 Hey, depending on where you are in the world, good morning or good afternoon, this is Ariana Longley from the Patient Safety Movement Foundation. And I'm pleased to kick off the Culture of Safety and CANDOR webinar today. We have our expert presenters, Dr. Dave Mayer and Dr. Tim McDonald. It is the top of the hour, nine o'clock, so we're gonna get started so that we can get through and make sure to have enough time for questions. Just a few housekeeping items. I have muted all of you just to ensure that there isn't any background noise. If at any point you have any comments or questions, there is a chat box that we'll be taking a look at. And we'll also pull from that chat box with questions at the end. So thank you again for joining. I'm gonna go quickly through the agenda for today. It is one hour, the first 10 minutes I'm gonna be spending introducing you all to the Patient Safety Movement Foundation and the actionable patient safety solutions or apps that we develop. I'll then turn it over to our expert presenters, Dr. David Mayer and Dr. Tim McDonald. And then we'll have 15 minutes left over for questions and answers. So to roll in and talk about the Patient Safety Movement Foundation, as many of you are aware, our goal is zero preventable patient deaths in hospitals by the year 2020. We know that's a very audacious mission and something impossible, but at the same time we believe it's the only acceptable goal to have to really be focused on zero because one preventable patient death in the hospital is one too many. So the Patient Safety Movement Foundation really strives to foster new efforts and build on existing programs through commitments. And so what we really wanna do is take a fresh approach without reinventing the wheel. So who can take action? We work with many groups. The first group that we encourage action from are hospitals and healthcare organizations. What they can do is they can make public commitments, sharing what they're doing to improve patient safety and to reduce preventable deaths in their facilities. To date, we have over 3,500 hospitals across 43 countries who have made these commitments. And last year, earlier this year in February, we announced that those 3,500 or so hospitals had saved over 69,519 lives. So through those actions of the hospitals and healthcare organizations, we can get closer to our goal, which is zero. Committed partners can also participate in the Patient Safety Movement Foundation. These are organizations that are other non-profits, societies, associations that are also focused in healthcare and have an impact on patient safety. What we do with these partners is we find ways between the two organizations, between Patient Safety Movement and them, that we can work together. They can help us spread our mission of zero preventable deaths by 2020 and we can help support their cause as well. We have about 26 committed partners to date that ranges from the American Society of Anesthesiologists to the Global Substance Alliance down to the Society of Airway Management. So lots of different groups that are involved with us to help us get to zero more quickly. The third group that we work with are healthcare technology companies. As many of you may know, our founder and chairman is Joe Chiani. He's also a well-known entrepreneur and engineer. He started the medical device company called Mathimo and we encourage healthcare technology companies, whether it's a bedside monitor, an electronic health record company, or analytics companies that can help give clinicians tools to better take care of their patients and understand how to deliver care to make sure that it's safe. So to date, we have over 70 companies who've signed that open data pledge, which says that they will share data openly without interfering or charging. Companies that have joined our GE, CERNR, Philips, even IBM Watson and Oracle, just to name a few. The fourth group that we work with, which is really important, is patients and family advocates. Not only do we share some of the stories of people who have lived to tell their story of harm and maybe survived a hospital stay that could have been deadly, but also we share stories of people who lost their loved ones and they want to share their story to make sure that no other family is affected like they were. We have both written stories and video recordings that we do every single year. We also have some resources on our website that can be helpful for someone going into the hospital for the fight the first time and we've also just recently released our first mobile application called Patientator, which you can download on the Apple Store or Google Android Store. And then last but not least, we also operate, in addition to our 501C3, a 501C4 so that we can engage policy makers and let them know what we're doing in patient safety and how we can impart our knowledge on policy makers as they go forward in their roles to create new bills and laws. So the actionable patient safety solutions are a core product, if you want to call it a product. They're free on our website and they're tools for hospitals to implement in order to reduce preventable deaths. We think that these 13 topics are some of the low-hanging fruit, which have actionable solutions that can really make a big difference and reduce harm and deaths. Today, the kind of topic relates to a culture of safety. CANDOR is really a fundamental and foundational toolkit that not only impacts culture, as Dave and Tim will talk about, but also if that foundation is set, a lot of these other initiatives and processes will be much more successful. All of these actionable patient safety solutions are available for download on our website. So I would encourage you if you are in a hospital and you haven't taken a look at these, check them out and see if there are any of these topics that your hospital is not focused on or could improve on. And in order to reach our goal of zero by 2020, in 2017, what our goal is, is to reach 150,000 total lives saved, that's U.S. and internationally. We're splitting up our goal to half of that coming from organizations that are making commitments in the United States and half of those that are making commitments internationally. As you can see on this graph, it shows the impacts that we've been able to show since our inception in 2013. In 2014, we had, or in 2013, we had about 60 lives saved. In 2014, it was about 600. In 2015, we announced 6,500. 