Patient Safety and Quality Improvement – Systems Perspective and Applied Approaches

Today we have the pleasure of learning from dr susie kramer who is the chief quality officer and vice president for clinical advancement and patient safety at carilion clinic she is also a professor with the department of internal medicine and we also will be learning from dr a lucktong the co-director of surgical quality acrillion clinic and professor department of surgery at the virginia tech carillion school of medicine thank you both so much for being with us today dr kramer i'm going to go ahead and turn things over to you well great well thank you it truly is a pleasure to be here today and um what you're gonna learn about is really just a combination of the pursuit of quality and patient safety from a systems perspective and then i'll hand it over to dr luchtong where he will show you some wonderful examples of how these principles are actually applied in a department and with teams my objectives for my talk are to describe the quality structure for carillion clinic health system highlight some of the essential processes there are multiple processes that really do support excellence in patient safety and quality improvement but we'll go over some of the the more important ones here at carillion recognize some of the common quality issues in health care in general and then why we're all here today is go over some examples of how clinicians and teens impact that patient's safety and quality at the bedside so on the next slide i always start many of my talks with this slide in particular because you know we throw the term around caps without really making sure that all of the stakeholders really understand what we mean when we say caps well let's let caps tackle it well maybe caps will have an input and caps is really it stands for clinical advancement and patient safety and it is the greater quality team for the carillion clinic health system and this relatively lean team of about 36 individuals is made up of all the groups that you see in front of you we have some outstanding uh experts in process improvement so so who are these people these are individuals who have black belts in lean six sigma national certification and project management particular expertise in data science and analytics and they really help create so much of the structure and then road map for how multiple projects get accomplished we have the quality improvement team which is made up of quality improvement facilitators and many of these individuals have ownership of the rca process from triaging the events to creating solutions for the rcas and the certification there is frequently um what you would see for example certification by ihi um the certified professional and patient safety or chpq certification and then moving on to the safe watch team they're constantly in safe watch our patient safety refor reporting platform reviewing reports triaging categorizing improving and this is a lot of work we have our clinical risk and patient advocacy team which manages patient grievances or risk events we became familiar with the accreditation readiness team recently as we just completed the joint commission survey that triennial survey just over a week ago and then the team which really makes carillion's approach to quality and patient safety completely different than any other team in the country is our human factors teams these are human factors engineers who also have multiple disciplines um again from expertise in data science to psychology to engineering to help our team members to help the humans that work in health care at carilion perform better and our ultimate purpose every day when we're here committed to our our role is to prevent serious safety events design and implement system level initiatives to ensure the health and well-being of our patients and team members and also to educate and support teams to lead their own quality improvement and as we move forward to the next slide um it also takes just a networking integration with so many other teams across carilion clinic on any given day for any given project we must ensure that we've defined and ensured the roles of infection control our nursing partners the system level and their physicians and nurses health analytics our legal team and of course the organized medical staff and i haven't even talked about the coding and documentation team human resources there's just multiple layers to all of the planning and collaboration required to drive quality and patient safety here at our health system on the next slide um i also wanted to really stress the point that although so many of our projects just because of sheer volume are focused here at the cmc campus it's obviously much broader than that and the caps team that structure exists across the health system so for over the 200 miles that our health system spans we have individuals who are also assigned and have expertise in quality and patient safety on the next slide this particular slide i decided to include so that everyone could understand really the cycle of how we determine what should be focused on and it starts first at the data that we have immediately available and so that would include the safe watch information the patient safety reporting structure being safe watch of course epic and there's another tool that we use quite frequently called strata and this is owned by our finance partners and um it's just a great way to bring clinical observations and operations together when we're looking for opportunities however none of that data none of that information really provides any sort of comparison to our performance compared to other academic medical centers other community hospitals or other critical access hospitals and we obtain benchmarking information with the use of the vision clinical database and that has been extremely helpful as we reflect on past performance and the improvements that have occurred and know exactly how much better we need to be to get to a top quartile or top decile performance we also spend a lot of time looking at these reputational and paper performance programs um a little more on that later but you'll notice um as we uh share information about these particular programs you know most of this work when it comes live in the current year's report it's over and done with it's two three years old and we can't really use that for appropriate target setting and benchmarking and then it comes back to what are the priorities that we need to establish for the next year the next three years and the next five years all of these platforms are rich sources of information on the next slide when we take that process when we use information from epic create those appropriate benchmarks understand what past performance has shown us for each carillion hospital we're able to create a quality plan and many of