Tackling Patient Safety and Quality Management Challenges: An Integrated Approach

Good afternoon, and welcome to the PSQH Patient Safety Now Online Summit. My name is Jay Kumar. I’m the editor in chief of PSQH, and I will serve as your moderator for this session. Our session, today is titled tackling patient safety and quality management challenges, integrated approach, sponsored by Origami Risk. Thank you to our sponsor for making this session possible and to you and our audience for participating. Before we get started, I have a few housekeeping details. Our program will be sixty minutes in length. Note that an on demand version of this program will be available approximately one day after completion of the event and can be accessed using the same login link you used for the live program. To ensure that you can see all the content for the event, please maximize your event window and be sure to adjust your computer volume settings and or PC speakers for optimal sound quality. Next, you’ll find a resources list for today’s webinar in the upper right of your screen. Here, we have listed the event program guide for you to download that provides topic and panelist information from each session along with some additional resources from our sponsor. At the bottom of your console are multiple widgets you can use. To submit a question, click on the q and a widget. It may be open already and appear on the left side of your screen. You may submit questions at any time during the presentation. However, please note that it’s likely your questions will not be answered until the q and a portion of the program. Finally, should you experience any technical difficulties during today’s program and need assistance, please click on the help widget, which has a question mark icon and covers common technical issues. At this time, it’s my pleasure to introduce our speakers, Elsie Lindgren, vice president patient safety and high reliability for ADVOCATE Health and Anusha Cannon, Senior Healthcare Market Strategy Lead for Origami Risk. Thank you both for joining us today. And with that, I’ll turn it over to you. Awesome. Thank you so much, Jay. Thank you, everyone, for joining background for today’s session. We plan to explore the current state of risk management in the health care industry, understand the importance of an integrated approach to health care safety, risk, and quality management, learn how Advocate Health, a large health system, has successfully implemented an integrated risk management solution, see how data transparency can positively impact patient safety culture and contribute to continued process improvement, and then ultimately leave today’s session equipped with the knowledge and tools to apply an integrated risk management today. So when we think of traditional risk management in health care, we think about the key role of patient safety, and rightfully so. A focus on patient safety and reducing preventable harm has historically and will continue to be a key risk unique to the health care industry. However, with changes in health care reimbursement models, regulatory and legal compliance, and the increased use of technology, additional risks have come to the forefront for health care organizations. We may tend to think of these risks in their own departmental silos. However, when we start to break down these silos, we can see that they are truly interconnected and often emerge in combination with others. Because of this, it is important now more than ever for hospitals and health care organizations to take a comprehensive, holistic look at their risk management, safety, quality, and compliance programs. Furthermore, we need to shift from a reactive response to proactive identification and prevention of risks. These complex risks often require many people from multiple departments to deliver a unified organizational response. Throughout today’s presentation, we’ll talk about how advocates’ integrated approach has allowed them to understand interconnected risks and see data that allows them to tackle the root causes of events. While risk management has always been an essential aspect of the health care industry, the current landscape of risk amplifies its importance due to several reasons. For starters, the complexity of health care systems has significantly increased over time. Complexity is due to system size, advancements in medical technology, sophisticated treatment options, and intricate care processes have introduced new potential risks like cyber, data privacy, medical errors, technology. Health care organizations must be equipped to identify, assess, and mitigate these risks effectively to prevent patient and organizational vulnerability. What’s even more important is that health industry where the consequences of mistakes or failures can have life altering or even life threatening implications. Unlike many business sectors where financial losses or reputational damage are primary concerns, health care decisions directly impact individuals and their well-being. The human impact is a key driver to risk management and safety in health care. As we’ll hear from Elsie later today, Advocate Health was motivated by their goals to achieve zero serious safety events and guided by a set of principles that always kept the patient at top of mind. Health care safety and risk management extends beyond the traditional scope of business considerations, emphasizing the moral imperative of protecting and preserving human lives. When you also consider factors such as the aging population, the rise of chronic diseases, and the recent COVID-nineteen pandemic, health care has been pressed with higher demand, increased complexity, and a greater need for coordination among stakeholders. Hospitals have been forced to deal with resource allocation dilemmas, capacity constraints, and supply chain disruptions. By adopting robust risk management practices, health care organizations can better anticipate and address these challenges to optimize patient outcomes and ensure quality delivery of care. As we’ve described, traditional approaches to risk management where siloed units attack interwoven problems are not reflective of the needs that health care is facing today. These are organization wide issues and they require an organization wide response. They also require transparency and data sharing, and an environment where individuals feel psychologically safe to raise concerns, and leaders and teams focus on addressing the systemic root causes to prevent future issues. Unfortunately, many modern health care organizations suffer greatly from the effects of their siloed approach to risk management. Poor communication, compromised efficiency, lack of data sharing, and potential duplicative or unnecessary technology licensing costs are just some of the effects of individual departments solving their problems separately. Now individual departments and roles do exist for a reason. We do need specialists and subject matter experts who can provide focused knowledge specific areas, such as pharmacy, quality, supply chain, safety, or legal. But when those silos are pressed to share data and tackle problems spanning multiple divisions, the lack of communication and teamwork strains problem solving. By adopting an integrated philosophy to risk management, health care organizations can contribute to patient safety, team member satisfaction, and productivity, and continued process improvement. Now don’t just take my word for it. As you know, I’m joined today by Elsie Lindgren, the VP of Patient Safety and High Reliability at Advocate