 Okay, great. It is 8 59. So I believe that by the time I'm finished doing our intro side, it should be nine o'clock on the dot. This is Ariana Langley, vice president of the patient safety movement foundation. Before I get started, I just want to make sure that you all can hear me. I think, Ed, when you're off mute, can you hear me? Okay. I can't. Thank you very much. Communications, it's aligned with our actionable patient safety solution number six today is June 28th, 2018. And today we'll have expert presenters, Dr. Steven Barker and nice and clear so that everyone can hear presenters. We will open up questions and answers at the end. Please feel free to chat your questions along the way. And we can always bring those up at the end. There is a chat box. The first 10 minutes, I'll be introducing the patient safety movement foundation and our actionable patient safety solutions, which we're calling our app by Dr. Steven Barker and Edwin Lawson. And then we'll follow with 10 minutes Q and a about patient safety movement. Our mission is zero preventable deaths by 2020. And so we say zero X, two, zero, two, zero or zero by 2020 and we believe that zero is the only acceptable goal because one preventable patient deaths in the hospital is one too many. The patient safety movement foundation is fostering new efforts and building on existing patient safety programs through commitments to zero. We're trying not to reinvent the wheel. We're trying to use the momentum and make as many. Commitments as possible. So these are the groups that can make who can take action. They're organizations, the patient safety movement foundation encourage, encourage us to make an online public commitment to improving safety. This can be an initiative that they're already working on, but can publicly share through our network of over 4598 hospitals across 44 countries. And so those organizations publicly share how they're saving lives and how many lives they're saving if they have the methodology to show. We have committed partners and these are nonprofits, professional societies, associations, advocacy groups, and we call them our committed partners and they sign a customized commitment to action letter. All of these are publicly available. You can find them on our website and it just encourages connections between all the stakeholders in health care that are working on patient safety. We work together and work on partnerships to align. The 3rd group that we work with our health care technology companies. This is a really important group for us because we believe that in order to improve patient safety, we must have open and freely moving data. And so we encourage healthcare technology companies, so med tech companies, lab companies, anyone who's creating patient data or can transmit patient data to sign a letter that we call our open data pledge and it encourages interoperability by removing barriers. Basically, companies agree to not block data or knowingly interfere or charge for that data connection. We have 83 companies who sign that pledge to date. The 4th group that we work with our patients and family advocates. We believe strongly that sharing stories is a really great way to get momentum and to encourage change within health systems. We also create resources. We have a mobile app called patient eater, for example, and we also utilize resources that have been developed by a lot of these advocacy groups like checklists for families that are going into the hospital. Just we call them apps in 2012. We vote on new challenges to appear on this list and everyone who's at that meeting gets about it and we vote on what the leading causes of preventable deaths are. And so you can see these are 2 or 3. So, for example, the CAUTI, CLABSI, SSI, VAP, and these are really good examples that can use to make sure that they really are doing everything that they can to improve safety. Today, we're talking about app number 6, which is handoff communications. And so our presenters today will be specifically talking about the role of handoff communications as it relates to patient safety and how we've seen improvements in that. Area. So, just to remind you how the patient safety movement is measuring our impact since we launched in 2012 and first started getting measurable results in 2013. We've seen a huge increase in the number of hospitals that are participating by making these public commitments to improve safety and then most recently last year we announced 4598 hospitals are participating in our work across 44 countries. And so it's really a good opportunity for whether, you know, here locally where we're based in Irvine, California or Texas or Brazil, hospitals are really rallying together and sharing how they're improving safety and learn from those hospitals. As I mentioned, also have the possibility if they are measuring C3 lives were saved in 2015 that jumped up to 6,571 and last year, earlier this year in February, we announced 81,533 lives were saved during 2017 and we really believe that we have to focus in on every single life. So we love being able to share these very specific numbers that hospitals are reporting back to us patient safety movement foundation. Dr. Barker, who will spend the first 20 minutes on some basics about patient safety about pass it off to Dr. Excuse me to Edwin Lofton. So, Barker received his bachelor's science and physics from Harvey Mudd College in 1967, his PhD in aeronautical engineering from the California Institute of Technology in 1972 and his MD from the University of Miami in 1981. He's reached the rank of tenured professor in both engineering from UCLA and anesthesiology from UCI UCI and University of Arizona. He chairs the department of