 Good day or good night everybody who has joined us for the patient safety movement foundation going outside the standard of care when why and how this should inform better systems and policies. I'm Lisa Maurice and I'm excited to welcome you to today's webinar. Next we have the next slide please Isabella. Our objectives for today's event are to discuss how systems can set clinicians up for failure. We want to examine the drivers and impact of stepping outside the standard of care. We will apply the just culture framework to evaluate decision making for systems improvement and describe the data that can identify system failures before harm occurs. We are offering CE continuing education credit for nurses physicians and pharmacists participants will receive an automatic automated evaluation from MedStar via email within five to seven days. Next slide. This is what the email from MedStar will look like if you would like to receive continuing education credit for the physicians nurses or pharmacists. Next slide. We are also offering continuing education for healthcare executives certified professionals in patient safety board certified patient advocates and certified professionals in healthcare quality. Next slide. As you can see the panelists including myself do not have any conflicts of interest to report. Now I'd like to introduce everybody to you as I said my name is Lisa Maurice I'm the executive director of consumers advancing patient safety, and I am a patient advocate for the past 25 plus years. I'm very excited today to welcome our panelists, and they include Robin bets who has been the vice president for safety quality and regulatory services at Kaiser Permanente. Robin helps further advance Kaiser Permanente's excellence in quality and patient safety and overseas health plan and hospital regulatory functions including compliance licensing and member grievances. The officers northern California region provide services that are integrated to 4 million members with 4,500 physicians and 21 medical centers and numerous medical officers I noted in her LinkedIn that one of her students had said if one has a chance to learn from her, don't miss it. We'd love to have Robin with us today. Laura Herrero joins us from Spain today. Laura is a PhD candidate and holds a degree in telecommunications engineering and is an instructor in medical simulation by the Institute for medical simulation in Boston. She works at the innovation department of I eat of all since 2010 as an innovation manager and since 2014 also as a human factors engineer in the research group eval tech. She's led several projects related to human factors engineering and patient safety related to the design and use of healthcare technologies and processes for healthcare providers and companies. She has been in fellowships in the United States and Canada in different reference centers for the use of human factors in healthcare and we're excited to have you join us today Laura. Finally, Nico cop team currently focuses on after incident investigations and strategic consulting and safety and security. He is the executive director of maruda and associate of the COT Institute for Safety Security and crisis management and an affiliated teacher at North Umbria University. He was head of research and consultancy at COT from 2012 until the end of 2018. His areas are safety and security strategy post incident review analysis and crisis management. His is on just culture assessment training implementation and evaluation before 2012 at Cap Gemini he was global operations director of public security and at TNO defense research he was responsible for scientific research consultancy and project management and defense and road safety. He's joining us from the Netherlands and we're very excited to have Nico with us today. Alright, as we get into this topic. The first thing we really want to do is define what by the standard of care. Robin. Thank you Lisa. You know, we hear the term standard of care it's often, it's often kind of association with a legal term, as it relates to medical malpractice we use it in in hospitals and health care delivery to look at how we review the practice of medicine. The standard of care we often have peers appear provider review practice when it's in question to see if it meets accepted guidelines from medicine perspective the standard of care is the medical or psychological treatment guideline and can be general or very specific to the appropriate treatment based on scientific evidence and collaboration between both medical and scientific evidence in collaboration between medical and psychological professionals in the treatment of a given condition. However, there are many other standards that we include in a grouping called generally accepted practice standards that define how we practice as nurses respiratory therapists, all of us how practice should be carried out and generally supported by evidence based guidelines not always but but when we often use peers in those in those specialties to help us understand if this is how one performer would do the job over another and identify opportunities for improvement. Nico, you might be able to add some insights into the term or the definition around standard of care. Maybe so I will try. Thanks Robin. So, of course, the standard of care as you described is like key has since it captures everything we've learned scientifically on how best to treat our patients and how how to do that in a very safe manner. The only thing is that in addition to that we've also like learned how complex our health care system has become, which means that was apart from just the standard of care in the way we treat like illnesses or patients. We also need like other principles and standards in addition