Of course, safety is the ultimate topic in patient centric care and creating a safe care, safe culture for your patients is amongst the most important things that we can do every day for every patient, and for each patient individually. So, again I have nothing to disclose. So some learning objectives at the conclusion of this presentation, participants should be able to demonstrate an understanding of what constitutes a safe culture in your endoscopy practice and unit utilize tactics and resources available to foster and nurture healthcare workplace culture and identify and develop opportunities to continually improve your culture of safety. The first element of patient safety culture is the extent to which an organization's culture supports and promotes patient safety. The values beliefs and norms that are shared by healthcare practitioners and staff throughout the organization that influence their actions and behaviors. This is measured by determining the values beliefs norms and behaviors related to patient safety that are rewarded supported expected and accepted in the organization. This culture exists at multiple levels from the unit through the department, up to the organization, and across the entire system. So this is a continuum, but it begins at the level of your individual unit. So, looking at this graphically organizational culture determines the behaviors that are rewarded. supported expected and accepted. And it exists at multiple levels and I like to look at this actually in the left to right action but it's in this graphic. The opposite. So it actually starts with you and your colleagues at the level of your own unit. And it goes through the department on to the entire organization, and across the entire system. So it is a continuum, but it begins with you and your patient. So where did all of this begin. It begins directly, about a quarter century ago, but I'm going to interject that it actually begins shortly after World War Two, when the whole idea of process improvement and system innovation came about in the mind of a genius from the Midwest, a man from Iowa, named Deming, who couldn't get an audience in the United States about the importance of process quality improvement in the United States so he went to Japan where he got a great audience. And this ultimately became what we all know as the Toyota system. Back in 99 there is a book called to air as human that was published by the Institute of Medicine, this is the 1999 so over 20 years ago, and in sort of applying the thought of process to medicine asserted that the problem with medical issues and medical care system issues was not bad people in health care. It wasn't individuals doing a bad job or making a mistake, but that the system wasn't setting the health care providers up for success. It's not bad people in health care, but that good people that are working in health care are working in bad systems that aren't setting them up for success, and that these systems need to be made safer. In this book as experts estimated that almost 100,000 people died every year from hospital medical errors and soberingly compared that that statistic was greater than the deaths annually due to motor vehicle accidents breast cancer AIDS at the time, etc. And that all of these were causes that are actually receiving more public attention than medical error deaths, which they calculated to be the eighth leading cause of death. So more people die annually from medication errors than from workplace injuries and this all adds financial costs to the human tragedy and medical error easily rises to the top ranks of urgent widespread public problems and that the cost and additional care lost income and disability was estimated to be 17 to $29 billion a year. So then why are we still talking about safe culture and zero harm almost a quarter of a century later well because we haven't solved the problem. Patients continue to be harmed by medical errors and avoidable accidents in all sorts of health care settings and increasing attention has been paid to the issue by the media and the media means a lot more portals than there were a quarter century ago, because of the increasing use of social media and various other channels of information dissemination which happens much more rapidly to more people more quickly and refreshed more frequently healthcare delivery and its systems and procedures continue to increase in number and complex complexity, of course, and it ensues the complex care requires more complex and device applications and maintenance. So there you go, the more complex the system becomes the more complex the problems that those complex systems, we get. So, does that mean that medical errors are the third leading cause of death in the US you know there was this study that was published. Not quite a decade ago, and 2016 by mercury that suggested or inferred I should say that this was indeed the third leading cause of death in the US, not number eight. And it was an analysis rather than a formal study coming out of Hopkins, and it was calling for better reporting actually have medical errors in an effort to get more funding to support safety and quality research and what they did was they took the mean death or medical errors from several studies so sort of meta analytical, and then extrapolated this mixed data to the total number of US hospital admissions that year which was 2013. And the data that they use suggested that there were two to 400,000 deaths, a year from preventable harm and healthcare annually in the United States. And this analysis concluded that medical error as calculated in this inferred fashion would rank number three in the CDC list of causes of death in the US. And, you know, not so