 Good morning everybody. This is Donna Prosser, Chief Clinical Officer with the Patient Safety Movement Foundation. Welcome to our webinar for November. Today we're talking about a patchwork quilt of improvement and how organizational complexity can compromise patient safety. Our objectives today are pretty straightforward. We're going to talk about all of the improvement efforts that we have been working on over the last 20 years, how that's evolved, how that has created the current culture of continuous improvement that we have and what those challenges that are that exist today. And then we're going to talk about what we can do on an organizational basis to improve that. As always, we are providing continuing education credit to nurses, pharmacists, and physicians. This carries one CE for those folks. Also, if you are a respiratory therapist, you can check with your state licensing agency. You may be able to claim this credit if you are a respiratory therapist. If you fit into this category, you will receive an email from MedStar with details about how you can claim your credit after the event. Sometimes it takes about five to seven days, but take a look for this email with the subject line that says action required. We also are providing continuing education credit for healthcare executives, certified professionals in patient safety, board certified patient advocates, and our certified professionals in healthcare quality. If you are seeking ACHE credit, please just log this event into your account, CPPS and BCPA individuals. If you selected that as your option, we'll receive a certificate from us for this event, and CPHQ, your attendance here will be documented by NACU. As you can see here, none of the panelists and none of the committee members who organize this event have any conflicts to disclose. We want this to be an interactive session, so please do use the chat and the Q&A. If you have any comments, put those in the chat function. If you have any questions, enter those into the Q&A. We will potentially address some of those during the event, but at the end we will reserve some time for Q&A and hopefully get to them all before the end of the program today. So it is my pleasure now to introduce our moderator for today's event, Mr. Ahmed Al-Muhana. He is the Assistant Director in the Quality Management Department at King Faisal Specialist Hospital and Research Center. Welcome, Ahmed. Thank you so much for joining us today and for being our moderator. Thank you so much, Dr. Donna and the PSMF team on hosting this special webinar, which is the Patchwork Quilt of Improvement How Organizational Complexity Compromises Patient Safety. I'm honored to be the moderator for this webinar with our esteemed panelists. We have with us today Mr. Jarvis Gray, Founder and CEO of the Quality Coaching Company, Dr. Lydia Albuquerque, the President of the National Association of Indian Nurses of America, and Dr. Carol Gunn, Internal and Occupational Medicine Physician and is a family member of a harmed patient. Before we get started, I'd like to kindly ask each of our panelists to introduce themselves with a brief background. Mr. Jarvis. Well, thank you very much and good morning to everyone. Huge thank you first to Donna and the entire Patient Safety Foundation team just for putting on exceptional programs like this and it's really exciting to see such a high caliber and passionate group of healthcare leaders and professionals online today. For me, I was fortunate to come into healthcare back in 2007, so my background is industrial engineer, turned healthcare professional. I actually transitioned out of the electric utilities world where I served as a project design engineer for a number of years and I remember coming into healthcare and just thinking that this was supposed to be, you know, one of the easiest and just most rewarding career choices has definitely been rewarding over, you know, the past almost 15 years now, but it's definitely not been easy. So just what continues to drive me now is knowing that I have the opportunity to support leaders and professionals that are literally just working tirelessly now to save lives, to impact communities, and that there's anything I could bring to the table to make it a little bit easier, to make it a little bit safer, then there's no way that I can't show up. So I'm really excited again to spend time with you all this morning and look forward to a great conversation. Thank you. Thank you so much, Ms. Farrmas, and I completely agree with you. I mean, it's just definitely a complex environment, so I'm so happy to be here with us. Dr. Lydia. Thank you, Amit, for introducing me, but I just want to contribute by saying that I have been a nurse for the last 35 years and served globally. I've served in the Indian Army, so I bring a lot of the Indian Army background into my service as a nurse, a nurse faculty, a nurse academia, and nurse researcher. I also served in America now since 2004 as a nurse and grew into the ladder of healthcare for the past 16 years. Patient safety is of utmost importance to me, and I see the value of it right from being a bedside nurse to an academician. That means in academia, how I could influence the students with regards to safety. Right from the time that they enter into the nursing profession, it is something that we have as professions need to take care and need to educate and involve and evolve a curriculum that will develop the next generation to patient safety. I look forward to contributing at this webinar today. Thank you so much, Lydia, and I can't wait to pick your brain. That's the amount of experience that we should all be striving for. And last but definitely not least, Dr. Carol. Thank you for having me. I, too, look forward to this conversation. I started my career as a safety engineer and practiced over 12 years in the Silicon Valley. And then, you know, what got into me, I'm not sure, but I decided to go to medical school, and I've been a practicing physician. I'm still practicing for the last 17 years. I practice both mostly occupational medicine with a little bit of internal medicine thrown in. And so I understand what it's like to be in the day-to-day trenches of trying to do patient safety for my own patients and to help try to influence patient safety for others. Thank you for having me. We're lucky to have two engineers, and it's amazing that you're able to transition to be a physician. I mean, I think we can all mention that health care improvement is often pursued in silos, which results in an uncoordinated patchwork quilt of, you know, disparate projects. And without harmonization teams, even within the same organization, will continue to compete for resources. So this webinar is a great chance for us to really