the programs so for carillion we have any year five to seven very high level projects that really require improvement um over the short term being the next year and they also have a common theme across the system for example safewatch reporting improving insulin use patient experience all of those are system level projects on the next slide it's really this stage of my talk is about a transition because that was the structure of how we're approaching things here at carillion clinic from a very high level but it's so much more complicated than that and the framework for excellence one of the best frameworks that exists in healthcare is what's recommended by the institute for healthcare improvement and you'll see these multiple competencies that make up this framework and as you look at each of those categories it spans things from having a just culture accountability from negotiation which is really about deciding on the right priorities for that moment in time obviously we're a continuous learning health system particularly in collaboration with virginia tech curling medical school i've mentioned the process improvement piece and being transparent with our performance and our data sharing not to mention leadership and when you think of all of these competencies i really want to ask you as you think about your day-to-day processes in the healthcare environment can you identify any competencies or structures or processes that support carillion's daily pursuit of clinical excellence i've mentioned a few of them but i'd really be interested in you providing that feedback as well and i'm going to highlight a few of them and as i said there's a lot more than just these three that i'm going to talk about but specifically i'm going to share a little more information about huddles safe watch the patient safety event reporting system and of course education on the next slides um wanting to share with you all when i'm talking to groups i frequently talk about huddle and sometimes um people don't really understand like why does she talk about huddle all the time well because it's considered to be one of the most fundamental processes that a healthcare system can participate in and refine to really drive outcomes whether you're talking about a small team in clinic or a large healthcare system intermountain healthcare has been showcased by harvard business review on their outstanding processes for huddle which helps them perform and stay aligned with priorities in a very efficient and most excellent manner and i would encourage you this is a quick read you could literally access and read in less than 10 minutes and you'll understand those principles of what a huddle is all about and how it really can create efficiencies and drive excellent outcomes so how do we use huddle here at carillion clinic on the next few slides um really wanting to highlight what that looks like and it starts at the bedside and all of our units are conducting interdisciplinary rounds the times may be a little bit different on each unit and when it's performing in a best practice manner it includes physicians nurses pharmacy physical therapy case management and everyone is taking their piece of their view of the patient and the priorities and sharing that information to ensure all are on the same page and then that information is then fed up to what we call our escalating huddle on the next slide which is the 11 30 system huddle and it was in person prior to the pandemic and what do you notice here so this is a room filled of senior nursing leaders leadership for environmental services patient transport physical therapy the lab leadership within the quality team and they also have their dashboards that are reviewed and utilized every single day obviously with the pandemic we haven't been able to meet in person for 18 months plus and we knew after about five months of holding huddle by phone it was just one dimensional we weren't seeing the operations and we weren't leveraging our knowledge like we could when this 11 30 system huddle was occurring in person and so we made a transition and we made a transition almost a year ago to the day and that of course took on a team's format and on the next slide you'll get a sense of of the structure that we've used and at the same time in addition to creating a little more dimension to the huddle process we also introduced a discussion of quality typically huddle has trans um has really focused on operations and that's a great thing it's essential for a highly functioning hospital and health care system and quality outcomes and patient safety are equally important and we really weren't having the discussion in huddle necessary to create that uh awareness from the larger perspective of multiple team members coming together so in addition to creating additional dimension with the teams format at this time we also introduced a daily discussion by unit by this senior nurse leaders of the foley catheters in place in each unit and the central lines in place and if these individuals heard of any barriers for following best practice specifically around the care of those lines and removal and of course we also shared at the top banner you can see the monthly performance to bring that awareness to everyone in huddle on any given day about 60 individuals participate in huddle and the goal is to take frontline observation and knowledge bringing it to huddle for barrier removal whether it be operation safety or quality such as removing a foley catheter finding a solution getting that barrier removed and then pushing the information back to the front line that is the ultimate structure and process of a well-functioning huddle on the next slide wanting to share with you so i mentioned huddle so huddle is one of those key processes that all high performing high reliable health care systems do really well the other really key process is the patient safety reporting system and here at carillion we call it safe watch and it's so important we track it every month on the quality plan and it's like wow well it's just people entering things that they see why is it so important well it's so important because best evidence is telling us that even in the um most highly functioning of environments only about 10 of events that are considered reportable are getting reported so we're potentially missing 90 of the opportunity for improvement and that's why we will continue to see the number of safe watch reports show up year after year on the quality plan and as you um learn more about safewatch we really also want to emphasize the great catches and the next slide really does share that the great catches we have to celebrate them we need to celebrate the individuals and the teams who've taken those observations and made improvements so they've identified potential harm that could have reached the patient but didn't because of