to this standard of care to make sure we develop a safe environment for our practitioners and patients, as we will. I think further explore in the conversations will will be having today has so nothing against the basic knowledge and understanding as developed in our standards of care, but we will need a bit extra next to that. A little bit extra is always helpful as we explore this and Laura with that in mind what does it mean when we say design systems in a way to make it easy to do the right thing. I'd like first to introduce what because I'm here as a human factors engineer and I don't know if the audience is familiar with that term. So human factors is. It's a science science a frame of knowledge that applies what we know about human people with human strengths and limitations both cognitive and physical. We design we try to design systems that address those those needs. And what is the system specially in in health care we have into account all the relations between. So we understand health care as a system in which the person is at the center person understanding patient or or clinicians. There are a lot of of interactions among persons tasks processes technologies, and we need to understand what what that system looks like. And I wanted to talk about an example maybe to to illustrate what what I want to say about how we can design systems so that they are safer. I don't know if Isabel if you can show the image. So I work as a clinical human factors specialist at Baldecia our hospital so we identified there was a problem related to urine deep sticks what what was this problem. Some physicians didn't started to not trusting these completely easy to use and elementary device or technology. And this is especially used frequently used in in pediatric and in pediatric emergency emergency rooms. So when we jumped in the project. This is what we saw. Most of the people in the hospital thought this is urine deep sticks are completely easy to use but this is what we saw. So what we see like for example the second third or fourth row, how slight different in colors, there is to identify the result and identify if the baby has any type of problem. What we also identified is that in within the same emergency room. There were two different products to different vendors providing these urine deep sticks. And this might not be a problem but we saw that for example, the rose didn't match the elements that they were testing so in the technology on the on the right. The blood was in one position but on the on the left was in a different position. So having into account that physician and nurse aids who are responsible at least in Spain for doing this, they do several in a shift. They think that this is a very simple and might not be useful and protocol to to to use. So they are on on. So what do we need, we need at least in this case for example to make sure that there's only one product. There are no different products coexistent and also that this is easy to understand which we identified that it wasn't. So this is like it might sound a bit silly but this is a clear example of how we can help design systems so that we can help clinicians and do their work and get to do the the easiest thing, the correct thing. I really like that explanation I appreciate you providing the, the example of making it easier to do the correct thing something as simple as having two different vendors that can use two different standards as it were for how you evaluate the test result is pretty scary actually from a patient standpoint. What are the circumstances like this that set us up for failure in clinical care. You know, I think there's several several factors that can set us up for failure. One of them is developing for the clinical staff instead of with them, not including the right stakeholders in the process of developing a new process or a redesign of something is a set up for failure those closest to the work can surface the best solutions for us and then attempting to generalize a policy or procedure to disparate organ to disparate organizations where it's difficult to operationalize an example I can give you as often our hospital systems have very large hospitals and then maybe you might have a few very small rural hospitals and you want to have standardized policies and procedures and guidelines. So if you had a policy that in maternal child health that requires a nurse to only take one baby out of the nursery at a time to assure that you have appropriate identification and matching of mom to baby. And then that policy also states that no baby can be left and attended in the nursery. How does a nurse who's taking care of both the moms and babies operationalize that in a small rural hospital where maybe both moms needed to break both babies are resting in the nursery. And now she needs to take one out. So we need to work with the staff to design it so we can be safe and compliant. But make sure that it's they can actually operationalize the recommendations. I think also we don't always resource them to be successful. So if you have a new central line insertion bundle. You need to work with your supply chain to make sure that the insertion packets those sterile packets come ready with all the new supplies and equipment that they need to be successful for safe patient handling. You want to make sure that you have available list equipment that you want your nurses to do and that it's easily accessible so that they will use it when ambulating ambulating or transferring the patient. And then also think about. Did you design with the idea to make it easy to do the right thing and hard to do the wrong thing and this is what Laura was talking about incorporating human factor science into that design. I know Laura might