Fostering a Culture of Excellence & Improvement

Fostering a Culture of Excellence & Improvement: Prioritizing safety, quality, and experience of care in your organization 

Transcript

SPEAKER_05 0:00

So we're excited to be here and we're going to be here for an hour with you. Gina's going to share about why we combined our time together. You see that most of our segments are in 30 minutes today, but we have a good opportunity to have really some discussion and what we're asking of you all is to participate with us. We want this to be an engaging session, conversation. Feel free, we're going to have some of those Slido questions that you'll be able to get your phones out. But really, we also want to hear from you. So if there are things that you do want to get into a little bit, we're here to dig in. We've built that time in to the session. And one of the things that as lifelong learners, we believe that it is really essential for us to learn from each other. And I always say personally, I can't make all the mistakes myself. So I'm going to learn from others, and hopefully you'll be able to learn from things that we've done the good, the bad, and the ugly, and all of that. So yeah, you want to talk about why we're doing it?

SPEAKER_06 0:58

Absolutely. So uh first off, thank you so much. I have been honored uh to this is my third session, my third year with you. It's been such an honor to do that. And if you've been here before, I know some of you are, we've traditionally done these separate. So there's a quality oversight piece, and then there is a clinical leadership experience of care piece that I've done for the last few years and have loved every minute of that. But I think we had a bit of an aha moment. Um, if you've ever had a good conversation with me around experience of care, the one of the things I always talk about is the integration of quality and safety, experience of care, and how it truly is two sides of the same coin. So, what a great opportunity. So, when they asked us to join, well, first off, when they ask you to present with your boss, you say yes. Of course, I'll do that. Um, but beyond that, it made perfect sense. It really did to bring this conversation together. So, so happy to do that. Proud to be part of here, and thank you again.

SPEAKER_05 1:49

Yes, thank you. And and uh Jesse wasn't kidding, there is coffee outside. If you need some, please feel free to get it because we do want to have people caffeinated and energized for our conversation. So, again, we're talking about fostering a culture of excellence and improvement, prioritizing safety, quality, and experience of care in your organization. So, a couple things we're gonna go over, and we've you've heard us talk and you've heard SHIP reference, we have the new book. So please take the opportunity to look at it. We're really proud of it. It's something that we're gonna continue to always evolve. Um, but we are gonna talk today about chapter five in your book. So, just for a quick reference. So, again, today's highlights for us your role in quality, uh, characteristics of quality care, aligning to patient safety structural measures, which we talked about last year. We introduced that concept as that came out this past year for our PPS hospitals, but we know that these are rooted and founded in good quality, so it's something that everybody can take advantage of. And we're aligning our domains around that today for our conversation for quality. And then board stewardship. We're gonna do more of those mirror moments, and actually, all of our questions for Slido, it's really about the mirror moments. So taking that pause, thinking about how things are going in your organization, and what possibly we could do different, and also what are the things that are going really well that we can celebrate? Um, and then we'll wrap up with some key takeaways.

SPEAKER_06 3:19

Yeah, sounds great. And I, you know, I love structure. Anyone knows something I love structure, but being able to build on that and be a bit flexible. And to your point, so much of this conversation today is really conversation with you. So I'd love to do stop and take a little bit of a temperature check before we go any further. I always do this and just say, um, based on what we're planning on today, anyone disappointed? Do you feel like there's something you wish we were talking about and you want to make sure we touch on, whether it be during our conversation in the next hour or afterwards? Um temperature check, are we good? All right, I'm seeing lots of thumbs up, which is great. Anyone who wants to chat, um, any other topics, please don't ever be shy, and we'll be here all week. Um, certainly we can connect um afterwards as well. So thank you. Super.

SPEAKER_05 4:07

All right. So we want to dive in a little bit to the board's role and characteristics of quality of care. You've seen this information before, it is not new. It's really a reinforcement and aligns to that board essentials book. So go ahead and make sure to note that as we go through today. You have such a big role to fill. And earlier today, I thanked you for being here and for taking time away from your families and so forth. And this is really one event. When we think about the board's role and our executive leadership role, it really is something that is a continual evolution. So we want to make sure to support you and to challenge you a bit to say, please continue to learn. Um, we don't want it to stop, we don't want it to be just for today. It really is sort of an evolution of that lifelong learning. So keep at that. We thank you for that. Um, and last year we got into a little bit of a discussion regarding quality about what happens when we don't meet those quality outcomes that we expect to. It's very easy to highlight the things that we want to share with our board, and I'm talking about our our executive leaders. It's very easy to share those things. It's a little bit more challenging, right? Whenever there are things that don't go so well, and you really need to share those too. So we need to be mindful because the board, as board members, you're responsible, right? You're responsible for that delivery of that quality of care. So we want to make sure that your eyes are wide open and that you know the questions to ask and some of that uh feedback and guidance to give when things don't go as well as what we intend. But this is a continuation of our learning from last year.

