 Hello and welcome to our last session for the day. My name is Sandra Jones and I sit on the board of directors as past president for NICU. I'm also the director of quality at Tixoma Medical School. I'm excited to be joining you today from Dennis in Texas. I'd like to welcome our presenters. Marty Hatley is president and CEO for Project Patient Care, the Chicago Land Safety and Quality Improvement Coalition that is dedicated to using the voice of the patient to improve care. He also serves as co-director for the MedStar Institute for Quality and Safety. MedStar integrates communication strategies and high reliability organization principles into safety and quality improvement. Vaudevayne Bates is an alliance builder and leadership coach for more than 30 years. She has helped people set and reach goals, manage engaged teams and communicate for influence. She's the CEO of the 10th Dot, a company founded by her late husband. 10th Dot coaches and trains individuals, teams and organizations to identify hidden potential, tap the benefits of differentiation and bring ideas to life. Chris Nazem Blackburn is a nationally recognized patient and family engagement expert in healthcare. She volunteers as a patient and family partner in several committees across the university hospital health systems, the university hospital's rainbow babies and children's hospital. Edwin Laughlin is a senior healthcare executive who works to cultivate a culture of healing and family center care. Mr. Loughlin led the medical center's efforts to become the first in the nation to earn the Joint Commission's Integrated Care Certification. Under his leadership, Parish Healthcare has maintained an impeccable quality in patient safety record. Danielle Ufri is an internist at Bellevue Hospital and a clinical professor of medicine at NYU. She is a founder and editor in chief of the Bellevue Literary Review and writes regularly for the New York Times, Slate Magazine, The Lancet, New England Journal of Medicine and other publications. She is also the author of six books about life and medicine. As a friendly reminder, there will be a 15 minute question answers at the end of this session, but you don't need to hold your questions until the end. Use the ask a question text box to submit your questions for the presenter at any time during the presentation. Please join me in welcoming these respective leaders. Thank you, Sandra. Welcome everybody. Today we're talking about engaging patients and families for safer care. I'm joined by an excellent faculty. None of the faculty have conflicts of interest to disclose. The NEHQ competencies will be addressing today include assessing patient safety culture and identifying and reporting patient safety risks and events. Our learning outcomes are to differentiate between some key concepts in the field that include patient and family engagement, person-centered care and patient and family-centered care and also to identify opportunities for improved collaboration, communication and coordination with patients. So what is patient-centered care? It's a concept that's deeply embedded in ethics and human rights. It was first articulated by the Picker Institute in the 1980s. They came up with eight principles, giving you here the prevailing definition, I would say, from the National Academy of Sciences, which really emphasizes some key concepts which are respect for patient preferences, needs and values and really working with the patient and letting their values guide decision-making. The concept of patient-centered care was exciting when it came forward and it was adapted in many ways. One major adaptation was the Institute for Patient and Family-centered Care was established to really spread the practice and operationalize patient and family-centered care, patient-centered care and a number of different organizations, including hospitals and other care settings. And also the concept got integrated into many different aspects of healthcare transformation as the field began to use it. So you see quite a bit of evolution in the way we talk about patient-centered care. We include the family now. We've built it into our notion of a patient-centered medical home. Engineers and design people have built it into their lexicons and their way of thinking about production and design of systems, tools and processes. So there's a lot of different ways you hear it described, but it really does focus on those four core concepts that you see over to the left of the screen that were captured by the Institute for Patient and Family-centered Care. Respect and dignity, information sharing, full participation of patients and families in their care and collaboration of partnership with their providers. So patient and family engagement. This is a distinct concept, but it's another way to think about how do we achieve patient-centered care? We do it by actually engaging patients and families. I like to think of this as almost existential. You become patient-centered by doing it, by engaging patients and families in your work. This is a definition that came out of the first framework for patient and family engagement that was published in 2013 as part of a dedicated issue to the field of patient and family engagement in health affairs. The editorial that accompanied this issue from Susan Dancer who was then the editor has become, has gone rather viral. She didn't quote, come up with this quote, but she certainly made the spread it and that was this is the blockbuster drug of the 21st century. This is the thing that can actually change a number of things, including outcomes. And it's been there all along. We just haven't really operationalized it. So this was a call to action for everyone to not only engage patients and families, but build it into our improvement work. This is that framework that I just mentioned. And it's a little complicated. I'm going to just give you the three levels here, which is we have opportunities to engage to engage patients and their families at direct care. So when they're actually a patient in our system, this is engagement in their own care. The red level is engaging them in improvement work in the things that organizations do to harvest the wisdom of patients and families. So think about improvement teams, think about your improvement projects, patient and family advisory councils belong here. Policymaking can happen either at a governmental level or at the top of an organization. And that's really bringing patients and families into the major decisions that guide our strategies, guide our priorities in an organization or in a governmental setting. And if you work across this framework, it's really listening to patients and families. That's consultation, it's dialoguing with them and then it's shared decision-making about what we're going to do to move forward. So a simple diagram, but it has really shaped the field. There have been a number of organizations that have really stepped up, especially in the patient safety context, to say patient-centered care is one thing. Patient and family engagement is another thing, but how are we going to engage? And here we've seen a really robust group of patient advocates, some of whom are with us today, who've said the prime area for us to be working on is safety and outcomes. Consumers Advancing Patient Safety was one of the first organizations to step up. You see their mission statement here, which is really about a partnership to improve outcomes and to prevent harm. Another major organization that stepped up early to really embrace this concept of the patient and family, engaging them in safety work was the World Health Organization. And this is their mission statement. It was promulgated in a document called the London Declaration in 2006, but I love some of the language here. We are committed to spreading the word from person to person, town to town, country to country. In honor of those who have died, those who have been left disabled and our loved ones today, we pledge partnership as we strive to improve safety. Beautiful language crafted by people working together from all over the world. CMS stepped up after the health affairs article, after the other inputs that we've talked about here and integrated person and family engagement into their quality strategy for the first time in 2016. I should say also