anesthesiology at UC Irvine from 1990 to 1995 and then at the University of Arizona from 1995 to 2013. He's published over 200 scholarly work. He's now professor emeritus of anesthesiology and aerospace engineering at the University of Arizona. Dr. Barker has been involved with Massimo Corporation, a world leader in medical technology since its beginnings in 1990 and he now serves as Massimo's chief science officer and member of the board of directors. Dr. Barker is also actively involved with the patient safety movement foundation and serves on its board of directors. In 2015, Dr. Barker received the lifetime achievement award from IMPOV, that's the innovations and applications of monitoring perfusion, oxygenation and ventilation for championing the development of vitally important monitoring technologies and assisting associated testing. In 2016, he received the JS Gravenstein award from the Society for Technology in Anesthesia for his visionary understanding of the role of technology in anesthesia care and lifetime commitment to patient safety. Also in 2016, he received the distinguished alumni award from Harvey Mudd College. He's the senior vice president of integrated and acute care services and chief nursing officer of Parish Mudd. He's a progressive senior health care executive who cultivates a culture of healing and person and family when led at the medical center's efforts to become the first in the nation to earn the joint commission's integrated care certification under his leadership, Parish health care has maintained an impeccable quality in patient safety records, including our five star Parish health care. He's also a member of the world renowned Mayo Clinic that Lofton's community service includes serving the South East and Truven advisory committee, board member of the state care group advisory boards for youth colleges of nursing, board chair of the Space Coast chapter of the American Red Cross, board member of the Brevard County Big Brothers and Big Sisters and serving as the United Way of Brevard employee campaign manager. Lofton earned his master of business administration degree from East Carolina, he's a fellow of the American College of health care executives and a member of the American organization of nurse executives. So we are so pleased to have these two amazing speakers with us today. So I will pass it on now to Dr. Steve Barker to take a step back about me. Then you ever wanted to know, but one thing I'll just that I was originally an aeronautical engineer and then went into anesthesiology. So that gives you a little bit of a hint of what my approach is going to be. I like to combine the two. I'm going to give you a little background on handoffs. Our committee has done so far our work group. And then I'd like to get very much like to get your input with that in mind. I'm actually going to try to stay below a handoff. Is it a is it a coordinated carefully time precision transfer of care from one provider or health care team to another? Or is it can be I like to use graphics by the way I should warn you it can be either one and let's talk about what what distinguishes one from the other. We'll start with some definitions. They're simple and they're obvious. So I'll go through them quickly. But I want to make sure we're all starting at the at the same point. A patient handoff between caregivers is a transfer and acceptance of care response, effective communication of patient specific information to ensure continuity and safety of care. And I will stress over and over again that the receiver is an active participant. The handoff process involves senders, the caregivers who are transmitting the patient information and transitioning care to the next caregiver, who are of course the receivers. Those caregivers accept patient information. They must understand it and accept the care responsibility when clinicians failed to properly communicate the patient's condition, either communicate or understand. The therapies or actions taken or planned or any other special consideration about the patient, the agency of help eating root cause of the required ingredients of a proper handoff. Well, here are a few and this is this is my list just for starters. Why is the patient in the hospital? What's the chief complaint? What is the problem list? What are all of the men to this hospital admission, but they might become in part important during the hospitalization? And there've been a lot of handoff at detailed description, complications have occurred. What is the discharge plan? How are we going to get this patient home? That's kind of the should say to the receiver here are my recommendations here is what I think and what I suggest. And of course, the receiver not only receives that, here comes my orientation warning, warning. It's a list and we check this list frequently, right? We check it and it's a list. Hey, it's a checklist. Of course, it's a checklist for forgetting stuff. Why do we forget stuff? Increasing complexity. That applies to flying airplanes and handing off patients and pay the other extra ingredient that often results in these disasters is what I call distract. Maybe it may just be the noisy environment in the hospital ward where you're trying to accomplish the handoff. Maybe there are some distracting events. And these are the things that kind of make you skip stuff receiving the handoff information and lead to disaster. Aviation has learned this in spades. Here's a checklist for starting up a 747. This doesn't get you in the air. It just gets you to the point where you release the brakes and start your taxi. Obviously, nobody could remember all of this every every day and nobody would even try. It's the same in medicine. And