 All right, we're right at 730. Good morning everybody and welcome to our webinar today. We're going to be talking about sharing accountability for patient safety today. I'm Donna Prosser. I'm the Chief Clinical Officer here at the Patient Safety Movement Foundation. We've got a lot of information to talk about today, so let's go ahead and jump in. We're going to talk about the culture of shame and blame that's all too common in healthcare and how a culture of shared learning and collective improvement can impact patient safety. And then we're going to discuss how organizations can develop a just culture and how that can reduce adverse events in healthcare. As you can see, we are able to offer continuing education credit today to nurses, physicians, and pharmacists. Respiratory therapists also may be able to apply this credit depending on your licensing agency, so please find out from your agency about that. We offer this credit through MedStar Health, so if you registered as a nurse, a physician, pharmacist, or respiratory therapist, you should receive an email from MedStar Health with the information about what you need to do to collect your continuing education credit. So be looking for this within the next few days. It can take a few days for them to send it to you, but definitely within five to seven days you should have your CE credit for that. We are also able to offer continuing education credit for healthcare executives through the American College of Healthcare Executives. If you would like to receive that credit, you can go ahead and log that into your account. We are also offering certified professional and patient safety and board certified patient advocate continuing education credit. If you registered as one of those, then you'll receive a continuing education certificate from the Patient Safety Movement Foundation. And then finally, we're offering CPHQ credit, and you will receive that credit in your NAHQ account from them. So let's go ahead and oh, I'm sorry, one more thing I need to say is that there are no disclosures from either any of the panelists today or from our planning committee. So today we are so excited to welcome Beth Beswick, Beth is the past vice president of Human Resources at Carter at Healthcare. Also, Mark Graydon, who is a management consultant, a coach, a speaker and a podcaster and an advisor. He's been an author of several books of which I have many back here on my shelf. So we're so excited to have Mark with us today. And thank him Gomez. Thank him as the founder and CEO of Signia Healthcare. She's also the president of the Association for Nurse Executives in India. So welcome all to our panelists. And I'm going to ask everyone to just briefly introduce yourself. Beth, can we start with you? Sure. As Donna said, I'm the retired vice president of Human Resources at Carter at Healthcare. And I had the wonderful experience of implementing just culture in 2008 in our organization and having the learning experience of going through that over a 10 year period. And it is truly a culture change that is takes time and is not easily done, but wonderful benefits once you do that. Excellent. Excellent. Mark. Hi. Thank you, Donna, for allowing me to participate today. My background is in industrial engineering. So I started my career in a totally different realm in manufacturing, but there are lessons, thankfully, about leadership and culture and improvement that are transferable in the healthcare. I've had the good privilege to work in healthcare since 2005. I'm really, really honored to be here today. Great. We're honored to have you as well, Mark. And thank you. Hey, everyone. Good morning. I'm very happy to be here. And thanks Donna and Patient Safety Movement Foundation. And I'm very honored that I'm being a panelist along with Beth and Mark, you know, veterans. And I'm a nurse by profession and I had been one for over 38 years had been website to the group nursing director. And now I have my own business. And I'm also the president of Association of Nurse Executives India. Now the underlying reason for all these things is patient safety. And because of that passion, I think I got connected with the foundation and I'm hugely, you know, attracted to the reasons for which patient safety movement foundation work. And we hope that together we are going to learn because culture takes about 30 years to change. And we are all trying together to see what, how can we at least change the climate if not the culture. So thank you so much, Donna, for this opportunity and look forward to having a great session. Thank you. Wonderful. Wonderful. Thank you. All right. Well, let's go ahead and get started. I'd like to just very quickly go, you know, ask each of the panelists to briefly discuss your thoughts on, you know, where we're at right now in healthcare. Unfortunately, we do have this culture of blame and shame and so many organizations. Beth, can you tell us what that, what that means? Sure. And you'll find many definitions out there. But I think first it's important to understand that in healthcare, our general focus is on finding what is wrong. That's what we do. We diagnose patients, we diagnose what is wrong with them. So our natural tendency and offshoot from that is to when something goes wrong is to focus on the individual instead of looking at other reasons that the event occurred. So I think if you look at any definition, you'll find that the focus on individual blame is eliminated. And that's so important because when you begin investigating events, you'll typically find that many, many events are due to system issues and not individual behavior or system issues that influence individual behavior. Then the team always shares accountability. Everyone has a seat at the table and everyone partners and share responsibility for outcomes. And then thirdly, the last element you always see is that there's open sharing of experiences and everyone is able to learn through those. Excellent. Mark, you've been working in the lean improvement space for a long time. Where are the parallels here? Well, I mean, I think there are great parallels. I mean, I'll add, you know, in addition to what Beth said, you know, as an engineer, we're driven to focus on problems. And I think part of the training and the education and the mindset focuses on what happened and why and better yet, you know, being proactive and not just being reactive, you know, designing systems that set people up for success. I often think of my friend, Darrell Wilburn, who worked for Toyota in North America a long time. And Darrell says it beautifully, and this is burned into my brain, that it's a leader's responsibility to provide