Okay, great, thanks, Dave. So we're going to segue now into the cornerstone of why we are really all here today, which is patient safety. And it gives me great pleasure to introduce Teresa Jason, who has over 30 years of nursing experience. So that means that she's 31. She has an extensive background in critical care nursing. She started her career at a level one trauma center, I believe, in Boston. Then she, I want you to tell a little bit about your story, but she ended up working for us. She was our nurse director, Manhattan Endoscopy, natural born leader, and we just couldn't keep her busy enough, so now she went on to an even Uber nurse leadership role, working with physicians, endoscopy, and overseeing the operations of many, many other centers in the Northeast. So Teresa, come on up and tell us how to keep a safe workshop. Good morning, again, and it is my pleasure to be here. As Dave had said, my name is Teresa Jason, and I'm currently the director of clinical support for physician endoscopy for the New York and New Jersey centers. And I'm here to discuss creating a safe culture for your patients, and I hope you find it informative. I also have no collusion, no disclosures. Learning objectives, as we all must have. At the end of the presentation, participants should be able to have an understanding of what is a safe culture, evaluate the safety index at your center, utilize tools to encourage a safe culture, and develop opportunities to improve that culture. So research published in the Journal of Patient Safety puts the number of annual deaths associated with preventable harm in healthcare between 210,000 and 440,000 patients. On the low end, that is the equivalent of 10 airplane crashes a week. Would the aviation industry accept these numbers? Why are these numbers accepted in healthcare? Not only should these numbers not be accepted, we should also be looking at why this research was not conducted from within our own industry. John James, who was a published researcher, did this research in 2013 and was not a physician. He was rather a space administration scientist who unfortunately lost his son to a medical error. This study has been highly quoted in the literature and has reopened the discussion regarding preventable mortality from medical errors. And I think it's a real conversation we should be having every day in healthcare. Thankfully, in recent years, these figures have not gone unnoticed. Organizations such as the Joint Commission, National Patient Safety Foundation, and Children's Hospital have found, have stated that they're going for zero patient harm. Does your organization share a goal of zero patient harm? When I was asked what subject I would like to discuss today, I chose this topic as it has always, I've always had a very strong passion for many reasons for patient safety. This slide is from an article I wrote last year, Shifting the Healthcare Culture. Many of the concepts and how to transform your culture in this presentation are from this article. I hope all agree we can no longer accept medical errors as the cost of doing business. So if you are the leader of a center, this concept starts with you. You need to assess your safety index. It's your responsibility to assess, evaluate, and encourage a safe culture. Where do you feel your center lies? So how to assess and evaluate what type of culture you are promoting? Can you answer yes to the following questions? I support my people when they report a safety issue. I encourage the sharing of errors to help improve education and performance. I model safety and walk the walk. I treat employees' safety concerns with respect. I treat staff fairly when they make mistakes. That's a big one. I act upon all reported safety concerns, and a big one as well, I always acknowledge we can do better every day. So staff have a responsibility as well. As the Joint Commission shares, preventing safety lapses before they occur is a two-way street between staff and leadership. Staff need to take individual responsibility for their actions, but they also need to know that administration will listen and act when they raise a safety issue. So this slide is from Professor Patrick Hudson of the Netherlands, who began his career in safety in the wake of the Piper Alpha oil rig disaster off the coast of Aberdeen in 1988. 167 men died that we believe could have been preventable. He has written countless articles on safety for all industries. He shares the three main components for safety in any industry, including healthcare, are culture, process, and technology. Many of us in this room are very comfortable with process and technology, utilizing a variety of tools for patient safety, but where does your center fall in terms of culture? Mr. Hudson defines an organization's culture as the common set of values, beliefs, attitudes, and working practice that determine people's behaviors. Can you identify where your center falls? Is there room for growth? So maybe discover your current culture is not where you'd like to be. Can you guys read that? Yeah, it is big enough. This one's a lawyer. Tom, no