2016, we quadrupled and we're around 24,643. And then earlier this year, we announced 69,519 lives saved. Every year, we announce our new lives saved at our annual World Patient Safety, Science and Technology Summit. So the goal of this slide is to be encouraging. We need everyone to join this movement in order to be successful. So if your organization has not made a commitment yet, we encourage you to reach out to us and talk through what kind of initiatives your hospital can put in place if you are in the hospital. So now I want to introduce our expert speakers. So we have Dr. David Mayer. He is Vice President of Quality and Safety at MedStar Health. He's responsible for overseeing clinical quality and its operational efficiency for MedStar and each of its entities. He designs and direct system-wide activities for patient safety and risk reduction programs. He's also the Vice Chair for Quality and Safety for the Department of Anesthesiology, where he is an Associate Professor of Anesthesiology and Director of Cardiac Anesthesiology. He founded and led the annual Telluride International Patient Safety Roundtable and Patient Safety Educational Summer Camps for Health Science students and residents over the last 13 years. He's also the Director of Medical Affairs of the Hospital Products Division of Abbott Laboratories and was President and Founder of E-SERGE Corporation. And Dr. Mayer was also presented with the 2017 Humanitarian Award of the Patient Safety Movement Foundation and the 2013 Founder's Award of the American College of Medical Quality, the University of Illinois American Association of Medical Colleges, Humanism in Medicine Award and the Sprague Patient Safety Award from the Institute of Medicine in Chicago in 2010. Dr. Mayer was named by Becker's Hospital Review as one of the 50 experts leading the patient safety field. Dr. Tim McDonald is the Director of Center for Open and Honest Communication also at MedStar Institute for Quality and Safety. He's an internationally recognized patient safety expert and was the inaugural Chair of Anesthesiology and Medical Director of Quality and Safety at the Sidra Medical and Research Center in Doha, Qatar and Ultra Modern Maternity and Children's Hospital and an affiliate of Wheel Cornell Medical College. He's a physician attorney who's involved in patient care activities for 30 years and quality and patient safety efforts for the past 20. He's published numerous articles on improving the quality of care while mitigating medical liability and other legal related issues. And he's received several national and international awards such as the American College of Medical Quality's Founder's Award, the Institute of Medicine's Chicago's Patient Safety Award and the Hope Award from the Medically Induced Trauma Support Services or MIPS in Boston. So with that, I am very, very pleased to pass over the presentation to wonderful physicians who care greatly for patient safety. Well, thanks, Ariana. And thanks to the Patient Safety Movement Foundation for inviting Dave and me to join with you on this webinar today. And thanks also to all of those who have joined us and logged in from all around. And we're excited to get started here. So if we can go to the next slide, Ariana, the title of that is, you know, when words and actions matter most, the case for candor, where candor stands for communication and optimal resolution. And what this really is, is how we will discuss how we develop the comprehensive response to patient harm that you're gonna see in the next several slides. As you know, we like to begin with a safety moment. And today's safety moment comes from Mother Teresa, where I think her words here really resonate with the Patient Safety Movement Foundation and with candor, wherein a lack of transparency results in distrust and a deep sense of insecurity, honesty and transparency makes you vulnerable. Be honest and transparent anyway. Trust, honesty, humility, transparency and accountability are the building blocks of a positive reputation. And we also believe building blocks for a patient safety movement. So beginning here with one of the critical issues that we all know, what started in many ways, I think the Patient Safety Movement. And the next slide is the book we're all familiar with, which is to Errors Human, where it discussed all of the preventable harm that exists out there. And again, this is in 1999. And since that time, we realized there's been many more, we understand many more preventable deaths happening every year. But tragically, as we go to the next slide, we will see that for all too long, we have made matters worse by building the wall of silence. And that wall of silence is not just with patients and families, but also with caregivers. When harm occurs all too often, we lean away instead of leaning in and trying to learn and understand what's happened from these events with an eye towards making certain that we absolutely present them in the future. So the next slide shows, again, one of my favorite slides, where culture eats strategy for breakfast. You can see the arrows going in the two different directions. And we understand that with any of these apps, the really fundamental issue is making sure we address the issue of culture. And particularly that culture that all too often is the wall of silence which prevents learning and improvement for what we're doing. So if you go to the next slide, as Dave talked about at one of the recent mid-year meetings, and as we've talked with others in the past, we were very fortunate to work together at the University of Illinois where we had a massive, difficult wall of silence in the early 2000s, but over the course of several years, we were able to shatter that wall of silence. And this is a bit of our story about how we went ahead and did that. And so in the next slide, you can see that in 2005, we got the leaders of the university to approve a very comprehensive resolution program, communication resolution program to prevent and respond to harm. And we followed many of Cotter's principles around this, the first of which is with the patient harm we had, as well as the wall of silence, we created this sense of urgency, particularly after a loved one who was the COO of one of our sister hospitals died at the University of Illinois and we did not communicate in the way that we should have. So we were able to get leadership and stakeholder buy-in and integrated the departments of safety, risk management, quality, credentialing, ethics, claims in the office of business and finance to really work together to improve transparency and to create a learning program. And that's where Dave created a lot of the learning materials he did for the medical students, the nursing students in resident positions that continue until this day. And it really did involve a complete paradigm shift from our previous response to harm. We started small and then we built over the years this particular