a system in which people can be successful. A leader's responsibility, which is different than some of the language we hear sometimes unfortunately of, well, we're going to hold people accountable. That's the blaming and shaming sort of language. So, you know, I think there's a strong culture of not blaming individuals for systemic problems in the Toyota production system or the lean management system. I think there are lessons to be learned from that. Great. And thank, and this is not a United States problem. This is a global issue. Can you tell us a bit about your perspective on India? Yes, definitely. As you said, it's a global problem. And though just culture as a word, it is very well known across many healthcare systems. But the word, the shared accountability, as Mark said, you know, we are trying to ask first whenever there is an event or there is a deviation. The first question to ask is, who did it? And we don't ask what went wrong. And we are very quick in making the judgment. So when I do trainings and when we do RCA, usually a pattern that I see is that we have already decided, the verdict is already out, that what you are supposed to come to the fifth, you know, Y pattern is usually the person. And the Kappa usually results in saying, you know, counsel the staff and, you know, send for training. And these are the probably the least influential, corrective action one can have if you look at the hierarchy of, you know, corrective measures. So this is something that we see it here. And I think finding a person to blame is probably faster. And you can say, okay, case closed. But getting a multidisciplinary team to come together, to have the shared accountability, to discuss, to say, how can we improve the system, the process? That is a little bit of difficulty because many, you know, leadership might think, you know, I have a risk manager, I have a patient safety officer, I have a quality manager, I have a chief of nursing, I have that, they are supposed to be coming together. But the endorsement from top down is very, very critical. I mean, this is what we are experiencing. How do we create an environment? It cannot be created unless and until the leadership is committed to that. You know, that's what, you know, Mark was referring to. And I totally agree with you, Mark. Yeah. Thank you. Thank you. Well, Mark, tell us how this culture results in medical errors in the first place? Well, I was surprised. You know, I was eye-opening when I had the opportunity to start working with healthcare organizations in 2005, different organizations where you start seeing common patterns, the language of blame, you know, jumping to that conclusion, being an individual problem, who messed up instead of understanding why systems allowed the error to occur, for example. The naming, blaming, and shaming, like that phrase is so prevalent because that behavior is really prevalent. So there are common backgrounds. W. Edwards Deming, the famed American, we'll call him a quality guru for lack of a better label, he was deeply influential on Toyota. And he was also directly influential on people I would, you know, many considered to be the paragons of the modern patient safety movement, including Dr. Lucian Leap. And as Dr. Leap testified and said to Congress, the single greatest impediment to error prevention in the medical industry was that we punished people for making mistakes. And, you know, there's, I think, an understandable dynamic there of when we punish people, that drives mistakes underground. Survival instincts drives people to hide or cover up problems. And when we don't know what the problems are, we've got no hope in understanding what caused them in the name of preventing recurrence. So I mean, I think that's the single biggest cultural dynamic, you know, like you were saying, thank them, it's faster to leap to blame in individual. And on some level feels good, I would argue, there are evolutionary traits that drive us to pass blame toward others. It feels good. It's a human tendency that doesn't mean it's effective. Yes, it's a human tendency in every industry, not just healthcare. Right. And so I think being aware of that is the first step to catching ourselves if the blame language was about to come out of our mouths to try to stop it. And I look, I'm not perfect on this. There are times I catch myself having the thought of blaming an individual and I try to catch myself and stop myself and go back and think, again, why was the system not so robust as to prevent the problem from occurring? In a way, I mean, Dr. Atul Gawande writes about this in his books about checklists and errors. Robust systems prevent a good professional from having a bad day that could ruin their career, not to mention the harm that could occur to a patient. All right. Well, Beth, I wonder if you can, you know, talk to us about, you know, what is a just culture and what is shared accountability and what are the two features there? Well, there are a number of features and it can sound a bit complicated, but it's really not. And, Mark, thank you for your for your summaries about blame. I mean, I remember when I first heard Lucian Lee, the Institute of Medicine, the study on 100,000 lives, and I was just stunned at that. I said, we've got to do something about this. And then not too much later, I began to learn about just culture and shared accountability. And I went, aha, finally a system and a process and a way to make a difference in those numbers. You know, I started my career as a staff nurse and in intensive care became a nursing director and then went into HR. So I saw the problems, you know, on the ground that the blame created. And it was just a disaster. But, you know, key features that you'll find in just culture and shared accountability is you have to create a learning culture. And it has to be from the top to the bottom. Everyone in the organization has to understand that there is risk everywhere. And it's not just individual risk, but it's also at the organizational level, as Mark was talking about. And that the organization learns through constantly reviewing events or processes and near misses and near misses is a term you'll hear me use. Because a lot of times events don't happen, but they get close. And if we're looking for those, we can learn from those to keep an actual event from occurring. That leads to designing safe systems. And that takes a lot of work, a lot of analysis, a lot of objective thought process. You have bringing people in, as you do in lean, to people who are not familiar with the system and say, what, what doesn't look quite right to you. And you get a lot of good input from that. But look at your