have other additions to this as well. Yeah, I think I like this, this quote by Lashen Leib saying that professionals 99% of professionals it's not literal, but 99% of healthcare professionals are trying to do the best work and is the system, help, not helping them to do it and making mistakes. And we know from the evidence that if people don't like to deviate, like, if there is a better way to do something and that better way is safer, there wouldn't be any work around but healthcare is complex. It's very difficult to standardize and even when when possible standardization is not always the better option. Yeah, I think, sorry. You're right standardization isn't always the better option and I think that gets to Robin's example of the larger facility versus the facility in a small community where the rules may need to be a little bit different so that standardization is one example Nico do you have some examples. Yeah, and it's also fairly generic point. We've learned, we have a tendency as human beings to when something goes wrong, when we are uncertain about a certain outcome, we just invent new rules or new procedures to make it so to say safer but in reality we make it more complex. There's a couple of publications where people have counted the amount of rules we have to comply with as a practitioner and it's even impossible to read them all. So we overdo it in a way there was way too many rules and they don't always make sense they're not like often enough evaluated and revisited. And you're right Laura and Robin mentioned it as well at the, the complexity of the system is not like it doesn't work to approach a complex system with just the rules and procedures and we have to allow professionals to do their job what they have been trained to do. And so it's like the overwhelming amount of rules is an element of the system that sets it up for failure because sometimes it's safer not to comply, because those who invented the rules couldn't like imagine all possible situations that like professionals may come across. So we need to find a balance between what we call like work as imagined had the rules, the way we think a process or a task should be done, and like work as done the reality. You can't predict all possible situations so you have to find a balance and to like make a helpful procedure standard. Anything that helps us summarize what we have learned as a safe practice but also we need to, to allow for flexibility and professionals to improvise and we generally don't do that enough. I really like that Nico because what you're talking about in terms of flexibility is maybe instead of setting things in, in what we use the, the term setting things in stone. Maybe instead of that we need to have a range of options for how processes and procedures are done I can see Laura that you had something else to say. Yeah, what Nico said made me think about another example for example that even when we can standardize processing in healthcare, most of the standardization goes into diagnosis and treatment, for example, especially in clinical practices, and there are many other things that are not taken into account in these cases and we had, for example, a project in which we studied how a team reacted to the massive hemorrhage, and everything was great. Everything, like all the diagnosis and treatment elements were very good shown in a protocol and it was easy to follow that protocol. But there were many other things that didn't went in that protocol such as what information does a nurse need to exchange with lab tests to send a blood sample to the blood bank, for example, to get to get the new box, or where was the the medication was some some of the drugs were located in one room, others were located in a different room, and there wasn't there were no signs and there was no information so everyone had the information on what they need to do. And then responding to the emergency, but there were many, many other things that no one had thought about or no one had explained like what information do I need to, to share with another physician when talking on the phone. Where do I get this drug what blood tests need to be what sample, and it's to be taken from the patient. These are really good examples Laura I like that you brought in an example that really may be a high stress example of something that is emergent in nature and needs to be taking care of immediately and there's a step by step protocol, but these other factors are included in that protocol and need to be examined. So going back though to the concept that Nico was discussing a flexibility. How does deviation relate to the standard of care and how do leaders and professionals normalize deviation or flexibility. How can we navigate accountability in those situations. Robin. Thank you. Yeah, I can answer that before I answer that I just want to give a great example for those who aren't familiar with human factor science. A great example is seat belts. We are seat belts are like right there we just slide them out now back in the day. You know you had to dig them out from your seats they they didn't retract some people cut them off because they were in the way. And in healthcare, we would have it was very not common but one of the, the serious safety events that was common in healthcare were tubing misconnections where a tube feeding would be infused into an IV to an IV infusion that would be going into your circulatory system. And a few years ago, finally the industry responded by changing the male and female connectors so that tubing misconnections are impossible. I mean you'd have to Jimmy reg it to make it happen. So that's making it hard to do the wrong thing and when you have a lot of lines a lot of IV lines and things that you're managing as