process. So if you go to the next slide, you'll see that the way we originally designed this, we did not get it right. This is sort of a traditional sorry works algorithm where you can see on the upper right the event happens. If there's harm, we would then investigate these events and make a determination of whether care was appropriate or not. And if it turned out our care was bad, we would apologize and remediate and all that would go into a database. And when we presented this to patient advocates from the patient centered standpoint, we did ask the question, sort of what's wrong with this picture? Because we quickly were sort of understanding that and you can see that question in the next page. And so we presented this to patient advocates. And if you go to the next slide, they gave us a lot of very important feedback to that basic sorry works approach. And what they told us was, which is demonstrated in the next slide, and again this is in 2005, is that we needed a rapid and ongoing response to harm. Not one where we waited until we did the event review before reaching out to patients and families. They wanna know within an hour. Of what's happened to their loved one from the standpoint of what we know. They may not and we need to tell them what we know and often it isn't everything. And it's not perhaps maybe the reason why their loved one has died or suffered serious harm, but the goal is to reach out to connect with them and maintain trust with them. So the first big thing we did was to create teams who could rapidly respond to harm within an hour. In addition to that, we weren't getting much input from patients and families in the event analysis. And that's another big part that what we did. And finally, at the end of the day, this really is a focus on a learning and improvement program that needs to be hardwired, not just a risk mitigation or liability approach. And we need to listen and not just communicate to patients and families. And we also understood at that time that billing patients when we know care was inappropriate added salt to the wounds. So we needed to hardwire a process where we hold the hospital as well as the professional fees until we really know whether or not our care was appropriate. The other part in here that we recognized is the need also to support, and Dave will talk more to this, of the caregivers who are involved in these unexpected events that happen in hospitals because they are harmed often as devastatingly as patients and families. So when we considered all this and you turn to the next slide, you'll see we created this diagram that became known as the seven pillars approach. This is what we published in the Journal of Quality and Safety and Healthcare. And you can see this is a much more integrated and comprehensive way of doing this where after the event is reported, even when there is not patient harm, it kicks over through the database into our process improvement efforts so that we can improve even from the near misses. And then immediately if there is harm, we consider the second patient or the second victim. We begin the event analysis and we hold the bills. And then off to the left you can see we immediately launch a patient communication consult service available 24-7 that can begin that process and continue that process of communicating to patients and families. And if it turns out that our care was bad, we will do a full communication of this with an apology and a reading mediation. And of course, all of this you can see is linked over to the process improvement piece because at the end of the day, creating this kind of learning environment, it is hoped that we change the culture and we create the opportunity to prevent so many of the harm events that is the mission of the patient safety movement foundation from that standpoint. You can also see we activate a crisis management team in these more serious events. And that includes letting the key leaders of the organization, sometimes it's letting media know, you know what it is we've done, but it's really that focus of all hands on deck within the organization to embrace the caregivers as well as the patients and families. If you go to the next slide, you'll see that this does represent a complete paradigm shift of where we were from incident reporting all the way down to patient and family involvement. The communication when patients and families clearly moving from that denying defend to being transported on going. The exciting thing about this whole paradigm shift is in every single one of these domains, there are tools within the candor toolkit that we're planning to certainly share with and work with the patient safety movement foundation to make sure they're easily readable and easy to use by any organization that is interested in moving in this particular direction. I'm gonna let Dave move on from now because he's gonna discuss how we respond to these events from an event reviewing care for the caregiver standpoint. Yeah, thanks, Tim. And thanks for the history on candor greetings to everyone who has joined us today. We appreciate you taking the time and hopefully we'll make this insightful and valuable as you consider the candor type approach to how you do things within your hospitals and institutions. And then one of the first things I'll say right away is for those that think that candor is predominantly a medical liability strategy, they're missing the real big picture here. It does have some benefits as Tim will talk about when we get into the results. But the main reason for candor and implementing candor is that it really is a comprehensive program around patient safety and helping reduce risk to not only our current but future patients through an learning organization mindset and one of the top priorities of that mindset is the slide that you're seeing currently about how we respond to these serious safety events, these preventable patient harm events, these serious unanticipated outcomes, different terms that we use a lot to describe these events. But really it's how we respond at this time defines who we are, I think as a profession as well as health givers individually. And this is a picture of how aviation and the NTSB responds when a catastrophe or harm has occurred. You go to the next slide, Ariana. The process that candor trains you and imparts within the program is the concept of a GO team. And that was taken from the National Transportation Safety Board and that immediate response to harm and that you need to, you're truly gonna learn and you're truly going to make change. You're truly gonna respond to your patients and families and you're truly gonna respond to your care teams who can be very devastated