policies and procedures. You know, sometimes you'll find that you have conflicting policies or you have informal processes that staff use that are not written down anywhere that are right for some sort of event happening. So constantly looking at your systems and designing out error is critical. Creating that open and fair culture where staff know that blame is not the immediate outcome of an event. As Mark said, they don't hide things because that's exactly what happens if the finger of blame begins to be pointed, people just go underground. So that sense of justice and knowing that a fair investigation will be conducted makes a tremendous difference. Staff are more willing to report. They're more willing to coach each other. And they understand that they will learn and help patients when that culture is developed. That, of course, goes back to eliminating the focus on individual blame. We've discussed that. Something else is not letting outcomes dictate accountability processes. And when I say that, I mean, just because there's a bad outcome, that the only thing we look at is that person or that particular event. If you go back and we had a question in our event reporting and investigation tool that says, what is usually done? And you go and you interview other staff and you find out everyone else is doing the exact same thing, but no one has had a bad outcome yet. So you have to go back and engineer that out. And then managing behavioral choices. In our language in just culture and shared accountability, we acknowledge that there are three different kinds of behavior. One is human error. It's a slip or a lapse or something. It just happens. An accident. Then there's at risk behavior where individuals are choosing certain behavior, but they may have a mistaken impression that it's not high risk. Nothing will happen. They've done it before. And then there's reckless behavior where there is a conscious choice to do something that can cause harm. And just a quick note about that is that when I started learning about just culture, I started looking at my own personal behavior. And I realized that every day on the way to work, I put my lipstick on while I was driving. And I thought, you know, this is a really bad idea. I've done it dozens of days, hundreds of days, and nothing bad has happened, but it could. So I need to stop that. So it's all about managing those choices and doing it ahead of an event instead of buying. Excellent. Excellent. And then you had some other slides you wanted to share from North Carolina. Yes. Yes. Thank you. And this is, I know it's very difficult to read this, but it is available on the North Carolina Board of Nursing website. This is something that they developed in 2007 and have been using ever since then. It is a matrix that allows them to walk through an event at an organization. An organization will report an event. The vertical axis has types of events that occur. The horizontal axis is divided into the three kinds of behavior, human error, at-risk behavior and reckless behavior. And there are scores, if you notice, there are numbers across the top. And they will evaluate an event and create a score for the event that happened. And it looks at everything from general nursing practice, levels of experience, policies that might have been involved, decision making, and then ethics or credibility, accountability issues. And not only do you walk through that through that as an algorithm and create a point or a score on the next backside or the next page. Donna, do you have that? Yes. You'll see they evaluate what they call mitigating factors. And you check all that are identified, like policies or procedures are unclear. The individuals worked in excess of 12 hours out of 24 or 60 hours to meet agency needs. That influences someone's performance when they're tired. And then there were aggravating factors that are very serious. Someone took advantage of leadership position. Someone knowingly created risk for more than one client. And those either for mitigating factors use some track points, for aggravating factors you add points. And then you fall into either no board consult required, board consultation required, and then board report required. If you want to look at this, you can go to the North Carolina Board of Nursing website. Look at the, I believe it's employer complaint or disciplined page. And then employer complaint and then complaint evaluation tool. There are lots of good resources out there and they'll actually answer questions if you have them. So if you're interested, please take advantage of that. And we'll also link to that for anybody who is interested. That and we also have another tool that we will be linking to for a just culture algorithm for anyone who's interested. So at the conclusion of this webinar, as always, we'll have we'll have a recording of this on our YouTube page and that's where we'll also have the links. So thank you, Beth. We really appreciate that. It's a fabulous tool. You know, thank him. Beth was just telling us all of the things that we have to do to implement a just culture. It sure sounds easy to do, doesn't it? I wonder if he could tell us just a little bit about your experience of implementation and how easy or how difficult it actually is. You're on mute. No, no, I think Beth has said the presidents very well. I think it's very easy to read something on just culture, very easy to put policies in place. And that's what because most hospitals have gone for accreditation. So they have all policies in place. So one of the mistakes that we tend to think about just culture is that I have all the policies in place, but not necessarily the policies are understood as something that is going to be safe for the patient and also for the caregivers. So when I was running nursing departments, I used to tell my nurses because they think that policies and procedures are burdened for them. Every time we are quoting, this is what is written there. So they used to think, you know, this is too much of pressure on us. So I literally had to tell them, please understand this is actually to protect you as well, not just the patient. You're also going to be protected because when you follow that, you are safe. And that's how we are written. So the organization's responsibility is to design processes and system, which are safer. And when it comes to share the accountability, the employee then takes choices. And that's already mentioned, you know, where you say that this was human or, you know, it's a risky behavior or a reckless. So having something documented the way that Beth had told probably can add value. And I would say that in India, I have not yet seen anyone