that the notion of person and family engagement and patient and family engagement are used interchangeably. The term person really refers to engaging the whole person. So not seeing people just with their patient hat, but seeing them as a whole person with skills and experiences that often impact how they're going to progress as a patient and their outcomes as a patient. So I like that notion of really seeing this person as a whole person and not just one dimension of their personhood. These are metrics that CMS has put into the field for about seven years now. It roughly follows that framework. So you see points of care, engaging patients and families in their own care, policy and protocol, that's improvement work, that's where PFACs are. And then their nod to governance was, and policymaking was to really call upon hospitals to put patients and families on their boards of directors or on board level committees where they can actually influence the priorities of the organization. One example this I'd like to share is a patient and family advisory council that was established at MedStar Franklin Square Medical Center in Baltimore. You see here pictures of the CEO, the PFAC itself, and Colleen LaPresto, who was a board member who was also on the PFAC. So there was great connectivity in this hospital between the board and the PFAC. At the very first meeting of this PFAC, they looked at their hand hygiene policy at this hospital. And the milestone, the benchmark for this hospital was 85% compliance with hand hygiene. The PFAC objected, they said, that's not high enough. Even if we never get to zero, we should be aiming for zero, we should be aiming for hand hygiene compliance, that's 100%. These are graphics that the PFAC produced and shared with the board. And the green line here was that meeting. That was the intervention. And you see that from that time forward, the patient family advisory council stimulated and motivated this organization to do everything they could to achieve the highest levels of hand hygiene. And they are now consistently much, much higher than they would have been before that PFAC meeting challenged the board and the organization to do more. It wasn't just the PFAC that produced these results, it was the PFAC motivating this in partnership with the organization that prompted the organization to throw everything they could at this priority that was set in collaboration with their patients and families. What we've learned from the field in general and the high performers on person and family engagement is that that connectivity to the board is key. When the person and family engagement is a priority for the board and is understood that way in the organization, it moves along. We've seen instances where it isn't a priority or there's lip service paid to it or perhaps it's just not as embedded as it needs to be and it tends to fail when that happens. Another key lesson is that patient family advisors get really embedded in improvement work. They serve on committees. They come out of their role as patients and come into their role as experts in sharing what they've learned and what they've seen with the field. And then constant innovation. I mean, I think that example for MedStar Franklin Square is actually a good example of how when you bring that new voice into your operations and tie it to your leadership, you see innovation getting propelled forward. One of the exciting new developments that really goes to collaboration has just happened this summer where I think it will be a game changer and that is that the Office of the National Coordinator for Health IT passed a new rule this summer that will require all hospitals to share pretty much the complete medical record with patients and families across all platforms including smartphones. So if you think about those core concepts of collaboration and partnership and working together to produce the best outcomes, this will be a much more powerful tool when this rule gets implemented starting next year. And with that said, I wanna close with just this sense that a patient and family engagement only really works in an atmosphere of trust and that requires transparency. So another frontier for patient and family engagement is really looking at the ways in which organizations are being completely honest with patients and families about their outcomes, their areas of need, there's areas for improvement. And also, in a disclosure kind of sense, when things go wrong with the patient, there's a commitment to complete honesty and transparency and having compassionate conversations with Kander about what went wrong. And I leave you with this powerful quote from Mother Teresa about the importance of transparency and being vulnerable as we go into this work. And with that said, I'm going to hand this off to my colleague, Vanda Baden-Bates, the CEO of Tenth Dot and a powerful patient and family advocate in her own right. Vanda. Marty, thank you just not for the introduction today, but also the years of guidance that you've provided, not just me, but so many patients and family members. Most of us, as you pointed to, that sort of blockbuster drug, most of us who have had an experience of errors turning to harm or in my husband's case, death, don't come in with a lot of the language and the healthcare-centric capacities and knowledge, but we do often come with a lot of skills. And I think that that's one of the reasons that I have taken these years since 2012 when my husband, Yogirash Charles Bates, died from a hospital-associated venous thromboembolism to really try to bring my skills and the skills of our family members and our loved ones forward on behalf of this dire need. I wanna just give you a little bit of a perspective on our family who gives me permission to talk about Yogirash and our experience. There were two people within one year that both went into the hospital and died for hospital-associated reasons. My husband in 2012, June, and then my grandmother, who's beside me here in this photo, died within the same, within a year's period. I don't have permission to talk about my grandmother's experience, but I'll just tell you that she was very, very dear to my heart. They were the only two people that I spoke with every single day, my husband and my grandmother. And so to see both of them go into a hospital, for one reason, get that issue mostly resolved, but then die for another hospital-associated reason, you can imagine it really got my attention. Our family decided then to go ahead and do quite a bit of research. So we started with my husband's medical records. We weren't sure at that time and we were not familiar at all with anything related to medical errors. We didn't have any idea what was going on in the healthcare field, but it didn't take long for us to begin to start to ask mostly our clinician friends, is this something that happens for you? And the answer was almost always yes, and it's very complicated. And what we soon realized is that the skills that my husband brought forward, which was about trust building, about transparency, honesty, he wasn't only just proposing that the world, not just healthcare, but any area of focus in business or community development started with transparency and honesty and he taught how to do that. So we wrote books about it, our relationship was founded on it, and we felt like, okay, our family felt like we could probably bring something to bear in terms of helping people get more comfortable with the transparency that we thought would really increase that engagement, both at the point of care, but also in the policy and the governance. I wanna just direct your attention briefly to the picture of our rings, our wedding rings. That's a symbol for us. It's a symbol of what we called our we, and I'll speak about that in just a moment. Here's a picture of our two grandsons. We have several grandchildren. Mackay was aged three months in this picture and he was getting an initiation from his Babaji, his grandfather. And on the other side here is our Julian Teo who was three years old in the picture. And this was taken just a few days before my husband died in the hospital. It might be helpful to just know that he went into the hospital for an insidious brain bleed. He had stroke symptoms and he had had that bleed for about seven weeks and he had a