quickly because this is an inference and it's not a study it's an analysis. And one thing that can happen with all of our media portals, is that there are all sorts of co opted interpretations that come about by special interest groups and of course this is catchy in the media and gets a lot of attention, but isn't necessarily precise or accurate. There are all sorts of headlines like medical errors kill the equivalent of three fully loaded jumbo jets crashing every other day to medical malpractice is deadlier than guns, death from medical errors were 500 times greater than deaths from accidental accidents, or how about more Americans are killed in US hospitals, every six months than died in the entire Vietnam War, or these errors and injuries are epidemics born of a cult of denial and complacency. All right, so enough of that, not so fast, and be careful about garbage in garbage out. But you know what, no excuses numbers aside there is a ton of work to be done in the culture of patient safety, the number of deaths due to medical errors are truly vastly underappreciated. And let's face it, these errors are discussed in locker rooms, nursing stations over a beer with your colleagues, etc. And while they live in the form of stories, they should be living in the form of data and studies, not just chit chat. But unfortunately death certificates don't even allow for the collection of data for medical errors so it's not easy to study this topic, or to get good numbers out of it. The goal though, is zero harm. No shame in that goal that's the bullseye that we should be aiming at because we know that harm in medical settings leads to long lasting impact on physical health of our patients. It causes financial setbacks as result that result from these medical errors, which be get a loss of trust and healthcare so that patients seek out treatments that are unproven, and much more dangerous than medical care, even if medical care isn't perfectly safe yet. And this leads to unsatisfactory communication, which leads to a sad deterioration in trust in healthcare professionals, and the scientifically backed healthcare system. This is an interesting graphic from a study done in the state of Massachusetts. When you look at the upper left hand corner of this graphic you can see that a lot of patients are and their families are dissatisfied with communication with them. Two thirds of them are in fact, and open communication here at the top right, provide by providers is linked with lower levels of harm. If you communicate well, you have fewer situations where the patient and the family feel abandoned or betrayed or sad or depressed, angry, or avoid a facility and maybe go somewhere else where they're not going to get good care or avoid a doctor really, it wasn't that the doctor did something bad necessarily complications are not always mistakes they can happen. Even if the process was 100% correct and if that could be communicated in a proper way and an understanding way with the patient and family. They might actually have appreciated the effort. They might have long lasting impacts on physical health too. As you can see in the bottom right, and medical errors lead to a loss and trust and healthcare loss and trust and healthcare is bad for the patient, ultimately, if they go to a witch doctor instead. Right. And then many patients and their families experience financial setbacks from medical errors, a third of them suffer a decrease in income, a third of them had increased household expenses of various sorts, and half of them were impacted by increased medical expenses so there you go. There's the cost of all of this, and our goal to right the wrongs should be to aim for zero harm. So how do we target that will mark Chaston, who was then the president of the Joint Commission. This was five years ago, said that first, it's the responsibility of leaders and healthcare, healthcare leaders should commit themselves to achieve the ultimate goal of zero harm. And that means zero complications of care, you should shoot for that. That's your goal, zero injuries to caregivers to, you know, we're scarce resource, and every one of us that's injured and out of work is a caregiver, who is unavailable to help a number of patients were a scarce resource and we need to preserve ourselves. That's one of the responsibilities of zero harm. It also means zero episodes of overuse and zero missed opportunities to provide effective care. So that's the responsibility of leaders second leaders must drastically overhaul the culture within their organizations too many caregivers are too often subjected to disrespectful and demeaning behavior when they raise concerns about safety and quality. That's what us we're talking about here. We need to be respected, and we need to be treated in a proper fashion so that we can continue to perform high quality work and feel safe in the environment in which we perform that work. Leaders must face the reality that healthcare safety processes very often fail at rates of 50% or more. Is that acceptable and other industries. So start your journey towards that target of zero harm. Here's a graphic that explains how to do it. Ensure that leadership is committed to a goal of zero harm that is the leadership's responsibility. In the meantime, with that support, develop and adopt a safety culture, incorporate process improvement in tools and methodologies for your work, and then demonstrate how everyone is accountable for safety and quality and that means everyone, because in a culture of safety and quality, everybody that is responsible and everybody that participates is equal, it doesn't matter what your job is, it doesn't matter if your job is to clean the room, bring the food