documented it and definitely we are going to look at those tools. There is another one from NHS. So I think they are great tools to look at because it is very clear. I think one of the barriers that when we make policies and when we say that this is the disciplinary decision tree, because somewhere people think just culture means we cannot blame anyone. Blame has got a different connotation. Talking to someone how it happened is not blaming. You really have to discuss with the person. And what I think is that we don't ask leaders, we don't come across as people who are kind enough to listen. So even our body language, when you're asking someone, maybe the first thing to say is, okay, tell me what happened. So that's a different thing to say, if it comes down, you know, I know that you are undergoing a lot of stress because of what happened. We would like to hear from you what happened. So even that becomes very, very important and becomes a barrier for the person to learn because when leadership is coming heavy, though they say we don't want to blame anyone, the way that investigation is happening can set a tone of, you know, blaming, shaming and naming. So I think the non blaming incident investigation, this is a nice terminology, which I think every organization should take that non punitive incident management. You know, these two terminologies I really liked. And I think, again, we all come back to the same thing. What is the leadership thinking about all this? I don't think the, you know, frontline caregivers are too much excited about it, but they'll be very happy if they are told ahead of time. And that thing needs to be told as soon as the employee endures the organization. And my personal feeling is that we do not probably have enough dialogue with them to say that this is what we believe in our organization. And this is how we go about managing if something goes wrong. So defining to them that this is your, you know, human error, this is how a reckless behavior will look like, you know, this is how we, you know, actually try to define because I don't think any one of is perfect. And we all are learning. So the more we can make things clear to people, probably they will understand more. So the recent, the connotation for all healthcare organization is highly reliable organization. So I like this three things when they come together, safety can happen. One is that the organization is learning. And the other thing is the organization is allowing everyone to report, you know, everyone, everyone is allowed to report. So it's a just culture, learning culture, reporting culture. When they all get aligned, then the patient safety starts to improve because we are all humans and we all know that we can make mistake, but are we willing to learn from that mistake? I think we do a lot of lip service, we want to learn from mistakes, but many times maybe going under the carpet or trying to find someone to say, okay, this happened because of this person after that maybe nothing happened. So my question sometimes is that maybe an event happens after 10 years. So in your data sheet, it could be zero point something, something, something. But for that person it is 100%. Would you like to receive, would you like to be the recipient? I said, that's how I used to talk to my, my organization leaders myself. I'm very passionate about it. And I would say we are learning Dona and I'm very happy that we are here sharing and learning from each one of you. And I'm really definitely going to get back to India and to talk about these more. And we are definitely going to look at the matrix for sure, because that's something we can help everyone to come together to align so that things becomes much easier and great sharing. Thank you. I mean, that's what I think about your question, my experience and where I would like to go. I would definitely like to go where people are very open, kind enough to say, okay, we goofed up. Let's see what, why did that happen? Just admitting, you know, that yes, things are not perfect. Let's look at it. That first admission is a problem. That's my experience. The first admission to say from the top, we goofed up is better to say you goofed up. That's very easy. You goofed it up. So let's now talk, you know, I am not to be goofing out. So that is the, a little bit of a problem. I think we need to overcome that first. And that is, that's for us in India also. Yeah. Well, thank you. And Mark, I know that Beth, Beth briefly discussed the components of the Just Culture algorithm. I wonder if you could go into a little bit more detail for those who aren't really familiar with it. Sure. So one thing that I found incredibly helpful when when learning about the Just Culture methodology, like for one, it was very familiar to me, like I think there are parallels to lean management philosophies and mindsets. But, you know, I'm going to hold up, you know, a document here you can find online from the National Health Service, what they call their incident decision tree, right? So it turns the Just Culture framework and mindset into an algorithm, a flowchart. So as an engineer, I love that. And I've tried sharing this back with people outside of healthcare that this is so applicable in different settings. It helps us distinguish between the difference and the difference between errors and intentional acts. So I think, you know, the old mindset, before getting into the algorithm a little bit, the old mindset in healthcare is we're going to assume it's a person's fault unless proven otherwise. And that's a very difficult bar to hit maybe. What I think under Just Culture, we assume it was the system unless proven otherwise, meaning, you know, proven to be an intentional act. So I think of two types of incidents that have been in the news in recent months, like there's a difference between a hospital where the vaccine freezer door was accidentally left open, hence ruining some vaccine. Like that was clearly a mistake. We could look at the design of the freezer or you look at different factors where not only was the door kind of faulty, the alarm failed, right? So there's system problem on top of system problem. As opposed to a case in Wisconsin where the first news reports were, well, this vaccine was left out overnight. My first assumption was to say like, well, the pharmacist must have been distracted or fatigued or something happened looking for mitigating factors or what the Just Culture methodology will refer to as the substitution test. Would somebody else in those same circumstances possibly likely make the same error? But then it came out that, wait, this pharmacist was intentionally trying to destroy the vaccine. That's