SPEAKER_06 5:58

Yeah. And you'll notice in the center of this slide it says safe, quality, patient-centered care. And just think about that for a moment. What is that? It really is the true North. It's your North Star. It's what hospitals are in business for, it's what we're all here to achieve together. And when you think about that and what your responsibility is, to Chris's point, it's absolutely essential. It's not just the people at the front edge of care that are delivering it, it is everyone plays a really important role in that. So when you look to this slide and you or where it comes back, we'll see. When you look to this slide, you're gonna see right there in the upper corner, um, you know, it is all about understanding and collaborating for continuous quality improvement. There's an understanding that no matter where we are, no matter how much we've achieved, there's always more. And the role that you play in that is very collaborative. We need to work together. It's not just that sharp edge of care, right? It is absolutely collaborative. And it's also an understanding that sometimes you need to challenge that status quo. There's that saying that nothing changes when nothing changes. I believe that. If you want to make a difference, if you want to have continuous improvement, you have to be bold, you have to be brave, you have to put forth how are we going to make those steps and make a difference. Because if you keep doing the same thing, you're always going to get those same results. So challenging the status quo is important. You have to be bold. Partnering to establish priorities and resources to meet those regulatory requirements. No one expects you to be the regulatory expert. You have people in the organization that are those experts. But understanding your role and helping to prioritize and moving us forward in that right direction so that not only are we meeting those, but we're exceeding. That's when results really happen. And the last piece of this, and I love this, is cultivating an organizational culture of excellence. Just let that sit for a second. You know, Chip and Jesse talked earlier about the definition of oversight and stewardship. That's stewardship. Oversight looks at what do we have in place, what structures are there, what have we done to make sure that the right pieces are gonna snap into place. But at the end of the day, how are we nurturing that? How are we moving that forward? How are we supporting that? That's cultivating that culture of excellence. And you really have an awesome ability to make a big difference there.

SPEAKER_05 8:29

So, as a reminder, we want to highlight the essential characteristics of quality care. You've heard these before, you've seen them before, they are in your book, chapter five. But just as a quick refresher, um, when we think about what is it that makes up that quality of care, safe, effective, patient-centered, timely, efficient, equitable, certainly understood, and coordinated. Right? These are not new. We've added a couple as time has gone on, when we think about making sure that people do understand and uh health literacy and our equity and so forth, but um certainly rooted with these essential characteristics.

SPEAKER_06 9:16

And if I could add to that, please. You mentioned uh you've heard this before. If we've ever had a conversation about it, I've certainly we've talked about it personally as well. When I was here two years ago, I talked about patient experience as a focus. And I always make sure to point out what are called drivers of patient experience or drivers of patient loyalty. What is bringing them back? What is committing them to you, what connects you to them? Um, and you'll remember if you if you paid attention two years ago, right? Um it was about high-quality, safe care where patient was at the center. Those are elements are right here. Then last year we talked about what drives employee experience. People get into health care for those very same reasons. They want to provide high-quality safe care at the top of their license and really be part of a team that's well coordinated to do so. All of those elements are here. So this year I'm gonna say not only are these characteristics of quality care, but think of this as characteristics of organizational excellence. How you're gonna get there. This is a great roadmap when you think about what that looks like.

SPEAKER_05 10:21

Okay, so here we are. Uh, you've been set up nicely by Jesse as far as mirror moments are concerned, and essentially, you know, it is what it sounds like, as she said. So this entire section is actually gonna be your opportunity to look in the mirror. So, patient safety structural measures. We started, as I mentioned, we started this conversation last year, and these are really domains that we're gonna use when we talk about quality of care. There's five here. We're gonna highlight them for you. You have these as references. We have much more material available, and we do have hyperlinks in the slides that you can actually just go to, click, and it'll give you lots more detail, and we'll have references for you as well. Wanna kick us off with leadership?

SPEAKER_06 11:08

Yeah, and as I get older, I am super sensitive to font size. So I'm gonna do you a favor and read the first one for you. Um, leadership commitment to eliminating preventable harm. So that is saying leadership and the board sets the tone for commitment to patient safety, must be accountable for patient safety outcomes, and ensure that patient safety is the highest priority in the hospital. So that gets back a little bit to what I said earlier about what's your true North. What is your North Star? Are we all rowing our oars towards that same direction and is that our priority? You have the ability to set that tone. And it really is a tremendous gift that you have been given. Thank you.

