 Good morning, everybody. Welcome to our part three of CANDOR. And today what we're gonna be talking about is evaluating CANDOR implementation, the impact effectiveness and sustainment of this great program. I'm Donna Prosser, I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. And I'm really excited to get started today because we have a lot to cover. So today we're gonna be talking about what the key elements are for successful CANDOR implementation, the evidence behind CANDOR, and looking at the challenges of caregiver burnout. Also looking at successful interventions for peer support. And then we'll talk about how you can evaluate strategies in your organization after CANDOR implementation. So lots to talk about today. As always, we are gonna be offering continuing education credit for nurses, pharmacists and physicians. This credit will come from MedStar Health. So if you indicated in your Zoom registration that you are interested in continuing education credit for either nurses, pharmacists or physicians, you will get an email from MedStar with an evaluation that you'll need to complete in order to obtain that CE. Respiratory therapists can also in most cases claim CNE credit in their state for, but check with your state board about that. We're also gonna offer ACAG credit for healthcare executives, CPPS, BCPA and CPHQ. So if you are looking for either CPPS or BCPA credit, you will receive a certificate from us. If you are looking for ACAG or CPHQ credit, we will be notifying those organizations and they will log your credit for you. As you can see on this slide, we have no conflict of interest to report for any of the panelists. We will be using Slido today, so get your phones out. And if you would, you can go ahead and get set up so that when the first question comes around, you are ready to go. You can either go to slido.com and type in this number, 923717, or you can use this QR code to access the app. So I'm gonna turn it over today to our moderator, Marty Hatley, and Marty, of course, you all know him. He is the co-director at MedStar Quality, Institute for Quality and Safety, and he is also a member of the board here at the Patient Safety MIMA Foundation. Welcome Marty, thanks so much for being here today. Thanks, Donna. It's always a pleasure to work with you, and especially today as we do this third in a series on candor, which I know we've had a lot of interest in. And we have a great panel today. It's just a fantastic opportunity for us to work with some old friends of mine. So just quickly, the panelists today are Heather Gok, who is the vice president of forest management and safety at Beta Healthcare Group. Beta is the largest liability insurer in California. I hope I have that right, Heather. That's what I always say. It has been a real innovator amongst liability insurance companies in supporting candor-like programs. Alan Frankel, I've known for years. Alan is with Safe and Reliable. And welcome, Alan. It's a great pleasure to work with you again today. Carol Hemmelgarn is an old friend who has just a distinguished record in patient safety. She came here because of a family event that impacted her family and has just done amazing work. And I'm proud to say she's a new member of the leadership team at MIQS, Master of Superquality and Safety, running the Executive Master of Program that MIQS does in partnership with Georgetown University. Tim McDonald is one of my oldest and dearest friends. He's currently the Chief Patients Safety and Risk Officer at Arle Dadex. And he's really been an architect of the candor program, did some of the original demonstration work on this that really has shaped this program. So we've got a great group of people with us today. Next slide, please. Tim, we've done two programs before on candor. The first one we did in January was just an overview of the program. And then just a month ago, we did a session that was really focused on the gap analysis and assessing your readiness as an organization to move forward. Can you just quickly, for those of us who, for those here who weren't at those two events, quickly describe what candor is and its components? Sure, Marty. So candor is what we would call a communication and resolution program. It is comprehensive, it's principled and it's a systematic approach to preventing harm but also responding in a very principled way. And it has at its core some very basic things that every CRP should have, where you identify events, you activate a system. In fact, when you see number three there, Marty, that's been one of the evolutions over the last five years is we don't even use the word disclosure much anymore. We talk about it as communication. And that's communication to patients and families as well as caregivers, the care for the caregiver component. And then while you're looking into these events, doing your event analysis, the circle in the middle indicates as you learn more, you share more with patients and families. And you also learn people who may be suffering a new peer support. And all of that leads towards resolution, although we know, and you and Marty, you and I've talked about, we need a better word for the R in resolution, related to that. But the goal is to kind of get to that point where with patients and families and others, that we are able to find ways to make it right financially for patients and families, but also hopefully engage them in the process improvements related to that. And so with the next slide, Marty, that's a paradigm shift, but this is fundamental to every communication and resolution program. And some add a whole lot more to it as we'll hear from Heather. Beta has taken that core, they put it on steroids, they've added other elements to it, but all those elements are contained in it. And it is his paradigm shift, Marty, where to be able to do this well, you need to immediately report and activate your system and begin that process of communication with patients and families. And then Alan's gonna talk a lot about the human factors process, redesign we need and not to rely on shame, blame and train, which has been kind of the history of what we've done. And then of course care for the caregiver has been critical in the times of COVID. And so that's kind of the fundamentals of it, Marty, doing the background again to where we've been the last two webinars. Great, and Tim, thanks for reminding all of us that this is a dynamic field right now. So the Canada toolkit that HRQ put together was published in 2016? Yes, in May of 2016 at MPSF, yep. And it continues to evolve through the experience of the hospitals and systems and other organizations that are implementing it. So we'll dive into that today. Just for those of you who wanna look at the toolkit, it is at hrq.gov slash candor, very