successful brain surgery, a craniotomy. And it was following that surgery that we began to notice symptoms of both DBT and PE. He had pain in his calf. He had an elevated D-dimer. He had these strange sudden chest spells that would last hours or took hours to recover from. His anxiety was very unusually high during those episodes. My husband was a meditator and that was not something that we found to be a normal experience for him. His breathing was labored. His pulse ox was low. He had often an inability to even complete physical therapy even though he was highly motivated to do so and would really push himself to do everything in his power to meet and engage the care practitioners with what they were recommending for his absolute full recovery. He did have two tonic-clonic seizures which you may or may not know is also associated with famous thromboembolism but is a little bit more rare. His risk was high. He had a stroke, as I mentioned. He had a craniotomy. That surgery was more than four hours and he had also a recent diagnosis of prostate cancer. His BMI was a little bit high. He was a little bit higher in age and he also had a serious oral infection. If you had put those risks on the Caprini scale he would have scrolled in the highest range which would have then indicated that the prophylactic care should have at least included compression socks or boots and anticoagulation once they perceived the risk for rebleeding to be changed. That particular hospital at that particular time he had no systematic risk assessment at the point of entry or at any point on the continuum of his care. It was an assessment that was given by the practitioners and it was never actually recorded in the medical records after his surgery. He did have IPCs on during the surgery and those came off the first time that he was ambulating and they never went on again and there was no prophylactic given to him from that. What I want to say just briefly is that the points of engagement that I think were missed were certainly not the point of engagement of creating a good relating environment. We actually had trust in the system and I think that the system had trust in us where we went amiss on that engagement was that clearly to me in hindsight there was no education about the common complications that can happen during hospitalization. And of course that includes HAVTE but it includes a number of other things as well. And what I think could have helped is if we had given some little spiel and probably a pamphlet to go along with it to say, well we're gonna do our best to help you heal complications can arise after hospitalization and especially after long surgeries like yours. DVT is one of those. Why don't you be on the lookout with us? Those words would have made a huge difference for us because we were, I would say, on the privileged side of being able and competent I was there with them 24 hours a day. We were the kind of patients and family members that you can easily engage. We're not even real trouble for doing so. And that's not to say that if it is more complicated it shouldn't happen. It's just to say that this was an easy scenario for engagement and person centeredness to happen. And it didn't at a systems level even though there was a lot of kindness in the care that was given to my husband and also to myself and our family. The other thing that I would say is that in the 13 days that my husband was hospitalized there were eight relocations and there were tremendous opportunities in those handoffs for there to be reeducation, reassessments for us to really be engaged in the care that he was receiving. I will just close by saying that as we married we created this term we and we seriously named that as a third entity in our marriage. We cared for it as a we. We symbolized it in the forms of not only our wedding bands but also this was his gift to me. This little box for the wedding rings which now contains both of our wedding rings because mine broke several years after he died. The we means to us it's a symbol. It reminds us of that agreement that we made to engage to be centric around the relationship. So I would even propose that as you're starting to embed person centeredness into your organization or continuing to do so that you name the relationship as an entity as well. And that might help put to the front of the line when you're starting to make key decisions about where to involve, how to involve and how to follow up. So my last question I guess would just simply be for you to maybe ponder and contemplate what reminds you to engage patients and their care partners. What's your symbol that would really help you do that? And that symbol could make all the difference and for each of you it might be very different. So I really appreciate you listening and there are a lot of other people to pay attention to. We have a great panel lined up. So I look forward to introducing them to you and here we go. We've got a great lineup and a number of good questions for them. Well, I told you that we had a great lineup of panelists and they've already been introduced but let me just reintroduce you to Chrissy Blackburn, Dr. Edwin Lofton and Dr. Danielle O'Frey. Thank you so much for joining us today. I have a few questions for each of you and a couple of questions that I think all of you would be ready to answer and would be really helpful for our listening audience today. Chrissy, I'll start with you. You have the unique role of being both a parent of a medically vulnerable child and I think if I remember correctly, you went into your career because of that and now you serve in a patient engagement role with the University Hospital. Can you tell us just a little bit about what you think helps you succeed in your role that might help others succeed in their role when they're aiming at person-centered care? Thank you, Vanda. Yes, I think there's a little bit of a unique component to how I got involved and why I was so engaged with my daughter's care and then eventually transitioned to this role at University Hospitals. So my upbringing, my mother was in healthcare quality and safety for her entire career, working at the Joint Commission, PhD and psych nursing helped launch the first quality institute, the Cleveland Clinic and helped with some of the partnership for patients work as well. So regular dinnertime conversations with me and my two older sisters were around patient advocacy. So she would tell us when you go to the doctor, make sure that people are cleaning their hands, ask to see labels on any labs that you might have. It's okay to ask questions, it's okay to be involved. And unbeknownst to me, my entire life I was being prepared for my daughter. So when she was born and we were in the NICU for the first couple of weeks of her life, I knew how to partner with the care team. I knew how to ask questions in a way that created a relationship instead of butting heads which we see a lot of the time. So as my daughter's care progressed and was getting more involved and it was overwhelming as much of a home education I had about healthcare. It was a lot to manage. And I was her case manager, that's what happened. She began to calm down and the hospitalizations calmed down around the age of four. I wanted to give back. So I joined Rainbow Babies and Children's Hospitals, what was then called their Family Advisory Council. About a month later, I talked to Marty Hatley and joined the PFE network for the CMS Partnership for Patients Campaign. And a month after that, I enrolled through my Master's in Healthcare Administration. It was sort of aligning of the stars, if you will. And about a year after that, I met some of the executives very easily at University hospitals. We began to have conversation around there was opportunity right now for patient and family engagement. There was no formal structure. So I was appointed to my role in 2013. We're going on 14, I'm sorry. We're going on seven years. So I think that what helps that involvement is respect and language and relationships. It's those three components. So as a patient family engagement advocate or a patient family advocate, I can't just come from the patient family side and perspective all the time. I need to respect Danielle and her role as an internist in knowing and learning more about what they do. That's why it's