their observation whether it's a dr murdis and his observation that reports for holter monitor that were ordered in the ambulatory setting weren't really getting back to the individuals that ordered them or was it on our unit that recognized that there weren't enough resources at night to place pick lines for patients and now we've designed improved resources to ensure that picc lines can get placed at night pharmacy radiology um six south icu all of these are examples of recent great catches and they really are great because i i want to stress again this is harm that did not reach the patient there are also best practices around patient safety reporting systems and those include being a non-punitive response that encourages reporting and you want everyone to submit including environmental services pharmacy physicians nurses it provides that 360 view of safety and improvement opportunities it really is also necessary to take lessons learned from any report and ensure that we're spreading shared knowledge for improvement and that there also is a structured mechanism our our safe watch team within caps reviews this on a regular basis they have algorithms for triaging events and we also review events at the 9 50 safety call monday through friday and these events are then fed into what's called a patient safety a pso a patient safety organization and it's through that that the privilege of protection and confidentiality is insured so that all of these reports for improvement aren't used against us it is truly one of the key structures in place to drive improvement within our own environments and we really as i was saying we really do celebrate the great catches and we keep track of that information as well so you'll see on the next slide that on average each month about 30 percent of safe watch reports are great catches so again the great catches are the events where improvement is identified and the observer prevented harm from reaching the patient and whether it's an ehr upgrade or the human factors coming to a unit to make a change in one of the refrigerator pixes or design a new process the great catches prevent harm from reaching the patient and these are some of our departments that have the greatest percentage of great catches on any given month most of their reports even exceed this average for how frequently they're sharing great catches within safe watch and they also are the same units as you'll see on the next slide which um have the lowest rate of anonymous reporting our goal is that over time we will continue to have less and less anonymous reporting so that we feel that that would be an indicator that there is no longer a punitive response to reporting opportunities for improvement so what are the barriers for getting there the one i hear time and time again which has been proven in the literature is i never get any feedback on what action is taken i agree you know you or you'll get very generic feedback that isn't really very meaningful i promise that this is tedious work you can imagine with all the thousands of safe watch reports it's a very volume dependent goal that we need to meet but we do have the obligation to you all to ensure that we're using safe watch to ensure feedback to our reporters so let's transition a little bit to some of the metrics that i mentioned before and boy i spend a lot of time reviewing these programs whether it's cms it's the hacc program which is the hospital card conditions or readmissions reduction program you know these are the pay for performance on the left side of the screen and then there's the reputational rankings cms also has the star program u.s news and world report in leapfrog and if you combine all of these together there's over 222 metrics there is no way you can't manage those individually the good news is is that about 50 of them are common across all of the programs and we consider these to be the fundamental area for cats to really have the pulse of our performance on a daily basis and um the other thing i want you to mention i mentioned that these reporting and p4p they were so lagging so it's a fiscal year 21 report and just look at the the dates of when the measurement of a period occurred 2017 to 2019 even dating back as far as 2016. so you can't really use this to determine how you need to improve today it only tells you how you are performing up to five years ago in some cases and yet we must have the pulse of of where howard how are we doing and in the next slide we're anticipating very early in october that there will be a dashboard that will go down to the unit level that helps all of the team members understand how we're performing on those key patient safety and quality improvement indicators um that will be truly transformative for our teams leading improvements at the front line on the next slide um the last segment of my talk is really about education so i've mentioned um you know we've talked about cuddle we've talked about the safe watch reporting system and the third key structure is education and there is a saying that you can't teach your way to safety however you can certainly shorten that journey and that's where education comes in caps is absolutely dedicated to partnering with teams with virginia tech career medical school and in fact we have started that journey where we were responsible for a significant amount of content of the health systems curriculum and i'll just remind everyone that you know our medical school is one of about 20 of medical schools across the country that has decided that this is just as important as basic science and clinical science you're not relying on the dwell time of someone in their career 10 years 20 years to learn about all of these metrics but instead you're being introduced to it in your first year of medical school nursing school or physical therapy education on the next slide it goes back so you've had some of this fundamental education and then how can teams take that information and get improvement at the bedside one of the examples that i frequently use is the patient who's septic being cared for by a multi-disciplinary team they're not doing very well and what examples can you think of to really improve the quality in patient safety as it's measured at the bedside and when you look at clinical science and basic science side by side well of course these are the foundations as you'll see in the next slide whether it's the pathophysiology of sepsis or pharmacology or what is the physical exam about the patient telling you and now when you're partnering that with the curriculum of health system science on the next slide that patient with sepsis also shows how the healthcare team has a duty to prevent harm that is considered preventable to have awareness of patient and family experience how is the unit preventing falls in their in their unit or preventing bed sores not to mention