SPEAKER_05 11:52

Next, we're going to talk a little bit about strategic planning and organizational policy. Um, and this is one of the things that if you have had any of the strategic planning process done in the last year or two with Jenny Berg, who leads our team, you will have heard her say, and if you haven't, you have one coming up, you will hear her say, that there really should not be any strategic plan out there that doesn't have a pillar, an element of quality. We are in healthcare, this is what we do. So I would say that that is certainly, I think it's been an it's been unspoken before, but now under this direction, we're really making sure that we are calling that out in our conversations as we're doing the strategic plans. And uh I just want to say thanks to Ginny for incorporating that in.

SPEAKER_06 12:42

Absolutely. That next domain is around having a culture of safety and learning. So it asks: do you have industry-leading best practices and protocols in place to get you where you need to go? Have you built that into the, just woven that into the fabric of your organization? You want to create that learning culture where you're always pushing for more, you're always wanting to move in that same direction, a new direction, and really be achieving at the top of your game. It's it's how it's not an event when something good happens, it's an everyday. It's just what we do. That's creating that foundational element.

SPEAKER_05 13:18

And something that goes along with that really hand in hand is about the accountability and transparency. So it's really about a culture to promote the event reporting without fear of hesitation, making sure that safety data, collection analysis, that there's free flow of that communication in the organization. And there shouldn't be that fear of um I don't want to report that, I'm afraid that this is not gonna look good. Remember, it's about how do we address all of the things, the good things, the bad things, the ugly things. You're gonna hear us talk about that too a little bit further in the presentation. But do we have that type of accountability and transparency in the organization that supports that culture of safety? And it's a culture of safety for our patients as well as our employees. It's everybody.

SPEAKER_06 14:08

And last but certainly not least, and of course my personal favorite, uh, patient and family engagement. This is saying that hospitals have to embed patients, families, and caregivers as co-producers of safety and health through measuring, I'm sorry, through meeting involvement and safety activities, quality improvement, and oversight. So I have a phrase I've used many times, I'm sure you've heard me say it, because I've borrowed it brilliantly from someone else, but from a patient perspective, there should be nothing about me without me. They should be integrated into every moment of that experience of care. So it's not just that we are doing it to them, but with them. And they really need to be part of that from start to finish.

SPEAKER_05 14:50

All right, here we go. Slido time. You will see as we go through these mirror moments and questions that we have broken them down, and as a reminder, the the domain is the first thing that you'll see. So this one is regarding leadership commitment to eliminating preventable harm. And the question is we have a culture of quality and utilize a plan to improve quality, safety, and experience of care at our organization. So it looks like a good majority of people are saying that they do work with medical staff and leadership and know those quality indicators. So that's great, about 79%, and then another 19% on top of that who work with the medical staff and leaders but aren't quite sure about what those indicators are.

SPEAKER_06 15:37

Um let's ask a question as a follow-up with this, um, with that first question that we had. And I know we have people with microphones in the audience. So if you know that you have it, but you're not sure what your indicators are, is there something that would make that easier for you? What is it that you need to be more engaged in that overall, knowing that we how important that is that you set that tone?

SPEAKER_05 16:02

Anyone? Bueller? There's one. Bueller, Bueller. Yes. We have a microphone coming for you. Yeah.

SPEAKER_01 16:08

I mean, to meet regulatory compliance, we have certain key indicators. Okay, and we do a good job of flashing all those. The next question is how deep is that quality program within our institution and how much of it as board members should we be seeing? Not just the key quality, you know, pieces, but the departmental quality that goes along with it.

SPEAKER_05 16:42

Yeah.

SPEAKER_01 16:42

Those two separate up there. How much do I need to know as a board member?

SPEAKER_05 16:51

So I would say thank you for asking the question. And I think it's really important as a as a board member to be thinking that way. So it's not just the the what meets the regulatory requirements, right? Yes, that's important. But we do want to know because I think when you dig down deeper, it really is about what's in the fabric of your organization, what's your culture, and how are you really doing on all of your outcomes, right? How many of you use a quality dashboard that you see as a board member? How many of you see that as a board member? A quality dashboard on a regular basis?

SPEAKER_06 17:29

Okay, some.