when these events occur. You've gotta take an immediate approach. And I'm old enough to remember the days that if we'd have a serious safety event, we would wait for three, four, five weeks before we could fit it into our schedule to discuss or just assign it to the next Orbitity Mortality Conference. And it's just not a good learning environment nor does it send the right message to the patients and families and the care teams that have been involved in these events. Next slide, Ariana. Thanks. So candor consists of three components or three separate GO teams. One is the discovery and learning team. How do we truly learn whether it's using root cause analysis models, RCA2 or whether you use the event review process that is on the candor AHRQ website that we've adopted throughout MedStar. It's also immediately responding to the care for the caregiver and our associates at the front line. And then finally, how are we communicating immediately as Tim pointed out with our patients and families? Next slide. So as you go through here, the first thing I talked about is discovery and learning. And this is, I think, probably the best root cause analysis tool or event review tool out in the market today. And I encourage you to go to the AHRQ site and put candor in the search. And this is clearly downloadable and free. It's a comprehensive event review process that was put together by patient safety experts, human factors experts, and members of the National Transportation Safety Board. They spent four and a half months reviewing literature from all industries and really designed a process that I have seen work and work extremely well. Next slide. The process in regards to the event review is again that immediate response in the box on the left, as Tim said, we make a goal to respond within 30 to 60 minutes and activate these three teams on the event review side. The discovery and learning then consist of about one to two days of interviewing those that have been involved. And we also try to interview the patient or family members if they're available and willing to talk to us at that time about sharing what they had seen and they had learned. We try to understand the context and the causal factors. And then within literally by day three, we have with that group a confirmation and consensus meeting which allows us to truly all walk away those that were at the site of the event and involved in the event. We've all agreed on exactly what happened, the timelines, the specifics. And then over the period of day three to seven to 10 we activate a different team which is a solutions team and they could be comprised of different people who have expertise in those areas that we've determined need to be corrected. Solutions or systems, processes need to be addressed whether it was EMR issue, a medication safety issue. You gotta bring the right people to the table to define those solutions. And then we have it set up that within the next, by day 21 we have come up with and identified those solutions and by day 30 we have started the process if not sooner to implement the changes that the solutions team came up with not only across the hospital but sharing it across our system and at MedStar we have set and our board has set the expectation that this is all done within 30 days and the process improvements have started if not completed if it's simple if it's something more long term like an investment in a new product that will help close that gap then it may take a little bit longer. Next slide. And then the other aspect that Tim touched on and I think it is really important and many of you have already or may have already started moving forth or have cared for the caregiver programs within your institution. The candor program really highlights that and many of you have seen this case about Kimberly Hyatt. Again, when we make a medical error, a medical mistake at the front lines whether it was a process solution, whatever technology related we feel terrible and when we don't support our people in chance of depression, the chance of making another mistake goes up exponentially and sometimes unfortunately it even involves our colleagues taking their own lives. Next slide. And when you look at the patient safety movement and just what we've tried to accomplish through the years I think Lucian said it perfectly when he said the single greatest impediment to air prevention and really learning in our industry is that we punish people for making mistakes. That's the easy way out, it makes it much easier and whoops, we just lost something, Adrienne. I'm trying to take over that. There we go, yeah, so you could go to the next slide but I did love Polynesia there. Okay, so that's really the extent. So we went through the three different areas, discovery and learning, we went through care for the caregiver and then we talked about how we respond to patients and families and Tim's gonna finish us off in the last 15 minutes before we open it up to questions and answers and talk about that aspect of the communication and resolution component and the results that have been seen from this work. Okay, before jumping into that, can you share one or two of the amazing care for the caregiver stories that you've had, particularly at Georgetown, which I think had been the lead for you at MedStar of really taking the care for the caregiver program to a different level? Sure, yeah, good idea Tim. So as many of you who've had care for the caregiver programs, you've realized that once you've implemented them, they become more than just responding to the associates who've been involved in a preventable harm event or a serious unanticipated outcome event. The culture of the organization finds other examples where that team can help support and one of the, we've got numerous examples of that in fact about 80% of the time the team now responds to non-preventable harm events. One that happened on Father's Day that still hits me and affects me is that we had a 18 month old child who had a sudden infant death syndrome event in their home. The family called the paramedics, they tried resuscitating the child in the ambulance ride on the way to the hospital and emergency department. That emergency department team then took over and they tried continuing the resuscitation but were unsuccessful. That was devastating to that team that on Father's Day and many of the parents themselves were deeply impacted by that. Even though they did everything they could possibly have done to try to save this child, they activated their care for the caregiver team and three of their fellow associates came in on that day from home to support them and be with them and talk with them so they could work through