put our minds together to see, you know, what has happened the past 20 years and what will happen in the next 20 years. So without further ado, let's kick it off with a joint question for all of our panelists. You know, it's been almost 21, 22 years since the famous journal to Earth as Human. So for each of our panelists, how did this kind of kick off performance improvement end the health care world? And how did it evolve over that 20 year span? So let's start off with Dr. Lydia and then Jarvis and then Dr. Joe. Thank you, Ahmed. And I would just say that medical errors are actually the third leading cause of death behind heart disease and cancer. And we know now with COVID, it still remains where it's supposed to remain. And it's great. In 1999 to Earth as Human, building a safer health system Institute for Medicine revealed actually there were 98,000 patients that died from medical errors each year. And the patient harm continues. We are all talking about zero harm, zero tolerance to patients. Every person in the healthcare team is responsible and needs to think of safety as their job and a focus to the best ways to work with all members of the of the team. Now, being a nurse for 25 years and being having practiced globally, patient safety was not talked about many years ago when I was a nursing student. It was a patient fell. Oh, yeah, yeah, patient fell. And, you know, we just took care of the patient that fell. And it was not made a big deal. But as soon as the release of air to air to human came by, Congress passed a regulation requiring agency of healthcare research and quality to issue annual reports. And these annual reports were designed to monitor actually progress in improving care. And so just 60 days after AHRQ actually released doing what counts for patient safety that outlined several specific strategies to curb medical errors. Then AHRQ also made an advance to develop patient safety indicators to collect data and that hospitals can use actually I do a class on patient safety and I show my students the progression where only the doctor was on the top to make the decisions for the nurses, for the patients. And then came the nurse and the doctors and then came the doctor and the nurse and maybe an infection control person. And now it's a whole team. So you know, just to make the analysis of how it has evolved over the years. There are other organization intent 2011 actually the national scope card on hospital acquired conditions were also developed. The joint commission came in and then there came the national patient safety goals, which we as nurses actually included in the orientation for all our new freshmen graduates that come on board. And in 2020, 2011 actually it's Center for Transforming Healthcare brought together health systems across the country in at least 18 more efforts to reduce falls and falls. And the falls actually data showed it reduced to 62%. So was it a good effort? Definitely yes. Then came the save the 100,000 lives in 2004 and Institute for Health Improvement instituted to improve this drastic change so that you know the lives would be saved. Then save, so actually save came into practice. And then the IHA came with the health care associated infections where hospitals were made responsible for any hospital acquired infection. And then came AMC actually promoted quality and safety in 2008. And they sort of came up out with that this needs to be included in the curriculum for all interprofessional, you know, all interprofessional groups or teams working in the hospital, then came the Affordable Care Act. So I see that there is a progression and it is being spoken loud and there's a big voice being heard out there. And I'm thankful to this group for promoting this. So that's my perspective of how patient safety evolved. Excellent. Thank you so much Lydia. Jarvis, do you have any points? Yeah, yeah, I have a couple of thoughts. I hope I can, you know, display them as eloquently as Lydia did. That was that was fantastic over you. And I do want to give a shout out to Nancy. I love the comment over in the chat being an engineer. I'm a little bit biased for that comment. But for me, like I mentioned, I came into the industry in 2007. And I remember some of the earliest conversations that I had with healthcare leaders were essentially, why do we need engineers in healthcare? And I even had some leaders who called it out to my face directly, you know, Jarvis, we hire you instead of hiring more nurses, right? So I've had, I guess the chip on my shoulder personally, making sure that every time that I showed up to work with a team to work on a project, you know, I really took that to heart to make sure that, you know, I could deliver and the colleagues that I partner with that as a as a discipline, we could deliver value for every project to really show them, you know, to let them know that this was the right investment versus hiring more caretakers, which we know is the absolute need in the healthcare setting. The evolution that I see now is that every, I mean, at least in the US to speak to the US alone, just about every healthcare organization is looking for engineers, safety professionals, improvement professionals, data professionals. So the demand for engineers for process improvement experts, I think is at an all time high, at least from my view of the world. One of the things I like to do for fun is actually to go on to ND from time to time, and just simply type in healthcare quality improvement. So that's something I think everybody can take away and do after the show, after this event today. I did it this morning, right before our call here. And as of this morning, there were about 136,000 jobs on the site that connects with that criteria alone. And, you know, these trends, they will add and flow with the job market. Of course, I remember doing it a few months ago, and there were over 200,000 jobs posted on indeed. Again, just healthcare quality improvement. And so for better or for worse, right, that's that's what the evolution is now it's in demand, it's the place to be. There are, I think, a higher number of coaches and consultants in this world as well. I represent that obviously with my work. And I think that's the kind of a for better or for worse also, because, you know, businesses like mine, we're coming in with the ideology about what quality and process improvement can look like for our clients. And so one of the best ways that I try to engage my clients early on is really helping to make sure that they flushed out their own internal philosophies, their own internal strategies for what quality should look like, for what higher liability should look like, you know, these are some of the key buzzwords that are very common nowadays, but it can't be the