a time for punishment. I support punishment there to the full extent of whatever the law can throw at him. I would not think it's just to try to punish, fire, get alone, prosecute somebody who mistakenly left the door open. I think Just Culture, the frameworks in the decision tree help us understand what's the difference between human error? When do we console the person who likely feels terrible that that freezer door was left open a crack mistakenly, right? So they say console the person. When there are at risk behaviors, when that's identified, not just a quote unquote near miss, but like, you know, the unsafe condition, that's the time to coach somebody to either say, Beth, I care about you, and I care about others on the road, you might want to rethink putting your lipstick on while you're driving or, you know, to a man in the audience who's using an electric shaver while they're driving. I think we've seen that before, right? That's an at risk behavior. And we want to sort of try to coach somebody out of that. And then if there's something that's just a reckless behavior, an intentional act, you know, that's the time when punishment would apply. So if we look at this framework, I think there are two key questions that are important when you think about the substitution test, would another individual coming from the same professional group possessing comparable qualifications and experience behave in the same way in similar circumstances? I think a lot of times the answer is yes. You know, we look at other vaccine related incidents, giving somebody the wrong second dose, that has happened in many places, which to me points to system problem. Patients being injected with plain saline instead of saline diluted vaccine, that's happened in enough places where I would point and say, well, seems it smells like a systemic problem. And then the other point and final point I'll make, and I think this ties back to the lean framework and methodology, this question of, were there any deficiencies in training experience or supervision? So I'm going to focus on the training or supervision, were there deficiencies? Controversial statement, the answer to that is almost always yes in healthcare. There's not enough focus put on training and supervision. So that we, you know, training and supervision, as well, supervision helps us discover unsafe acts. And risky behaviors and unsafe conditions. It's not just then react afterwards and say, well, you shouldn't have done that. Who's supervising people? How are we training them? Those are really important frameworks, I think, from both lean and just culture. Thanks, Mark. Yeah, Beth, you know, we talked a little bit already about implementing a just culture, but you know, what recommendations do you have for an executive who's looking to implement this? What are some of the first things that they should be thinking about doing? Well, first of all, they need to be garnering support for the rest of administration. You have to have full administrative support for this, because it does require resources. Mostly time, but sometimes there will be financial commitments that need to be made, particularly as you begin investigating and you find out there are system problems, that can cost, that can cost some money. So that commitment in terms of having everyone on board, making sure, as Mark said, training, training, training. Thoncom brought up a very good point about leadership training in order of how to do an investigation appropriately. You know, if you walk in and you start the interview with what did you do? You know, that's going to put someone on the defensive and you're not going to get anywhere and no one's going to learn anything. So leadership training as to how to do an appropriate event investigation is absolutely critical. So it's more of a collaborative approach. Yeah, I know you're upset about this. Tell me what happened in your words and let's just walk through this one step at a time. And it's important that the leaders don't just accept the first thing, the first thing that comes out of their mouth because they may not have a good perspective on what happened. So you have to be inquisitive. You have to ask additional questions. Why did you think that? Or what made you choose that and use the tone of voice that will not be blaming? That's so important. Recognizing safety is a value for the whole organization. Everybody has organizational values that they put out there. Safety should be one of them. Also, getting started, how do you know where to start? I mean, this is a huge elephant. So looking at your own data, hopefully everyone has some sort of event reporting system and you can look and see what how many and we looked at serious safety events and deaths. And when we started back in 2008, we had 32 serious safety events or deaths every year. That was appalling to us. So of course we set a goal of zero and we worked and we're down to about one, maybe two, sometimes zero, we hit zero and you know, that's a big cause for celebration and we celebrate those those achievements because that's a big yes, 31 or 32 people who were not harmed and that that's significant. Looking at what are your most common errors or events? You know, is it medication errors in most places? We found that our medication rooms were right behind the nurses station. Phones were ringing, people are talking, people are talking to the person administering meds and it was just set up for failure, set up for med errors. We moved the med rooms down the hall, put a box of tape around the computer so anyone who was standing in that box could not be interrupted unless there was an extreme emergency and our med errors dropped tremendously. So you know, it's looking at what you're doing that's causing potential for error. You know, as Mark said, managing those three behaviors, making sure you have an event team when you first get started that will kind of go through events using an algorithm or whatever process you choose so that you see that everyone is approaching this with a like mind because you may go through an event and one person is saying that's reckless behavior. Somebody else is saying that's human error. You have a problem and you need to get, let the team work through, okay, how do we assess this? And what for us is human error and what is is at-risk behavior? There's very little reckless behavior out there. You know, most of the time it'll fall into at-risk behavior or human error, but you need to have a group that are approaching it within the same in the same manner. So those are just some things to be aware of. Excellent. Thanks, Beth. And I wonder if, I mean, just tell us very quickly