those issues. And I know Tim as well as I like to use a slide about Sully Sullenberger talking about how healthcare doesn't do that well, doesn't support their people, they just expect them to go right back into the frontline work after an event like that. So that was just one of many stories we've seen that really show you could change your organization of culture and really bring that associate caring back into a field that's desperate for it when we consider all the burnout and other issues that healthcare frontliners are dealing with today. Yeah, Dave, and that program has evolved even to include non-clinical people. I think I remember a story about, it might have been an environmental services person or one of the non-clinical people who developed very rapidly signs and symptoms of a stroke I think in a kind of a distant part of a hospital organization. Yeah, we had a security officer who while during a morning huddle, all our departments do huddles in the morning and talk about the day from a safety issue standpoint. And the security force was doing a huddle in the basement where their main office was located and one of them would start having a stroke and collapsed. And it was very difficult for that team to try to get support. So they literally created a human cart where they carried this gentleman up on his back, six of them, into the ED. They rushed him up there real quick. And fortunately, with their quick actions, we're able to get him into the stroke therapy and save this gentleman from any injury. But the trauma on that team to see one of their colleagues going down right in front of them added a tremendous stress and something that they were not sure how to deal with. It was another episode of how they activated care for the caregiver and showed the support of those people and that we truly love what they're doing and thank them and need to be there with them when they do have these events that could impart devastation to their daily activities. That's great, Dave. And thanks for sharing that. I think both of those two stories illustrate that the goal of Candor is to create this learning and improving, but also loving environment in hospitals to bring the culture around to one where we're able to hug and love patients and families through these events, but also everybody in the care system who may encounter them through this as well. And so looking at the slide we have up now, you can see the whole process when we did this work with many of the experts throughout the country who've been involved in communication and resolution programs. We came upon this sort of diagram that really looks at this process in five major bundles. How do you identify events? There's lots of ways that happens, whether it's a hotline, your online and current supporting, learning from patients and families, all sorts of ways of identifying it. And again, there's tools for every single one of these major bundles within the toolkit that we hope to be working with, the Patient Safety Movement Foundation, again to simplify and make super easy for folks to use. And then there's that activation of the team like you hit her Dave say, so that you are jumping out and supporting the families, but if need be, you're also launching the care for the caregiver. And then simultaneously, you have those two domains where we respond and we communicate to patients and families and as we learn information from our investigation, we continue to share that until finally we meet on the far end, which is the resolution, which more often than not is a non-financial resolution. It's merely an explanation of what has happened and that commitment to try to ensure that it won't happen again. There will be those times where it is appropriate when we know that our care was not meeting our standards, what we expect in our organization, that there will be times where financial resolution is very appropriate and Candor proposes a process where we don't force patients and families to sue us to come to this, but that we're able to more easily on come to some sort of resolution. If you go to the next slide, the ultimate goals of this program critically, and this is what really fits with the Patient Safety Movement Foundation is to reduce harm to transparency learning environment. But in the meantime, one of the side effects of this is to reduce legal involvement through this early and effective communication. And when we know our care was bad to resolve these cases early and efficiently and fairly for everyone and critically support patients and families as well as caregivers when these sorts of events happen. If you go to the next slide and then the slide after that, Ariana, the real critical piece here in that early response is the communication side. And there's a lot of material in the tools. One of the most powerful ones is a communication skills assessment tool where organizations can identify through this tool who their super communicators are. So when they have these really serious harm events, often a small team of them are trained to be those early responders or even to create what we call a consult service, much like you'd have a cardiology consult service or an infectious disease consult. These are people in the organization who are really good communicators, who are trained to give people advice and how to communicate honestly with patients and families and sharing the information that is known and maintaining trust with them. And that has been a huge value in the whole candor or seven pillars approach. And the next slide you can see as well that the critical piece of this that we highlighted before is that resolution part where this is where you really begin to see how we can improve things because most patients and families when bad things happen, do wanna know from us what are we gonna do to make sure that we prevent that in the future? And that's critical. And then the other parts of resolution often are and most of the time when it turns out that our harm events are caused by care that we've deemed appropriate, we still need to resolve those where we tell the patients and families everything that we know and we explain to them in an empathic way how sorry we are about the particular outcome but that when we've looked at it we do believe that our care was appropriate and we wanna continue to stay in contact with them and support them through this. And this is a critical piece that really highlights the difference of what you saw in that earlier diagram where the communication often would only occur when we deem that care was bad and we would apologize. This program really is about communicating anytime there's a significant harm event because that's what