called a partnership. It's a two-way street. I can understand how doctors are overwhelmed. I can understand why nurses are overwhelmed and any of the other staff at a hospital. If I don't respect and understand their roles and don't come to the table with appropriate language of being an effective partner, those relationships can't happen and then we can't succeed. So I think it's really those three main ingredients that was out. I can imagine you being very effective at preparing everyone for that partnership and sometime I'd love to get more time around how you do that specifically. For now, I want to turn to you, Dr. Ophry and I recently read something that you wrote. I can't remember what journal it was in. I think it, yeah, you can tell us what it was in but you posited that Florence Nightingale may have been one of the originators of the concept of patient safety. And I'm curious what you think if you were to try to channel Florence Nightingale today, what do you think she may have offered for us in a modern day society around patient safety? What do you think she might have had to say to us today? Well, I'll say that I came upon Florence Nightingale and researching my book, When We Do Harm, became interested in medical error and I had previously thought of Florence Nightingale as most people do. He was the nurse, the lady with the lamp. I hadn't thought of her as the patient safety patron saint or the epidemiologist that she turned out to be but as I learned what she did, when she went into a situation, in this case it was the military hospital where there were four times as many deaths due to illness and disease and actually battle. And the first thing she did was to collect data to see what was going on, where it was happening. And of course, she drove for supervisors crazy with their insistence on meticulous and longhand detailed notes and they thought she's just wasting our time. And but of course, without recording data, we don't know what's happening where. And I think that was her biggest contribution, I think as a biostatistician to recording data. And so often we go as, okay, let's just make everything safer. Let's do 27 things. But we don't take the first few steps to measure what's happening now. And so I think that she would say, whoa everyone, stop for a second and take the time as boring as it might be, as slow as it might be and figure out how to collect the data. So for example, one thing we don't have in the US is a national repository, a data bank for medical errors and adverse events. We have individual hospital data, some statewide data, different organizations where there's no centralized place. And so we don't know what's happening where. And if we don't know what's happening where, how are we allocating our money and resources correctly? We may be throwing all of our money at one place, but in fact, the real harms are happening elsewhere. So that's the first thing I think she would say. The second thing she would say is that you have to go right to the top. So when she finished writing her book Notes on Hospitals, she hand delivered a copy to Queen Victoria. And that's a great way to go, right? You need to get the attention of the top brass. And that was as top of the brass as you could get at that time in 1853. Because without the leadership really buying into it, we're running around and we're kind of wasting our time. We may clip at the edges, but nothing will happen unless your medical center director, the chair of the department, the head of nursing, the head of your whole institution says, you know what, this is really important. So I think her first two things would be, collect the data, know what's happening where, and then go right to the top brass. Thank you. I think that's a really nice move toward you, Dr. Lofton, because you have, I think, what is a unique position in your organization to have influence in many different areas within your hospital. And so thinking through the lens of it being a hospital or a healthcare institution of some other kind, can you give our listeners the maybe top three things that you would recommend for both administrators and clinicians? Where do you suggest people put their focus when they're striving to include patients and families in creating that culture of safety? The value of this is completely immeasurable, whether it's protecting your child as Chrissy has done, or whether it's recognizing the influences of those leaders like Florence Noggedale that Danielle spoke of. I'd say that sort of the hierarchy of the three top things in looking through the lens, especially from a public perception, is one, understand the issue. We are still the third leading cause of death in the United States. And as clinicians, as hospitals, as healthcare systems, our first commitment has to go back to the original oath, do no harm. And we have to say that with meaning, with effort, and with our literal and our subjective checkbook, where are we spending our energies? Where are we spending our dollars in creating systems so that the nurses, the physicians, the technicians can do the work without harm? And as a scientist and as engineers, we know that that comes through the development of process. It cannot be based on an individual's actions. Everybody has a good day. Everybody has a stress day. And if we defend the individual, we will fail every time. But by building evidence-based processes around zero harm, we can achieve, not just get close to, but we can achieve zero harm. So the first is that true commitment to do no harm. The second I've already sort of stepped into, which is building those performance improvement-based processes, give the clinicians, give the pharmacists, the nurses, the physicians, the processes that are safe and protect them as well. We do not want second victims. And third, and especially related to this panel, I think is by far the most, is be transparent. Be transparent with each other, be transparent with the persons that we have the honor to partner and care with, and be transparent with their families. I have found countless of times in my 35 years of nursing that when we bring the family to the bedside, include them, and we treat the person in the bed as a person, not a patient, that we have the opportunity for no harm and exceptional outcomes every single time. It's like I teach my nursing students. How much in a person's life are they a patient? Typically, most people are a patient, less than 1% of their life, but they are that person 100%. So when Sam Woodard needs our assistance, we need to talk to Sam, not the paraplegic. I hear all three of you really pointing toward what I think of as sort of the immediate opportunities that sit in front of us, prioritizing it, putting the systems in place to support that, treating ourselves, whether we're treating our colleagues or our patients and their family members as people first. Let's talk a little bit about some of the obstacles. Dr. Ofree, would you begin just from a clinician's point of view, what's your advice to work and overcome the obstacles and what are some of those obstacles that you see are common? The obstacles for the clinic, for the family. Yes, for the clinicians. For the clinicians. Well, so the first one for me feels like time. So today I was in clinic this morning, I had patients scheduled every 20 minutes and most of them had medical problems and complexities that take far longer than 20 minutes if I really wanna do a good job. But 80% of my time with them was spent battling with the electronic medical record, that I had to make the EMR work so I could get the visit done, get the meds ordered, get the tests going. And so I really didn't have a lot of time to focus on the patient, especially if their problem was not straightforward. If I had to think maybe the diagnosis is not correct, maybe we need to rethink what we're doing. There isn't really much time or no time at all for deep thought, consideration, discussion, that type of thing. So when we think about medical error, I often divide into two big categories. One is procedural error, something that is actually quite amenable to checklist. But then there's diagnostic error or misdiagnosis and you can't really checklist that thought process. And the way we have things set up now, it seems it actively works against deep thinking, cogitating, which