what barriers can can administrators anticipate as they begin to implement? The barriers, I would like to quote this one study which is done by Paradiso and Linda et al in June 2019. I think this was done in a large urban teaching hospital in Brooklyn, New York. And what they have tried to understand is that what is the just culture? What does that mean? So in the study, I would sum it up to say that what is it that they were saying as the barriers, the inability to speak up? Maybe you have already told in the policy that every employee can speak up, but not necessarily the frontline caregivers are feeling that they can speak up because the leaders say no problem, you speak up. But there is a misalignment between the leadership and the frontline caregivers because they don't trust. They don't say that we don't believe that we are not to be blamed. Our incidents will not go into personal file. This is the same thing in India also because we can tell them any amount of time, any number of times that we are not going to blame you, nothing is going to happen, but we are not aligned with them. So there is a disconnect between the leadership and the frontline caregivers. I think that is one of the major barriers because we think we are doing the right thing, but they think not the same. So there's a disconnect. And I think more than there's another study where I think about 600 plus hospitals were surveyed and in that the response was that the improvement in non-puritive response. So they bought more than 50% of them told that they want to see an improvement because they are worried that it goes into their personal file. So I think the major gap is when we are sitting down to do a RCA or when we are trying to design a process where the frontline caregivers are involved. We usually don't have them in the team to say, does it work for you? This is one of the major lack may that I have found and I am guilty of doing that some years ago when I was very young leader and probably I thought I know it all. So I call my immediate people and say, okay, guys, this is the problem. This is what we are going to do. Never knowing that the people who are supposed to execute it, they don't believe in me. But I learned it over a period of time. I said, if they have to do it, they have to trust. And that trust becomes a very crucial factor in that actually becomes a barrier because they don't trust the broadly nursing per se. They're very quiet. They're submissive in India definitely because we have this huge respect for our seniors and not necessarily it means that internally I respect, but I will not speak up. That's the culture that we have. So to come out of that it takes time and when once in a while when someone speaks up, then hell breaks loose. Not only within the nursing department, it is the medical fraternity, the organization and me as a nursing director, I have faced this myself. So I had to put my foot down and say, look, we are asking the nurses to speak up and today someone spoke up and you're asking to her to write an explanation. I said, no way. She will not write and I will not write because she had the right behavior in the interest of the patient. Now that is also a huge requirement today. So in India we have a saying that everybody is trying to protect their chair. Just like politicians, you know, that we are trying to protect the chair. So the chair that you are holding that we are trying to protect. So error reporting is nice, but it is like tip of the iceberg. The tip is what we usually see. I'm sure that Beth will agree with me that what we see is the sentinel events, the big events, but all those little things which are actually indicating that we are actually sitting on a time bomb or a landmine. We miss it. So one day it is going to blow up. So that iceberg needs to be unearthed. That can only happen when the leadership tell that please flag anything that you see, we are here to listen and we are going to fix it. Now it's very easily said, not that easy to be implemented. So I would summarize to say that the barriers are that they are not feeling that they can speak up and the negative response they get when they actually speak up. It could be from anyone. I'm concerned about the patient and I voice it up to the consultant. Maybe he'll turn around and say, who is the doctor? You or me. And that's enough. And then that girl is not going to talk again and the risk of discipline, the fear that I am going to be disciplined rather than, you know, heard. So there is a lack of trust. And in case by mistake, we have taken a disciplinary action. And once we finish the investigation and we find that it was the system or the process that failed the person, do we go back and tell the individual that we are really sorry? We made a mistake. We are not to be blamed, but we are going to correct. These are these are good thought process, but I think they are like dream situation for me. But I'm very optimistic. And I think the more and more that we discuss about it and we interact with each other more we discuss, I mean, commit to discussing just culture and more leadership again, I come back to leadership. I think that's where our major problem frontline caregivers are more amenable to understanding. If we give them that trust factor that it's okay, you can report. Nobody is going to come after your life. You know, I think that is the major barrier, I would say, which is not spoken always very openly, but it exists. I'm very sure that will agree with me on that because unless and until the top leadership is not aligned, you know, they are the only listening people, consultant comes, okay, good, good. It's a nice idea. Very good. Go meet my team and implement. It will not happen. You know, I think that's the major, major lack in any system. So lack of alignment of what leadership thinks as the just culture and what the frontline caregivers think as they experience. I think that needs to be bridged before someone can actually think of saying that we have a just culture in place because it's a small word, but it's a culture takes 30 years. So I think we should start with small climate change. And I think these are great platforms for all of us to be sensitized and then go back and look at your system to see if this is something that I can change. Exactly. Well, I do want to make sure that we have plenty of time for questions. So before we get to Q&A, I just very quickly want to review one more time the CE information for anybody who did not join us at first. We have CE available for nurses, pharmacists and physicians, also for respiratory therapists and depending on your licensing board, they may also accept that credit and