Jarvis show or the Jarvis culture that has to be specific to what they want it. And then the very last thing I'll touch on is, is really the overuse of jargon. A lot of what we use in lean, lean specifically, but even in six sigma side of quality improvement. There's a lot of it that goes on out there. Unfortunately, without a lot of conversation about it, you know, actual tangible results or tangible improvements. And so again, those are the conversations that I try to tilt, but I'm hearing more data and results driven conversations, more so than just kind of the platitudes or, you know, the next Japanese word that's thrown out there. I really want to, to express to folks, you know, this is quality improvement, which is a full contact sport in my world, like you have to get on the field. You have to be able to test, experiment, improve, learn, and do it over and over again. So those are just some of the things, but I'm seeing it now, you know, more now than I have when I first came into the industry. Well, that's an amazing point, Jarvis. You know, we've really transformed these past 20 years, we've seen even more engineers like yourself, Nancy and Danelle, that really comes into healthcare, and they have that perspective that drive the new culture for safety, which is just really amazing. Carol, can you give us some of your feedback? I went to medical school back in 97 as a 37-year-old, and at that time, it was just right at the beginning of the, to air as human, and we had previously thought of airs as complications and kind of blamed it on the system. In the last years since then, healthcare has become more complicated, and we need to really acknowledge that, the electronic medical record system has not made it necessarily easier. And other things that have come up is we realize that our culture of medicine is not always that kind, and we do not always welcome people into medicine the way we probably should. I said it was a safety engineer. Safety engineering also has changed over the last years, and instead of just only focusing on preventing mistakes, that's considered safety one. There's now a new paradigm called safety two, which has the people actually doing the work. That means the foot's on the ground, people, the physicians, the other staff around them who are doing the actual work, looking at their processes to understand how to make critical things go well, and to anticipate when things might not go well so that they can ebb and change and be ready for that. And right now, I think we're still in healthcare, still in safety one, where we're on preventing mistakes only, and we really need to marry the two safety one and safety two theories together in all the areas, excuse me, in all the institutions. That's a really great point, Carol. I can see in our chat that Nancy's even saying that the culture of safety is to allow for our staff to speak up. So I think that resonates with the fact that it really does make a difference on what that culture looks like, and it's such an important part. Before we continue, I see there's a few people that have asked some questions already, which is an excellent opportunity for people to ask. Danelle Wilkins asks Jarvis, what are you hinted a lot about some of the jargon or QI jargon, especially with the next Japanese buzzword. So what in your experience are some of the most adopted quality tools that you have seen in healthcare? I've been around long enough that I've seen a little bit of everything. I came into an organization that was heavy on Six Sigma. I see trends nowadays where organizations claim to be, you know, we are a lean organization. You know, again, I think there's a lot of perceptions. There's a lot of, you know, I hate to say flavor of the month, but I haven't seen groups bake it very deeply into their strategic planning process. Those are really the ways where I can tell if a group is really serious about it. If their executives are leading some of the projects, that tells me it's a group that's serious about it. But, you know, the different tools and techniques, I've worked with a lot of groups who are really big on kaizans. I'm actually working with the group now, and we are laying out a number of kaizans, train the trainer and executing. So there's groups doing kaizans nowadays, A3. So those, I mean, there's a mix of stuff. Personally, I love it when a team creates their own internal process and give it their own internal name. They put their stamp on it. Those are always kind of exciting to see as well because they're truly adapting, you know, the mindset. But there's a lot of stuff out there. It's not a one-stop shop anymore. That's a beautiful comment, Jarvis. I think it's another question that I'm going to open it up to both Lydia and Carol before we move on with our program. Should there be an identified safety monitor each day who's a member of the team? So think about the unit for the shift who's expected to identify any risks and to take action. Just someone who's dedicated. What are your thoughts, Lydia and Carol on that question? I think Lydia is muted right now. Yes, Lydia. Sorry. Let me answer some of it that in terms of, you know, identified and having monitors, we do have monitors with relationship to falls, patient safety, where we have sitters that are available who sit and watch a group of patients in terms of their safety in terms of falls. But we also have monitors that, you know, monitor seizures and epilepsy and things of that. But we need to look at safety from a different perspective, right? The environmental safety too. What's the practices in the hospital with regards to environmental safety, with regards to patient safety that are working? We do have monitors doing all of this where, you know, it's captured. But do we want more of it or do we want less of it? Do we want to maintain the privacy of a patient when these monitors are being placed around? It may impede into the privacy of a patient, but is it required? What do we do with the data? Do we have a safety analyst in the hospital? Do we have a safety engineer who's taking care of all this? Or is it just being handled by the quality department who may not have the specialization to do this? And as I heard, I was saying is there has to be engineers included now into the healthcare industry to develop and bring about more technology, more equipment, more data analysis. You can collect a lot of data, but that data, if it is not looked into, and it is not analyzed, then it is not brought into perspective during, you know, safety meetings. It has no meaning. So to me, it is important to monitor. But what we monitor, how do we maintain privacy of a patient is also very important. So I think it is a long way to go in the healthcare industry. When we look