patients and families expect from us. So if you go to the next slide one of the great benefits that we had was significant funding to then analyze and really investigate what the impact of this kind of approach would have. So this paper here where you can see that the sort of title was published at the end of 2016 and it involves 13 years of data. Five years of data before we implemented this approach and eight years after we implemented the approach and we looked at all kinds of patient safety information as well as liability outcomes. And importantly on the patient safety side which also reflects the culture we saw logarithmic increase in event reporting from our nurses, our physicians and very importantly from our resident physicians. We went from about and we were a 250 to 300 bed hospital. We went from about two to 3000 event reports a year up to 13,000 reports that we had when Dave and I left the University of Illinois a few years ago. The really cool part about that data is that thousands of those reports came from resident physicians. Because again one of Dave's focuses on education was you can't learn what you don't know about and using this event process to provide feedback to residency program directors and others was hugely helpful and continued to show this big increase in event reporting. We also saw a big increase in interdisciplinary event analysis from the GO team with a lot of process improvements in harm reduction that flowed from this more aggressive and rapid response to patient harm. And on the other side, the liability side and one of the side effects we saw was a massive decrease in our claims as well as the cost of litigation and the cost of resolution to the point where when you see in the paper there were tens of millions of dollars of swing in terms of the money we were able to save before and after looking at some pretty rigorous statistics to see that. So being open and honest with patients did not increase claims. It did not increase lawsuits. It was actually associated with a reduction of all of those. And critically also as you'll see we saw a massive reduction in the time to resolution from the events until full resolution dropped from five years to nearly about a year. Again, when we left the university which we'll talk in a second about why that's so important for patients' families as well as caregivers. If you go to the next slide you'll see one of the other things that we did is we looked at the physicians who are engaged in this very comprehensive educational training program over the course of years and we looked at their practice patterns compared to all of the physicians in the Cook County area. And we were labeled to identify with statistical significance that physicians engaged in this kind of program order far fewer tests that are most often associated with defensive medicine which again had a huge financial impact on organizations due to this. And again, we're beginning to see this even in other organizations where we have begun to implement this approach. Going to the next slide, you're now going to see that this time to resolution that reduced more than 70% really had a huge impact on the Care for the Caregiver program. Imagine the physicians and the nurses having four fewer years to go through the hell of depositions and uncertainty related to the legal issues but also the patients and families who don't have to struggle to get information for four or five years. It's the win-win for both parties. And so as we've talked about in Davis at many times this sort of approach is not just the right thing to do it's also a really smart thing to do for organizations that are looking to improve their patient safety outcomes but also their bottom line. If you go to the next slide so these research grants that were as Dave mentioned supported by the agency for healthcare research and quality known as ARC when we had seen the data that we had that had come back in the early 2013s the decision was made to begin this production of this toolkit which had at least 30 experts in patient safety and liability event reviews human factors involved and created it was completed in September of 2016 and then released in May of 2016 at the National Patient Safety Foundation. And the kind of things that are contained again in that toolkit include organizational assessment assessment and gap analysis tools and then all again the things that Dave mentioned about human factors based event analysis and process redesign all the way down to how do you operationalize this stuff with a communication team, a care for the caregiver team and even that process for ultimately resolving some of these more complicated cases and there's also a big section that we have that helps facilitate and push patient and family partnership and engagement. And so I think at this point Arianna we're in a position to move to the next slide and open it up for questions. Wonderful, thank you so so much. I know that it's hard to fit all of this content into 30 minutes but I think you have both done an incredible job introducing the subject and getting enough detail for everyone on the line and on the webinar to understand fully the benefits of CANDOR and this type of approach. So I want to thank you both so so much for being with us today. I do want to open it up to questions from the group but before I unmute everyone there is one question so far on this. It's from Howard Burgendahl and his question is with two separate meetings at the end of the process how do you keep continuity between investigation conclusions and decisions on resolution actions? Okay so if I think I understand the question correctly and it's a good one, is Tim alluded to many times in those early conversations with patients and families we don't know what exactly happened. We may have an idea, in fact we may have a strong suspicion but you never want to in these conversations share suspicions or inconclusive thoughts on what happened with a patient or family member because if you're wrong you can't go back and sort of reverse that. So what we do is we always as we continue to learn what happened and dig down deep into the issues we share that on a regular basis with patients and families sometimes on a daily basis where we update them on what we learned in the last 24 hours and where we're at in the discovery and learning process. There does come a time that you do this efficiently that you will come to conclusions on probably 75 to 80% if not more of what happened. Some things are very obvious and it doesn't take long. Other things sometimes take external reviews or you've got to wait for an autopsy or other results to come back and as long as you're open and honest and