you will receive a email from MedStar if you'd like to get that credit. If you would like to receive credit for the American College of Healthcare Executives, then all you have to do is just enter the information into your account for CPPS and BCPA certification. You'll receive your certificate from the Patient Safety Women Foundation. And if you want a CPHQ credit, then we will submit those names to NAHQ and they will enter that CE credit for you. So, and so I do want to have time to get into Q&A, but very quickly before we do, very last thoughts, Beth. Any last thoughts that you'd like to share? Just that this is a wonderful process. I encourage everyone to try to undertake this if you can. It will have very meaningful results and Thakwa is absolutely right. What you see in terms of recorded errors is only the tip of the iceberg. There's much more out there. Yes, Mark. This has to be CEO-led with the support and understanding of the board because otherwise a well-intended director in a department can try to create this culture locally. And then as soon as something happens to where somebody higher up at a VP or a C-suite level comes back in with a name-blame and shame, then forget about it. Your progress is gone. People will go back to hiding problems and fearing punishment and they're right to have that fear. So, we can say the right things, I think, but we have to demonstrate over time so that people can build trust, you know, kind of just building on part of what Thankum said there. We can't just make one pronouncement and say we now have just culture. It's going to take time. That's right. Final thoughts Thankum? Yes, I totally agree with Beth and Mark, but I'm also very optimistic and I believe in reverse mentoring. So, a particular department head can try to influence their super bosses to think in the right way. So, that's where the influential communication, you know, strategies work. And I think a long time ago, one of my very senior quality guru, when I was, you know, just lamenting, I said, sir, what is this? You know, we are talking about quality. He just don't get it. So, he told me one thing. He's told, you know, Thankum be like a woodpecker. So, you have to keep on picking, picking, picking and one day it is going to make a hole or it is like one single water drop falling on a stone. Nothing will happen on day one, day two, but over a period of time it can create a dent. So, I think we need to persist and insist and I am sure that things can change slowly. And yes, we have to get the buy-in of the top boss. That's very, very important. And I totally agree with Mark when he said, you know, a particular department can try to drive the, you know, just culture, but it will not sustain because someday somebody will come and ask one question and that HOD will be standing like a fool, you know, oh, what was this all about, you know? So, we don't let that happen, but that does not mean we give up. At least as a nurse, I will say, I will not give up and I'm going to pursue where I can make a change and I will definitely do through various sources. So, because I am totally sold to the just culture, because I think that's the only way we can actually aim for zero harm. Preventable harms needs to be prevented and it can't happen by blaming and shaming and naming somebody. So, that's what I was so much. Still, I stopped with my optimistic note, not on pessimistic note. Thank you. We did have a question that appears that somebody may have heard you incorrectly that you said it takes 30 years to create organizational change. I didn't hear you say that. I believe you said three. No, if you want to change a complete culture, you know, if you look at the management books, they talk about it takes a long time for a culture means you change the entire behavior of the DNA of the organization and everyone who comes in, they will believe they'll do the same thing. So, it actually takes 30 years. This is actually told by another CEO to me when I was training someone. He said, we don't want, we don't have 30 years. Let's start changing the climates. So, when you start changing the climates, slowly start getting into a culture pattern. So, the 30 years is what the, you know, understanding in management books are about that when you want to change the culture. Now, Toyota culture did not happen over three years. Right, Mark? It took a long time and we are taking it from them and we are working on it. So, obviously it takes time. So, you need to be patient and insist and persist. You know, that's very important. But don't be deterred by the thing that, you know, I don't have 30 years to change. Yes, go ahead. You will be able to change at least in about 13 years for sure. Beth, what do you think? How many years is that going to take? Well, I just, I might say the culture, not build sustain. Right. I'd say it probably took us seven or eight years to really integrate just culture as a part of our internal thought processes. And for the front lines, as you said, to have experienced on a consistent basis a review of system issues rather than that individual blame and finger pointing. It took a long time. I'll just throw out a modification of an old proverb. The best time to start changing the culture was 30 years ago. The second best time is today. Totally agree with you. I totally agree with you. Yeah. But I mean, I think we can make progress. And I've seen the role of, you know, committed executives make a big difference in a relatively short time. But I think maybe that bar is set where at some point you say culture is the way we do things here, the default of how we think. Like for that really truly to shift from when I hear people talking about implementing just culture, that's a program. At some point, when does it really become the culture that's going to take time? That's a great explanation, Mark. That's a great explanation. Yeah. We've got a lot of questions about how we can educate patients and families a little bit better so that they are not in a position to blame others. But I'd love your thoughts on that. You know, because when patients are harmed, they tend to look to blame somebody. Also, I'd like your thoughts on the difference between these errors that are happening in healthcare that happen all the time and those that somebody actually is successful in litigating. So, Beth, I know you've had a lot of experience in this. Can you kind of address the differences there? Well, for errors that actually reach the patient and there is a serious safety event or harm, those are the ones that typically will reach litigation stage. But that doesn't mean those are the only ones that we should pay attention to because it's