SPEAKER_05 17:30

A good number. Um and we always have, I think, this debate, and this might be part of where your question is coming from, too, as far as what is for our oversight and stewardship from the board versus what's more operations. And I think you know, when we talk about and we think about what are the most optimal relationships with boards, what's the and boards and um executive team members? What's the what is the most beneficial for organizations that we see? And we see that open dialogue, and it's not just the key performance indicators that were required to, but it really does get down to that deeper level of do we have the structure in the organization to make sure that we address perhaps its infection rates that aren't where we want them to be. What's happening? So you might get that level of information, but are you getting more information about what's our structure in place? And I think those are important conversations that should be had with the board, so the board is aware. There are many of you that have shared with us, you are out in the community and you get questions, right? And there's public reported information that is out there. Consumerism is such a big part of the world that we live in today, that I feel like board members have taken note that people are questioning them more about what is it that's in place at the organization to address XYZ concern. So I feel like those conversations should be happening with your board and your executive leaders if they're not. Certainly, we could spend hours on going through quality and the action items that that hospitals are taking. But I think as a board member, having that comfort level to know that yes, we know that we are monitoring these indicators. We also know that there are committees and structure in place at the organization that address this when we don't get the scores that we want, and I know who to reach out to if there's any question that comes up. But I do think your your quality dashboards can go much deeper than what is required from that regulatory perspective. Anyone else have thoughts from our hospitals that you want to share how that works in your place? I'm sure there's somebody out there who's really proud of the communication that you have between your board and your executive leaders and who those conversations are being had with. I know they're happening. Anyone back here? Yes.

SPEAKER_02 20:19

And it used to be that uh as board members we were mostly focused on quality and um maybe some finance and um new construction. But it over the last probably five years, ever since COVID, we've been kind of diving down since financials are so much more difficult, and it's made the board's job a lot harder, in my opinion, into small things like uh patient flow, how many patients the practitioners are seeing, you know, trying to get involved in management of office practices, not managing, but being more aware than I think we ever had. I don't know if that's healthy for a board, but we spent a lot of time looking at practices in our community now when historically we never did. I think it's a lot more work for the board. I I would throw that out there, probably more stress for the board as well.

SPEAKER_05 21:15

And I like how you said it's about the awareness. It's not necessarily sort of stepping over that line for the the operations piece, but for that awareness, so you you can speak to it. Thank you for that. Yes.

SPEAKER_03 21:29

I'm actually not on the board. I'm I am one of the medical, I'm the chief medical officer, so one of the docs that the boards will be working with. Um from the provider standpoint, we want what's best for the patient, right? That's that's why we went into medicine. And so having that feedback, that communication as to hey, these are the things that we're concerned about. We are ready and willing to engage. And I think that you'll see that amongst any providers. Um and so I Having that open dialogue is super important, and I think that that will allow all of us to be more successful. Sorry, very broad, general thoughts, but I just wanted to put it put a plug that your medical staff wants to hear from you, and we want to be on the same page.

SPEAKER_05 22:17

Thank you for that, and thank you for being here.

SPEAKER_03 22:20

You are very welcome. Yeah.

SPEAKER_06 22:22

Well, I love that partnership too. You know, when we talked about how we work together, it really does all of us together and connect it in that way.

SPEAKER_05 22:29

So and we're gonna talk um in a in a few slides also, but but back to the point also about when we think about what should we be doing with um from a board perspective for patient safety and also workplace safety. We really should be having 20% of our board agendas focused on that. So I want you to tuck that in because we're gonna come back to it. 20% of your board agendas should be focused on patient and workplace safety. So start thinking about how does that work in your organization? Do you have that in place? And it's something that's been um highlighted over the past year, so it's gonna continue to be a focus. All right, let's move on. So just a little um a little recap, we don't want to spend lots of time on this, but um a couple things when we think about um well I'll jump in here that 20% of the um governing board agenda is related to safety. The other piece that is um new within this past year, as board members, are you getting the communication when a serious or I'll also say sentinel event has happened in your organization? Are you getting notified? And technically, you're supposed to be notified within three business days, and that was new this past year. So, is that happening in your organization? So keep that in mind, and that's a definite mirror moment. If it's not happening, we need to partner together as executive suite members and board members because it really is both of those groups need to be communicated within three business days.

SPEAKER_06 24:21

Okay.

unknown 24:23

Great.

SPEAKER_06 24:24

All right, so we're gonna jump to strategic planning and organizational policy. So you should have another question pop up there. And this is really that reflection of I'm familiar with how financial performance measures, and it could be such as value-based purchasing if that applies to you, or fill in the blank with other measures that apply are gonna impact our fiscal health. So take a moment and say, am I definitely familiar with this? I'm not, or I don't know. And know that Herb is in the audience and he's gonna be talking about this today, so he's paying attention.

SPEAKER_05 24:57

91%. Yes, I'm familiar. This is super. Yeah, all right. Uh we comply with national performance goals, formerly known as national patient safety goals. So that's still in a lot of our language and so forth, and that's okay. Just want to make sure to make the connection there.

unknown 25:18

All right.