Health. Elsie has a broad range of health care experience that includes safety, quality, regulatory, case management, infection control, and operations. Her career has been tightly focused on patient safety since arriving at Advocate Health in two thousand and eight. In her role, Elsie oversees the development, implementation, and evaluation of strategic initiatives to enhance reliability and safety for enterprise. Join me in a conversation with Elsie to hear about Advocate Health’s journey toward eliminating serious safety events through increased transparency in safety event reporting led by a just culture and technology that supports the organization’s unique needs. Elsie, I’ll go ahead and turn it over to you. Well, thank you for having me. Actually, as I reflect on your introduction, it dawned on me that I’ve been a registered nurse just shy of thirty years and have spent the last fifteen of those specifically working in patient safety. So that’s technically half my career. I don’t know when that happens. All right. So I’ll give you a little bit more information about Advocate Health. On the next slide, you’ll be able to see that Advocate Health is a large health care system with one hundred and fifty thousand teammates, over twenty one thousand physicians, and sixty seven hospitals. This organization was formed in December of twenty twenty two by the strategic partnership of Chicago Milwaukee based Advocate Aurora Health and Charlotte based Atrium Health. But for the purposes of today’s conversation, I’m going to be discussing the work that has been done at Advocate Aurora Health. This is a twenty seven hospital system spanning Illinois and Wisconsin, which we now refer to as our Midwest region. As you can see, our statistics on the bottom left of this slide, we have a very large footprint including seventy seven thousand teammates. And this is important because safety event reporting is, at this point, mainly a manual process, which means we have seventy seven thousand people to work with in identifying and reporting our risks to patient harm. So the World Health Organization defines patient safety as the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum. Patients suffer preventable harm due to variations in generally accepted practice. That’s a known fact. Fifteen years ago, when I started with ADVOCATE, we had been working on patient safety, but not really in a coordinated strategic manner. I was part of a team that came together to figure out what our long term sustainable solution was going to be to eradicate harm from our organization. We brought safety leaders together with operational leaders, presidents, frontline teammates, and others who we felt were really safety minded, so that we could do a deeper dive on our current state. We then identified that we had siloed approaches to safety, and I’m sure, many of you may have recognized that in your own organizations. What we then ended up doing was looking at best practices and developed a formal strategic plan to create a culture to support the work, not just these end deliverables like do this or do that, but really truly looking at the culture. We then worked on teaching leaders how to lead to safety and how to empower our frontline teammates to fix the issues that set them up to fail. Since then, we have been on a very deliberate and mindful approach to safety through embedding high reliability principles in all that we do to get us closer to zero events of preventable harm. Near miss events and precursor events have helped identify many opportunities for improvement. The safety team alone conducted over eighteen hundred cause analysis last year. Risk management has evolved over the years through organizational liability as being a core priority to now their main focus being safety as their beacon. Awesome. Great. Thank you so much, Elsie. Thanks for being here with us today to share your story. Now that we know a little bit more about the background of advocate health, can you describe some of the key challenges impacting your team and some of the goals that were identified as part of your journey? Sure. I’d like to start off a little bit on talking about safety event reporting. One of our areas of focus is on event reporting because we can’t fix what we don’t know about. This is one of the main components of our safety management system. Reporting is more than just a repository of safety events or patient complaints. Safety event reporting helps us identify those vulnerabilities and safety gaps within our system that allow errors to occur that impact our patients. As you see on this slide, we call out three main components of safety event reporting that if done well, can shift safety event reporting from being just this repository of events, an electronic folder of sorts, to truly a learning platform. First, it’s about building the culture that supports event reporting, ensuring that there is psychological safety, which you mentioned earlier, at our organizations so that people feel empowered to report. We teach in all in our organization that we want more reporting, especially those of near miss events because those are the warning signs that something’s going to go wrong and can potentially lead to harm if we don’t address it. But if we’re going to ask our teammates to enter these events and in the multitude that that we want, we then need to make sure that we’re making it easy for them to do so. We need to ensure that there’s a tool in use to capture these events that’s fast, that’s intuitive, that’s reliable, and that can easily adapt to our needs because we know we’re going to evolve in what we need out of a system. And then finally, data use. Those who need the data need to have access to it whenever they need it. So those are that’s the main components of safety events. But there are many barriers that can impact event reporting, such as cultures that don’t permit that permit retaliation for reporting to cumbersome and time consuming reporting platforms. And although event reporting is person dependent in this time, this type of report reporting currently remains the best option we have to identify our system vulnerabilities while we continue to find ways to potentially detect harm and even mitigate them more proactively. Personally, I think we’ll be able to get there with our partnership with Origami. But to reinforce the benefits of safety event reporting to our frontline and to our leaders, we needed to ensure that safety event reporting, again, is just that easy to do, has that loopback, gives them information. Basically, as our culture evolves, leaders need access to their data in real time so that they have a better pulse on what’s happening on their units. If you go to the next slide, I’ll go through a little bit more of our challenges. So while we’re in grading high reliability mindset, implementing practice changing, solving system issues, really fostering that psychological safety to implementing these technological advancements, we’ve seen a continuous reduction in serious safety events year over year. We have sustained a great reporting culture. However, now that teammates understand the value of reporting, all the great stuff that comes out of it, they want more. They want to know what happened to the event that they reported. We also spent a lot of time, teaching leaders about systems thinking, right, to think beyond the human failure and to seek out what are those system or process failures that set the human up to fail, but we have to find different ways to help continually reinforce it. Another issue was