easy to find there. There's a whole toolkit, but again, we're gonna talk about how those tools are being used and modified as we move forward. Okay, let's go to our first slide of question today. Thanks, Tim, for that overview. So what is your organization's level of interest in candor or a similar communication and resolution program? CRP is the acronym we use for that. So if you haven't yet done it, join Slido, let us know whether your organization is very interested, somewhat interested or not interested. Okay, and it looks like we have some very strong interest on this phone call coming up. Okay, let's move forward. Heather, can I start with you? And Donald, let's move to the next slide. Heather, I mentioned that beta healthcare has been an innovator in this space. You've taken, one of the innovations you've taken is sort of the guts of the candor program and reinvented it for your members and your clients. Can you tell us a little bit about beta heart and what you're doing to support a candor-like approach? Absolutely, thank you, Marty. And first up, I wanna say that all of these people on this phone call today, all of the panelists have informed our work. So we certainly don't wanna attest to the fact that we've modified anything over time. It's all been the input of everyone here on this call. Beta heart stands for healing, empathy, accountability, resolution and trust. It is our holistic approach to respond to harm and healthcare. And what we've seen over time is it truly has transformed culture in our organizations. Of course, the cornerstone of this whole body of work is to reinstall trust in healthcare. And the goal and objective is to heal both patients, patients' families when we've harmed them and also our caregivers. So again, just kind of moving around that entity. It's all about really learning about the defects in our systems where we can eliminate that risk and protect patients all along the way. Next slide. So we introduce this in five domains. We actually split it out in five domains and work through it methodically. What we believe is that culture is kind of just that foundation that we need to lay and make certain that we understand the organizational culture before we actually move forward with programmatic design. We administer a validated and integrated culture survey called the SCORE instrument. And what that does is it helps us look at not only the aspects of safety in the organization, but the level of engagement and also burnout in the organization, which I think we'll speak to at a later point. We look and actually look at that data. And of course, in healthcare, we always assume that when we survey individuals, just providing them with the data might inform them of where the organization sits. But we'd like to go a step further and we actually promote that through these conversations at the front line where we debrief information with particular individuals in the front line in focus group sessions to further learn about the defects or the pebbles in their shoes. The goal and objective of learning about this particular information is that culture really sits at the unit level. So actually doing focus group sessions in the units where both scores are high and scores are low in culture, it enables us to really understand how we might promote best practices in those high scoring units and perhaps actually move those best practices to the low scoring units as well. So we debrief the data with the front line, we further learn about the defects. Of course, all of this sits on a foundation of just culture. So if we don't respond to error in a fair and just way, we ultimately need to hear that voice. And if individuals don't feel psychologically safe to speak up, we wanna make sure that we're actually responding to them in a fair and just way when errors occur. We do like to disseminate those lessons learned. So ultimately, all of these domains connect to one another. And Tim will talk a little bit about that interconnection. But of course, we have again, another domain of an analysis and which is actually looking at the timeliness and the ability for organizations to respond to error when they occur. We apply human factor science and cognitive interviewing techniques, which is a bit different a way to investigate and collect information from individuals. We call them witnesses. And ultimately take that information that we've collected one-on-one with these interviews, which are actually near to immediate after an event and which helps us understand those human factors and those defects that exist in the organization. We can't forget the importance of collecting the input from patients and patients' families. Because the goal and objective of this is really to understand what they saw and what they can actually offer in terms of perspective to healthcare. And oftentimes we ignore that fact, but that is a key aspect of what we teach throughout Beta Heart. The communication and transparency we'll talk a bit more about. So I won't go into that in detail, but ultimately we want to make certain that it's timely, it's open, and we actually move toward the patient and family when they've been harmed almost immediately after the event has occurred. So we open that lines of communication and ultimately establish that trust that can go back and forth over time. But again, as Tim talked about, the communication component of all of this is really an ongoing process. It's not an endpoint of disclosure. Care for the caregiver, we can't ignore that. We know that individuals feel emotionally traumatized when they've come in an error. And ultimately that can lead to burnouts. We'll talk a little bit more about burnout, but this association between emotional exhaustion and our ability to learn in an organization is really key. So we must heal our own as well. And then ultimately early resolution, we always kind of think about the financial aspects of all of this, but there are non-financial means to help heal these individuals we've harmed. And again, we need to actually meet them where they are at when we have harmed them. And so talking through and really understanding what's meaningful to them is very important in terms of early resolution. Great. Thanks Heather. And again, just it's surprising to me still and I think just kudos to your organization that you as a liability insurer, prioritize this as a program that you wanna offer your clients. We've spent a lot of time in the last session talking about the gap analysis process. And I know you've worked with Tim to design that for the heart program. Can you sort of give the listeners a sense of how you use that data from the gap analysis either quantitatively or qualitatively to help organizations implement? I mean, what's the next step? Actually, I'd