the public sector that aren't necessarily legislation. Dave, you're muted, I think. No, I should be okay. So I want to add one comment, Dave, just because I know we're winding up and you know what I say this often is healthcare providers, hospitals, organizations need to understand the conversation doesn't end until the patient or family says that it ends. So even though we go through this you may think you have this conversation once and it's done, we have to find a space and a place in our heart and our head to put this. So the conversation is over when the patient and family doesn't come back anymore and has no more questions. Thanks Carol, it's always a great summation. Steve, any last comments before we turn it back to Donna and thank everybody? Well, first off, I can't tell you how much I appreciate being included in this stellar group. My mom, she would be so proud to know that her story is being embraced by folks like you and that it's making a difference. I can tell you one little piece of good news that we've had recently is that the new CEO of the hospital system where my mom was injured, they've merged, I say names all the time, that my mom was injured in a place called Aurora and there's one called Advocate Illinois that just merged, it's called Advocate Aurora and it was Radio Silence for 12 years until just recently. I had the CEO reach out to me and he and his team of folks, we just had a conversation last week, it was our second conversation and we're trying to figure out a way to move forward in some meaningful way because they've now seen the impact of my mom's story and also that I partnered up with some pretty great people in the patient safety movement. So I've got this incredible group of people who are continuing to push the story and have been doing it for all these years prior to us coming along and I think that they're finding it hard to ignore us anymore. So as I would normally, most people would say I'm cautiously optimistic, I'm actually cautiously pessimistic that we're actually talking with the CEO. He said he would never lie to me, I take him at his word and I hope that I can share soon some good news that will hopefully help not only all of us on this call but people in that particular system because boy, we need you folks out there, we really do. Like I said a million times before, we thought we were alone when this happened and then when the film came out, we realized that we were not alone and thank God for all of you. You guys give me hope and every time I'm on something like this and I hear you guys talking, it just fills up my gas tank. So thank you. Thanks, Steve and thanks to all the panelists. Donna, I'll turn it back to you. Thank you, Dave. Thank you so much for moderating this today. This was a fabulous panel today. We had so many great comments and questions and so we'll be sure to save all of those and look through and see if there's any outstanding questions that we didn't get to and we'll make sure to include that in our recording that we'll post on YouTube. Hopefully we'll have that up within the next day or so. And again, if you are seeking CE credit, you should get an email from MedStar within the next week with an evaluation that you'll need to fill out in order to obtain that CE credit. So thank you everyone for joining and I hope everyone has a wonderful rest of your day. Bye bye. Thank you.