SPEAKER_06 25:20

I have a follow-up question on that. Oh, please do. Okay. I saw about 27 people percent said or percent, excuse me, said I don't know. I'm curious, and this isn't a slide, so we can be uh shout it out. Um, is it that you don't know what your national patient safety goals or national performance goals are, or that you don't know if you comply with them? That's probably a hair I should have split in the responses. I'm curious. Or do you think others, if you don't want to admit that you didn't know, do you think others perhaps don't know what the goals are? Or whether you comply? How's that? That's fair. That's fair. What the goals are. I think that's fair. As I was here thinking through, I suspected that might be it. So as you kind of had that mirror moment, maybe that's a good question to ask at your next board meeting. What are those goals? Are they in alignment with what we are, you know, reporting on and we're we're good, we're complying, or do we need to really think about that? And is our direction, our strategy pointing to the right elements? So I just kind of wanted to do a little follow-up on that. So thank you for that as well.

SPEAKER_05 26:27

Thank you. All right, you want to do a little summary there?

SPEAKER_06 26:30

Yeah, sure. So um, as far as that strategic planning organizational policy goes, now they do provide us with some five key strategies. And as you look at these, one of the things up top there, it says, Do you have a strategic plan that publicly shares your commitment to patient safety as a core value? So I mentioned earlier in the first element, if you will, about having a true North or having that North Star. Um, is it that you have zero preventable harm? I mentioned that because a lot of organizations will set goals to say, well, we'll just decrease the number of bad events that are happening, or number of infections, number of incidents. If it were me, if it were my family, do I want them to be one of the ones that we said it was okay we hit a number? And even though they had that infection, it was all right? Probably not. So we need to set that goal at zero preventable harm. And what are we doing to make sure that our plan and our policies align with that goal? So, you know, I I think about that, I was joking a little bit last night with Chris. I said these domains, they're not really distinct, they're not separate. It's a bit of a five uh Venn diagram. It's gonna look like the Olympic rings. I'm in that mood. I don't know if anybody else is obsessed with that right now, but think about the Olympic rings for these domains. There's a lot of overlap in what that looks like, and this is a perfect example of that. So, really, what leadership oversight do you have to make sure not only is this planning and policy in place, but that we are absolutely setting the goal where it needs to be, so that our North Star is where it needs to be as well. I feel like I could talk about this all day, but I feel like that's the really the one I wanted to highlight the most. And of course, you again have these as reference, and and as a side note, if we didn't mention this, as part of that, you know, the rollout of these domains, there is an attestation. And these are specifically what you are expected to attest. So if these are, if you're looking for a playbook, I would say these are things to really be thinking about.

SPEAKER_05 28:24

Okay. Culture of safety and learning is our next domain. My organization is in a continual state of readiness for regulatory and accreditation surveys at all times. So the options are yes, we are always ready. No, we are not ready. We may or may not be ready, I'm not sure.

SPEAKER_06 28:44

I definitely have a follow-up question for this. Yeah, so we have uh overwhelmingly, 69% said yes, we're always ready. I love that. But I want to help those who aren't quite sure if they're ready or not sure even if they know if they're ready. So I would love to hear from someone who said yes, we are ready. How do you know you're ready? What does it look like to be ready that you're doing good in this? Share for your others, fellows in the room.

SPEAKER_00 29:15

We know we're ready. Uh we just had the Ohio Department of Health uh do our certification survey. And uh another way we know we're ready is we are DNV accredited, so they come unannounced once a year. So our organization is forced to. Uh it sounds negative, but forced to stay ever ready because you know we always have a chance of being surveyed.

SPEAKER_06 29:36

Oh, yeah, great.

SPEAKER_05 29:38

Thank you.

SPEAKER_06 29:39

Thank you for sharing anybody else? Uh oh, we have another hand here in the middle.

SPEAKER_04 29:46

We've had a couple instances that uh during our regular board meetings, they have showed up the morning of our board meetings when our staff isn't completely just going crazy. They're like, Yeah, they're here, we're dealing with them. We've got people putting stuff together. One or two of us may get called out during the meeting, but we're we're okay. And they're very calm, and we'll get through it. If there's findings, we'll deal with them. So, yeah, the the staff is calm, they're not in a tizzy, and I feel we're ready for them.

SPEAKER_06 30:16

So it's a tone, it's a vibe.