to the patient, provide the surgery to the patient or fix the wound. Everybody is equally responsible, and everybody is equally important and everybody's voice counts. Right. So, with with healthcare organizations, there are pillars for high reliability organizations to maintain the leadership that we just underscored, that's their responsibility. They need to preach this, they need to support it. And as Dr. Eisenberg said, they need to fund it. Secondly, all of us from the bottom up, not the top down, this is bottom up. Right, like Dr. Kabilian said it's the upside down pyramid throughout our organization, safety values and practices are used to prevent harm and learn from mistakes. And then, don't be happy with today. Remember that there's tomorrow and tomorrow is going to be better than today because you believe in and sustain continuous process improvement across the organization from the unit, all the way up through the entire organization, and across the system. And with change management the result is an organization that celebrates transparency and contributes, and everybody, every individual contributes equally regardless of their position because everybody's voice counts. So first is your organization have a shared goal of zero patient harm chest and said, achieving zero harm is a daunting challenge satisfaction with the status quo and quality and safety is on tenable. Right, it's not just about being great today, it's about being greater tomorrow. Secondly, does your organization support a safety culture, it's leadership's responsibility again to assess evaluate and encourage a safe culture. If you don't think that's happening. Talk to your leadership, ask them, and nicely. Make it clear that you consider it important for them to exercise their responsibility, but you're going to start it at the level of your unit with your patient. This is an excellent graphic from Hudson. And I'll bet you don't work in that mill you. But what about a low one. This is defensive right safety is important, we do a lot every time we have an accident. This is the reactive level, right, so you have a problem, you react to the problem you're going to sit around and wait till a problem develops develops but when a problem develops okay you'll put that fire out defensive. That is a low functioning culture of safety, a moderate functioning culture of safety is where you're at least actively evaluating in implementing systems to address some safety concerns. So you're not just being reactive you're being proactive. Sometimes, well, higher than that is being proactive, all the time, and actively anticipating and mitigating for most safety concerns most safety concerns so you're being vigilant, right, and you're being a security officer for safety culture, very high which is what you should be aiming at is this is what it's all about safety is number one patient safety is job one we live and breathe it culture processes technology, everything is aligned to support where are you in this ladder. If you're not at the top strive to be at the top, because getting there is going to make you great as a leader, strive to be able to answer yes to the following questions I support my staff, 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 staff safety concerns with respect. I treat staff fairly when they make mistakes, I act upon all reported safety concerns, all reported safety concerns, I acknowledge that we can always do better. We're great, but we're going to be greater tomorrow. I know staff have a responsibility to let's not forget that the Joint Commission says 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. If you tell your staff, let us know, but then when they let you know you don't lift the finger, they're going to stop letting you know and you're going to deserve it. How you transform your culture includes equality, responsibility, openness systems, accountability and privacy. Let's take a look at each for equality, when it comes to a safe workplace culture. Everyone is an important part of the team and everyone's voice matters. It doesn't matter whether you're the housekeeper the assistant the tech the nurse the physician. Everybody is equal, right. If you're running a code. Everybody's equal, everybody matters, everybody has a part. The patient doesn't make it. If everybody doesn't do their part. No one's concern should be dismissed because of their position or lack of seniority, because everybody counts equally. If staff see leadership, building relationships and trust with everyone who works in the facility, even workers from outside agencies. This is going to create a tighter knit community within your walls. Your patients must always be the top priority. It's all about the patient, the patient safety and well being take center stage day in and day out. If anyone on your team is unwilling or unable to give patients their complete attention, working in healthcare is probably not the right career choice for them, help them figure that out. Openness, a sign of strong safety culture is when anyone working in a facility feels comfortable speaking up without hesitation, and without fear of retribution. When they believe something isn't right, you should be actively soliciting these critiques, and you should be celebrating it when somebody gives constructive criticism, not damping it down work to promote such an environment when concerns are brought to you. Take them seriously, be appreciative that somebody had the guts the insight and the observation, and then respond in a timely manner that recognizes their significance be appreciative accountability. When it comes to education and training the promotes yourself environment staff should be expected to follow what