a nurse and having to trace those lines and make sure that everything's connected correct correctly. It is hard to get it right so making it hard to do the wrong thing has really reduced the incidence of tubing misconnection failure. So I'm going to just reflect on that. As far as normalized deviation, normalization of deviants was brought to life by Diane Vaughn who reviewed the, the, the challenger disaster and Vaughn described this phenomenon as occurring when people within an organization become so insensitive to deviant practice that it no longer feels wrong. It's just how we do things in our department. We are very casual about a time out because the chance is really slim that we're going to have a wrong site surgery. Of course we've marked it. We did a consent. However, failures do happen when we get casual about these standards. We norm when we normalize deviants. We do not address the root causes of why we fail and design the process that supports compliance with with processes that are proven to meet that and evidence based and result in safe and quality outcome. The impact of stepping outside of the standard of care is failure and the severity of harm can be very, but we want to avoid harm at all costs. The other variability is outcome. If you have an evidence based standard of care is strictly adopted. Every patient and family member has equal opportunity for the same quality outcome and experience. This is compromised when you have just accepted deviants in your department. Leaders and professionals normalize deviation when they actually support and reinforce that behavior. Lisa, you actually shared an example when we were first coming together as a group to just talk about this topic and I think this would be a good time for you to share what that normalized deviation look like. Oh, okay. Well, I was going to say, I was going to say that later, but I'll bring it up now that I was a, on a patient and family advisory council as was a colleague of mine on the patient and family advisory council. We were in a different hospital than the one that we advised. But we had gone through the hospital systems compliance training and we were aware of many of the protocols that were required to be done. And specifically in this case, when a nurse was checking medication out of the locked box at the nurses station, two nurses had to be there to sign off on that the medication was accurate. And in this case, one nurse went to another nurse clear across the room to borrow her employment badge and carry the badge, not the nurse just the badge over to swipe into the computerized lockbox system, so that she could open the lockbox and get the medication out. So a system that was designed to have two people there actually only had one and a batch. So my colleague and I brought that up to the nurses that they weren't supposed to be doing that and they were a little surprised that patients would be aware of the protocols that had been put in place. And, you know, as we as we look at that, you could think that maybe reporting those nurses would be the right thing to do. But Nico, I think you have some perspectives on how you would apply a just culture framework in that situation. Yeah, definitely, because I have seen cases where like a nurse failed to have a colleague double checked double checked the medication before applying it as it is supposed to happen. And if in those cases we would have like approached the situation as it seems fairly clear cut because it's a very simple instruction. It's not adhered to people deviate from the procedure. So what else to look for as you could say, let's simply born or sanction the nurse involved. And that's it. The only thing is if you do that, you feel to look for a potential like other factor that came into play like in a specific example I have in mind. It was like a home care situation where there was a system that was supposed to help the nurses to have this like second set of eyes on the situation, but it didn't work well. It wasn't really doable. And if you would have simply punished that nurse and wouldn't have asked for like, why did it make sense for you had to do it this way? And why didn't you simply follow procedure and if we would have failed to do that in a safe way like welcoming people to share their accounts had to like in a safe way explain what happened before we already would have punished them. We would have stopped that source of information and failed to use the opportunity to make it safer. And it doesn't mean to avoid misunderstanding. It doesn't mean you need like a blame free culture because that's not the same. There is always time to look at someone's behavior a bit later in the process. But first we look at like what happened? Who needs help? Who's hurt? Who is impacted by what happened? How can we perhaps restore some of that hurt? And then later we try to understand so why and how more of the details of that situation only later because we make sure we have stabilized that situation. And that the same thing wouldn't happen again while we were looking into the situation. And then later there was ample time to find out whether we need to address the individual's behavior as well. So when you're looking at this, what are the, what is the framework of the just culture? What do we look at as we go through situations? Yeah, so the framework I'm working with, I'm working with Sidney Decker. Some of you may have heard of him. He's like, he's published on just culture and patient safety. And also, by the way, the topic we addressed before he calls it drifting to failure that's similar to the concept we discussed earlier. But I work with him with like healthcare organizations in different countries and we basically apply the approach he's