outside the window, doctors, nurses, healthcare providers, we look outside the window and engage and embrace our engineers into this field, maybe healthcare industry will go grow in leaps and bounds. That's what I think right now. Thank you so much, Lydia. And I see someone even agreeing with you, Danelle, saying the quality is fast with everything. So that's a, it's resonating to what you're saying. Carol, do you have any additional comments? I do. I think having monitors around might work for some organizations. I really think we have to be tailoring, the organization needs to be tailoring to what works there. I've heard surgeons complain about why am I checking off about the lasers in my surgical suite when we have no lasers. So they have a checklist that says they have to check on a laser. They check it every single day, every single operation, but they don't even have lasers in that facility. So we have to really make sure we're asking people do the work that they need to do for their own work. And so it has to be really tailored. And so there is no one size fits all. But if you see another organization or another part of your organization where something works well, bring it over, check it out, ask the people in the organization who are going to be working with it, because let's look at our doctors and our nurses. They're overloaded. They can't take one more little piece on their overloaded plate. And if you put it on there, everything might collapse. So I really want people to be nervous and afraid of what we ask our nurses and our physicians and other healthcare partners to do in their line of work on a daily basis. Thank you so much, Carol. I think, you know, looking back the last 20 years, definitely I would say the current setup of healthcare is even more complex than ever before with increased computerization, electronic health record, the rich availability of data, and even the patient involvement and what we do, we sometimes lose focus on building that holistic approach to continuous improvement. So let's talk about that impact and the current challenges that we may all face. So Jarvis, with the expanse in our complexity, how has the utilization of data changed for that holistic approach to continuous improvement? Yeah, so data to me, honestly, before we get into so many conversations about quality improvement and so forth, I think this is really the most important part of, you know, the improvement culture within organization. I think one of the first things we have to appreciate is that there is a cost to collecting data. And it's, you know, if it's going to be through electronic systems, if it's through manual data collections, or some other repository, you know, that has to be factored into all of our projects, ideally, into our strategic plans and budgets within the organizations. I see a lot today, again, more so than I have kind of coming up in my career path, that there's this focus on big data. And big data, you know, sounds big and sexy. And yet I still touch base with teams that are right there at the bedside that can't tell you how many people they saw today, how many people came through the unit, the average wait time, you know, right there in the moment. And so, you know, the focus and a lot of the work I do with quality improvement is really small data. It's the process center data that gets us to an outcome. So I always like to kind of pull people back, you know, are we doing small data the right way? And then again, I think I kind of mentioned, you know, when organization says they are lean only, that scares me sometimes because lean is not as quite as data intensive as a six sigma or some of the other methodologies in our improvement toolbox. And so, you know, again, it's just bringing it back. Are we making data driven decisions? Are we analyzing things appropriately? Are we reporting things? The difference can be the, you know, that's the difference between understanding what is going on and why things are going on, right? So the reporting versus analyzing. One of the best analogies that I came across working on a project and one of my team members taught me this and I've used it ever since is that data can be looked at in kind of three different ways if we were driving the car. If we were looking out of the windshield, our ability to kind of see what's coming at us. That's one view of data that might be appropriate for managers or directors, decision makers. If we're looking, you know, for driving the car, and we're looking at a speedometer, right there in the moment, I can moderate, you know, the flow of my my ability to get to my destination. So that's the kind of data we want to put in the hands of our frontline team members so they know what's going on minute to minute within their organization or their departments. But then if I'm driving the car and I look in the rear view mirror, it allows me to see what we just passed the past performance or if anything's coming behind us more strategy. And that's a view of data that could be very well utilized for executives. But it's all of us in the same vehicle. We're all going to the same location, but we have three different views of the same information. And I don't always see that organizations do that well, but applying that concept, I think can can provide more of a holistic approach for data and continuous improvement. But what a beautiful analogy. I love this, the car analogy, what a nice way of looking at it. And I can already see that there's a few people that that would agree with you like Marion McCabe on, you know, how does that data impact the sharp end? And even Hugh Wilkins, when he mentioned about, you know, utilizing the healthcare scientists that are available in healthcare to look at that data. There was an interesting question by Mohammed al-Ba'dani that says, you know, that during the pandemic era, there's been a huge shift in how patient safeties look like. And that you think that we should reconsider performance indicators for patient safety and how can that be bridged between patient safety and infectious control departments? And what other separate departments are there in healthcare that we're not looking into so that we can connect those data points? Yeah, so I guess the first part of what I take away from that question, when I look at some of the external organizations that a hospital can provide data to, and this is just, you know, again, love it or hate it, I think they're just too many. Unfortunately, there are too many awards and best hospital criterias and all of the above. Personally, I would like just a single source that we can provide our data into that can define, you know, success, good, bad or other. Internally to a hospital, I'd love to see more focus on process relevant