like to hear from both you and Tim on this quickly. Tim, you wanna start? Well, sure. So I do believe Marty the gap analysis is the opportunity to gather the qualitative sense of what's happening in the organization like we talked about on the last webinar where we had Amy speak to what we discovered at Samaritan. But there's also a big quantitative part which is what I love about that first domain in heart. It's what really sets it apart from all the other CRPs. And it's kind of more of that quantitative part. So Heather, over to you. It's just been really fun to see the two of these kind of sources of data come together and the organizations really appreciate the feedback Marty that they get from doing this process. Right, we really can't underestimate the value of the gap analysis process because it's sort of that lens into the organization where we really understand, okay, well, here's where we really need to meet organizations in order to implement, right? Where are their weak points because we do hear from the front line that information is critical. But what's actually really connected to the gap analysis as well because the gap analysis, again, just a slice of information. And when you feed that back to executive leaders, there are sometimes a little doubt about what we heard in terms of voice. The quantitative piece where we use the score instrument and deliver that information actually is the proof. So that's actually showing a larger sample size. It really actually brings the story to life. And ultimately with the gap analysis in combination with a culture survey and that information, it really kind of shows the organization where they need to head and it serves as a catalyst for change. Okay, good. The other thing Marty, I know we're gonna talk about hybrid liability later. The key to this is if you're going to implement this and as our talk is about sustain it and measure it, getting this early upfront data, remember, you're gonna repeat this. You're gonna do follow-up score surveys. You're gonna do a follow-up gap analysis. Any program that looks at implementation has to have that component or it's not really looking at it in a high reliable way to do that. Okay, great. So what I mean here is that the gap analysis gives you really good information to help an organization know where to start but the importance of support throughout the implementation process is crucial. And BetaHeart is a program that offers that support including the inputs from patients and families along the way. So it's a fantastic model and it really does feel like a paradigm shift, especially coming from a liability insurance company. Okay, we're gonna move on to one of our next panelists. It's Alan. Franco, Alan, welcome. When you're with Safe and Reliable, when I think of Safe and Reliable, I think of just the phenomenal work you've done to support the development of culture of safety. Can you tell us a little bit about Safe and Reliable and that culture of safety focus that you've got? Marty, I appreciate being on the call and it really is, it's wonderful to listen to Tim, to Heather describing the work they're doing. In large part, we've been fully and highly integrated in that work. So much of what Heather was describing is to some extent the piece of what we do. The reference to score is actually the name of the survey that we use. We think of it as kind of the, well, it is just about the only validated, holistic survey of culture in the industry right now. We publish around five publications per year on it and my group has surveyed a little under 15% of the healthcare employees in the United States. We're heading into the 2.5 million respondents. So we have a very interesting picture of the attitudes and perceptions of healthcare workers and participate in the heart program to support CANDR through the beta efforts that Heather was describing. We're a company now of about 60 people. What we are interested in is indeed the high reliability transformation. We came to exist in the mid 90s because the two folks who started this, Michael Leonard and myself were involved with major catastrophic events, the death of a child, in Mike's case, in my case, the death of two women right after giving to moms, right after giving birth. And the question we asked is, how do we make sure those things never happen again? So in essence, if we were successful in what we are aiming for, we put ourselves out of business, but we put CANDR out of business too because we get rid of terrible events. The problem, of course, is that if you take human beings and put them into a complex environment, errors are inevitable because human beings are fallible. And then the question is, how do you create an environment where the events that occur become increasingly less frequent? And you begin to approach what you see in the middle of this slide, which is this concept of failure free operation over time, which is the engineering definition of reliability. The cultural definition of reliability, I'd say is mindfulness, which comes from Wike and Sutcliffe's book, Managing the Unexpected. And the combination of those two was beautifully described by Heather in the CANDR and hard effort. We intervene in organizations small and large, small and very large, some of the biggest systems in the US, but small, you know, turned to bed hospitals to create the internal leadership and management systems to support mindfulness and the engineering definition of reliability, failure free operation over time. So SCORE is the instrument we use. We have an academy where we train senior leadership, middle management from the front line, and we've created a visual management software system that we embed in organizations as essentially the foundation or the skeleton structure on which we then build the management systems that predispose to higher reliability. And we're doing that across the US in Canada and England and now heading into Europe also. So I'm delighted to be on this program. I'm the one trying to avoid these events from ever occurring as is Heather and but then also making reliable that when events do occur that the candidate type response is equally reliable that you act immediately are able to have the conversations in a psychologically safe environment. So while we want the events to never occur, we want the reliability of the process when they do to be highly robust also and we help to support that process too. Alan, thank you for those thoughts. I often hear people ask, what is a culture of safety? I mean, you spend a lot of time thinking about this working in the space. If you had to summarize sort of the indicators of a culture of safety, how do you know when you have it? What are, I mean, mindfulness you've mentioned, the different tools that you've mentioned