SPEAKER_05 30:18

Absolutely. That's great. We agree with that much. And you know, there are oftentimes when we work with organizations, and if we are doing um a prep survey, a mock survey, people are very anxious. And um, you know, I think that there's an element of that just based on uh historical surveys. There was a time, and there still may be, but there was a time where our partners in the in the accreditation world didn't view the process as much of that educational learning environment. And years ago, when I first started, I'll say years and years ago, um, it was very um strict, structured, there wasn't a lot of discussion. And I feel like probably in the last 15 years, that tone has really changed. And there's, you know, there's always going to be various personalities as people are coming into your organization and they they want to see the the evidence, right, of why you're doing things well and and that you're compliant. And the goal of all of that in the regulatory world is really patient safety. Sometimes we lose sight of that because of the anxiety behind it, or because maybe a surveyor was maybe not warm and fuzzy. But I will say in the last 15 years, I feel like that space has really changed. Yes, they are still going to point out the areas that we have opportunities, but I also feel like there's good follow-up with the education and the rationale behind why. So it is sort of setting the tone, so I give you credit in your organizations for okay, we're gonna, we're gonna, we're gonna deal with it. And truthfully, folks, there's always going to be findings, and we want that. That's why we want people to come in because again, it is a reflection of that quality of care and the patient safety. But it is best, and organizations perform best whenever they're able to manage it in that type of a tone. Okay, we got it. Thank you for sharing that information, and we're going to be able to fix it. And many things, as you know, are able to be fixed right there on the spot, and they accept those changes. Other things we may have to work a little bit harder with a plan of correction, but it's all we really do all want the same thing, and it's that patient safety. Anything else you wanted to do?

SPEAKER_06 32:39

Yeah, absolutely. What I would add to that is, you know, when you think about these these visits, these accreditation surveys, to me, I I know I am I speak in um phrases a lot, but you know, it's not about the destination, it really is the journey to get there. Like how are you going to be in a constant state of readiness? That it's not an event that happens every three years and we'll be ready by the time it gets there. But how are we always ready? These are unannounced surveys. So you know, I talked earlier about when we get to culture of safety, it's just woven into the fabric of your organization. Think about that as far as this goes as well. Um, really, how is it just part of what you do is you've strive to meet these standards, but that it's just your very nature. And achieving that is, you know, you can start by looking at data, you can start by looking at those elements and the preparation pieces as well, but you know, kind of getting to this nirvana, if you will, where it's just where we are. That's just what we do. And then so when you come here to an event and maybe you are expecting a surveyor to come on site, you can say we're not even worried about it. I heard that um someone yesterday mentioned to me, and I love that. That means you're in that state of readiness. You're nothing about it is gonna be a surprise, for then they're ready, they're ready to go. Because you've helped to nurture that along the way, you stewarded that, um, and really that's the culture that you have.

SPEAKER_05 33:56

And I am gonna um shout out that was Karen from Prowers that we were talking with, and we were just, you know, doing our greeting, and she said, Oh, it's great, you know, we're here, and for sure our regulatory body is gonna show up tomorrow because we're here. Karen, did they show up today? Okay, see, excellent. But you know, it really does come back to that's why we have our leaders in place, right? And that's why we have to prepare them and give them those opportunities so they can stand up and do the leadership in your absence. So thank you for that um attitude, Karen. All right. We regularly review public data, comparing our hospitals' quality to similar hospitals.

SPEAKER_06 34:36

Do you regularly review that? Do you occasionally review that? Do you say we don't want to know how others are doing? So we're gonna put that aside, or you just don't know.

SPEAKER_05 34:47

This is one of our favorite topics actually when we think about comparing data and how organizations do that, and it leads us into we had mentioned consumerism earlier, and you know, consumerism is such an influential factor for organizations, and I think appreciating and understanding that public information that is out there and using those comparatives really is essential for organizations so they know what what the community is thinking. Um when you are seeing that sort of that black and white data, it does give you a moment to pause to be able to identify what are the things that we're doing well, what are the things that you know our competitor is doing better than we are, and how can we maybe adjust ourselves to think about that. Consumerism really became, as you can imagine, much um much more popular since the pandemic. And um Dina has spoken a lot on you know the resources that are out there, on um the care compare, and people had a lot of time during COVID to be online and searching for their providers and where they wanted to go, who they wanted to choose to be partners in their care. And it just exploded with this consumerism. So a huge part I think that we can't underestimate. Um, we've heard people say, well, we know that we do well, we know that we do. But how are you doing in comparison? I think it's an important piece to consider. You you worked in this space for many years.