accessing data was just not easy. Leaders depended on data being sent to them, and usually that was only if they asked for it. And then the other concern up was that different data related to that particular safety event was housed in different systems. So outside of the claims department, we had no line of sight as to the outcome of of those particular cases if they went to litigation. What are some of the learnings that would come from that? So again, really needing to support our high high reliability journey, we really needed to figure out can we transition to a database or reporting platform that can support our cultural growth? So we needed more of that holistic approach. So we sent out to find a reporting platform that could double as that learning platform, that could give us the insight, when it’s first reported, that allows anybody who needs to review that event to review it, that it captures the cause analysis information easily, can support our peer review process and connect those dots, and then again connect to those claims the claims information. We wanna capture all that information in one platform so that that data is connected and we can see everything that impacts that safety event from the beginning of its life to the end. Yep. Absolutely. So myself and the vice president of risk management, we then became executive sponsors of this work. And together and along with the input of stakeholders and front end users, we developed these goals. The goals was for us to find a reporting platform that can help us destigmatize safety event reporting. I am sure many in the audience, have seen their reporting platform used as a verb when people are describing, events being entered. This is a never ending process, but removing negative connotations associated with reporting errors to encourage that open communication and learning is a must. We needed a way to provide reporters feedback on what they reported to acknowledge their input. We needed to provide training, on that systems thinking. We needed to figure out how we were going to reinforce that. So again, that holistic approach to analyzing safety events, sharing our lessons learned more broadly. Again, thinking about the interconnectedness of the health care systems and processes that also helps to guide the leader through, like, that Just Culture decision matrix. Right? How if they’re reviewing the event, how do we help them shift from, you know, just looking at what that person did wrong to really thinking through it from a just culture perspective. And again, having operational leaders have access to their own data in real time as much as possible. That’s that’s one of our biggest areas of risk is if, you know, leaders say they don’t have the data to help them identify easily what were their top challenges. So, after vetting a number of reporting platforms, we decided, you know, to go with Origami because Origami really did provide us what seemed to be the most flexibility in the design and the expertise to build more of this learning platform, and I know that it has capability to grow with us and support our journey. Yeah, awesome. Thanks so much, Elsie. So we know with any major change that takes place, including the implementation of a new technology platform, that definitely a strong culture and leadership are key to ensuring this success, something that you’ve mentioned quite a bit in the past few minutes here. In addition to that, though, what are some of the other motivators and the guiding principles that supported this change within Advocate Health? Absolutely. So really the motivation came from feeling like we have all these great ideas, but then we need the data to support it and we can’t get there. Right? So, you know, when we want to do drill downs, we’re a big health care system with, you know, specific service lines. I want to be able to pull out data that tells me how many pediatric urology stents, you know, stayed in past discharge or for a lengthy amount of time, and I can’t find how to get that data, easily, Right? So with the past reporting platforms, that was a kind of a difficult thing to do. So we just again, that’s just one example of a tiny little thing that we’re we’re trying to investigate. But being able to pull together, you know, data that tells me how many incidents occurred during a transport of a patient, from one unit to another or things like that just didn’t happen. Again, the learnings from, you know, how do we tie this in with performance improvement activities and, you know, that peer review process. In peer review, we’ve done a lot of work to ensure that we can identify system issues out of peer review, that it’s not just about a clinician’s, you know, decision making, but looking further as to what supported that clinician making that decision and how do we help others from, not doing the same thing or from doing the same thing or whatever the case may be. Again, difficult to do when you have disparate system and it’s not connected to the safety event. So a lot of that was kind of our motivating factors. But, when we then decided to kind of sit down and build the system, we said, okay, well, we really need to make sure that all the different folks that we’re gonna bring into the room are working and and rowing the boat in the same way, in the same direction. And that’s why we put these guiding principles together, and we obviously bucketed them under the high reliability principles because we know that if you build the high reliability principles into everything that you do, you’re going to get the outcomes that you’re looking for because of being that having that purposeful mindset. So as you see on the slide here, these are our guiding principles. I’m going to start, you know, every project plan will begin with something like this, and we tailor the questions. You know, we’ll think through what is that project and try to tailor those questions to really get the best out of whatever it is that we’re designing. So looking at preoccupation with failure, you know, when you’re thinking about designing a new reporting platform such as this, we have to be really thoughtful about what those downstream effects are going to be. If we connect this, you know, if we’re going to ask this question and now we’re going put if then logic, what’s the end result to that or what report is it going to impact? And just having that questioning attitude to constantly be thinking about that. And then encouraging speak up because there’s oftentimes you you hear about, you know, the shuttle story where people knew that the o ring had an issue. There’s, you know, hesitancy to speak up sometimes, and sometimes people do speak up and they’re not heard. But in this for this perspective, we we want everybody to speak up because that’s where you get those, oh, shoot. We didn’t think about that. Let’s mitigate it, you know. Sensitivity to operations, you know, again, reducing redundancies across the system. How often have you found that you might be trying to get certain data points and data sets and then you find out by happenstance that another department for a different reason is looking at the exact same data, and now we’re doing duplicative work. So really being mindful of our redundancies, even between patient safety and risk management and the way that we investigate cases. Are we all looking at the same elements of that case, or are there things that we can share with each other versus having to do the same work, again, more efficient with our time? Having a one stop shop to handle all safety events, as I mentioned