but for those of us who just kind of wonder how far they are in creating that culture, what would you say are the key indicators that you're there or you're moving in the right direction? Yeah, let me reshape it slightly. I was a patient safety officer with a large health system for partners healthcare, the Harvard hospitals. If you asked me to title myself today if I went into that role, I'd wanna be the chief reliability officer. And then if you said to me, so safety and reliability are linked because of operational excellence is great and you're reliable. When you walk into an organization and you walk up to people one by one and you ask them, what's the experience like of working here? And they turn around and they say to you, it's in healthcare especially, because we have a, there's the mission to help patients. When those people turn around and they say to you, this place is really special. I feel better about myself because I work in this organization than I would feel if I worked down the street where they could actually pay me more money. And I work in a community where people care about me and the combined effort is in service of operational excellence to get things right for the patients when they come in. You're getting the firsthand description. Imagine if every single person said that across an organization from the CEO to every discipline, through all the clinicians, through environmental services, the dieticians and if they all said this place is special because of what I do here, it makes me feel special about me because I'm able to deliver the best of myself to this organization. And then you add to that the leadership and management structures that make things transparent and visible the package together is likely to get you a culture of safety and reliability. So I mean, I could go in a more detail about organizational design and management systems and psychological safety, but what I'm describing requires all of those things to happen and when you see them, the organization seriously hum. Yeah, yeah, that's interesting to me, Alan, because as you know, I do a lot of work in patient and family engagement and I would sort of say the same thing when you walk in and can talk to anybody that you see in the hospital or the organization about how they're engaging patients and families and get some kind of a response, you know that the culture is there. I know it takes a lot of practice and training to around communication, also to really implement this and sustain this. So, Tim, we're gonna take a look now at one of the training tools that you used or helped develop to really help people understand the importance of communication to a culture of safety and to implementation of candor. Do you wanna set that up for us? Sure, thanks so much, Marty. And we do refer to it as experiential learning. It's a lot of what we developed with Heather and the team at Beta, which is really connecting the heart with the head. So taking these real events like Alan described and demonstrating how do you respond empathically knowing for all too long, Marty, a wall of silence has gone up and everybody in this panel has helped us. Like we've heard from Carol, every hour that goes by without effective communication, following a serious harm event is another harm event and it feels intentional. So we use these cases to drive that home and also lessons learned when we don't quite do it well, which is kind of what happened in the real case. But if we go to the next slide, I'll go through these quickly. I just wanna give those attending kind of the background. It's a real case. It happened at the University of Illinois when I was there. This patient has abdominal surgery. She's very allergic to non-steroidal anti-inflammatories, but as it turns out, Alan, in a non-highly reliable way that allergy is typed as a free text in the dropdown menu, which our policy allowed at the time. And with the next slide, what happened was, since there was no, not a lot of the systems were in place to prevent this, even with the armband, the patient gets catorilac. They get extremely short of breath and they require urgent admission to the ICU. Fortunately, with very aggressive bronchodilator therapy, they get better. And with the next slide, you're gonna see we now have this opportunity to communicate to this patient and their spouse about this error, why they're in the ICU and be prepared to answer questions. So this is that, how do you prepare in a highly reliable way to address this? And with the next slide, we do this setup here. It's the patient's ICU room. You're gonna see we film this during COVID. So you're gonna see only one dot come in, have the conversation with the patient and their spouse. What I find really interesting, Marty, is when you pull this video up, people are surprised at the patient and the spouse. And I think in June, it's just particularly important to use this particular video. So if we go to the video, we can watch this conversation because we'll try to hit those elements. Great, thanks, Tim. Hi. Hello, Donna. Hi, my name is Chris. I'm the ICU doctor. It's been taking care of you over the last little while. Yeah, hi. How are you feeling? You've had a rough night. Yeah, thanks for asking. I feel better now. I feel much better now. I was pretty scared there. But yeah, man, I'm a little groggy still, but breathing is much better. Yeah, I don't know what happened. That was very scary. Yeah, I can imagine. And I'm glad to hear that you're feeling a little better this morning, and I hope that that continues. And the reason we wanted to talk with you this morning is because we wanted to explain why you didn't in fact end up in the ICU. And the reason is that we give you a medication that we should not have given you. As I'm sure you're very well aware, you're allergic to NSAIDs. Right. And we gave you a torolac, which is an NSAID, and that's what produced your allergic reaction, and that's what ended up putting you in the ICU. We are still looking into exactly how that could have happened, but it did happen, and we take full responsibility for that happen. How could something like that happen? I mean, Jamie was wearing a wristband that said that she had the salargy. I mean, I've been allergic to... He told people forever, it was in my chart. I made sure everybody knew that. But you guys gave it to me anyway? Yeah, I want to stress this so, so much. This should not have happened. This is a failure on our part. And you're right, there's so many ways in which you're identifying the fact that you're allergic to us. This is our failure. And as I said, we're still looking into what happened, and over the next hours and days, we're gonna get a clearer picture, and as soon as we find out anything else, we're gonna share it