advocated in his book. And that starts with like find out who is hurt, how they are impacted, what they need, how we can address those needs. And since we also at the same time stabilize everyone's safety, we have time, a little bit of time to look after the hurt and to restore rather than to add more hurt to the situation by focusing on retribution. Again, not no blame, but this is the order of our steps. And then later, when we know a little bit more, we have like developed also with Mercy Care in the UK healthcare organization. We've developed like a process as a gateway to answer a number of check questions before we would go, like after someone's individual choices and behavior. And that would, for instance, address whether all on the same team would do the same thing in the same situation because then it wouldn't make sense to just focus on that individual or whether the manager was aware of the practice, hasn't said anything about it, let it happen for like a couple of months and then the manager, of course, could be asked a couple of questions first before he would address like the team member. Is the rule applicable? Did it make sense? And so a couple of those questions. And if there was all yeses, there was ample time to like find if it's really someone's individual behavior consciously not following a rule where it did make sense to do follow. To do follow that rule. There is always time to like design and find for proper sanction. I can see in the chat that this example has really resonated with the participants in this webinar and Kelly Wood said we call that a cash register workaround referring to the badging issue. And Genie's Gubiski said badging rules are as described are often seen as inefficient by frontline workers. And Irene Young has posted a just culture assessment tool measuring perceptions, healthcare of healthcare professionals. So you might want to check the chat and feel free to chat in your question as well or your comments around what we are talking about. You know, Niko, people who practice psychological safety encourage risk taking and innovation. That's not really the same as breaking rules, but how do you apply a just culture framework? Yeah, just to be clear on what is meant with psychological safety and risk taking. Hey, it's like Amy Edmondson's work that's that's referred to here, and it's about interpersonal risk taking. So to be safe to ask a question to make a comment to share an appreciation of a risk. And so that's the type of risk taking we want to develop. Of course, we don't want to like just take risks with our work or patients without any further purpose. But to make people feel safe to talk about safety about risks about things that didn't go as expected as planned. That's really supporting a safe culture. Absolutely. And Robin, you have a comment. Yeah, I think when you have an idea, it's great to share and capture the idea of our team members, especially if it's something that could improve a process or system. But in that innovation in designing it, there need to be some controls and measurement to assure that we get the consistent outcome that we want. So really making sure that you're not just testing on your own and and trying, trying things without having embedded it with a stakeholder group. That's also going to measure and monitor for any ramifications of that change that test of change. So I think making sure you do that and control the environment. I just wanted to add to Lisa on the someone asked if there are resources and there was that link provided and, and there are quite quite a few resources around when something happens an event happens to to to use an algorithm to help determine the actions and motivations of an individual. And if another caregiver with similar skills and knowledge would react or act in the same way in a similar circumstance. And through that process, we call that the substitution test. We say, you know, so everyone in this department might be doing that and that's one of the ways to identify normalized deviation and to begin the course correction in my my learnings I really like the holistic approach that they have to the just culture because they, they, you know, on the initiation of identifying an event they look for immediate remediation opportunities that are very supportive to the team, while they're trying to understand the deviation that happened and I just really appreciate that and look forward to learning more from him about that to in my own personal future. That is absolutely true and you know that that normalizing of issues relates back to the human factors. Study doesn't it Laura. Yeah, here, it might be language barrier, but to me deviation sounds like the people are consciously doing things wrong or willingly. And I don't know, I think we should try to understand why deviations are happening and maybe using human factors and system think systems thinking methods to understand why those. I like to say workarounds, instead of deviations, why those those workarounds are happening and especially studying and listening to all the elements of the on the system. And in this case, I understand that there's a there's a workaround in place but but why is this nurse doing doing that. Did she felt that that option taking someone else's badge was the right thing to do in that moment, and maybe after, and I like they just culture framework and maybe combining it with human factors. So it's our system systems thinking. First, we could go into understanding what should have happened and what did happen that day, and also relating to what Robin just said I just said, what happened what happened that day is is usually what happens more often. And in those cases we substitute interviews and questionings for observing