I'm not the first to have made this argument, obviously. My hat's off to Dr. Atul Gawande, an endocrine surgeon at Brigham and Women's. First, he published this book, the checklist. We did a follow-up study where he has shown has actually caused reductions in surgical morbidity and mortality. That's quite impressive. And my hat is really off to Atul. I've had the opportunity to talk with him for actually getting surgeons to use this checklist approach. So what can we do? Again, going back to aviation for an example, if you don't use a checklist, and this is my one cartoon far side for this talk, the fuel light's on. Frank, we're all going to die. You need to be sure of what you are hearing, what you are saying, and that you understand it. Here's an example from aviation. This is the only one I'll use today, but it's dramatic. You've all flown in these high performance. When these airplanes take off, they're weighted the airplane at about 450 miles per hour. But the plane has to take off at about 120 miles an hour. And that wing that's designed to support the plane at 450 has to generate a lot of extra lift with a speed of only 120. How does it do that? By putting down these flaps on the back of the wing, and you can also see the leading edge slats. They have to be made for takeoff before takeoff. Otherwise, the plane would need so much airspeed to lift off the runway, which you don't have. It's part of the pre-takeoff checklist. In this flight in 1908, not that long ago, why did they miss it? We'll never know before death's only 18 survivors. So 18. I'm not going to read all these to you, but you can see that there are four categories of senders, the emergency department, the hospital ward unit, the operating room, and the paramedics, the ambulance. And they send their patients to all of these other receiving. And for each of these sender-receiver combinations, you need a handoff checklist. We started in 2016 in our work group with these six, and we actually, 17, we added four more. So we've got a total of 10 of these checklists I'll develop now. I will show you just three, but you can study these at your leisure. You will have access to this slideshow. Here's the handoff checklist for emergency room to the operating room. This is one that I wrote. And you can see it kind of has a logical order, starting with the cheap complaint. Why is the patient coming to the operating room? What is the plan? The special anesthesia needs, et cetera, et cetera. Now, this is one of the handoffs that has to take place in some of the, some of the manicure advice on that. Here's another handoff. This is more leisurely handoff. There's usually not an intense one that can take place at variation, or it may be at the patient's bedside. And so there's a high incidence at the time of the handoff. And here's a third example, which is another one that's under intense time pressure. And that's basically from the ambulance, the paramedics, to the emergency department. And we kept that in 10 ABCDs, airway breathing, circulation, and drug. Now, 10 of them, there are at least 18 to be done. In fact, the number is more large. Are there any of these that can be combined? Are there any that, frankly, can be eliminated that we could do without? That's what I'd like to discuss. What are the next steps? What do these checklists actually look like? Where are they physically? Are they 5x7 laminated plastic cards in the pocket of your white coat? Or are they something else? And I'll show you an idea, kind of an idea on that. Some of the checklists are time limited. Here's an example of, rather than a laminated plastic card. Maybe it's on your iPad or your iPhone. This is just a very crude iPad. I want to stress, receiver, these checklists are not forms to be filled out. And I don't want people to have that impression that we're creating more paperwork. It's quite the opposite. But if we did it on iPads, they might be able to enter data. The next item on the checklist might depend on the answers to the previous item. So there's a logic to it, not just a one-dimensional list. It can be updated either by the standard or the receiver and the updates would appear on both. And that's something very desirable. As I said several times already, the receiver is not a passive participant in this. And it would, as I said, connect with the electronic medical record, get updates on labs and everything else. How about voice recognition? A. Siri or A. Alexa? Why is this patient here? Sure, why not? And I think that's... In going to the electronic and digital versions of these checklists, we are limited only by our own image. I want us all to think of these as more than just pieces of paper or plastic cards. It would be probably different for each checklist. We are not alone. We, the patient's safety movement, are not alone in tackling handoff communications. We had an excellent meeting of the Anesthesia Patient's Safety Foundation last fall, the Stolkin Conference, which was devoted entirely to handoff communication flowchart. Now these are just the perioperative ones, perioperative holding room, the room that the patients are waiting in before they go to the operating room. Every one of these white arrows between all these boxes is another handoff. So APSF is working on that and plan to continue that this year. The Joint Commission is also actively involved, not only in their... I want to point out one thing from this newsletter that I think was a very good point. Common problem in the information and the receiver. That, I have to agree, is a key part. Sixth time I've said this, the receiver cannot just be a pass ending the communications. And the receiver wants more detail or doesn't understand. I don't