sharing that with patients and families as you learn they tend to stick with you and appreciate what you're doing. It doesn't mean that they're still not upset or pissed off or angry at you. You know, Rick Boothman always said when you do these types of disclosures and transparency don't ever expect hugs from the work you've got that you've still done something that has changed the life of a patient or family forever but at least if you keep them in communication in that early process and update them honestly and accurately it does work well and you get to that final resolution. I'll let Tim talk about then once you've decided to take this to the resolution side based on what you've discovered, how that plays out. Yeah, and I agree with that, Dave. You know, Arianna, the real key is reaching out very quickly just to provide an empathic response when these unexpected things happen. And as he said, you really want to avoid any kind of speculation and you want to stick to absolutely those facts that you know to be true at that time. The, and as things move on as you begin to learn more and more information the hope is that you identify a person who can be that liaison of that contact with that family. So as more information is known there's a consistent message that is shared with them. And then it may take some time to do your full review to understand fully what happened, what the causes were and then making that determination of whether care was appropriate or not. And we recommend separating those two processes. There's one process that always is looking at like the go team would, what can be improved? How do we need to redesign this? What do we do? And then there's this whole separate conversation that needs to have about was the care appropriate or not? And they take all the facts that are gleaned from the review of the behavior of the individuals as well as the event and its timeline. And it's then when you have this really critical stakeholder group that makes that determination of whether care was appropriate or not. And if it's not appropriate you do need that separate team of people who is very well skilled to be able to sit down with that family and empathically explain to them that money cannot bring their loved one back but the organization does hold itself accountable and believes that in any particular case that providing financial resolution is appropriate and will help again the organization hold itself accountable. Great, thank you so much. I have two more questions that have come in on the chat. One is from Nick Andreonis and he says, I'm curious about the method for sharing across units since there are often similar potential harms and those teams may be working simultaneously on the same thing and might it be unnecessary? Yeah, it's a great question and I think as everybody on the call realizes, you know, we should never compete for safety. We try to share as much as possible not only across our systems but with others across the country and across the world to help reduce risk. We've got even another comment I like to do. We steal shamelessly from each other and that's what we should do in safety. So the first thing we do here is we realize that an event whether it occurred within a hospital or occurred in one of our ambulatory sites could have occurred at any one of our hospitals or ambulatory sites. It's good people trying to do good work and they get caught up in a process or system issue that when you really drill down you see how that happened and you go to correct it. So what we do at MedStar is these events are all shared on Friday afternoon. I send an email out across our system so people both in acute and ambulatory can read about any serious safety event we had, the cases that would fall into these categories of preventable medical harm and we even do it with others that may not have been preventable but there's great learning opportunities from them. And I send that out every Friday afternoon between five and seven. And those learnings then, the leaders as well as the people at the front lines look at what happened at one of our sites and start assessing their system, their processes to see if the same thing could have happened there or if the recommendations that are shared with them could be hard to be implemented within their site. Sometimes when it's an EHR or electronic health record issue we could change it at the system level immediately so everybody is affected by that change. Same things with medication issues and formulary decisions. We can make those at a system level but many times it goes deeper and so that goes out on a Friday afternoon and it's a large health system. There are weeks that we don't have any serious safety events that go out and we use it as a week to celebrate and to have a trivia contest which gets a lot of fun and excitement around it. So again, we try to understand that that week we had an event or two that we need to learn from and move on and get ready for Monday and a new week to try to do well. Wonderful. Okay, another question from Vonda Vaiden-Base on the chat and then I'll open it up as long as there's no more on the chat. She is asking, recent studies show the link between burnout and low empathy. Low empathy likely curbs enthusiasm for approaches that emphasize transparency like candor. Fiscal benefits help break through this barrier. Stories especially close to home help such as the board member's sister influencing the university engagement as well. What do you see as most effective to bring leaders on board with candor? Well, I mean, I think she hit it on the head. I, the goal Ariana that we really try to push it is connecting the heart with the head. And that's where I do believe patient stories can be the most powerful to get leaders on board with this. Very few times have I met with boards of organizations and shared the stories as well as the data and not have them lean in and wanna consider this kind of implementation. The exciting part of Ariana is, and it was in the newsletter is we now have over 200 hospitals throughout the country where the boards have gotten on board and are really asking us to help them implement this kind of approach. And the cool piece is to get to the root of the question is in some of these organizations where we started doing this a few years ago, they are seeing improvement in staff engagement scores, empathy scores, as well as burnout. And primarily, and I think that's what Dave was trying to get at, that comes from this super robust care for the caregiver program that doesn't replace EAP at all, you know, employee assistance. It's just, it augments it by using, you know, voluntary peers who can support each other. And with