offense. We better wash our hands. There you go. So how to transform your culture, how to encourage a culture of safety in your center. The above concepts that I'm going to speak on are derived from almost 30 years in healthcare. Lesson learned from being that 20-year-old RN who first started out who was too afraid to speak and probably regrets 30 years later that she should have, to now who's running multiple centers simultaneously and hopefully still tries to sleep at night knowing that I'm doing whatever I can to give the safest possible care for every patient every day. So what are they? Equality, responsibility, openness, systems, accountability, and privacy. So status intimidation, as we all know, can be a significant roadblock to a safe culture. When it comes to a safe workplace culture, everyone is an important part of the team and everyone's voice matters. Physician, tech, nurse, housekeeper alike, no one's concerns should be dismissed because of their position or lack of seniority. If staff see leadership building relationships and trust, it's going to work. It's going to create a tight-knit community and you're going to have a safer environment. Responsibility. Patients must always be the top priority. Their safety and the well-being take center stage day in, day out. If that's not the concept, then maybe healthcare is not the right choice for that person. You cannot be everywhere at all times, and we all know that. As a center leader, your goal is to make sure that both staff and physicians are comfortable talking to you, and it's a sign of a strong, safe workplace. Systems. The reality is, in any industry, systems stay around. Individuals may not. So you have to try and set up processes that work towards success. Build systems that allow for individuals to prevent them from failing. And then when an error occurs, you must perform a root cause analysis to see if a change or process can prevent that from ever happening again. When your team sees you working continuously for patient safety, they will respect the process and it will encourage more staff buy-in for future safety changes. Blame the system, not the individual. Accountability. When you provide education and training that promotes your safe environment, staff should be expected to follow what is taught. If anyone resists, they must be held accountable. A single person unwilling to fully support the safe workplace culture can weaken the entire effort. And privacy. When staff admit they made an error or confide in you, keep it private. If staff believe word of their actions will leak out, they are much less likely to come forward. So is it all really worth the effort? How important is a safe culture? So because this was such a significant incident in New York that Dave and I chose to share the same slide. Unfortunately, in 2014, Joan Rivers died at a prestigious freestanding industry center. As Dave mentioned, this tragedy had a significant impact on ASCs in New York and beyond. In my opinion, Joan Rivers' death prompted many, if not most centers, including my own, to review their safety procedures and protocol and evaluate, are they really promoting safety as a major priority? Was Mrs. Rivers' death preventable? The federal and state investigation revealed many areas of fault in this unfortunate situation. What similar in-depth investigation at your center would they find? What would they reveal? So this was another significant Nevada endoscopy with a hep C outbreak, 40,000 at risk. The CDC investigation revealed the etiology of this outbreak was due to reusing syringes, using single-dose bottles of anesthesia on multiple patients, and in some cases, failing to clean equipment thoroughly between patients at the clinics. Where were the safety protocols here to prevent this? This was another one that was hot in the topic, 2015 UCLA. We all know this. Eight patients sickened, three of whom died. A positive step here was the transparency displayed after the outbreak. Dr. Stevens, a clinical instructor in the Division of Digestive Disease at UCLA, made this statement after the outbreak. Our interest is in protecting public health. We feel a professional and academic responsibility to learn from our experience and add our findings to the limited body of research on this topic. UCLA physicians were directly involved in reporting the outbreak, tracking down its source, and halting it. UCLA's actions helped educate the public about the risk posed by these scopes, whose complicated design makes them very difficult to clean. And this one's tough to read. Three brain surgeries performed on the wrong side of the head at the same hospital. What type of culture do you think might have been at this hospital? One operation went wrong when the doc argued with the RN regarding the correct side of the head. He was wrong. The resident cut into the wrong side because he failed to do the pre-op checklist. And the third, the RN was aware of the mistake but did not speak up. It was the nurse's fault. Always. Always. If the moral of the story there was, it was the nurse's fault. I have had my own personal