data, more so than just outcomes. We track a lot of outcomes. We do that fairly well. Not always, I guess, a strong, we can get stronger with our focus for process, for input data. I think those are some future opportunities, but I'll stop there and see if Carol or Lydia have thoughts. I'd also like to see the whole bridge between worker safety and patient safety be built stronger. I mean, I think the pandemic showed how bad we are at that. You know, the number of healthcare providers that passed during COVID, how we were using personal protective equipment and things to that extent. Those two departments, you know, we do know by looking at OSHA data here in the US that when there's better worker safety, there's better patient safety. And so I don't think we've done a good enough job of protecting our healthcare providers. And if our healthcare providers aren't well, aren't mentally well and don't feel safe, our patient safety is going to suffer. And I don't think we've done a good job there at all. Excellent. I don't know if Lydia, if you have any additional comments that you want to add to that point. I would pass it for now because they both have covered a lot. Yes. Thank you. So let's go to the next question about for you, Lydia. How has the advancement of computerization changed over the last 20 years? Do you feel like it has helped or hurt our continuous improvement efforts? So let me take that question and answer. So the advancement in technology actually has been exceptionally fast in the 20th century and the 21st century. And you will always all of you will agree with me. So what is happening in the world right now? Computerization and technology, the world has become round and it's you, everybody's able to get information and a click of a button. There is information overload sometimes. And then what has happened in the healthcare industry when I got into this whole healthcare industry in 2010 when computerization started coming in the form of electronic health records and it was made mandatory for hospitals to be connected together with all electronic health records. We saw that it was good. It was good in many ways, but the workload on the nurses increased now because of computers, everything was integrated, connected. And what came in or integrated were the errors in that? Certainly there were errors. Certainly that increased the job of the nurses to actually pay attention to those errors, although there was integration that is taking place. Errors happen whether it is blunt errors or sharp errors. We know sharp errors are human errors and blunt errors are system errors, right? So human errors can happen, especially with nurses in the present situation where they are overburdened with a lot of patient workload. COVID-19 has brought a different perspective in how nurses were put in the forefront and they had to be face to face. I'm a nurse practitioner and I remember days when I was in front of a patient who was COVID-19 not even worried about what is going to happen, but more concerned about the patient. So when you talk about electronic health records, there's definitely a benefit because it has enhanced electronic physician orders and e-prescribing. Remember the days when I had to read physicians ineligible writing and if there are physicians here, pardon me, but it did happen the unit clerk had to call the physician 100 times to find out what did he write? Did he write cardism 120 or did he write cardism 20 or whatever it may be or did he put the milligram? So he did and then came joint commission saying physicians could not use this, this, this and it added another extra layer of burden on physicians. So I'm going to talk both sides how it helped and how it did not help. So that part of it was taken care of, but is human errors still not, do we create human errors? Yes, because through electronic healthcare system, a number of patient load has increased, taking 100 patients, then we used to take 50 and we may enter an order in a wrong patient shot and if the pharmacist is not alert or the nurse is not careful, the patient may receive a wrong medication. So that is the biggest error that can take place and that's still happening. So in spite of electronic health record put into place, then electronic health records also help in clinical decision support. Sometimes, you know, I get a call from the, from the K coordination department saying that the type of order yet you have written is not correct because it does not fit the criteria, the minimum criteria, whatever criteria that that particular hospital is writing and I'm like, why? Because the diagnosis does not fit into that criteria. Patient cannot stay for much more than one day, but actually the patient, if you look at the patient, patient is really very sick, but people who are making those type of decision makings about hospital stay are distant from the patient. So really that cannot be taken as the only predictor of the length of stay of the hospital. So it again takes time on the part of the healthcare provider to talk about that particular clinical decision that somebody else wants to take because it does not fit the criteria. So that is the second thing. And there again, errors can happen because if you are so busy with so many patients, you may say, okay, do what you have to do, but that patient may be very sick and does not need to go to observation unit, but actually fills the criteria of going into a critical care unit, right? So that is another error that is taking place because people are looking at the computer and really not looking at the patient. Electronic sign-offs and handoffs have been terrific. They have been good provided. Hospital have made the process clear of how electronic handoff has to take place or handoff is a very important process that needs to be built in every hospital, whether it's for the nurse, whether it's for the clinician, whether it's for the radiologist, whether it's for anybody, doctor handoff to nurse, that has helped to a greater extent. I work in a magnet hospital. So we do have a multidisciplinary patient team rounds in the morning and Electronic Health Record helps us to look into the progression progress that the patient has made. Spark pumps have helped because now here we are able to do better things with the smart pump, but at the same time an error made on the smart pump can be traced down. So in a lawsuit, remember that whatever errors are made can be traced down quickly than it used to be before with the hand written. So the patient is taken care of overall, automatic medication dispensers also are very helpful. And then Atelier Medicine, which is coming up very rapidly right now after COVID, has taken a better turnaround for patients in terms of their safety for them to interact