a culmination of smaller issues that can get you there. So, you know, worrying about getting sued should not be your purpose. It is preventing harm, as Mark and Bakum said, as preventing harm to the patients in every way is your focus and that will then lead to fewer incidents or potential incidents of litigation. Absolutely. I just want to share a quick thought. I mean, I think, again, this tendency to blame is part of the human condition. I'm always impressed when there are families who respond to preventable incident that causes death when they react in a way that looks to the system. What can we learn? How can we prevent harm to others? Like, that's such a loving, caring response. And I think of the Louise Bats Patient Safety Foundation that's been a partner of the Patient Safety Movement Foundation. Louise Bats, her family in San Antonio, responded to her death from medication error by looking at systems and looking beyond that incident. And there are others. So, I mean, I think it's admirable when people can respond in the face of personal loss and tragedy in a way that steps back and looks at systems and trying to help others. So, I really admire what they're doing. Great. Agreed. We have several. I would like to add to Mark is that in this part of the world, I admire what is happening there. At least there are case studies where the patients have become champions, though they have been at the receiving end, but they have understood that to err is human and they want to make things safer. And we are learning from that. I would say our country is far away from that kind of acceptance by the public. And right now in our country, it is not so easy to actually inform someone, say that, you know, sorry that this is what happened so it can have very negative and a very harmful repercussions. And I think there was some discussion which was happening on the litigation part that the judiciary sometimes is, you know, it's like they are trigger hungry. They get something and they say, okay, someone to fix and they take a, you know, stand and say, okay, this is the person to be, you know, blamed and, you know, maybe we also have a responsibility to advocate to the judiciary. Also, what is this just culture all about? And what is human error? You know, maybe they are not trained for that, you know, they are just supposed to look at all the circumstances and decide who is to be blamed, right? So I personally feel yes, that there's also a need to champion and advocate to the judiciary. Also, how does health care, safe culture, they come into place and how difficult it is to implement also? It takes time, right? And we did have a question about, you know, about how and Mark, I wonder if you could, you could address this, the question was about implementing just culture for the staff and what can be done so that it's not perceived as an imposed program on them? So I mean, I think, you know, collaborating and getting input early on always helps and the acceptance of any change. I don't know why staff would have any heartburn about not being blamed for systemic problems. I think the challenge is going to come at, let's say, the frontline manager level. Well, you know, and I think trying to bring them on board with these new habits and redefining, you know, they may have in a way framed their job as reacting to incidents, writing people up, retraining, I won't get on the soapbox fully on this one, but you know, throwing retraining out as a countermeasure, I think is dubious. And like, well, if the effect, if the original training wasn't effective, you know, as a way to prevent error, why is retraining? It's like two times zero equals zero, maybe. But so I think some of that resistance or cyber resistance, just the challenge of embracing new approaches is probably more likely at the frontline manager level. And that's where I think they need coaching. Let's not blame a manager for blaming an individual and recognize that that manager is also part of the system. Those are a couple of thoughts at least. Great. Great. Bank up. Yeah, I just wanted to add when Mark mentioned about training and retraining. I think one of the things that I have seen as a gap, because I had been a trainer also from 2012 after being a nurse for so many years, being in administration. So one gap that I personally experienced is that when we are training, we usually don't tell the rationale. Why is something to be done this way? You know, that rational part is mostly forgotten. It's like you want to train, you have a policy, we explain you the policy, but we don't tell them why is that there? I think if they understand why part of it, I think this is what Simon Sinek talks about. We know the what, we know the how, but we don't know the why of it. I think we need to start with the why. And I think the training can get more influential and more impactful. Then the retraining will not become zero plus zero is equal to zero. The first training has to be influential. It is to be impactful so that they understand. So like this, the question was, you know, how do we implement just culture? It's not, it's nothing. It's not a word. It is a way that, you know, you're going to explain to them, this is how we do things here. And they have to experience what we tell, they have to experience. So there is a gap and there could be a challenge. Yeah. And Donna, a technique you can use is to pull together some generic examples that are not actual examples, but are similar to things that have happened and walk staff through the process when it's not them or not one of them. And you walk them through the process of how you get to a conclusion. And they can sort of see, they can see how it happens and how it works. So they might be a little more trusting, but they do have to actually experience that themselves when a real event occurs to begin to truly, truly trust and then have that move through the front lines. Well said, Matt. Well, we are right at 830. And we didn't get to all of the questions, but that's okay. And we'll do as we always do on our webinars, we will address any questions and writing that we did not get to during the webinar. And we will make sure that we post those on our YouTube page, along with all of the links to all of the tools that we've discussed today. So there were several questions about, about being, thank him some of the the resources that you mentioned. So any of the resources that our panelists mentioned today will be available on our YouTube page in in a 24 to 48 hours. So thank you, everyone, to Beth, Mark, thank them. I appreciate you so much for being here today. And thank you to everybody who took the time out to join us on this webinar.