is often what we need. So that to me is the biggest obstacle. It's both time and I'll put the EMR together with that. And partly because the EMR and our systems, they're primarily built for billing and patient care came second. And we feel that every single minute that we use it, that it's really intended for the billers. So that's a big one. The second thing that is a big problem is how we've really been separated out into different categories of medical workers. And although we talk about the team, the medical team in practice, that's very hard. I often think about the big medical error that took place in Texas with the Ebola patient when the patient came to the ER and the nurse took a history that included recent travel from West Africa, but the doctor's screen didn't see that. And of course they weren't physically together, so the doctor didn't take that same history and sent the patient home. Now in the old days when we actually sat together, we'd actually talk and you'd hear, oh, by the way, this guy just came from Liberia. But now because we're physically siloed, our computer screens that we see are siloed, we don't have communication. And of course a huge error was made in a misdiagnosis which had tragic outcomes for many, many people. So those are the two biggest things that I see now. Do you, just a follow up question on that, do you see some immediate opportunities to help course correct from that time constraint? Well so often the suggestions for course corrections fall on the shoulders of the clinicians. Well, you doctors and nurses, how could you do things better? And I really want to flip that. I really don't think that it's, we have enough on our plate just taking care of our patients that making this work is a systems issue as Edwin alluded to and that it really has to come from higher up. And I think that the thing that we can do as clinicians is say, you know what? At this point, the system we have in place is actually dangerous and it makes medical care harder to give. And so I as a clinician in my do no harm oath, I can't actually take care of my complex patients in the system because I'm forced to cut corners and I think that there's an error. So I need to put my foot down. And so one thing I sometimes do when I have a little, you know, a little bit more mental space is try to file patient safety reports every time the EMR trips me up and does something that makes me potentially make an error. And of course that's a labor intensive for me and I only do it in fits and starts. But to remind our administration that it has to start from higher up. We can't rely on the clinicians to fill in the gaps of mediocre systems. And I think that points to a larger issue of how the healthcare system runs. It runs on the sort of good nature and the professional commitment of our clinicians. And because we know they'll stay late and they'll fill in the gaps and they'll make up for a lousy, you know, system. But that's not really a way to run the system. And of course, as Edwin says, we have good days, we have bad days. And I think COVID really revealed how much the system relies on the individuals to do their best. And of course we largely do. And that's wonderful. That's why we want people to go into these professions. But you can't run a system on that. So it really does have to go to our higher ups. And of course the next step is our society. Part of the reason that we only have a few minutes for a visit is that if I sit and chat with my patient about how to take their diabetes medications for a long, complicated discussion is very poorly reimbursed. If I thread a tube into one of their orifices while I talk about broccoli and quinoa, that's reimbursed a lot. So of course we lean toward procedures and things that earn a lot of money and don't a lot, a lot of time for patient education, for, you know, nurse giving the discharge education because that's not, doesn't pay the bills. So that's really a societal question of how we fund our healthcare system. Those are excellent points. And Dr. Lefton, I want to pick up from what we've just heard from Dr. Ofri there, looking through the systems lens and specifically administrators who are putting those systems in place. What have you seen as the obstacles? And even more importantly, how have you seen those obstacles mitigated or managed well to give back more time for that person-centered care and creating culture of safety? The obstacles are a couple of fold. One is ourselves, we get in our own ways, especially, you know, I am a nurse, I am a clinician, I am an administrator. So I look at it from the prism view. And in the business of healthcare, in the business of hospitals, just like Danielle spoke to, we have pressures that are not person-centered related, that we have business pressures, we have financial pressures, we have operation pressures, we have pressures from the community. And so we as individuals can get distracted. And that's one of the things that we've got to keep that very focus on the culture of safety. In my doctoral thesis, my work was on zero harms and transitions from the ED to Med-Surg. And so one of my solutions is that we engage our entire team and back to Danielle's component on that and Christie's input. When I put the team together on how do we have a transition of care from the ED to Med-Surg with no harm whatsoever? And that harm definition is from the person's perspective, from the clinician's perspective, bringing in the patient family engagement team, bringing in the nurses, the physicians, the technicians, the transporters, use the data to understand what's going on and then have them be the solution. It's amazing what those persons who are committed to healthcare can do when they're given the autonomy and the focus and the direction, get out of the way because they're coming at you and they're gonna make it happen zero harm. Thank you. Christie, you are in that unique position as a bridge. And I can't remember the three things that language and communication and respect, I think was the third one that you named earlier and the three really important things to be paying attention to, especially as a clinician administrator, somebody within the healthcare environment trying to deliver that safe care. I want you to look at it and give us a perspective from the patient side and the family member side, if you will, what are some of the barriers for patients to be engaged, to stay engaged, to sustain engagement in their care? So I think a couple of things and this all does come down to leadership, both what Edwin and Danielle have already spoken to, what is starting at the top and what is that high reliability culture that we have in place? And that takes time, culture takes time. From the patient family perspective, I would agree time. I don't have time to sit there and be engaged and be involved. The other part of for patients and families as far as being involved, even in their own care to have self-management of their own care is fear. A lot of the time, we're trying as a health system, well, make sure that you go to your radiology appointment and make your follow-up appointment and there's a number of things that you need to do. And I think a lot of the time, there's fear. Patients don't want to know what is wrong or they don't have the time or they don't have the resources, much the clinician perspective to manage what they need to manage. I always say that when it comes to pediatrics in cancer care, you don't just get the patient, you get the whole family, right? And somewhere in that acute care, med surge, emergency department area, that family member falls aside. We're just focusing on this person with this ailment or this diagnosis or disease. So I think it's a matter of truly understanding what patient and family engagement is. I think there's a lack of awareness and that education needs to be very consistent and clear. I think over the last couple of years, we've seen some conflicting messaging as far as patient engagement and patient experience. It's not the same thing. They do work hand in hand, but looking at the fluidity of safety, quality, experience and how we round it into this HRO bucket and culture so that we can truly look at that fifth principle of high reliability of deference to expertise. Every single person on that care team has an expertise. And