with the provider and to access the care in a place where they are. I mean, they don't have to travel. What about inner city patients where they have to spend a lot of money to travel when they cannot afford a square meal? So should I say electronic health record is not helpful? It is helpful, but there are chances because we are humans. I can talk on this topic the whole day, but I have to stop because we are humans that can be human errors. As I say, sharp errors and blunt errors. Keep that in mind. Every good system has something bad and ugly to be dealt with. And all of us are ultimately it is the individual responsibility. A nurse has a license. A doctor has a license. A physical therapist has a license. Everybody has a license. And I agree time spent with the patient is reduced because I see what we all do and including me in my practice, they're looking at all the numbers, but we are not looking at the patient. The compassion. Somebody said the compassion, the kindness. That is getting to be narrower than it was earlier. I do not see many nurses, doctors, physicians, nurse practitioners really spending their time with the patient. So we need to look into that and we say every system has something good. Every system has something bad. Every symptom has something ugly. But the patient is our customer. The patient needs to be addressed. The patient's needs come first. It's not our needs. We have a job because the patient is there. So with that, I would say, you know, computers are good. Computers, what you input into the computer, the computer is going to spit out, right? It's not going to make its own decision. So the algorithm that is developed by the hospital is going to come out. So be careful as nurses, doctors, practitioners, healthcare providers, you have to be very, very careful with what you do. Absolutely. I think computerization is definitely a double-edged sword. And I can see a lot of people that are agreeing with you that nurses can't do everything. And, you know, there's a lot of beautiful comments saying that, you know, organizations need to redesign how they're working for units to be inclusive with specialized trained people and improvement on the units for empowerment, as Susan Bowen said. And it really impacts how we look at that. And, you know, when we're focusing on patient safety, I think Ms. Rani and Obadi mentioned that, you know, focusing on patient safety only is only adding additional load and is ignoring the staff safety and how we can involve one another. So in that kind of sense, let's look at, you know, how we involve our patients themselves. Carol, can you talk a little bit about, you know, now there's patient family councils, how have this new PFAC, you know, contributed to continuous improvement of safe care? Are we involving patients in performance improvement? I think we are to a limited degree, but I think we could do a better job of it. You know, PFACs, the patient family councils, you know, they come together, they're usually people who are really concerned about what's going on in the hospital. So they're a great group of people. But a lot of times we only give them a narrow focus. And when we give them that narrow focus, that disillusions them, and they don't want to contribute. I mean, it's not just painting the color of the lobby, you know, they could give information on how long it takes to get a prescription filled, or how long it takes to move the cancer patient from the diagnosis in the primary care office to actually seeing an oncologist, or the, you know, the cost of parking for the cancer patients, which has been mentioned as being outrageous in many articles. So I think PFACs have a lot of great information. But I don't think yet we have not really mind that. And I think part of the reason is we haven't really put money and energy and time into doing that well. Thank you so much, Carol. I think there's a few people that will mention the comments, you know, Marcy Romario saying that she's a manager of the PFAC and she's participating, she's involving the patient family advisor in the QI PI project. And I think that should be expanded all across the, the world really to involve that. Let me switch points to Jarvis. Based on what we've heard so far, do you think, you know, healthcare or what we were going through, do we have an unrealistic expectation of how we implement this continuous improvement? I think there are more unrealistic expectations than not. I would say maybe one of the first things that come to my mind is thinking that process improvement or quality improvement, continuous improvement, thinking that it's a silver bullet to solve all of the problems that we have in healthcare. You know, I always kind of coach people up. We have to use this as one of a number of strategic tools with the real focus there being strategy. I think there's an opportunity, you know, with the process improvement mindset before we can become process improvement experts. I think a lot of times we have to be process experts, right? And you don't have to do a project, you don't have to get trained or get any kind of, you know, a colored belt to be, to really master the processes that already exist within your organization. A few other thoughts really quickly and I know we're going to have to jump into some Q&A, but just to, you know, for healthcare leaders, everyone on the call today, I would definitely encourage you to zoom out, you know, have a focus on developing a systematic approach for quality management, which means we have to be very cognizant of how, you know, the processes for quality control, quality assurance, quality planning, and then quality improvement or continuous improvement is only one piece of that entire pie. So I think those are, you know, just some of those unrealistic expectations that we may skip over before we kind of pull it together. We almost always jump to QI first and not seeing the comprehensive system. Last but not least, executives, you know, we need you all leading the projects, not just showing up to the meetings or the debriefs. We need you trained, knowledgeable, and on the front line, leading the projects with any of these improvement teams. I think those are things that start to shift the reality and shift the culture in a lot of ways. Absolutely. Thank you so much, Jarvis, and we're about to approach our Q&A session. I already see there's already lots of questions, so please keep those questions coming in. I have one kind of question to ask our panelists, and then I'll go back to the PSMF for some points that they want to raise, and then we'll continue with the Q&A. So based on what Jarvis had said, if I were to ask each of the panelists, if you can talk, if you have the opportunity to talk to each and every single