before. And I mentioned here CAPA process, and for those of you who don’t know CAPA, CAPA stands for Corrective Action Preventative Action. And in Advocate Health, we have a program in place with our quality department where they have trained everyone the same way on performance improvements. So we’re using all the same performance improvement plans or performance improvement tools. And one of those tools is that corrective action, preventive action document. That is truly to capture certain ISO nine thousand and one types of data elements regarding the action plans, and then it’s a very formalized way on conducting your actions, and and measures of success. We have then built that same tool into, like, our cause analysis section, so it’s all coordinated in the same same look and feel across the board. Designing for that meaningful output, again, just making sure that we’re thinking about what’s the end result. If we’re going to ask these questions on the safety event, tool, what’s what purpose does that serve? What how are we going to get it out of the system if we wanna show a story about it. Right? And encouraging collaboration and participation is, self explanatory, and developing the standard workflow. So with anything that we’re putting into place, making sure that we’re process mapping it or writing out that standard work so we have it, and we can always go back to it and and figure out, okay, where do we need to tweak? What do we need to hardwire, etcetera? That reluctance to simplify, explore all avenues with all other electronic reporting data bases for possible integration. So looking at Workday as our source of truth for teammate, you know, information, looking at Epic as our source of truth for safety event, clinical locations, you know, being very mindful of that. Commitment to resilience, adaptable for continuous improvement, meaning we are going to need an annual sustainment plan that we’re going to always be looking back at and refreshing and, you know, making sure that it’s evolving with what we’re doing in our organization. We have a centralized process for vetting and making changes with streamlined communication plans, and that is an absolute must with any project, but especially a project of this magnitude. Making sure that we are being very thoughtful of who needs to know what and that there’s only one avenue to make these decisions. It just makes it a lot cleaner. And then respecting consensus. Right? We’re not gonna satisfy everybody all the time, but we do need to be respectful of of consequence of consensus. And that is easier done when you’ve gone through each of these guiding principles in your thought process for decision making. Right? So if we’ve already thought about all the unintended consequences, we can make a strong recommendation on why we need to do x y z, and your support is much easier gained. And then last but last, not least, is deference to expertise, designing for the user with the user. And this was extremely important to us because I’ve been I’m a nurse, but I haven’t worked the bedside in a long time, so I need to depend on those who are doing the work to talk to us and inform us throughout the build. And for one of those reasons, we we brought in our partner in, human, factors engineering, Badcent, because she was able to do tons of usability studies, focus groups, and really helped to be helped us to be very mindful on the design. Awesome. Great to hear, Elsie. And I I know we’ll see a little bit of that as we look through here in a moment the relationship between Advocate Health and Origami Risk. So I know we’re focusing really today on the patient safety event reporting work, but this partnership does go back a few years. I know we’ve partnered with teams across the health system to help support that single platform approach to risk claims management team member and patient safety. So let’s take a look at kind of the timeline and talk a little bit about that journey. Sure. So advocate Aurora Health, the Midwest region portion of Advocate Health care of Advocate Health, we first launched Origami in our professional liability areas. They were the first to move over onto this platform, and we heard a lot of great feedback about it. And oftentimes in health care organizations, at least this is from my experience, most health care organizations utilize safety event reporting platform once they transition from paper incident reports. Right? They’ll use what’s available that is part of another system, whether that’s, you know, workers’ comp has a a product and they have safety event reporting available, etcetera. It was kind of the same thing for, our organization where we were using the reporting platform that was part of a bigger package. But again, what we found was that it wasn’t really satisfying our needs as we continue to evolve. Same thing happened with claims and liability. They found that they needed something that was a bit more evolved, so they transitioned in twenty twenty. I think they finalized in twenty twenty one. And then next to go live on that was workers’ comp. Now remember, this is May twenty twenty to February twenty twenty one. Workers’ comp is going next. Patient safety and risk was really in the weeds with all things COVID at that time. So, you know, every time we pop our heads up to breathe, we’d be like, wait. We wanna see what that system is. Oh, wait. We gotta get back to, you know, to doing what we’re doing. So we came in a little bit later in the game, but at the same time, when we started looking at the program and what was available and really thinking about what our limitations were even during COVID, we decided we needed to purposefully look for a safety event reporting platform that would support all the other things, the safety event entry, the reviews done by multiple people, you know, the peer review process, the cause analysis process. We were doing cause analysis in our Excel workbooks, which probably many folks are. But it’s very hard to then to pull together data without doing redundancies. Right? Taking information and putting it into some electronic tool that we can then run data off of. So we started that journey, on looking at what systems could support what we’re looking for, And we met with quite a few different, reporting platforms and decided that since one of our guiding principles was truly to see the life of that safety event from beginning to end, and the fact that Origami had that flexibility and it was really like, if you can dream it up, we can build it kind of a thing, we decided to go with origami. Now, part of the delay in us getting, you know, getting on to the build part of the of the plan was finances, and I’m sure many folks have that issue. Right? Because we already had a platform that had event reporting in it. We’ve already shown that we’ve decreased our serious safety events by a considerable amount since we launched a very formalized, program. So to make the case on why we needed to leave something that was already part of something else and being covered by that contract to a new contract that’s gonna cost us a considerable amount of money, that wasn’t easy. But when you showed the interconnectedness, you showed the possibilities, you showed the ease of use, we were then able to get that support and move forward with the build. Now when you look at the build on this timeline, you’ll also see that it was a kind of a lengthy amount of time as well. And that was purposeful, right, because we didn’t want to launch with something that just replaced what we had before. We wanted to launch something