again, Daniel, to your point, how can we bring us all together again and lift some of those barriers because the barriers that we have for clinicians will directly impact the barriers for the patients. That's really perfectly put, that the barriers are very similar, no matter whether you're delivering care, receiving care, supporting care, administering care. I wanna bring all of you into focus for a moment around that definition of engagement versus experience that you just brought up, Chrissy. And particularly, I'll give you just a very concrete example of recently a friend's granddaughter had a delayed diagnosis of a very serious brain cancer. And the third physician who did identify it and got things rolling wrote, as you just pointed out, Dr. Ophrie, she wrote a formal statement to the prior two doctors so that they would know what had happened so that it wasn't off of their radar. And when I asked my friend if they had considered writing something as well so that it would just maybe raise it up a little bit further, she says, I don't have time for that. Who has time to report when something has not gone well? And I wanna ask all three of you, if you are seeing any inroads, progress, some ways that we can begin to track these things through medical records, IT, where is it that we can start to get this information in a way that's useful? What's happening there and how can we build upon that? Dr. Lofton, would you begin? Sure. So one of the things that we have done at my organization for several years now is again, through our culture of safety, through our journey to higher reliability, as Chrissy spoke to, is every week we have our weekly check-in, the fancy name for a conversation that is held by almost every leader in the organization. In which we review the previous week's documented events and we do it in a open, transparent form so that we can learn from each other and that we can take those events not in a retrospective focus but in proactive learning sessions. So if we had three events where a person fell out of bed, what were the common factors? Use our PI science process and methodology and make changes. So every week, we continue to make changes in our practices. It is so important that nothing is to interfere with that meeting and that conversation except direct patient care. So back to everybody's point of priorities and timeliness. We have time for what we determine to be important and that's in our personal lives and our professional lives. And if patient safety is not the most important thing on our horizon, yes, we get busy. It happens to every one of us but having that transparent, focused, proactive approach. Thank you. Dr. Ofrey, your thoughts on that? So I would say two things. So one is we rely a lot on clinicians to file those patient safety reports but again, we don't have time. Do we report the near misses? And so we only get a little taste of what's happening. So I'm intrigued by ways to use the electronic medical record to actually pull these things out without requiring clinicians to report them. And so it'll be a different set of data but for example, something like the global trigger tool which uses certain red flags. For example, a patient comes back to the ED two or three times in a short period of time or is readmitted quickly or a major diagnosis changes or restraints are required or, you know, the steroids are given. It's things like that that can say, hmm, some things up, let's go have a look here because we're not just looking for errors but places where patients are getting adverse events even without an error in place. So that's one way we can gather data, clusters of C. diff infections, things like that. The second thing is I look at the system in Denmark and they've actually switched to a different method. We use the malpractice system to sort of, you know, find and treat medical errors but of course it's a very blunt instrument and very, very few patients can actually benefit from that. Most patients with an adverse outcome don't have enough quote, unquote enough for a lawyer to take on the case. They have a system that is where they separate the litigation for negligence from a separate, non-letigious database of just things that didn't go as well as they should have whether it's an error, an adverse outcome, an unexpected event and if anything happens you can file and anyone can file a one page report, it's free. The doctor can do what the nurse can do if the patient can do it and it's more like workers' compensation and that is if, so things somehow didn't go right compared to whatever the standard of care is, you know, committee will adjudicate that in the course of months as opposed to years and there could be a settlement if necessary but the bigger thing because that data can't be used for litigation people are less afraid to file reports and as a result then the government now has a growing database, right? If there are a lot of pressure ulcers coming from this hospital or this region oh, let's go in there and see what's happening so there's a way in a non-punitive way to encourage clinicians and families and patients to let the government or the patient safety organization know what's happening on the ground. Ed, I really appreciate you bringing up that model Dr. Ophry, I have not heard about it but I definitely will go research it because every person that I've spoken with who has experienced harm after error whether they were on the delivery of that care or the receiving end of that care has said something very common and that the most important thing is to prevent it from happening again and that's not what is happening right now. We are not doing everything that we can to prevent that from happening again much in part because of the systems that I think we have in place. Christy, I'll give you a minute or two to respond to that question and then I wanna take us in another direction before we end our webinar here. Thank you. As far as the reporting I find Denmark's model very intriguing as well because I think that a lot of us as patient family-centered care advocates and PFE advocates, how can patients report it and getting their perspective too. So as far as how a reporting error and I can just speak on behalf of university hospitals similar to what Edwin was saying we meet every single week and review all of what we call the past reports that were put in for that week and then determine whether it needs to go to a QA, RCA or a performance improvement and who will own that as we move forward. I think the important component too is over the last couple of years as my role has developed and changed and morphed in many areas is I'm part of RCA's. My role is part of RCA's. I am part of the quality assurance process. I am part of performance improvement. I am part of the past report meetings so that the patient family voice is never lost. So to what Edwin was speaking of before we have these pressures, we're human, we have operations pressures, we have business pressures. When you have whether or not your organization has a role similar to mine you have the relentless drumbeat and you need to have that person or that patient family advisor be the disruptive innovator and not afraid to raise their hand and say, you know, we've been talking about this and no one has said the word patient in the last 25 minutes. So that we're keeping our focus. I do believe and what has been said so far we need to make it easier for the clinicians to be able to put in what is happening. But I really, really strongly advocate for some sort of mechanism for patients and families to do the same thing and not necessarily just going to the Joint Commission or the CMS but what can be something that's non-punitive as well for health systems. I'm curious about your statement about we need to make it easier. What makes it easier? What gets a clinician and administrator past that point of hesitancy and all those obstacles that are in place? What makes it easier? Would each of you just respond to that? Chrissy, would you begin? I think that begins with a lot of what we already know of just culture. We need to have a just culture in place to know that when you report something you're not going to be smacked on the hand for reporting it. You're not going to lose your job. We look at that human error as was it risky