board of directors, board of trustees in each organization, what recommendation or call of action that you would make to them so that they can achieve this holistic approach for continuous improvement, not the whole fragmented portion that patchwork quilled, but what is that holistic approach that they would need to do to achieve that? So let's start with Lydia, Jarvis, Carol, just some brief points so that we have enough time for the Q&A. All right. So to me, I would focus on academia because I'm in academia and I'm in practice both, but in academia, I think there has to be a curriculum change that has to take place. Curriculum change in terms of patient safety has to be brought into the curriculum and it has to begin. Like we say discharge planning starts right from the day of the admission of a patient. So patient safety talks have to be started with the new nursing students right from the day they enter into the nursing program. So that is one way that we can influence and bring patient safety issues and talks so that they are influenced and their minds are influenced. Just not to get the nursing degree, but to get a degree that encompasses teamwork, interprofessional development, talking to each other because nobody works in Zylos. A nurse cannot work by themselves. So another thing that comes to my mind is for the culture of an organization, where is the culture? A culture assessment of the organization needs to be done. Where are we? Where do we want to go? And what do we want to encompass to bring this at the top most? Because patients can safety causes a lot is cost a lot of dollars, you know, because that impact can be and that influence can be or those dollars can be used in educating the nurses, educating the physicians, educating the team workers, interprofessional, respiratory therapists, social workers, case managers, nutritionists, how much of dollars are being used for educating? If there is a fall, it costs you say $200,000, but if a nurse has come up with a proposal for some sort of education, you have just turned the table around and said no, right? If you do that, probably things could change. Probably people should not be focusing or administrators should not only be focusing on those numbers, which in reality may not be true. The nurses will tell you or the doctors or the physicians will tell you, yeah, those numbers are nice for us to project ourselves, but that's not the reality. So I think there has to be a soul searching that has to go on. Every organization has to do it at a different level, involve the grassroots level workers, you know, that is what my suggestion is. That's an excellent suggestion for the next 20 years. That's great. Jarvis and then Carol. Yeah, so I know they say was a culture strategy for breakfast. So for me personally, I'm a strategy guy. So I would have to encourage all board of directors to overemphasize, you know, the processes and organization for strategic management, for strategic execution definitely means, you know, if they're not comfortable, they're not familiar, they may have to go learn exactly what that looks like. We have programs like Baldrige, for example, that offer a model of sorts. And there's many others out there. Things like balance scorecards, strategy maps, you know, these are best practice tools. But just asking the questions, you know, how does this organization develop strategic objectives? How do we manage? How do we leverage data? Those are things that I think every board should just be all over. Absolutely. Thank you so much, Jarvis. It's a really great point. Carol. One needs both the top management support as well as the line support. If you don't have both, you're not going to get anywhere. And I think culture is where you get both. The second thing is, in the vision statement, patient safety absolutely has to be in that. Because if the healthcare system doesn't believe that patient safety is part of their vision, then they shouldn't be in the business. Absolutely. I think definitely for the next 20 years, all three points that you made are really key. So thank you so much, everyone. Before we go on the Q&A, I think Donna wants to, Dr. Donna wants to speak to us about the CE. So go ahead, Dr. Donna. Thank you so much on that and the panel. This has been such a fabulous discussion. I do want to get to the Q&A, but for anybody that might have joined us late, I just want to real quick reiterate our continuing education process. Nurses, pharmacists and physicians are eligible for one contact hour from MedStar Health. So if you registered in any of those capacities, you will receive an email from MedStar Health within the next several days. ACHE, if you want that level of continuing education credit, then please just log that into your account. CPPS and BCPA professionals will be receiving a certificate from the Patient Safety Movement Foundation, and certified professionals in healthcare quality can have your attendance documented by NAHQ. So thank you again to all of our panelists. We're going to get to the Q&A in just one second. I do also want to reiterate that we provide these webinars here at the Patient Safety Movement Foundation free of charge, and we provide our continuing education credit for free. So if you are interested in helping us continue to be able to produce these wonderful monthly webinars and at no cost, then please consider donating to our organization. So with that being said, I'm going to pass it back over to Med and anybody that has any questions about CE, please don't hesitate to reach out. Thank you so much, Dr. for that thing. I mean, the PSMF is really helping to connect these thoughts. And personally, I think we can compete on everything else except quality and patient safety. This is a time for us to always share and learn from each other. So this is a great opportunity for all of us. I see there's a lot of beautiful comments. I love to talk about the compassionomics and all the different types of suggestions that everyone doing. There's two questions that popped in right here, one from Melody saying, what about the hospitals that don't have a lot of resources who are limited by those resources who perhaps could not adopt these more advanced technological tools? What would be the most important components to have an institution to address these fragmented silos that we're talking about in an institution to help improve patient safety? So if I can get just a brief input from Jarvis and Carol and Lydia from that. So I mean, my initial thought on that Melody strategy is free, right? Quality is free. There's an exceptional book called quality is free would encourage for everyone. But you know, these are just disciplines. These are practices. These are business best practices that you just