SPEAKER_06 36:22

Yeah, absolutely. Absolutely. And I think you know, it it's the first step is to look at your data and look at your own trajectory, right? Are we moving in the right direction? Very important. But to start looking externally and to look with the mind of a consumer, who our patients truly are today, is taking it to the next level. So when you start to regularly compare yourself to those benchmarks that are available, you really are setting that standard of we want to be moving our trajectory in the right direction, but how are we compared to others? Exactly as Chris mentioned so eloquently. So, you know, really thinking about patients as partners in that, and we talked a little bit about them being at the center of their care, they're gonna be smart consumers and are gonna do their homework before they ever come to see you. So a referral to you isn't alone and isn't enough alone any longer. You have to have that out there to kind of support that you're gonna deliver that high-quality, safe care that we talked about. So the elements of what quality really is really does drive this piece as well. So it's just uh can't speak enough to what consumerism has that's blown up. Um, but really, if it were me, absolutely, um, I wouldn't have gone um uh just to anyone. I would do my homework, I would do my research, and you have to respect that as partner, having them partners in their care. Can I jump on this just for a second? I do want to say because it's a survey thing, so I wanted to mention about culture of safety survey. Sorry. Um, one of the recommended things you attest to is around having a culture of patient safety survey. Um first one that's listed there. So it's talking about having an actual instrument annually or every two years if you do a pulse survey that talks about the culture of safety at your organization, but it also says that you share results with the board and staff. So, top to bottom, you know, throughout the organization, are we not only measuring that and may ensuring that we have this culture where people feel safe to report, but are we getting back to them as well? And my advice is if you're ever going to do a survey for anything, whether it's a patient survey, whether it's an employee survey, whether it's a culture of safety survey, make sure if you're asking someone to share, because you're asking them to feel safe with you and share their thoughts and concerns, that you get back to them. There needs to be something that loops back to them that really talks about you were heard. Maybe you can't give them all the details of what you're gonna do about it, but if you expect to get another survey in a year or maybe two, and you continue to want to get feedback, you have to let people know that their voices mattered, that they can have this environment of a safe culture, and that we're creating a space where not only are they safe, but we're gonna improve based on it because their voice makes that difference. Sorry, I just when I get excited about surveys, I had to say, because we get really wrapped up, I know, a lot in patient surveys, but remember these are just as important. Getting the feedback from employees to say what does this look like from an experience for you, but how do we make sure that there's this environment of safety where you feel like you can report freely and that we're gonna do something about it is really important.

SPEAKER_05 39:28

Accountability and transparency. So does your organization regularly share quality, safety, and experience of care data with the board? Yes, we always receive data reports. We sometimes receive data reports. No, we do not receive, we regularly receive, a little bit of a tongue twister today, regularly receive data reports, or I don't know. Well, you take this one.

SPEAKER_06 39:51

Well, here's the follow-up question. So we did put this one in a SID-O, right? So not only are you getting those reports, but is your organization accountable to those? So your quality, safety, your experience of care data, not only are you getting the data, and when you say what do you mean by accountable, do you also hear what are we doing to improve? What work is happening around this? What space are we at with what that improvement process looks like? Remember, we said you know, you're going to be a partner in this. So you need to know not only what's the number, but what's the plan and where are we moving in that direction? I would say think a little bit about not only is your organizational accountable to it, but what would you need that you could confidently put yourself to the top of that the next time I asked? You know, what would make you feel like I know better about the accountability in this organization around this quality data, around our safety measures? What is it that you would need and let them know that? That's part of being a partner, a good partner, is voicing that and saying, this is what I need to know, or asking those questions. That's okay too. You get to do that for sure.

SPEAKER_05 40:57

Thank you. Okay. I am familiar with the credentialing process at my organization. All right, so pretty overwhelmingly. Um 85%. Yes, I understand the credentialing process. 12, no, and three, I don't know. So when we think about the accountability and transparency, um, you know, we we certainly have um talked about this a lot. I don't want to spend a lot of time here, but really it is about how are we managing this safety piece? And it's so important that board members understand this and making sure that the organization is accountable, transparent, and know that there are there's an infrastructure in place to be able to manage. So we'll keep going.

SPEAKER_06 41:43

All right, patient and family engagement. Uh, you know, I'm familiar with what we're doing to improve and achieve an excellent experience of care for our patients, workforce, and community. So you're thinking about what are you doing uh data-wise, but what are you doing to improve? Say, yes, I'm familiar with this, no, I'm not familiar with this, or honestly, I'm not sure. I see it's quickly, lots of people are saying, yes, I'm familiar with this. That does my heart well, so I thank you for that. Um, but if you weren't sure, if you're not familiar, remember what we said earlier about the tight integration of quality and safety and experience of care and how it's two sides of that same coin. So if you're not having the opportunity to hear about what your organization is doing to focus on improving this as well, then you're really only getting half the story. Um selfishly. I feel like you want to make sure that's part of it because that's just as much what people are gonna stop you on the street about and tell you stories as it is gonna be about maybe those quality metrics that you are hearing about more familiarly. So if you're not part of that 80%, just think about what might make that successful for you to get to the top of the list here.

SPEAKER_05 42:56

So my organization administers an employee engagement survey, and I know what we are doing to improve on this. Yes, we're administering a survey, and I know what we're doing to improve. Yes, we are serving, but I don't know what we are doing to improve. No, we are not currently doing serving our employees, or I don't know.