that was much more intuitive, that met all of those goals that I mentioned earlier, you know, helping that manager think through that event from a systems perspective. How did what what was that gap between what happened and what was intended to happen and how do we fix it? You know, we really needed to be very mindful of that build. So that’s what really took us a long time, especially because of how large of an organization we are. We also needed to go through extensive vetting processes, you know, meeting with all the different stakeholders to design their event reports and thinking about those outputs. You know, again, applying those guiding principles to every session we were in to get the information needed to then build took a long time. So I’m happy to say that we were able to get it right in the nick of time to start the year off so we have a full year’s worth of data, so I’m really excited about that. But that was only phase one. So, you know, my team says, okay. We can breathe now, but now we’re going to jump right back in because phase two is a continuation of what we’ve already built, but continually tweaking it, making enhancements to it. But there’s also some portions that we need to finish up, so I I think I’m gonna talk about that in a minute as well. But phase two is also going to be looking at how do we pull information from Epic into the database because I think that’s where the future is going, and I’d love to become more proactive in nature, and I think that’s where some of that could happen. So more to come on that as well. Awesome. Great. And I know that this slide just talks a little bit about some of the key components that you’ve implemented for phase one, if you want to just touch on a couple of these as well. Absolutely. So as I mentioned earlier, safety event reporting was truly the reason why we wanted, you know, something different, to support that. Safety event reporting is when we did the culture of safety surveys, oftentimes, the big chunk of those, comments were, it’s too cumbersome to use that that reporting platform. I wanna report it, but it is so many steps, you know, to take. So there was a lot of commentary from the front line, which is interesting because ten, twelve years ago when we first started the journey, the barriers to safety event reporting were a little bit different. Right? They were like, I can’t report that. My man will get in trouble with my managers and you know? Or when you saw event reporting, it was very much about equipment issues or it was about someone else, but you would rarely see safety events being reported about me. Right? Like me entering an event of something that I did or almost happened. So we’ve seen that culture shift. As a matter of fact, last year alone, across the enterprise, we had almost three hundred and fifty thousand safety events entered, and that safety events with near misses. That’s huge, and I’m very proud of that number because so much has come out of that. But even more important, why we needed a database to house that type of volume that could give us the ability to slice and dice it in different ways and get bet different stories out of the data. So it was really important for that. And then, again, supporting that just culture, making sure that folks feel, you know, that we can now have a better way to monitor reporting by unit, by, you know, site, location, etcetera. It’s easier to see now and trend with capabilities in Origami. Those reviews and investigations, really, in the past, it was folks were doing their own reviews kind of siloed, and there wasn’t a lot of information shared. You’d have to toggle between screens, etcetera, to be able to do that. Now if you’re provided a certain level of security for those types of reviews, you’re able to utilize some of that information as part of your own. And, you know, we have a validation process in place, it’s it’s it’s become a better communication vehicle. Additionally, the ease the ease of use for, the reviewers and the investigations, right, the emails that go to the frontline leader to say, hey, you’ve got this, event that was just entered, the ability to respond through that venue, you know, just how easy it is that it’s web based and, you know, not a totally different product that you have to install onto your computer. It’s much easier to use. Our home care folks, we’ve seen an exceptional increase in safety event reporting with our folks who work in the ambulatory space, specifically those that are providing home care because of the usability of its use. And then cause analysis was extremely important for us to build within the system, again, because of the duplication that we used to do in the past with those Excel workbooks. Now being able to have the information placed right into like, we our patient safety leaders are working their cause analysis right in the system, and then during the cause analysis meeting, using the system to display it and walk through it and do the work. So again, removing the need to have to utilize different, you know, products, words, you know, Excel, whatever, which you now have a little bit more concern for discoverability. When we have a database like this, you can attach your notes, you can keep all your things in one safe place, and it’s considered patient safety work product. So it’s all wonderful stuff for us. The patient experience piece, we also house complaints and grievances in the same system. And one of the real nice things about this, if you remember the guiding principles where I talked about being mindful of that connectivity, we were able to, design the dash dashboards for our managers to be able to see their data from a patient experience perspective as well as their action items from a cause analysis, their events reporting, so everything’s in one view. And that’s that last column. That dashboard and reporting is significantly important for our managers and for our leaders. That visibility that they have for their data now is something that they just have not had before to the level that they have it now. So it’s been truly a game changer for us. They’re able to see trends. They’re over time, they’re able to see who their, rep who their top reporters are, which makes it super easy for them to provide that positive feedback and reinforcement. That acknowledgment of what folks are putting into the system is huge to continue to get them to report and see the value of their reporting. So these were all the things that we first started in our phase one. We’re building out the peer review piece now, and I think I might have a slide on that too. But the any questions that you have about some of this some of these areas, I’m happy to answer. Awesome. Thanks, Elsie. So kind of jumping off of that last portion that you mentioned with the feedback and ability for leaders to see their data with dashboards and reporting. How are team members liking the platform so far? I know you’ve only been live for a little over two months now, but it sounds like you have some early results that we could share here as well. We do. Yeah. No. The feedback has been really great. We did a survey, just to kinda get a pulse check and see how things are are moving along, and you’ll see a couple of the comments that we had. You know, I met with one of my directors in safety and who stated, you know, the the way that we can see data now makes our life so much easier to do quality assurance. Again, the managers just talking about the the the ease of being able to see their own data, again, a game changer. I’ll mention this too. At the