with you. And we do know that the computer safeguards that we have in place to prevent this kind of thing happen, they failed in this occasion. That is not an excuse by any stretch of the imagination. This is, there's a bigger picture here, and this was a system-wide failure. We fail you as an organization. And I want to stress that this was our fault, and we are so, so sorry that it happened. Oh my God. This is so good. I can't believe this. Now this is, this is something like that should never happen. Of course not, and we had to, I mean, she had to be in the ICU overnight. I mean, also, that kind of thing's expensive. You expect us to pay for something like that when it was your fault? You know, I'm an ICU doc. I'm not on the financial end of things, so I can't make any cast iron promises, but I can tell you that we are really committed as an organization to make sure that patients such as yourselves are not held responsible financially for care that was a result of mistakes that we make. We take that really seriously, and we want to make sure that you know we're committed to that. That's good to hear. And we're gonna, I'm gonna put you in touch with people in that department to make sure that they reach out to you as quick as possible so that they can explain the situation in as much detail as you'd like, and you're right, this shouldn't happen. It really, really shouldn't happen, and... It was really scary. I knew something was really wrong. I don't know, I don't know how I can feel comfortable staying here, you know? Like, it's such a simple mistake. How do we know that this is not gonna happen again? How can we trust you guys after this? Yes, a great question was we have already put in place additional measures that we'd like to share with you, and we have to rebuild your trust. We understand that, in us, and one of the ways we'd like to do that is during your stay here, we wanna have one of our nursing staff show you and explain to you the medication that we're gonna give you prior to giving it to you so that there's no question as to what medication you're getting. And in addition to showing you the medications, I'm also gonna have your surgeon come in here, pharmacist come in here, other nursing staff come in here to answer any questions that you might have, and also talk to you about your treatment going forward. That would be helpful, I mean, I'll tell you what, I'm not gonna have anyone administer anything to me without me knowing exactly what it is and double and triple checking, because that's, I mean, I didn't even think to double check any of that. I didn't think that I had to, you know? Oh, of course not. You shouldn't have to, that's the truth. This is your failure. This is nothing to do with you double checking, triple checking anything. You shouldn't have to worry about that. So what do we do going forward? I mean, am I gonna have to, you know, it ripped open the sutures. Am I gonna have to have another surgery now? I'm so sorry that that happened, and thank you so much for telling me. I'm gonna let the surgeon know that the surgeon was already gonna be coming in to see you, but I'll make sure that they chat with you about that and what that means. Good. Once again, I'm kind of apologizing enough. I'm so sorry that this happened, and we're gonna do everything we can to figure out exactly what happened and tell you everything. Who can we be in contact with about this going forward? Like, is there someone who we can call, or I don't know, it just seems important that we keep the lines of communication open so that we have questions. Absolutely, that's vitally important, and as I said, we're gonna have the surgeon, the pharmacist, and the nursing staff come in and talk to you, but of course we will provide you with a number and a contact that you can reach out to when you have any questions, but also we'd like to reach out to you and to make sure that you're doing okay and that you have the information that you need so that, you know, you don't feel like you have to keep phoning us to get information. We're gonna be proactive in reaching out to you if that's okay. Thank you, I appreciate that. Once again, I'm so, so sorry. Thank you. I think we're gonna have to talk about what we wanna do. I know, yeah. I want you to feel safe, that's absolutely the most important thing, so. We do too. Okay, Tim, we wanted to show that video to give people a sense of what implementation of candor involves. So Alan reminded us that it's a lot of structures Alan and Heather did, but it's also just a lot of training and a lot of focus on communication. Yeah, absolutely. And the one point I wanted to make, Marty, and then we can have them comment is, in the real case that happened at the U of I, we weren't highly reliable in our response, Marty, and we actually published it, what really happened. And with the next slide, you'll see what really happened because we hadn't fully hardwired it. And in fact, this is proof that apology programs don't work because CRPs, you know, beta heart, candor, it's not an apology program, it's that comprehensive response. Cause in this case, what happened is the ICU doc did explain the error and apologize, but never submitted an event report. So the patient was billed for their ICU care. And then they were sent to collections when they didn't pay their bill. So they filed a joint commission complaint and CMS grieve it and they sued us and they sought care for the follow-up because of the sutures got, you know, torn up and they had to go to another hospital to get the care. And of course it cost us a lot of money and we didn't learn very much related to it. So I like using this case as a point for why you need that comprehensive approach like heart to really take advantage when you put these things into place, how to prevent heart, but then respond when it happens. Yeah. And Tim, the, correct me if I'm wrong here, but my sense is that you, part of the implementation process is you challenge your organization or find in the organization who the really good communicators are, recruit them as coaches and then train everyone and that, you know, everyone can learn to communicate better. Am I saying that? Okay, good. Thanks. No, absolutely. Okay. We're running behind on time now. So I'm gonna quickly turn, Carol, we haven't even heard from you yet and I apologize for that. So I'd like to bring you in. Eileen Karina in the chat box in the chat room has wondered, questioned when we bring patients and families into this process. So you've had a lot of experience working with Tim and others on the Kander program. What do you, what would you say to that? What role do patients and families bring to implementation of Kander? So I think the first thing is Marty is when Heather was setting up her