SPEAKER_06 43:16

So we still have some coming in, but we're seeing it's a little more spread out, right? And not surprising. Employee engagement surveys, if it were official, it's admitted, they come at a cost. They come at but they come with some work. Um, and it's just as important though, when we think about patient experience, to think of that hand in hand. You really can't deliver on a quality patient experience of care if the people at that sharp edge of care aren't feeling it as well. So knowing where your opportunities and employee engagement are are really critical to get things kicked off and started here. But just as important, I mentioned earlier as if you do any survey, do you know what we're doing to improve? And I'm not Saying that's all on you. Employee engagement is a it's a partnership, they have to be engaged as well in improvement overall. But if you're looking to kind of say, like, you know, you know, uh maybe we're surveying, but we're not really doing a lot with that information, then boy, you're missing an opportunity to move your patient experience forward because you want to make sure that you have both sides of that moving together in the right direction. So I won't belabor that point too much because boy, I could get on a bit of a soapbox around it, but boy, um just can't over-emphasize the importance of that connection with employee engagement and how that's going to help your entire experience of care.

SPEAKER_05 44:36

And literature supports and hands down, we see it all day, every day. When you have high employee engagement, you will have high patient outcomes and quality of care. You cannot have low engagement and have high quality of care. It does, it's an inverse relationship. You can't have it. Patient and family engagement. So, you know, last year we asked this question. One of the things that we really want to also have you think about how many of you have those patient-family advisory councils? How many of you have those in your organization? Just raise your hand. I see some. So last year when we surveyed, what we ended up with um 33% of you said yes.

SPEAKER_06 45:19

Not only do we have um uh a PFAC in place, but they we get to hear what they're working on, it's an active participation. And then about another 20%, yeah, said uh we do, but they don't necessarily have patients on that council. That's missing something.

SPEAKER_05 45:37

Yeah. And those PFACs, you know, the feedback that we have received from uh patients and families, it is they want to be involved and they want to work with you, partner with you. It is not about we want to be able to pick the paint colors in the patient rooms. They actually want to dig in and partner with you about addressing real problems that that do occur. And there's so much love and affinity that we hear from patients and families about things that maybe didn't go so well for them that they truly want to put goodness out there in the world and make sure it doesn't happen to others. So definitely encourage you to think about that in the upcoming year. We have also talked about this at our CNO council and at our symposium. So we know that there's a lot of work going on out there, so we're excited to hear this year how many new councils we're gonna have. Yeah, absolutely. All right. Some key pillars when we think about how do we achieve this culture of excellence and improvement in health care. We're not gonna go through these, we've talked about each one of them, but really the questions are what does this success look like in your organization? And we're gonna continue on with those mirror moments and and thinking about that. But um, one of the things that we we will share with you that Gene and I will be here for the rest of the week. If anyone would like to have any private conversations about what's going on in your organizations, we are happy to. Um we also have some upcoming uh webinars, I think in April to tune into as well. And we're gonna continue this conversation throughout the year. So quickly on our takeaways.

SPEAKER_06 47:15

Yeah, absolutely. And I love how Chip said if you're gonna rip one page out of the presentation, this is gonna be it. Because it really does summarize the things that you can be doing, and it really starts with you set the tone for patient safety at your organization. Uh I talked about that true north, um, your your North Star. Think about what that is and make sure all of the oars are rowing in that direction. That's right.

SPEAKER_05 47:36

Thank you. And then we're gonna follow up. A good strategic plan aligns itself to patient safety. We've talked about that a couple times, gave a couple shout-outs. Absolutely needs to be embedded.

SPEAKER_06 47:48

Third, that culture of safety. Remember, I said you're gonna weave that into the very fabric. It really needs to be based on industry leading and evidence-based practices so that you're aligning with what we know out there, the research is telling us are the right things to do, and that you're moving in that direction from uh from a culture standpoint, the very foundation.

SPEAKER_05 48:07

And number four is about that accountability and transparency. And one thing I want to highlight too, and and I'm I'm sorry, we skipped this stewardship and oversight, and they're indicated here on our slides and how that's weaved in. So oversight's really about our structure, and then stewardship is about how we're nurturing that, how we take it a little bit deeper. Um, so accountability and transparency, we think that goes a little bit deeper, so we say that that's stewardship.

SPEAKER_06 48:32

Yes. And last but not least, um, excellence is achieved when patients and families are partners in the care. We work with them and that they are uh those co architects, if you will, and true partners in this overall. So back to that, there's just going to be nothing about me without me when I'm a patient laying in that bed or receiving care in any of your organizations, that they truly are partners in that.