experience that I would like to call a near miss, but we did shave and stabilize the head with the pins that you do in a craniotomy. I'll set the scene. It's 2 a.m. at a prestigious Harvard level one trauma hospital, back when I had the stamina to be up at 2 a.m. assisting with a 2 a.m. brain surgery. It was an expanding subdural hematoma and there was the usual control chaos in an emergency operation. Everyone working diligently to complete their part to get this case started. I was scrubbed and the other RN in the room was putting the films up when she noticed the error. We had just placed three pins into the patient's skull on the wrong side of the head. You can imagine the reaction at first. This was over 15 years ago. The MD was not happy, to say the least, and the event left a significant impact on me. This nurse should have been rewarded for saving the team from opening the wrong side of the head, but she was almost criticized for alerting the team. I asked this same RN days later if anyone from management had ever acknowledged her actions. Unfortunately, the answer was no. So patient safety is everyone's responsibility, and failure to speak up can genuinely cost lives. So one recent study has medical errors as the third leading cause of death in the U.S. How can that be? Dr. Macri and Michael Daniels from Johns Hopkins discussed the severity of medical errors in the U.S. in an article, Medical Errors, Third Leading Cause. The number of deaths due to medical errors are vastly underappreciated. They are discussed, unfortunately, in locker rooms and in nursing stations. They live in the form of stories, not data. And one significant reason is debt certificates do not allow for the collection of data for medical errors. The volume of funds attributed to the top two, heart disease and cancer, is substantial and very appropriate given the amount of the large percentage of patients who die each year from these diseases. But where's medical errors here? Why is it not getting the same attention and funds to prevent and reduce these deaths? So you can see it. A lighthearted look at reality. But there's some truth to it, right? So blotched attempt, but can anyone suggest a more friendly way of describing what happened? So medical error review. Can we do better? So back to the analogy of aviation versus medicine. So a plane crash. A plane crash is vigorously investigated with the results being shared throughout the industry. The entire pilot community is educated on the investigation and the results are disclosed to prevent any future plane crashes. Versus medical errors. There's no standardization of medical error investigation. Should we start making the transition to the same methodology as in the airline industry? We are making the same mistakes over and over again. Is it time to start some solid legal protections to offer stronger protective measures for health care personnel against lawsuits to allow for full disclosure and full review of all errors? So what can we do? Recap. We've got to change the culture to allow for open communication for errors. Are errors discussed openly at every staff meeting? Work towards correcting the system, not the individual, when an error occurs. Be willing to share your own errors. The conversation must be frequently discussed to share your organization's goal of zero patient harm. And a physician in the last research year named Dr. Woods has published extensive studies to reinforce the significance that culture plays in preventing medical errors. He goes on to say health care organizations that don't have a culture that values teamwork, accountability, and environment that promotes speaking up, then you're more likely to experience quality issues. He has statistics that are just scary. 20% of health care workers said they would not speak up if they witnessed an issue. In a retrospective wrong-sided site surgery review, 60 to 80% of people interviewed said they knew the incision was being made in the wrong place, but they did not speak up. According to Dr. Woods, the one word that best describes culture of safety is civility. Civility, illustrated in the next slide, facilitates a safe work environment in which people feel comfortable speaking up and changes are implemented and communicated. So this is his very simplistic version, and it's everything we covered. No one is ever, you know, no retribution, open environment. So his word civility, again, is for the safest culture. It seems like a pretty simple concept when you call it civility, but the reality is creating and maintaining a safe culture for your patients takes a lot of effort and dedication to create and sometimes even more work to maintain, but it has to be worth the effort. In closing, patient safety should be your center's primary objective, and studies have consistently shown one very effective way to maintain safety and prevent medical errors is by creating a culture of safety and a global expectation for zero patient harm every day, every patient. Thank you.

patient safety

safe culture

healthcare organizations

medical errors

preventable harm