think all of these are universally applicable, but it's worth reading these suggestions. Conclusions are, before I hand this off to the next provider, handoff communications are not rocket science, but in stressful environments like we work in every day. It is very easy to forget stuff. Same as those design aviation. We forget the obvious stuff because there are about 20 different inpatient handoff types. As I said, we have developed preliminary versions of paper or cards. Some may be better off. Institutional variability is definitely appropriate. Different patient populations, different procedures, different protocols. One size fits all. There will be at least a minor group of pilot programs actually implementing this. Let's try these handoff procedures and checklists in some real clinical settings. To my colleague and friend, Edwin Loftin, who's going to telethical center, which is an outstanding picture of the F-22 Raptor, my favorite airplane. Thank you very much. Edwin, I hand it off to you. Well, Dr. Barker, thank you so very much. An excellent background in setting the stage. And as Dr. Barker said, what I'll do is go through the actual implementation of one of these checklists. I've had the privilege of working with Dr. Barker and the Patient Safety Movement Foundation and the subgroup on handoff communications. And I've developed the current handoff for emergency department to inpatient medical surgical units. So next slide, please. So first, a little bit about who we are, Parrish Medical Center. Parrish Medical Center is located in an area called the Space Coast of Florida, Brevard County. We look out our window and we actually look at the launch pad for Kennedy Space Center. So as Dr. Barker said, handoff communication may not be rocket science, but actually rocket science needs checklists and appropriate handover and handoff communication. It's interesting when we listen to the countdowns from Kennedy Space Center and their attention to detail using the checklist of every component of safety until that launch actually occurs. We are a standalone not-for-profit community hospital. We are the largest employer in our part of the county at 1,200 care partners and volunteers and physicians. And as Arianna said in introductions, we are a member of the Mayo Clinic Care Network. We're very honored in that we were able to build a replacement facility in 2002 that is based on the principles of healing. So we've created a physical environment that is focused on person and family-centered care. And as we approach patient safety and safe practices, our philosophy and what we believe should be everybody's is to make sure that the person and the family are part of that handover and that transition. So we spent quite a bit of time over 2017 looking at the existing patient safety movement's handoff checklist and began researching and applying principles behind our development of the ED to Med Search handover checklist, which is what you see before you. We've used several evidence-based practices that Dr. Barker referred to in our development. One is we have the background of FR situations, background assessment and recommendations. We also looked at the research done by Tull Gawande and others. We use the eight tips of recommendations from the Joint Commission. We use literature from AHRQ and the National Patient Safety Foundation to come together and say what information is critical for zero harm in that transition of care. And again, like Dr. Barker, I'm not going to read every component of this for you, but as you can see on screen, we covered very, very specific components within there. A couple of things to point out is really looking at the recommendations and the last thing. The next to last thing you see is a statement that says, my story. And this is intended as we are doing a clinical handover in the care of a person. We have to remember that it's the person that we're partnering and care with. We're not here treating pneumonia. We are here partnering and care with Sam. So who is Sam? Is Sam a 26-year-old athletic football player in college and has a sports injury that may be ending his career? Is Sam a 88-year-old great-grandfather of five who all he wants to do is be able to go home and have his great-grandchild sit on his lap one more time? That is a driver in not only the clinical care, but in our approach to safety and our connection with the person and the family in making sure we do that. The very next item is face-to-face. The evidence is very, very strong that when three faces are together during that handover and the use of the checklist, that's where zero harm can be achieved. And those three faces are the sender, the receiver, and the patient or the person in the bed. We have to include them in the conversation and we have to use language in that checklist and that handover that they understand so that they can, in a very transparent manner, ask us questions, understand what their plan of care is, and have input into their plan of care. So this was the checklist that we created. During this timeframe, I also did some data analysis at Parrish Medical Center of what could our potential impact be. So from calendar year 2017, I actually did a review of event reports and I used a very broad definition of harm or injury and we had 48 events that either were harm or injury or could have led to. And I used definitions, everything from missed medications and correct medications, missed information if a patient fell during transition or if there was a rapid response call within 12 hours of transfer, those types of definitions. So we had 48 events. One is too many in our point of view. So then we went to implementation. Next slide, please. The