behavior? Was it reckless or was it opportunity for further training? That's how we sort of gauge those things when we're doing a root cause. And just even the formatting of how you put something in that report. How many boxes do you have to click, right? That's what clinicians say with the click, the click, the click. How many clicks do I have to make? And ensuring that you have the proper structure within your quality and safety departments to handle that. So they're very specific people that will tackle certain situations or certain areas that are occurring. And then again, coming from the top in your leadership, make it easier. Thank you. Dr. Lofton. I agree completely with what Chrissy said. I also think in that culture of safety in that just culture component, we also have to give people permission, permission to raise the question, permission to be that voice that does not stop, permission to not accept, that's the way we do it. When we can have that conversation and people believe they have permission to speak up, to step out and to raise the level of awareness, we as an organization, organizations can make a difference. Thank you. Dr. Ohfrey. Well, second Chrissy's comment on making it easier to do, recently I thought I would file a patient safety complaint. I couldn't even find the database. I couldn't find the link. And I thought this shouldn't be that hard. I think I'm no smarter, no dumber than my colleagues. I couldn't find it. So just that, making it really easy to find. Then once I found it, I had to make a password with an uppercase and a lowercase and a special, so I'm like, I don't have time for this kind of thing. And so it was just so intimidating to do that I gave up. So just make it easy. And then the other thing I point to is, how do we define what is lauded in our culture? And so the term hero gets bandied about a lot. And I got bandied about a lot during COVID. And in the term that many of us found very awkward because we didn't feel like heroes. We feel like we're doing our job. But we always tend to think that during your training, someone's either, they're really strong. They're an excellent clinician or they'll go work for a drug company. There was nothing in between. We had this culture of perfection. And we associate the heroic model with that really sharp doctor who's got an answer in 10 seconds. We don't think of heroic as a person who admits their errors, who comes forward with an embarrassing uncomfortable admission or who says, I don't know. And so changing the idea of what we call heroic would go a long way to changing how we see and how we invite people to step forward because it's not easy to talk about an error. It's shameful, you feel guilty and humiliated. You're often ashamed of what you've done. You feel terrible. And so we need to make that positive, maybe a little stretch of it, but to make that a lauded thing that we look up to, wow, that person, how courageous they were, that they stepped up and that person gets the employee of the month award because they stepped up and revealed a difficult error. And then there's a system in place to really support them in everyone in being able to continue in that speaking up. I can see how that would go a long, long way. One final question for all of you and I'm gonna ask you to make it brief. We've reviewed a lot of very practical ways in which clinicians, administrators, and everyone who's involved in helping deliver patient-centered care on behalf of the culture of safety can move it in a very practical way in their organization. What's just one thing that you think, if you were to leave them with one thought, one practical matter, what would that be? Dr. Lofton, would you begin, please? Go, do something. Doing nothing is the worst thing we can do. Great, Chrissy. Listen to your PFACs. If you have not, if you don't have one, create one. If you've deactivated during COVID, reactivate. And if you have positions such as mine, best practice should be reporting up through your quality department. Sorry, I have two. It works, Dr. Ophry. Being comfortable with not knowing and being able to be honest. When you have that feeling in your gut, something's not quite right. I don't know what's happening. We tend to want to hide that, but actually to be creators and then admit in public to your team, I don't know, or I'm not sure if something feels wrong here, can we stop and take another look at what's going on? Great wisdom. Thank you all so much. And I know I also really appreciate the opportunity to bring this helpful information forward during this next conference. And I hope that it's been valuable for everyone. And now we will take some questions. Thank you so much to our speakers. The stories and examples shared truly touched our hearts. We will move on to our questions as our virtual audience has been quite engaging. So question number one is for Chrissy and it's from Sue out there. And so we have an active PFAC, but we have so many projects on the strategic plan to complete that we don't have the time or resources to implement their ideas. How do we effectively prioritize improvements and be sure the patient and family voice is heard? Thank you so much. And that is a great question. I'm hoping I can be heard. Yes. Yes. Okay. So I really believe that again, is we talk about so many things in healthcare organizations that to effectively engage and have the resources to implement your PFAC ideas has to come from your leadership. Again, this is part of the culture. And with the number of strategies that so many organizations have and there's so many priorities and everything is competing, it's really important to bring that strategy to bring your health systems goals to your PFAC, explaining what these goals are, explaining what the strategies are, and then asking them to explain their goals and their strategies as well. So if you have an active PFAC, I would very much assume you have a mission, you have a vision, you have annual goals that you're trying to meet and you are inviting your health system leaders or hospital leaders wherever you might be to your meeting so you can align. That's really what this is about. And even as I had mentioned in the session, that is what partnership is. So let's learn about what you need, what even financial needs that the organization has and the needs of the patient and you have to meet in the middle on that two-way street. Well said. Thank you so much, Chrissy. And we'll move on to question number two. And this is from Jen and it's from Marty. So Marty, the reality in my organization is that the frontline clinicians don't really want patient-centered care. They see dealing with the family as a burden. How can we improve this culture? Jen, I've heard this question before. It's one of the reasons why I think starting a PFAC, if you don't have one already, it's a great strategy. I mean, I talked about how that's a way to operationalize patient-centered care by bringing that voice of the patient in. And if you really want to hit that strategy as a ballpark, make sure that senior leadership comes to the PFAC meeting or that you've got a board member who's on the PFAC. That will get the word around the culture pretty fast. But this is a place where things happen. If you don't have a PFAC, then you need an internal communications campaign about this being a priority for the organization. You could feature the voices of patients and families who use your care, making it really relevant to tasks that your frontline workers do. You could build it into newsletters. You could build it to your employee orientation or even your employee recruiting. We've heard from hospitals who basically highlight that as one of the things that is a marker of that organization in their recruiting mission. So those are all some good strategies. In terms of actually relating it to work, one success story you could build on is there was a lot of opposition from nursing to doing nurse shift changes at the bedside engaging the patient and family in the conversation. And that's then almost completely turned around. Most nurses are now champions of that. You could use that as an example about how patient-centered care really works in an organization and really improves relations and also looks at outcomes. Wisely said, and just even this presentation if there's any way that