is taught. If anyone resists, they must be held accountable because it's not about the thread. It's about the fabric that's woven from the thread. Each thread is important, or the whole fabric falls apart. But it's about the fabric, not the threat. A single person unwilling to fully support the safe workplace culture can weaken the entire effort, and the entire fabric systems errors and healthcare were historically addressed by punishing the individual, remember that, who made the error, as opposed to blaming the system that allowed the individual to fail. Right. So the philosophy is not, you're a bad person because you messed up. No, you're a bad system, because you didn't provide the support to the individual. You didn't provide them with the safety net, so that they could do a good job. Let's fix the system, not dump the individual. Not only that you can't afford to dump the individual, their professional health care gift, right, they're a scarce resource. You need to help them do the job that they can do by providing a supportive system, and when errors do occur, conduct a comprehensive root cause analysis and fix the issues that contributed to the error. Help the individuals perform the best at the top of their curve the best they can, by providing them with the best system privacy when staff admit they made an error, or confide in you about the inappropriate actions of another team member. You want to keep your discussion private, and this individual's identity confidential, you want to encourage people to come to you with this information by not maintaining privacy, you discourage that action. If staff believe word of their actions will leak out, they will be much less likely to come forward, you will then not have the data to improve your system. So, going on, third, how are you going to create lasting change not just for today but for tomorrow, and here Chaston and the JC say evidence is accumulating the process improvement methods long use successfully in industry, whether it's lean six change management, etc taken together are far more effective than the one size fits all best practice approach. What's different about them, is their capacity to pinpoint and measure the frequency that critical few key issue causes of persistent quality problems interventions targeted to eliminate the key causes lead to major improvements and the key causes differ from place to place, but that necessitates the identification of those key causes before deploying interventions. So he was mentioning lean six sigma. And there's also rapid process and cycle improvement, which is quality improvement that identifies implements and measures changes made to improve a process or system rapid cycle. And that implies that the changes are made and tested over short durations just three or three or four months or less, rather than the usual year or a little bit short of that. A few years ago the Joint Commission ambulatory healthcare national patient safety goals, recommended to identify patients correctly use medications safely prevent infection, prevent mistakes in surgery and procedures and to do this by using to patient identifiers upon arrival during admission and intake and a timeout to label your syringes properly address blood thinners, and to undertake medication reconciliation perform hand hygiene regularly endoscope reprocessing standard operating procedures reprocessing competencies and continuing education, and to conduct a pre procedure timeout using a checklist. With medical error review. Of course we can, what can we learn from other industries that do this well. You know a plane crashes vigorously investigated with the results being shared openly throughout the industry, the entire pilot community is educated and the results are disclosed to prevent any future accidents and this isn't just true in the airline industry this is true across the board and transportation. I remember years ago when I was putting together a talk on the same topic, I got together with one of my patients who was a train conductor, and on one of the systems in Chicago, and she educated me greatly on quality improvement in the train the rail transportation industry, and they are way ahead of us in medicine, and not only this sort of thing, but also in using simulation in education and training. So there you go. For medical errors, believe it or not, there's no current standardization of medical error investigation. Should or could we begin the transition to the methodology that's used in the transportation industry. We're seeing the same medical errors repeatedly, right, and we also need some legal protections through tort reform. So, change your culture, work toward correcting the system and not punishing the individual. and have frequent discussions towards the goal of zero harm we do a number of these things as you see listed here at my institution. None of these are revolutionary, they've been evolutionary for us, but we do them every day in every unit, and we've seen the results. Remember to be civil in your discussion so that people actually come to you. When they feel that something's wrong with the system. Take them seriously and fix the system in short order, don't let it drag out, or they'll stop bothering coming to you. So, to wrap up practice pearls here a commitment to zero harm and safety culture are going to benefit your patients and your business, create a safe culture, but that requires more than just posters and new furniture, your entire organization is going to need a shared goal of zero harm, and you're going to approach that through a reliable process for addressing your own risks to achieve zero harm. Thank you so much.

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