same time of rolling out Origami, our launch date was January second. We had also standardized our safety event reporting policy. We had one in the past, but we wrote another one that was safety event reporting management. And in that document, in that policy, we spelled out that we wanted managers to complete their safety event reviews. There’s, you know, rules and regs out there that kind of dictate, you know, having to do it in a timely fashion. There’s definitely more stringent rules when it comes to grievances, so that was a very well set thing. But when it came to safety event reports and near misses, we still wanted to have something that would help guide, our leaders to a target to meet, basically. And so this fourteen day turnaround time was part of that policy, and we took it to our CME councils. We took it, you know, to our ancillary services areas. Like, we got a lot of folks to kinda weigh in on that, and we all we all thought that might be a little bit of a, I wonder if we’re gonna have to go back and look at that. And I’ll say that we have not received pushback on that. If anything, we’re now getting other leaders saying, hey. Can you put that on my dashboard too? Because I wanna be able to include this when I have my one on one with my leader over this area so I can easily see their data and say, oh, hey. It looks like, you know, you may you have a couple that are still outstanding or your average is this, turnaround time for for. So it’s been very helpful, from that perspective as well. So again, very positive feedback. Being a high reliability organization, we’re constantly looking for how we’re going to improve. So we we added those types of questions in our survey as well. So we wanted to understand what can we do better, because you’re never done. If you’re a high reliability organization or striving to be, you will never consider yourself done. Like, that’s it. I can hang up my hat. I’m done. I can retire. No. We’re never done. The the cause is always there. So we’re always looking for ways to improve the system, and we’re already seeing folks being so happy with what they’re getting that they’re now asking for that next level of information, and that’s what we’re going to be working on now. Yeah. This slide here talks about that frontline feedback loop. So and that’s again a huge positive because they’re getting a notification that we’ve acknowledged that you sent something in, and then they’re also getting a notification when a manager is done reviewing that event and picks from these particular choices. That will also be incorporated into a response to that frontline team member. And so that’s had some positive response, but we’re also looking at, well, how do we continue to evolve that? Can we make it a little bit more individualized? How much information can we push? How do we connect it with some lessons learned in the long term? So the mind is always going on how we’re gonna improve that. The at your fingertips data for operational leaders, if you see the, the box here that has that dashboard, the numbers look huge because that was early on and it was my view from an from the whole Midwest region perspective, but each manager will have smaller numbers based off of what’s on their unit. And that’s basically your average frontline managers dashboard in Origami. So as soon as they open up Origami, this is what they would see. And, again, being able to see the events that were reported, easily usable for safety huddles, looking at how many events are outstanding for them to review. They click on that number, it takes them to their list, and they can work right off that list. Looking at those action items, so let’s say we did a cause analysis on one of the events, and the action item has their name attached to it, it’ll populate here, and they can click on that and see their action items. Just totally different than what it was before. That manager identification for system issues, when they’re reviewing those events, we did set it up to almost be like mini ACA’s or apparent cause analysis where it is very, you know, high level, like what happened, what should have happened, what’s that gap, is there anything here that has a system, implication? Meaning, you know, if we’re gonna need to change, if if there was an order that popped up or an alert that failed, that’s going to be more than what is that site’s responsibility. That’s really a system responsibility. So when that’s checked off, we get routed and we get involved and help to kind of escalate those issues as well. So, again, just really great data, at their fingertips. And then that Just Culture decision guide, I think, is another, winner for us. The fact that our leaders are able to use the Just Culture decision guide to help get them to a fair, outcome for their teammates, a fair but, you know, being fair, holding accountability where, it’s warranted, it’s just a much better way to process these safety events than it was in the past. Now preliminarily, you’ll see that our safety event reports, had gone up. And to me, you might look at this and go, well, it doesn’t seem like that many more than the old, platform, but we expected a drop because of it being a new platform, and we did not see that. We not only didn’t see it, we saw an increase, and we continue to see an increase in event reporting. And I imagine that as we complete certain things in our next phases of work with that integration with Epic, etcetera, it’s gonna be even more because it’ll be even faster and simpler to do. Absolutely. Absolutely. And I believe this next slide here talks about when we talk about high reliability, we talk about the high reliability principles that were those common characteristics that we found years and years ago, probably over forty years ago now, when, we were looking at industries that, you know, have a high potential for catastrophic errors if an error was to occur. These five guiding principles, you know, really do lead to safer care when you apply them in the health care arena. But what we found was that it’s absolutely important for safety, but it’s also important for quality. You know, we get clinical excellence if we’re applying those high reliability principles consistently, doing the same things the same way over time, consistent practice over time. We see those positive outcomes from, you know, operations. That operational efficiency occurs when we’re applying those same guiding principles, same things from an equity perspective. So what we identified is that by applying those guiding principles to the by applying those high reliability principles to the guiding principles that we used to develop this database or this platform with Origami, we found that the outcomes really do touch on all of Advocate Health’s pledges, that we came up with a few years ago when we first started to integrate. This these pledges are when the Midwest and the Southeast region came together and said, okay. As this new advocate health organization, what’s what’s the most important things to us, and what are we going to pledge to deliver on? And as you’ll see here, first and foremost, it’s we’re a safe clinical enterprise, so clinical preeminence and safety is top of the top of the, road here. Health equity, advancing health equity, improving affordability, building that next generation workforce, accelerating learning and discovery, and then environmental sustainability. So when you think about all of the things that a reporting platform like this can, has impact on, it impacts all of these different areas to a certain degree. I can make a