program, I was brought in other patients and family members were brought in to help the ones create it. So first, if you're gonna create a program and you think it's gonna be successful and not have patients and families, you're wrong. We look at it different. We ask different questions. We think different. So I think the first thing is bring in patients and families. If you have a PFAC, bring your PFAC in to be part of the work. You can't create something that impacts the end user without having the end user be part of the process along the way. So I think that's the main part, Marty. Okay. And Tim, you do, Tim, Heather, you do really bring in patient and family voices as part of the GAP analysis, correct? When you do that, you find some way to do focus groups or bring that in and we bring them along. Actually, we actually help them understand Kander and the paradigm shift that we're trying to create. It's absolutely correct, yeah. And involving them in event analysis is actually key, right? Their perspective is amazing. It's not something as healthcare people, I'm a nurse. It's not something we can think about really because we're watching it or they're viewing it from a different lens. And so the learning that comes from that is incredible. And of course, it's super important, right? It's critical that we hear that. Yeah. Heather, you know, Jonathan Stewart, you know, who's part of the beta heart team brought in, Marty, some of the best in the world in engaging patients and families in event review. And it was part of the webinar that they put on recently, you know, where they have the different domains, Marty. It's a lot of the people you know, because I know you've done a ton of work and I know Alan has done a ton of work, you know, in the NHS as well. It was so cool to be part of that webinar that Jonathan helped coordinate and put on. Fantastic. The other thing I want to kind of hit onto and the importance of Carol's voice and so many others, unfortunately, but just kind of setting the stage with the purpose of doing this work is super important. So connecting the heart with the head and really getting to pull on the heartstrings of individuals who went into medicine, who don't intend to harm people, but yet found themselves in the situation and or, you know, unfortunately just connected to a situation such as that, that's where we really can move the dot because that is what we start with at every conference, at every learning. And that's really key to actually get the word out around that and hear that patient's voice. Okay, we're a little out of order here, but since we brought it up, I want to address this now. Engaging patients and families in event analysis, Heather, you brought that up. There are very few organizations, I think, in the country that still do that yet. Could you and Carol and Tim, any of you speak to the importance of that and the value that you get from that to the RCA process or to the event analysis process? So I'll go up in real quick first, Marty, is you'll never have a complete event review process if you don't capture the narrative of the patient and family. We're the ones there 24-7. It's a revolving door of the providers that come in and out of the room and they only see a snippet of the whole movie and we are the whole movie. And unless you capture what we have to say, you're always gonna be missing something. It may not be big, but we do see things. We see the breakdown in communication. We see the lack of double checks. We may not have the vernacular that you use, those terms, but when we describe it to you, it's huge learnings. So the biggest gift we can give is we're giving you opportunities to learn frontline from the patient and family perspective. So, Carol, you're talking about really, if you're the patient or the family member involved in that event, bringing you into that process. You've also mentioned the PFAC as a structure. I mean, Tim, let me ask you this question. What structures do you try to implement in organizations or help organizations implement to really bring that patient voice, patient family voice into the process? Well, so a couple of things, Marty. One is you can build it into your software. Your event review software, you should be very intentional to include having brought the patient and family perspective into that. And I know Heather is, and Carol will talk about this later, the metric side, you can actually measure that. But you can get this from patient and family advisory councils like we did at the U of I. You can put patient advocates on your serious event review teams. So, again, they're reality checking, Marty, what's out there? And as you know, you were at some of these at U of I. When they're there, they ask some of the best questions, even though, as Carol said, they don't have the vernacular. It's just so powerful to have them in the room while you're talking about these cases. Yeah, that hit her connection, Tim. I was amazed when I walked into UIC and saw the people that came to those events and the way in which the Molizo family, who you brought in really helped. I mean, I think you referred to them as the conscience of your community. That's right. It was very special to see. Okay, we are gonna get to metrics in a second, but I wanna back up a little bit, Alan. We've talked a little bit about high reliability, and I'd like to kind of bring that concept back with a question to you. I mean, this is what you focus on. You've spoken a little bit about how candor can help or candor type approach can help, you know, foster that. But will you speak to the issue of burnout? I mean, we're hearing so much about it, especially after the COVID crisis. And that's gotta be, you know, a challenge in creating a safe culture, psychologically and physically. No, sure. Monty, I'm happy to talk about it in terms of what we factually know and then to theorize a little bit about, you know, what the relationship is. If we look at our burnout data, and as I mentioned, you know, we have, at this point, you know, two and a half million respondents to our survey at any point in time, we've got about 400,000 in our benchmark. We've actually, I think at this point, got the largest benchmark database about physicians and nurses worldwide. So I can tell you that when you ask nurses and docs, but also respiratory therapists, pharmacists, et cetera, what the levels of burnout are in healthcare in general, they are staggeringly high. And there are units where eight or nine people out of 10 would say, you know, 80%, 90% say, yes, I feel burned out. There are other departments and hospitals where you're sitting at, you know, 30, 40, 20%. But in every organization we look at across the country, burnout is high. So it's worth defining the term burnout to then think