flow chart you see here is the methodology that we have chosen to use in that handoff. And the checklist is in the background providing the guidance for information, making sure we're not losing anything. But this flow chart is that literal movement of information, of knowledge, of person and of materials from the ED to the med search floor. And as you see in the bottom part of that, the person is in the center of everything that we do. We have now implemented the, this checklist and an associated process with this flow chart since May 6 of this year. So we're coming up on two months of implementation. And last week, I'm sorry, earlier this week, I did a data run of events during that time frame and knock on wood, whether it's by dumb luck or what I hope is more true by intentional use of evidence. Based practices, the checklist and person and family centered care during that this trial period, we have had zero harm at the bedside from transitions of care from the ED to med search. Next slide, please. So again, that's sort of the summary of where we are. Now, in addition to at this point in time having zero harm, we've seen actually several side or additional benefits come to the organization by use of this flow process and handle checklist. And that is efficiencies and operations. We've seen a 30% reduction in time from the patient being ready to move out of the ED, having a clean bed until the patient actually gets into that bed. That 30% reduction opens up beds on the inpatient side decreases lags and holes in the ED. And again, even just within itself at that point in time decreases opportunities for errors during holds or misinformation within there. So our early analysis is the handoff, the evidence based handoff checklist does allow us to move to zero harm by 2020. So that's sort of where we are in our implementation. Dr. Barker, I appreciate any input or challenge to the process and look forward to questions and conversation. Great to have both you and Dr. Barker provided with some background and then actual implementation of an example of one of the checklist and actionable patient safety solutions. So we'll move on. Dr. Barker, did you have any comments before we move on? I just want to thank Edwin for an excellent presentation and this is exactly the kind of pilot implementation program that we learn from each one of these and make changes and refinements and make it better. You're very welcome. And again, this is what I think whatever organization has the opportunity to do and what our plans at Pierce Medical Center are is probably after another two months of truly hardwiring this process. We've already begun looking at how do we edit, modify this and adopt the other checklist for the additional transitions of care when we can see this kind of improvement in zero harm for one transition. Like you said, Dr. Barker, there's at least 20 if not more other types. It's our obligation to carry those forward as well. So that you have an opportunity to ask questions. I do see that there is one question that we've noticed on the chat so we can address that one first before we unmute everyone. This question comes from Linda Chansey. We've tried processes where the nurses go to the other nurses unit to hand off where the patient with the patient and family involved, but there's a desire to change the telephone handoff with a transporter that's in quotes pushing the patient to the floor. That's actually a great question and was was was and is one of our biggest challenges as everybody I'm sure in the webinar is very well, very well aware that a nurse leaving the unit is a challenge. It's a challenge for the ED because of other patients coming in. It's a challenge for the med surge unit because of assignments and what we did in developing this process is I had the entire leadership from clinical coordinators, managers and directors from med surge and ED together. We went through a very detailed lean six sigma to may it process. We kept the focus on zero harm and we had to culturally work through how we would do that and what we ended up with is a shared approach. We now have sometimes where the med surge nurse will come to the ED and get the patient. Sometimes the ED nurse will go upstairs. But what we've done is eliminated the majority of time required for that face to face. The face to face is really an acknowledgement of the patient in the new location and a warm handover with the person in the bed seeing that clear communication between the two nurses. The majority of the information, the checklist information is actually built into our electronic health record or our EMR and as our process goes through its system. Once the bed assignment is made that trigger goes to the med surge nurse that med surge nurse then looks up the EHR reviews the information. If they have any questions for clarity, they will contact the ED nurse. They will have that clinical clarification via phone. And then again, the face to face handover is a warm person centered approach. Thank you so much. This kind of leads into another question, which I think you may have already partially answered, but it's from Mitchell Goldstein and he asks, could you comment on EHR integration of handoff communication? I think both Dr. Barker and I can do that. As we, and I'll start with, we all have different EHRs, whether it is Surner, Epic, Meditech, whatever it is. I would beg that we need not get hung up in the integration, but instead how do we use clinical information that's already collected and already existing within the EMR and pull it to a common place so that in the review of the checklist in review of the preparation for handover, the sender and the receiver have a single source to