case on any one of those buckets. So I feel, you know, it’s really delivering on our pledges. Awesome. Great to hear. So so now that we’ve discussed some of the exciting feedback and, early results of phase one, you had mentioned that there’s a phase two. So let’s talk just a little bit about what that entails, and then also wrap up, I think, with some of the key lessons learned for the future. Sure, absolutely. So during phase two, we’re going to complete our peer review build, again, being very mindful of the interconnectedness with the safety events, with the requirements for, you know, having that privacies around it, but still being able to pull out any of those system learnings or those system issues. That’s going to be very important. Aligning how we do peer review, like designing the workflow so that everyone is successful in completing them in a timely manner. That’s definitely part of our phase two as is the expansion of those quality improvement tools. You know, we put a lot of time and effort in training our our teammates, our leaders in performance improvement. Our quality department has done just an exceptional job with that, with that standardization. So now we wanna be able to provide folks the tools to use and be able to capture their outcomes. So again, we have tools, usually Excel based, that live independently on a team site or whatever. But what we want to do is really have it all in one database that we can pull data out of it based off of all of the performance improvement activities that were done, you know, have more data to support bigger issues, right? So, if we’re able to, you know, run all of the PDSAs that were done regarding a particular process, we can then use that information to make a valid reason or pitch of why we need to institute new technology or why we need to, you know, buy more of a particular piece of equipment or whatever the case may be. So that’s gonna really be a game changer for us. And, one of the things that I didn’t mention on here was that connection to the Epic platform because I do believe that that’s going to be something that’s gonna be necessary for us to be able to evolve and move into, you know, into being more proactive. What I’d love to see is future state. There isn’t really a need for a patient safety person to do something or re to do something when it leads to harm. It’s gonna be patient safety saying, hey. I see something bubbling into you know, I see something brewing over here. We’re gonna get in front of it. We’re gonna deploy. We’re gonna do whatever we need to do to get in front of that event before it happens, and that only works if we’ve got that integration with Epic to help us do that. So more to come on that. I’m really excited about those possibilities. Now some of the challenges or those lessons learned when we built this, worked together with Origami to build this platform, was, I will say having this internal governance committee because it’s very easy to fall into your own siloed space. So being that origami was already in place with professional liability, was already in place with workers’ comp, that decision making that we are making for our databases or what they’re making for their databases, we really need this internal governance structure to make sure that we are all, you know, rowing in the same direction. So I think that’s an important lesson learned, and bringing those folks in right away so that we don’t have to do any rework in the future. Because you you sometimes don’t think that there’s gonna be this connection, but then there ends up being a connection, so it’s better to be, you know, you better identify all of that ahead of time than when you’re already further down the line, in building the database. And I will always stand by having guiding principles to help support the work, for something of this size. Obviously, you wanna use a particular performance improvement tool, whether you use an a three or whatever the tool it is that you use, still have a set of guiding principles that you can all fall back on and say, if we’re having disagreements on something, does it fall in line with our guiding principles? And that helped so much to keep us moving along whenever we felt we were meeting a bottleneck in decision making. And then, for us, configurability, making sure that, the technology is meeting the organizational need, not the organization changing to meet the technology. Right? So that’s one of the reasons that we went with Origami was because of that configurability. Being mindful, I will say going through the process, I know so much more today than I did when we first started looking at platforms and started thinking about, you know, what are the requirements from a platform. Now I feel much more experienced as to what I would be looking for, what else I’m gonna ask. So as we go into phase two and phase three and phase four, the ideas now that I know the capabilities, the ideas just keep coming to me on how we can make this even bigger and better. So I’m excited about that. Awesome. Thanks so much, Elsie. Thank you again for sharing your story and your lessons learned with us. I think many teams on this call today will really benefit from hearing about your journey and your considerations for the future. I’d like to take this time to summarize with some key takeaways that I heard you mention today. So in order to be successful, implementation of an integrated approach to risk, safety, quality, and compliance management definitely needs unwavering support from senior leadership. It’s clear that advocate leadership across multiple levels and departments were a guiding force and constant supporters of the work that was being done by the team. Senior leadership can help set the strategic vision. They can help make decisions about resource allocation, and they play a vital role in change management. Leaders can and should engage with stakeholders throughout the organization, including the frontline staff, providers, and even patients to ensure that there is appropriate buy in and opportunity for feedback. When applying tools for adverse event monitoring, it’s important to adopt a just culture. You mentioned this quite a bit. One that promotes fairness and learning from errors and system failures, as opposed to assigning blame to any individual. An emphasis on continuous learning and quality improvement is a key component of Just Culture and allows all areas of an organization to benefit from those lessons learned to help enhance knowledge, improve practices, and prevent similar occurrences in the future. Adjust Culture further encourages feedback and collaboration and helps employees feel connected to the success of the organization and improving patient safety processes. Elsie, as you described, your implementation of the Origami system intentionally took quite a bit of time. And this is due in part to the fact that frontline teams and staff were engaged every step of the way in the design and configuration, really helping to ensure that the system would support your needs and your workflows. This type of culture and collaboration not only increases a sense of psychological safety for your team members to allow them to perform optimally, but it also contributes to the development of staff as well. With advancements in technology, it’s no surprise that risk management solutions have also evolved over the past several years. In the past, organizations had no choice but to select multiple point solutions to support each department’s unique needs. This really hindered communications and collaboration. By