ethnographic research going right there on a regular day today like what a normal day should look like but what happened that day or what, what is more hectic or more relaxing day what what are the different variables. In this case, maybe nurses have too many patients to care for, and while one nurse is taking care of a patient and needs to do something important taking temperature medication whatever the other cannot wait for the first nurse to go in and share that and double check and that so we might need to think about what the, the policy or the, yeah the policies is making them is that doable. Absolutely I think I think you're on to something there that you need to look at a number of factors that go into that decision making process one thing that I would ask. One of them is, if the nurses understood the reasoning behind using two badges, and if they thought it was just a throwaway procedure, they understood the severity of medication error and the frequency with which medication error occurs occurs, and what that means for the entire system. I think that Una McFadden had a great comment and of course I would think this as a patient advocate but I, she said I think many patients or carers have good ideas for solutions for safer care, but are reticent or reluctant to speak up and patients do not make them feel welcome to identify scope for an improvement. So I've seen several systems where patient advocates do have input relative to how that could be a smoother process or even an easier process for the provider. And they may not be heard, because they weren't asked in the first place. So that's, that's a great, a great comment. We've had a couple of other really good comments in the chat and we're going to try to get to some of those questions to. But first, I wanted to ask, what are different just culture frameworks, do we have some different frameworks that we could talk about Niko. Yeah, we, we do and I guess some of the audience will be aware had if you would like Google for just culture. There was like two basic frameworks that you would find and one is more like a more interactive approach where there is like a clear algorithm that would help you to decide about culpability. So, depending on what whether it was like a simple mistake, or some negligence or even malicious intent had that to make that distinction a number of algorithms available. That is not the type of just culture I'm working with, because the risk there is a couple of risks with that it's very difficult to make that distinction often it's not really done independently. There is like the focus backwards on and there is a risk if you focus on culpability too much and too soon, you will like forget or pay less attention to understanding improvement and investing in safety. And that is why the other approach that I summarized before starting with finding about the hurt the impact restoring these, these hurts these impacts. Yeah, that's, that's the David Marx that's one of the advocates of the other approach. And of course they aim the same outcome and they also aim to have like a safe system and a safe culture. So, nothing wrong with intent by that just believe the other approach works works better because then we have like this ample time later on if there needs to be a talk about culpability about that type of backwards looking accountability, we can, we can go there but before we get there, we can do so much to learn to restore to have like a positive forward looking accountability outcome without losing anything from the from the other end so these sort of. Retributive versus restorative just cultures is both what you would find in literature. We know I use you used a word that that really resonates with me and that was intent, because as we look at just culture, we often look at the intent and usually people don't have any intention of doing harm. And yet, their actions may lead to harm if they fail to follow certain protocols. Robin what do you see as a framework for just culture in organizations you've worked with. I think that we have in the organizations I've worked with we've generally gone with the, the earlier models of just culture using the algorithm to help managers identify culpability. So, look at the first step is that they analyze the individual caregivers actions via five measures such as impaired judgment malicious action reckless action was it a risky action or was this an unintentional error. The second step was to determine determine if the other caregivers and similar skills and knowledge would be act the same way in a similar circumstance and that's that substitution test. And then the final step is the, you know, the important determination of whether the present system supports reckless or risky behaviors, and that needs to be redesigned. What I really like about Nico's work is the, the word he uses of restorative to restore the confidence and the capabilities of the team to set the stage right up front that we just want to understand let's put in some remedial action to make this doesn't happen again in our unit so let's move quickly, and then we just want to learn. And I just, I think it's really important that we don't jump to conclusions too quickly. And the more mature framework that Nico and his team has been working on really facilitates that kind of restorative culture and love that word I think we really need it in these times when, especially when with coven and all that has happened. Our, our staff and our clinicians have been really challenged and being as supportive as we can as important, while at the same time holding them accountable which, which the work that Nico presented does do. So I really like that. I wondered Lisa if I could just share a great story of how patients can