look at and that's, we're working on that. We've got a pretty good process right now. It can be refined a little bit. And when you have that pull of information, it does not require double entry. It does not require rework. But again, the checklist and the process of the, of the handover is the foundation of how we began sorting and pulling that data to a single location. I'm glad you could join us. That one slide I showed, which was, I didn't spend a lot of time on that, but the idea was that, yeah, this would be something that was wirelessly connected to the EMR. And the pertinent results for this particular handoff would, would automatically show up in any results that either the sender or the receiver wanted that were not automatically showing up. They could demand, ultimately verbally, hey, Alexa, show me the MRI results, you know, that, that sort of thing. I think the sky is a limit on this now that we have integrated EMRs. And I, you know, I have my, my share of objections to EMRs, but the end result is going to be great because for the first time it ties all the different parts of the medical record together into one file. And you don't have to go to radiology and then back to pathology and then, you know, back to the clinical lab and it's all tied together. So it should all be accessible during the handoff. One other short comment I wanted to make, I'm a, I'm an anesthesiologist. So obviously my world is the operating room. I'm used to totally accustomed to handoffs being face to face in person. I got to admit, I have problems with handoffs by telephone. And I realize that in the real world, that's going to be at least partially necessary sometimes unavoidable, probably. But boy, there's so many advantages to face to face. And maybe we can learn from that and even make the telephone handoffs more like face to face by having do, you know, do them on something like Skype where you're actually looking at each other. And facial expressions are worth a lot. So I just wanted to put in a plug for that. Thanks. Great. This is Ariana from the patient safety movement foundation. So we have a monthly newsletter that comes out at the beginning of each month. So you can look forward to on July 2nd. If you subscribe to that, seeing a spotlight on handoff communications from UCI and parish medical center UCI talks about incorporating their handoffs and their EHR. So watch for that. And if you haven't subscribed, head to our website and join it's called follow our progress and you'll join our mailing list and you'll get that resource. Okay, we have lots of questions here on the chat room. So before we open and unmute, I'm going to continue going through some of these questions. We still have a lot of time. So how one question from us is actually used as intended and that staff aren't just science. That's in the culture. Great question again. From my perspective, that is in the culture of the organization. The organization and the individuals have to be committed to outcomes of zero harm. And if we're going to be committed to outcomes of zero harm, we have to use the performance improvement tools that are evidence based and drive that process. Healthcare is finally learning after many, many years that when we are person centered, when we are person dependent, we make errors just like Dr. Barker shared in some of the historical information, whether it be in the area industry or whatever else is when the person is there, we can make a mistake. When we use those evidence based systems such as checklist, that's when we can approach and achieve zero harm. Also, the existence of the checklist and the flow processes need to be a natural part of the EMR, a natural part of the visual of that planning for an actual transition in care. So we have it both in the EMR, we've got it hard copy and we review it on a regular basis as part of an expectation. That's a tough question to answer. Aviation obviously learned it the hard way and they are religious about it now. They do not ignore their checklist. We would obviously want to use both a carrot and stick approach. I like carrots a lot better than sticks. The carrot is that it's going to be best for the patient and you know that. The stick frankly is, I hate to sound like big brother, but, you know, we can listen to handoffs and audit them. It's like all these procedures that are being used to audit compliance with hand washing in the operating room. To coin George Orwell, big brother is watching you. Like I said, I like the carrots a lot better than the sticks, but yes, we do have to make sure that people do apply with what we're doing. And if they don't think they should, we want to hear reasons. We have a question from Kathleen O'Neill and I think it's posed directly to Edwin. So it says, how does the pilot hospital, so I'm assuming that's Parish Medical Center, have pre and post data on the length of time for handover using this new process? Yes, and as I stated earlier, we've seen a 30% reduction in that time frame. So industry best standard for clean bed assigned to patient in the bed, best practices at 30 minutes. We were not even near that world. We were greater than 60 minutes for that time frame, more in the 65 to 67 range, and almost immediately upon the implementation of this process and the checklist, we dropped that down to 40 minutes and are working on that timeframe now. So we've seen significant improvement in efficiencies. A new process with respect to handover communication. I think the answer is the potential is there. As I reported, we had 48, and again, I use a very broad term of potential harm. We had 48 events in the calendar year of 2017. Since this implementation, we have had zero events to date. And