about its implications. The Maslack inventory or the spectrum of burnout starts off with, do you feel frustrated? Then the next level is, are you getting emotionally exhausted? So the implications there are, I'm frustrated around the experience. Now I'm so frustrated, I'm getting exhausted by it. Then the next level is cynicism. I'm frustrated, I'm exhausted, but nothing's changing, so I'm cynical. Then after that, I begin to feel ineffective. And then finally, I begin to depersonalize. So when we look at healthcare, the levels of burnout, people will say, yes, I'm frustrated, exhausted. I feel ineffective. I am burnt out, depersonalizing is massively high. What are the implications in terms of the ability to achieve high reliability? And the answer is pretty straightforward. Burnout leeches from, the analogy is, I plant a seed called high reliability in the soil. Can I get it to grow? It depends on the fertilizer on the ground. Burnout is leaching your fertilizer out of the ground. The willingness of the workers to participate in making efforts safer diminishes as the levels of burnout go up. So you're just gonna be more error-prone. And ultimately, if you get the levels of depersonalization, you're not looking at patients as people. So it becomes even more of an issue in terms of how people apply there and do their work. So burnout is a massive factor in healthcare worldwide. We see it in New Zealand, Australia, Germany, France, England, Denmark, Canada, the US in varying degrees, but all intensely. It's the job of leadership to look at the underlying factors that lead to burnout and to ameliorate them. And it's the ability to avoid adverse events and then for Canada to act effectively on adverse events is linked to the levels of burnout in your organization. Hone, can you quickly just comment on this? Because this I think is the nugget. Does candor implementation help address the burnout issue? I mean, that focus on communication, on head-heart connection, on engaging patients and families in the process. How does that improve our impact? It's huge. Let's put it another way. What are the things that decrease burnout? And two of the biggest factors that decrease burnout, and one is, and I mentioned this before, when people walk into an organization and they look around the people they work with and they say, this group of people care about me, it's called community, burnout goes down. When people have a sense of voice, that they speak up and they have a sense that actions are taken to improve things, burnout goes down. And lastly, when they say my values and the values of the leadership in the organization are aligned. We see things similarly, burnout goes down. Candor and the way Heather described the heart program is aimed at improving that environment of delivering care that increases community, increases voice and increases value alignment. And then on that, you then build your candor program. So when you add those all together, you're absolutely working towards decreasing levels of burnout in frontline employees. Tim, Heather, I know that part of the motivation for advancing candor has been care for the caregiver. I think that was almost a surprise to many of you at how important a factor that was, how much care was needed for the caregiver. I do wanna, and so I just wanna acknowledge that, but I also wanna turn to Carol, because Carol, you've been doing some really interesting work about the emotional harm done to patients and families long-term. Do you wanna comment on just the importance of this kind of caring attitude to the healing of patients and families? Yeah, it's really important and I'm glad that there's care for the caregiver programs, but we don't have the same thing for patients and families. And we suffer greatly and now we're seeing intergenerational harm. So those of us who have either been harmed, lost loved ones or children, we are now starting to see that impact on our children specifically when there have not been candor-like programs, that we had to fight for all the answers that it took us years and sometimes we still don't know. That was lost time that we couldn't heal. And when you look at Maslow's hierarchy, if the parents or the loved ones can't heal, the children can't heal, they don't feel safe. And we now are seeing that. And so I encourage organizations to now start to what is the program you're gonna create to take care of harm families, just like your harm providers. Great. Marty, if I could follow what Carol said and what we learned from her was, the communication part in candor or heart, it's not over until the family says it's over and sometimes Marty, that's years and we need to be committed to that. And my sense is, and I'm gonna turn to you for comment on this, Heather, is that the implementation is probably never really over, that implementation must require some sort of continued support for the process. That's exactly right. It's like I said, disclosure is kind of that term itself is sort of this endpoint, but this requires ongoing commitment to walk beside those we've injured. And ensure that we don't really harm them more through failure to communicate or kind of disconnection or whatever that is. And of course, it's they who say when it's, when they're healed or when they're at least okay to walk away. Yeah, Marty, let me add, because Carol's comments are just so powerful because Carol, I totally agree with you. My world is predominantly how to stop the events from occurring. You're describing out to the event occurs, how do we take care of people? You know, there are interesting, there's a relationship in this long-term care of patients and the ability to galvanize an organization to further efforts towards reliability. So for example, in the VA system here in the US, you know, the biggest healthcare system we've got, the four major efforts they have underway, one of them is safety forums. So what's the logic behind a safety forum? In a safety forum, you are looking at events and analyzing them and understanding how they happened in order to keep all of your frontline providers thinking about the risks and trying to ensure that they won't occur again in the future. And the ongoing relationship with patients and people are bringing folks like you, Carol, in to talk to people and remind them that the preoccupation of failure, that the concept of mindfulness is so key is an intrinsic part of achieving high reliability. So it's both designing the system to be reliable and on the mindfulness part, bringing people back to the core work and why it's important. We've done some fantastic webinars on the importance of building that patient and family engagement structure for that continued input. And Candor is just one of the things that, you know, continued voice and