inform a process to improve. Because we were talking about that just before this. Sure. Let's do that quickly because we have a couple more questions to answer here. Go ahead. Oh, good. I just. Yeah. So it's been come common practice that many units department that have huddles every morning. And at one of my hospitals in the neonatal intensive care, they invite any parents or family members who are attending to join the huddle during this huddle. They is just really a quick look back on the last 24 hours and a look ahead till we anticipate our challenges instead of react to them when they come up. So during a huddle you can raise safety concerns that speak up culture and one nurse raised the concern that because the babies are in the unit for so long, their ID, our band start to wear off and, and the barcode and things like that that that create them safety. So it was decided in the moment that they would select a day of the week and they would just change all arm bands. Well, a parent was there and said, you know, we're wearing our arm bands to and that's one of the safety identifiers when we come in the unit. So could you change parent bands on the same day that you change the baby so that we make sure all the right people are coming in and who know the environment and know how to behave safely in the environment and and they're the right people who are matched with the right babies and just an example of, you know, how when we don't include that participant that stakeholder, we miss opportunities to elevate safety. So anyway, just wanted to share that quick story. Well thanks so much for bringing the parents into it and as a NICU parent myself of many months in NICUs with different children that I had. It's that's very important and it would be interesting if more facilities included patients and family members in in safety huddles. I really want to address a couple of the questions that have been asked by our participants today. A couple of people have mentioned that the staffing issues are one of the overwhelming reasons for nursing errors and creating an inadequate safe environment due to inadequate staffing, especially with COVID and the pressure that is on facilities. Earlier, another person had brought up staff to patient ratios as driving factor in deviation from norm or variance. What do you all have to respond to that Laura have you looked at staffing ratios as you've looked at human factors. Actually now with COVID but what can I say I think that's a that's a common problem problem. All over the world and that leads. And I think that's also a sign and we see how good people and good professionals are trying to do their best work with what they they are given. And I haven't got an answer because it's a it's a great issue here as well. Well Robin what do you see in terms of that. Yeah. Thank you. Yeah, you know, we need to be highly reliable organizations and we need to be able to be resilient and and have consistent outcomes. No matter so what is our, what is our system for onboarding new staff what is our system when we have broad covert exposures in our department we have a lot of contingent nurses how do we bring traveler nurses or on call nurses into our environment how do we support them when we're there. So there should be, you know, leadership standards and practice standards on boarding standards that support the capabilities and competencies of your team. In, you know, I have 21 hospitals we have 4.4 million members. I really have not seen staffing as the core element to our safety events. We have more normalized deviation or just deviation work around and I when we when we do the deep dive and really look at the staffing staffing actually was not a contributor. They were generally what we call rule based errors where we knew what to do but we chose not to do it. And a lot of times it has to do with casualness around practice standards, doing a great time out, doing really great consenting. And is one doing the nurse double check. So, I'm not seeing that trend. Don't even right now with COVID have, have you haven't you had any issues hiring, hiring nurses. So we do, you know, we have a very large organization. So we have a lot of resources to help do our contracting with contingent nurses and then we have a way to on board them. So we do that in advance. We have a lot of predictive algorithms as we watch what's going on internationally and across our country to anticipate our surges. And even normal every, you know, we have surges with flu every year. And so we anticipate, and oftentimes travelers come back. So they are familiar with us so we have I'm not saying that we never have never had challenges, but we work as a community with our other hospitals to help each other. This really is bringing up a kind of a visceral feeling for me because I've had situations where staffing has impacted my child's care and I'll just give you one example. I had a child in the hospital for meningitis, my complex chronic, the ill child developed a ninjal encephalopathy actually, and the hospital didn't recognize that the child was dehydrated initially and ended up having to do a cut down on the pain in order to get an IV going and placed my kiddo on a floor where the staffing ratio was seven to one. And the person who is staffing my child was a licensed practical nurse instead of a registered nurse, and could not change addressing the terminal line. The terminal line of course is in an area that's particularly risky for a child who has not yet become toilet independent, and we had stool on the dressing. And I tried for literally 12 hours to get to that dressing changed, and it did not get changed, which of course poses an extreme infection risk for my child. And because the nurse that was