a very, you know, big intent in doing that but also studying it and see the impact. I don't know, Dave, if you have any other ideas, I know when we talked to your leaders years ago, it's that heart with the head conversation that's often what changes them. Yeah, it's the best way to educate people and PowerPoint slides will bore the death out of you but stories and narratives compel you for other reasons to learn and to make change. And so I totally agree with the question that was asked. We have to bring joy and meaning back into the workplace. Lucian Leith has talked about this for many years. There's a number of papers and, you know, national publications that are calling for it more and more. And I think care for the caregiver, I think the other thing, good catch programs, we've seen this at MedStar. We celebrate people and they share good catches about how people use, in our case, high reliability tools or techniques, either validate or verify or voice a concern. And even when they're wrong, we still celebrate them within our institutions and then at the system level and we've got a good catch, a luncheon we do every year. It's like a Academy Award celebration with a red carpet and 60 front care associates even in security and transport. They don't have to be physicians and nurses are celebrated for stepping up and using the tools. And I think the combination of these things has really elevated the culture. You heard me tell about some stories at Georgetown. When those stories get shared around their hospital as well as across the system, people really, it elevates why they do what they do and the work that is so great every day. I mean, we're doing some amazing things in healthcare and yet our subgroup always gets involved with those bad cases and stuff. And we've got to embrace and celebrate all the wonderful things that are be done at the bedside today while acknowledging we still have work to do. Yep, unmuted. If you have any questions out there, please feel free to ask them now. This is Jim. I'm just inquiring how impact patient safety and how they've been used in your practice and how do you look at them for the future? You know, I'm a big believer in Gwande's approach on checklists. I think we just got to be careful that we just don't put a checklist on everything we do. I think some areas of checklists work well. I'm an anesthesiologist as is Tim by training and we used to have our morning set up checklist for our anesthesia card and our anesthesia machine. And I know it helped me in regards to making sure I didn't forget a step even though I may have done it hundreds of times, sometimes my mind's wandering or I'm not thinking as well. But I think we've got to be careful in how we use them. There are other tools that could be used that might work better than a checklist in certain situations. So I'm a believer in them, but I think we just got to be careful and we're checklisting our checklist. Yeah, and Jim, that's a great question. It goes back to one of our slides, which is culturally strategy for breakfast. You don't wanna lose a culture of mindfulness in common sense. We've got a really good friend from Australia, Kim Oates, who's a pediatrician who always talks about, you don't want the protocol to just fly blindly. And again, you need to keep your common sense with you and your sense of mindfulness. Appreciate it, thank you. Hi, my name is Fatima Keoni. I wanted to say thank you for the great presentation. I have a question about, have you ever implemented these toolkits in other countries? So, as Ariana mentioned in the beginning, I worked for three years in Doha, Qatar. And a large number of these approaches and tools, we actually have discussed and began implementing in the Middle East. In fact, Dave and I will be back in Qatar in October working with medical students, nursing students and resident physicians over there on many of these kind of concepts. In addition to that, Dave and I have worked super closely with the Clinical Excellence Commission in Australia over the last many, many years. And we actually work with some of their policy makers and those who write the laws in Australia to help them improve from a legislative standpoint ways to facilitate these kind of conversations. But yes, our goal is to continue to move this as far internationally as possible. We've actually had conversations with folks in Spain as well as some folks in Mexico about some of the opportunities that exist there. And one of the things that they see is the patient safety comprehensive program. Even some countries don't have quite the medical liability crisis we do in the States. They still see the overall comprehensive program that improves care to patients and families as being the key driver of it. Thank you. Great. I think we have time for one more question. If there's any out there, one minute before the hour. If not, we can close. This is Vonda. We have time for one more. I'm curious if you have had the experience of working on the patient side. Through that lens, I would have much appreciated some sort of protocol or guidance as a family member after an event in our family. And so I'm just curious if you've taken it to the patient engagement side and if you're having some success there as well. Thank you. Oh yeah, we certainly have Vonda. Thanks for asking that. We work really closely with Marty Hatley, who's done a ton of work with a lot of the patient engagement work as well as Rosemary Gibson, Helen Haskell, Patty Skolnick, Carol Hemmelgarn. A whole lot of the patient advocates have been wonderful in helping to advise this program, but also helping us find ways to really connect with patients and families after harm events so that even years later we're still in contact. In fact, what we learned from them, Vonda, was the communication following harm is a process, it's not an event, and it never ends until the patient or family says it ends. And so we've had conversations that have gone on now six and seven years with the family because of the connection we made following our outreach following harm. Thank you. Well, it is 10 o'clock Pacific time, so I wanna be respectful of everyone's time. I really appreciate both Dr. Mayer and Dr. McDonald's time going through this. Again, such an important topic. Thank you so much for the engagement on the attendees side. I just wanna remind everyone that we will have the slides posted as well as the audio recording of this webinar within the next 24 hours on our website. I posted the URL in the chat. So if there are any other questions, please don't hesitate to reach out to us, and we hope to see you on our next webinar, which will be coming up in September. So thank you so much.