experience of patients and families can really latch on to and grow and become, you know, part of a trustworthy culture. We are close to time and there's one more issue I wanna get to. So I'd love to talk to you all more about what we've already teed up. But there's gonna be questions about how we're measuring effectiveness of an implementation of a candlelight process or a CRP process. And I know there's important work going on. Carol, if you could break up the slide about the accountability collaborative. Carol, you're part of this collaborative and would you talk to the work about the work you're doing on metrics? Sure, so about two years ago, a group of people, Marty being one of them and four at the Collaborative for Accountability Improvement said, you know, we need to measure, we need to see are we being successful with communication resolution programs? So along with Tom Gallagher and others, metrics were created and there was patient families involved in these as well. And so the first iteration that came out, you know, there were some good metrics, good feedback. However, they were very organization-centric. So it was easy to capture the organizational side of it. There was some more qualitative that were patient-centered and organizations had a more difficult time. But then what we really realized is we now have a group of patients that have worked together to really create metrics of what we feel are important from the CRP. And it's really, again, it's that soft side. It's that qualitative side because even though you can get your metrics from an organization that says you're great, it's really how we feel it went in the end that really says was this program successful or not. So that's what we're working with now with Tom and look to, you know, test these. That's always the hard part is getting the feedback from the patients and families. But when you do, it's probably the best data that you get to the success of your program. Okay, so this is a project that Tom, when you mentioned is Tom Gallagher out of the University of Washington, one of the preeminent researchers in this area of communication and CRP. And just for those of who are tuning in today who are thinking about implementing Canada or already implementing, when will these metrics be available for them to use? What's your best estimate of when the project will be? I know it's being piloted now, but when will it be available? So I believe the first set of metrics are actually out there. I believe they're part of the whole pack program that's going on. The new set with patients and families and how we're gonna take those and put them in, I'm thinking still Marty probably a year until we get that and test it. Okay, great. That's a year is they go by faster and faster. So that's almost here. So Marty, I will say, and Heather, you probably could speak to this. They're already using a lot of their metrics that also include the patient and family engagement part already. I mean, they already have their organizations creating dashboards and other stuff. So kudos to you Heather for building that out and helping your organizations do that. Again, informed by the National Metrics Task Force and which I was a part as well. And I know that we still have some work to do. So as per Carol, we really don't have metrics to measure the patient's experience from all of this. We do collect information, as we roll out each domain, there are culture survey items and domains that actually tie to each one of our domains. One of them is burnout for care for the caregiver, for example. But we look at staff turnover and other process and structure metrics pertaining to the program. We certainly look at timeliness because timeliness is key. When we open up that line of communication, it has to be near to immediate. And so ultimately, we do look at that. And then we also look at outcome metrics as well, being a liability carrier. We of course look at claims and costs and things, but it really pales in comparison to what we really need to be looking at. And that is truly just, what are we doing to transform culture in an organization and get it to that next level? We're wrapping up here and it just feels like we're getting started. So, Donna and PSMF team, I think we may need to do more on Candor because we've given people a lot to think about and a lot to talk about today. I do wanna just thank my panel. I hope you saw the connection that we were drawing between, if you're on a higher liability organization journey, how, what a great fit Candor is. There was a little bit of a polling question that popped up there about, if you're on that journey, please consider building Candor or a CRP program like Candor into it, like BetaHeart. And I can't thank the panelists enough for sharing, where you are on the journey and all the great work that you're doing. It feels transformative. It feels like a paradigm shift. And with that, Donna, back to you to kind of wrap us up today. Well, thank you, Marty. And thank you to all of our panelists. This has been such a great discussion and we really appreciate it. You're right, Marty. I think we could spend an entire year talking about this topic. So, thank you very much again. I suggest to, again, a little bit of housekeeping. If you are a nurse, a physician, or a pharmacist, or a respiratory therapist looking for a CME credit, you'll receive an email from MedStar within the next five to seven days with an evaluation that you'll need to complete to be able to obtain that CE. This is what the email will look like. So, you know that it's coming from MedStar. If you are looking for ACHE credit or CPHQ credit, then we will be submitting your information to those organizations and you can log your activity in the appropriate portal for that professional organization. And for CPPS and BCPA, we'll be providing you with a certificate for attendance today. We do provide all of our webinars for free and we're very proud to be able to do that. And in order to continue to do that, we would appreciate your support. If you are interested in helping us keep our education free, then please visit our website at patientsafetymovement.org slash donate. And we will be sharing these slides along with the video of this webinar on our YouTube page. So, we'll be sure that you have access to all of this very soon. So, thank you all so very much for joining. We are right at 9.30. And thank you again, Marty, and to all of our panelists. Thank you. Thank you, Carol. Thank you, Heather. Thank you, Alan. Thank you, Tim. It's been wonderful to the audience. If you've got questions or want more information about Canada, let us know. Let us know what your questions were and we'll respond. Thanks so much. Thank you. Thank you, everybody. Have a wonderful day, everybody.