have to learn and apply and then understand, you know, strategically what the need, you know, what gap is your organization trying to fill based on its objectives. At a team about a year ago, we did some strategic planning, for example, and we came out with over 53 things. And the realization what I coached them up on was a best practice organization is probably only doing four to eight things throughout the year. So just know, you know, the focus strategically, it can really help an organization focus and that that's not an additional cost, no matter what size the organization. Excellent. Thank you so much Jarvis, Carol and then Lydia. I would identify where you think the biggest problem is and then go to that area where the worker bees are and try to understand what they're thinking of that big problem. And maybe you find that big problem on your Yelp reviews on your Prescani, but identify what you think and maybe your clients or patients think it's the biggest problem. Work on that. And then also identify some key people in your organization that want to fix it. And are the leaders, they might not be the leaders in title, but there are leaders within the organization and identify those and move it forward. And that's all free. Dr. Dunn, to your point, this is the most advanced technology you need most of the time. So just keep that in mind. I agree. I agree. Sometimes it's just back down to basics, just a pen and paper, really made a difference. Yeah, go ahead, Lydia. Yeah. Thank you, Jarvis and Carol for your input. But I just want to say into, you know, the Affordable Care Act made it possible for most hospitals, all hospitals actually, to become, go into computerization and embrace it to whatever extent they could afford to do it. But I think it's important, as we have said, is to find out the root cause. What is it that the hospital is lacking? What is it? What are the gaps? Where are the gaps? How can these gaps be addressed? There are gaps. What are the gaps in electronic health record? Are the gaps in just, you know, ground level? What is it? And as Jarvis says, you know, every hospital has strategic planning being done. And every hospital has a mission and vision statement. If that is not there, it can never be carried forward. So everybody voice matters. And I think if you are where you are, you need to speak up and speak up in a manner that it can be addressed. And, you know, you always have opportunities to improve everything for us patients because they are the target, not even the target. They are the ultimate reason why we are there. They are the ultimate reason why health care exists today, right? So we should have a compassion to that to improve quality patient care. And a conscience that is also very important. You can have, I teach nursing students, you know, nursing is, you know, we give the definition, but it is an acquisition of knowledge, attitude and skill. And I said, you may have knowledge and the knowledge is so much that you feel very bloated, but you may not have the heart, which is the, you know, the attitude, not the right attitude and skills it develops over a period of time. So all this is required for our patients to be safe, right? So that's what we need to do. We need to belong to an organization. If anything good has to come out, you can stand on the sidewalk and say, it's not my business. The administrator, it's yours as well as everybody's business. Right? So that's what I would like to say. Great, great point, Lydia. I mean, I wish we can spend more time. We only have about four minutes left. And there's plenty of really great questions that we have from our attendees or participants from how we apply to, how we apply our practices to family medical practices. How do we challenge the stereotypes of the front line of how they view quality department staff as theorists? These are really wonderful questions, and I wish we have additional time so we can tackle each and every one of them. But let's just close up with one final remarks. If I could ask one simple take home message from each of the panelists, if you can give me one point of our take your take home message or a nugget that you want to give to the audience, what would that be? I'll start with Carol and then Jarvis and then Lydia. I would go back to something I said earlier, and that is employee safety means patient safety. So we have to protect our physicians, our nurses, our staff and have it safe, then they can provide great care. Beautiful nugget, I completely agree with you. Jarvis? Probably going to break your rule on it, but so I've got a couple of quick take, I'll be fast though, but a standard approach to strategic planning and execution, implement a strategic approach to problem solving, whether it's lean or six sigma, it doesn't matter. And then last is keep it fun and keep it simple, you know, this should be something that attracts people and makes them want to engage. It doesn't have to be scary, intimidating or anything. Really great point. Thank you Jarvis for those nuggets. So I would say is teamwork together, everyone achieves more. If you want something to be achieved, you have to be in the game together. Keep it simple. People do not like things to be complicated, they cannot process it. Communication is the key to any successful program. Communication is the key for our patient safety. I would leave you with that. That's a beautiful nugget, Lydia. And my nugget would be that we all go through this together. And at the end of the day, we're all hospitals, there's thousands of hospitals around the world and guess what? Same everywhere. And so we've got to break that kind of ego that we all have and just share that learning. These infections, these things that are happening everywhere, let's talk about it. And I understand people are confident or proud of what they do. And there's a saying between cockiness and confidence and something called humility. That's the difference between confidence and cockiness. And so let's have the humility that we all make mistakes and we all need to learn from those errors and advance ourselves. I personally wish that we could stay longer with each and every one of you and answer these amazing questions. Just as a last touch base, there's a survey monkey out there for you to answer that evaluation and let us know how we can grow together. So thank you so much to all of our panel members from Jarvis, Dr. Carol, Dr. Lydia, and our hosts, the PSMF and Dr. Donna. Thank you so much, everyone. Thank you, everybody. And just for everybody that is in the audience, any questions that we didn't get to, we will be sending those out after the event and we will make sure that those are posted on our YouTube page along with the video. So thank you all for joining.