taking care of my child had so many other patients, and the only person who could have changed it was the charge nurse, and he didn't have time to get the charge nurse or the charge nurse ignored his pleas for help. I was able to elevate my concerns eventually and get my needs met, but I think there are issues where staffing makes a huge plays a huge role, particularly when there are certain procedures or protocols that some members of staff need other members of staff to do for them. And it just as a caregiver that becomes an extremely frightening situation when care isn't being given. So, I think that that is an interesting situation. Emily Halu says perceptions of short staffing time pressure and not being flexible, or not critical thinking causes more errors than true short staffing physically not having enough bodies or hands in my experience as well and that's a that's a good observation Emily. Yeah, I was hoping to add a little bit to that because as was apparent in the introduction I'm involved in many like after incident investigations as they are often called and then of course the perception of short staffing or real short staffing. It's always at the table sometimes we may find there is like a link with what happened but but not always and but sometimes there are like related topics have for instance because there is less staff than planned things go differently than expected differently than agreed before and procedures cannot be carried out exactly how they were designed, but it doesn't need to be a problem. And so what I always look for is whether people are safe enough to really like speak up when it's not safe because of short staffing. It's not just counting counting the number of people it's simply how what is your practice because they can be like one or two person sick or absent for any reason and it doesn't need to become an unsafe practice just because of that. But if it does the needs to be a safe system to talk about it and to find for solutions and also to make sure safety is not unnecessarily compromised in the meantime. And so sometimes people do feel that being short staffed is the reason for things well going bad in a situation, but it takes really a careful look to find out whether whether that is exactly what went wrong. Having said that we have seen had to respond to Laura in the Netherlands in the UK in many countries I have seen many cases of short staffing in the past two years. And in many cases we did find for safe solutions but especially in the beginning of COVID when there were no tests there were no vaccines yet. There was I guess a different standards in reality, because there was so much compromise safety in other ways already like following a procedure wasn't the main concern at the time. And in my experience when we've done some research on events shortage of staff is never on the table for the people reporting I mean they assume that's the way it should be like if I need to take care of 10 patients that's my job everyone does. But even though it's unconscious that might be that might be a problem and relating to the example Lisa mentioned before. And having many patients or different protocols might lead to a nurse for example in this case to do a workaround that if there were more nurses she will need to. And and also have we have like long waiting lists for some types of care and that's an unsafe unsafe situation in a different way so you again you better look holistically and not just single on this one instance with how many people were doing their jobs at the time it's a larger picture because it may also be unsafe to have like short, short staffed situations for longer stretches of time. It may be totally perfectly doable to do a shift with one or two people less than normal, but maybe not every day. Yeah, I don't know if it's the same in the US but at least in my hospital and most hospitals in Spain, what we've identified now is that every COVID wave implies a reduction on surgeries that might need ICU and certain procedures that might need ICU and I think we're going to see in the near future, how we are diagnosing and treating several diseases a bit later than. Yes, and I wish we could spend more time on this and this has just been such a robust discussion I really appreciate it. And, and Laura, it is true that it has caused for a reduction in scheduled surgery and that kind of thing but that also happened before COVID with the flu in at least in our community. So that is something that that we need to think about in terms of, it's going to happen. I appreciated also that Kathy Eden said that the Joint Commission in the United States requires a discussion of staffing challenges during Sentinel events if it was a contributory factor and so that is something that that can be discussed. We would love to have more discussion on this and I want you to know if your question wasn't answered that there will be a follow up. I want you to also be reminded that we are offering continuing education for nurses, physicians and pharmacists and you'll receive an automated evaluation from MedStar via email within the next five to seven days. Next slide please. We've got the email from MedStar will look like obviously your name will be in the slot instead of a black bar, and we are offering CE for healthcare executives certified professionals in patient safety board certified patient advocates and certified professionals in healthcare quality, and we heard the person who said that they'd like to also see CE for positions assistance and we'll be looking into that. Thank you so much for joining us today. And please feel free to continue to send the patient safety movement foundation your comments and suggestions for future content. Thank you all have a great day.