some of those leaders can watch some of this information, I think it goes a long way as well. Question number three will be for Edwin and it's from Christie and it's discussed family inclusion during this time of COVID-19 and reduced visitation. Great question. This is probably one of the most important things and challenging to your commitment to PFAC. My organization like everybody else went to a no visitation or very limited visitation during COVID and especially for the peak for us back in June and July. And when we went to limited visitation we were very, very intentional in defining what visitation would have and what would be around the term compassionate care. When compassionate care is needed by a loved one, by a partner in care, we would arrange, we would screen the person and make it permissible for them to be there. It was not just for end of life situations. There were a couple of very unique situations. We had a young man who was autistic and the person that could give him the calm and the sense that he needed was his dad. So we made that happen to get out of the bedside and we saw several situations where providing compassionate care and allowing the family friend to be there, the person is better because of that. Thanks, Edwin. And I know everybody's experiencing that out in all the healthcare facilities and across the entire continuum. So thank you for sharing. Yes. Yeah. On our next question, this is for Dr. Ofri. Do you have suggestions on how to create a national database on medical errors or a repository, maybe something similar to the national practitioner database where data could be sent? Sure. I wouldn't mind just taking 30 seconds to address the two questions ago about frontline clinicians being somewhat resistant to be engaged with patients and families. And I think it's not resistance. I honestly think it's time. I think most of us very much want to be. This morning I spent more than an hour making phone calls of families and patients, but not an hour that I'm ever allotted so that hour comes out of just staying later. So I think if we want clinicians to be involved, we have to allocate time and of course, time is money in terms of prioritizations. When it comes to a national database of medical error, I think this is critical. We are missing this in the U.S. And I think a great model is our VA system, but also countries like Denmark that have a reporting database. And the key element is that this is not used for litigation, retribution, or about practice, anything like that. That these is a place in a non-threatening way to report errors, mishaps, adverse outcomes. If we don't have a way to protect people from being punished for this, no one's going to report. So I think we need to distinguish between whether we need some kind of system for clinicians who are negligent, and that's one thing, but a separate system for people to feel comfortable reporting things that aren't safe without feeling they're going to be called out for that. Thank you so much. And thanks for pointing out that time factor as well for clinicians, because I think that's really true. And we have to be able to allow for that in our healthcare delivery system for it to work as well. So thank you. And, Rhonda, this question next is for you from Chris. And she asks, how can we better engage the public in understanding their role in engaging patients in patient safety? Well, I will start by saying that, you know, I think creating an environment of receptivity in the culture, in whatever system it is that you're helping manage and leading in is really important. So, you know, that sense of receptivity, we know when somebody really wants to hear what we have to say. And to make it pervasive, I just mean whether it's good news or bad news, like Edwin said earlier, Dr. Loftin said earlier, I would also say just make it really proactive. Look upstream. And I'll also draw attention to the first words, I think when I was telling the story about what happened for my husband in the hospital 2012, you know, we have a symbol for our we. And I would just draw your attention back to what is that symbol? Share that symbol with your patients, with your family members. Tomorrow's World Patient Safety Day, the color is orange, that is a symbol. The words that we choose when we are narrowing it down to that mission statement, when I see that in a hospital or a care facility or my clinic, I know that that means that somebody has given it thought and that they want to hear from me. So I would just make sure that we are educating because the general public is not familiar with this topic. They presume that when they go to the doctor or they are meeting with that nurse that it is a safe environment. And of course, we don't want to really set alarms off for them. So our activities, for example, the reason we're uniting for safe care tomorrow in DC and around the world is because we are creating a symbol, those four words, it's uniting for safe care or unite for safe care, is those are words that we want people to remember. We want, hopefully you'll be using them with your patients in a year's time. Who knows? Maybe everybody has heard those words once or twice. They're not nervous or worried about being safe in their care system. They know they're a partner in it and they know that those words matter and that they mean something. It's like a battle cry. Unite for safe care. It's wonderful. I get everybody to rally behind it, right? I love that. Exactly. I should say just to make sure that it's uniteforsafecare.org and the virtual event tomorrow is going to be very inspiring. So I hope we'll see many more familiar faces there tomorrow. Yeah, love to see some pictures too. We'll be sure to share for sure. Very thank you. Have a little time for some final comments. Do anybody have anything else you'd like to share with the audience before we end? Okay. I think that's a wrap for our final presentation. We've done it together. That concludes the programming for NACU Next 2020. My mind is spinning at 100 miles per hour with new insights, ideas, and to-dos. How about yours? On behalf of the many volunteers and staff who worked tirelessly in recent months to pull this together in a fully virtual environment amid these difficult global circumstances, I sincerely want to thank you for taking time from your busy schedule to participate and engage over the past few days. There's never been a perfect time to step away from the grind, step back reflectively, and truly assess your skills and opportunities for development. I cannot wait to hear first and second hand the success stories and transformed careers that come from these type of conferences. Your role in supporting quality was always important, but in the weeks and months and even years to come, while we wade through this perilous, unpredictable, and often scary reality, your skills, your knowledge, and most importantly, your passion, will be of indispensable value to others. In closing, I will remind you of something you already know. The journey of learning is just that, a journey. You never really arrive, and if you think you have, that's when you are most at risk of backsliding or becoming stagnant. To that end, in a few short weeks in October, NACU will be hosting Healthcare Quality Week. This is a week to shine a light on the profession and the discipline of healthcare quality. It will have a lot of exciting elements to it, many of which you will be able to share and cascade across colleagues and coworkers, appreciating that many of them may not have quite the level of awareness and sophistication that you may have by coming to in-depth conferences like NACU Next. Be on the lookout for announcements and details as that draws closer and be sure to engage with us then as you continue this exciting journey to excellence and quality. Also remember, all of the content that will be continued to be available to you in the days ahead. Anything you may have missed in this busy week is at your fingertips now. Take care, stay safe and thank you, thank you, thank you from the bottom of my heart for being with us here at NACU Next. It's been an honor to serve you as this year's president. You are all gems in our quality treasure chest and are appreciated so very much. Thank you for all that you do. Keep on rocking the quality world, we need you.