continuously evolving our solutions and product modules, we now have the integrated capabilities that are needed to support a truly holistic risk management approach for complex organizations. When selecting a risk management, safety, and compliance solution, configurability is key. You talked about this quite a bit. The configurability of the Origami system, we know, was a key deciding factor for you and your team. Why is this so important? Well, as you and everyone on this call, I’m sure, knows, no two health systems are alike. They each have unique needs, teams, and workflows, and these processes and needs may even change over time. So picking a solution that allows for flexibility and then grows with your organization can help support team members, reduce burnout, and streamline processes for the future. Lastly, the solution should also be scalable. As we’ve seen here with Advocate Health, this large organization has been able to leverage the Origami system across multiple departments, allowing teams to collaborate and transparently share information and data across the life of a safety event, from safety to quality to risk, and ultimately reducing the future need for additional point solutions that can be costly and limiting in function. With that, I want to once again thank you, Elsie, for sharing so many great insights with us here today. And thank you all for attending today’s webinar. I’ll go ahead and turn it back over to Jay for questions. All right. Well, thank you, Anuja and Elsie, for an excellent session. And as Anuja mentioned, this now brings us to the q and a portion of the program. So we’d now like to invite you to ask live questions of our speakers. As a reminder, to submit questions, you can click on the q and a widget at the bottom of your screen. And we’ve got a bunch already. So first one, with Advocate, did you create your own reports, use boilerplate reports from Origami, or learn to create your own reports and dashboards? If the latter, how did you get trained, and do you have an Origami guru among your own IT team? So I would say the answer to that is all of the above. Their Origami, just like I would imagine any other reporting platform, will say, here’s what’s available. Here’s some standard reports that we have. But because we really did customize it to meet our workflows and to meet our deliverables, we also then customized a lot of those reports as well and and the dashboards as well. So the answer is a little bit of all of the above. There might have been some things that we were like, this is perfect just the way it is, really. But then there’s other things where like, well, we need this information. We have different verbiage. We wanna be consistent, you know, with our taxonomies. So we we did customize quite a bit of it. In regards to who is in charge of that, so we have a a core team that was part of the build, includes safety, risk, human factors engineering, our IT folks, EBI, which is our business intelligence partner partners. And we all have certain levels of training on the the build, the reporting, those kinds of things. And we’re standardizing what the long term solutions are like, which kind of things will get will go to this part of the organization, and which is being done by this part of the organization just to stay consistent and have very limited number of folks who are making those particular changes. So a little bit of all of that. Alright. The next question is, who creates the dashboard for the managers? Is that provided by Origami, or is that built individually by users? So what we did was we pulled together front end, users by role. So if we were going to be creating the manager dashboard, we pulled in a couple of the different managers to get their feedback on what would you like to see, what would you like to, you know, to have at your fingertips, etcetera. And then we, the core team, along with our human factors engineer, etcetera, would come together and say, okay, now let’s build per role. So each role, if you’re a manager of a clinical space, will have the same dashboard. If you’re a pharmacist, you have a different dashboard. If you’re, you know, someone from EVS, you have a different dashboard. So it is customized to their roles or to their areas of what that team of both users and leadership for those spaces have determined to be the important things they wanna see. They people have the ability to make dashboards, but we are really trying to limit, not because we don’t want thousands, but it could it then becomes very unmanageable if you have if if we make changes to, like, the standard, you know, director’s dashboard, if that director then at the unit is not using it anymore, they won’t get that update because now they’re using their own customized dashboard. So what we prefer is to have their voices collectively make a make a recommendations for adjustments, etcetera, so that everyone’s benefiting from, you know, the evolvement of what gets included in those dashboards. Yeah. And Elsie, I think one thing I’ll just add to that is just the idea of data security, right? So we know we take data security very seriously. And so I think as part of the roles that you described that are being set up in different levels and different areas of the organization, we made sure and we consistently make sure that only those who need to see the data can see the data, right? So we’re making sure that only the information that a certain role or certain title or certain level needs to see is able to see it. Just being able to make sure that we focus on managing the security of data in in the system. Alright. Next question. Can you talk about the RCA module you have in Origami? Was this a custom build, or is this module available to other clients? Sure. It is more of a custom build, based off of the taxonomies that we use, the event categorization, our our harm scores, you know, the tools that we use. It has the five whys, it has the fishbone. It does have other tools that we can utilize now, in addition to what we’ve done in the past, and again, all in one database so that we could get much better data quickly. So it is more of a custom build. It’s available through Origami. But, we we then just took a long time to make sure that we had it fit our workflows. Yeah. And and, yeah, I’ll I’ll I’ll add on to that as well, Elsie. So with our tools, Elsie mentioned a couple, the fishbone diagram, the five whys analysis. We have these tools in Origami that we want to allow organizations to use as a great starting point. Right? If you if you want to use it as quote out of the box, you absolutely can. But we know that organizations want to do that additional configuration on top of it. You mentioned some of the unique taxonomies that you might use. Right? So so we wanna make sure that the tools are fitting your needs and that you’re not stuck using only a certain standard if it might not necessarily organization’s needs. Alright. Well, that is all the time we have for questions today. I wanna thank our speakers once again for an excellent session and everyone in our audience for participating today. Finally, I wanna give a special thanks to our sponsors for making this event possible. For the past several hours, we’ve heard from health care experts and our session sponsors about key strategies and tactics for tackling the future needs of health care organizations as well as making sure you’re set up for success. Look forward to seeing you again for future PSQH webinars and summits. This concludes the PSQH Patient Safety Now Online Summit. Thank you. Thank you.