because of that, we will have the ability to intensely prevent those harm events from happening. Come studies, that's always holy grail. Is there a study that shows that your change has affected as improved outcome? Those studies are coming. And as Edwin said, we're going to see the results. I think the things I've read in the Joint Commission newsletters make it clear that the outcome of this will be positive. But we can't wait for outcome studies to be implementing this. I'll just remind everybody there are still no outcome studies showing that the use of pulse oximetry in the operating room improves mortality. And yet we wouldn't dream of doing surgery without a pulse oximeter. Great. So we still have plenty of questions coming in, so we're not going to unmute just quite yet. So keep the questions coming in the chat room. We have a question from Christina Hayes-Camp. She asks, how would you suggest that a hospital or unit of providers implement, measure, and sustain use of a handoff process in order to truly change the culture of handoff communication? I'll start, and Dr. Barker, please. For me, from my perspective, it starts with a organization's commitment to a culture of safety. The commitment to a culture of safety requires very strong, visible leadership involvement. It involves a culture that listens to the frontline staff members. It involves a culture that honors and respects the input from patients and their families. And a culture of safety requires a commitment to zero. For healthcare for years, there was pretty loud voices that zero was impossible, but we've proven. I mean, Arianna's first slide where we've saved 81,000 lives just this past year, zero is possible. And when we believe that, and we put this, and here's my soapbox for a minute, when we put the science and methodology of performance improvement, and we use Lean Six Sigma into the process, that's when a unit and an organization can intentionally implement handoff checklists and processes that achieve zero. I'll just add that this culture of safety issue, it is also one of the key emphasis areas of the patient safety movement, establishing the culture of safety. And I encourage all of you who haven't had a chance to yet to visit our website and look at all 16 of our actionable patient safety solutions attacking these different problems, one of which is handoff communications. And yeah, it's culture of safety, right. Perfect. We have another question from Lindsay Schwartz. She asks, what are some other measures of success or metrics utilized? Incidents reported on handoffs or patient satisfaction? Actually, I am tracking those items. I am looking for HCaPs data, which that obviously is lagging. I have seen, and I don't want to give numbers yet, in our vendor, I am seeing some early indicators of improvements in improved communications and improved transitions of care. We are looking at also indicators related to staff satisfaction and staff trust in each other. As I described, we've taken several months in building the team between the ED and med surge, and we've seen walls come down, virtual walls come down between those two teams. And I hope to see that as a measurable component in our next in the NQI or in satisfaction survey. A feature we've discussed of these handoffs that hadn't occurred to me is that in quite a few of them, not all, but in quite a few of them, the patient and or the family members can and should be participants. You can learn things from the patient that you can't learn from the doctor. Zeena Hayes-Camp, she says, in aviation, are takeoff checklists universal? Should there be a universal handoff communication method in medicine to ensure maximum benefit? Well, I can start with the first answer because the short answer is basically yes. Nobody in their right mind would take off in any airplane from a Piper Cub to a 7777 without going through a pre-takeoff checklist. Because when you push that throttle forward and pull that stick back, it's your life that's on the line, which is one place where the aviation analogy sort of breaks down a little bit. But yeah, the answer is yes. So why shouldn't it be universal in medical care and specifically in handoffs? I completely agree. And there is evidence-based practices such as SBAR, which provides us that starting point for universal process for developing and utilizing checklists and handoffs. And would rather ask their question by speaking. Can you hear me now? Okay, so yes, actually we use the IPAS and the research within the IPAS in developing our checklist. And we made an intentional choice to use SBAR as the format, but there are elements of IPAS within the both flow chart and content that we used. So I think making sure that we use all relevant evidence-based information is critical. I'm going to just do a quick shout-out newsletter, which is virtual. Our July issue is focused on handoff communications and does highlight successes from UC Irvine Health and Parish Medical Center. It will be released on Monday, January, excuse me, January, July 2nd. Our next quarterly webinar will be related to central line-associated bloodstream infections. We'll be announcing some speakers soon, but it's several, it'll be two speakers, hopefully, that will be speaking about how several units within our here at UC Irvine Health. You can request your invitation today. There still are some spots open, so we hope that you'll be able to join us there. And then our seventh annual World Patient Safety, Science and Technology Summit will be held January 18th and 19th at the Hyatt Regency Huntington Beach Resort and Spots and Registration Open soon. So we thank you so much for your... Thank you. Thanks, Edwin. Thank you all. Bye.