the documentation requirements that really capture that patient and complexity when you're learning that so early in your educational educational journey it really is considered to be transformative for a health care system on the next slide some examples of how we take the model of teams working together to improve outcomes for patients the the evidence-based model is called cusp dr buffabani often talks about it we try to promote it every opportunity we have and it's the comprehensive unit-based safety program and it's a formalized structure to date most of the outcomes centered around hospital imparted infections but it can be leveraged to also improve team member experience patient experience or any other opportunity for improvement in the unit and in a very specific example i want to share with you on our next slide is how our neurotrauma icu took this model of cusp and they used it to improve something it's not measured by cms it's not measured by leapfrog or u.s news and world report but they knew it was essential for their patients and that was the extra ventricular drains they had too many infections in these devices and they knew they had to make an improvement so they brought together their leadership they used this multidisciplinary approach they used data to create that cadence of accountability they met frequently as a team and to date for the past year they've had no more of these device infections and as a result of this team coming together they've also prevented catheter-associated urinary tract infections i'm told their patient experience and their falls are down significantly as well and that's the power of bringing a team together using these principles to lead improvement so on my next slide it's really about thanking you for the opportunity to share this information i've intentionally tried to keep it at a high level and but also share with you that it is part of carilion clinic's vision 2025 that our quality and patient safety team are absolutely integrated and partnering teach all of our team members whether they're a medical student a nurse pharmacy tenured faculty we have a duty to educate all of our members over time and we're just scratching the surface and it really is an exciting time to be part of curling clinic and this great journey that we're on so with that i'm going to hand it over to dr luchtong and um again a big thank you another example of a unit doing great things in response to the covid and during coven we also had a 50 reduction in hospital card infections across the hospital it really speaks to our expertise and our teamwork and all of the values that we have in our health system so thanks dr electron thank you dr drammer can you hear me okay great um i'm i'm going to change gears a little bit and dark crime brought a really good high level overview about um you know quality quality and patient safety in our institution um what i'm going to talk about is how how we teach this to our students in the clinical setting my discussions not so much about the quality project as as much as how we're we're trying to convey how we do this and you know educate our learners uh next line so i'm going to talk about the challenges of teaching quality improvement in surgery to medical students and describe some approaches to teaching quality in this clinical learning environment i don't have any disclosures health system sciences is is essentially the science of healthcare delivery um and as as most of you know in the audience health system science has is becoming a major pillar in our medical school curriculum in our medical school approach to uh to educating our students so there's there'll be basic science clinical science health system science and inner professionalism as major pillars of the educational process next one way to look at it is to view what we do for the patient as only the tip of the iceberg um in that there's so much else that's involved in um in producing the the care that we provide the patient and so many things that affect our outcomes that's underneath the surface and you can look at some of those elements another way to look at this is the organization scheme on the on the right side which you saw a slide earlier on um with the patient family and community at the center all these other components build around the uh the center to um as components of the healthcare delivery system next our focus here today for me is to talk about health system improvement this is really our area in in surgery where we try to improve performance um without within our health care system within our department and section um in surgical care of our patients next slide so in brief this is a framework for how we approach quality improvement projects first we try to identify the problem and understand what it exactly is and next we identify stakeholders for nursing or nursing residents attendings the patients themselves and try and identify what it is that that is important to our stakeholders and how the the process um or issue affects the the patient the stakeholder next we're trying to assemble a multi-disciplinary team so we can approach the problem from from different angles a review of the literature should give us best practice guidelines evidence-based guidelines to help us direct our intervention we you know as part of define the problem we want to look at the current state and identify any barriers to getting to the ideal state at some point that an intervention is designed to take us from current state to ideal state um as part of the process we want to determine metrics figure out what we want to measure measure the baseline implement the intervention and then measure our our change and continue to monitor for for um potential improvement opportunities next slide so this is just a sample of some of the quality improvement surgical quality improvement projects we're involved in uh cold rectal sepsis reduction uh reduction of low value testing um reduction of opioid uh prescriptions on discharge we'll go into that in a little more detail period of glucose control protocol perioperative management of suboxone surgical site infection reduction on a system-wide level um vte reduction um smoking cessation as and perioperative nicotine replacement therapy next slide so this is an example of the kind of um kind of work that we do this is uh some an excerpt slide from our ex a few excerpt slides from our opioid reduction uh project the goal is to reduce the prescription of opioid discharge after surgery as you know there's an opioid epidemic in america and we live in one of the epicenters and so we want to do what we can to reduce opioids in the community reduce opioids to our patients so that we reduce the risk of developing opioid dependence so as part of this what we've done is create we created discharge order sets to help standardize prescriptions prescribing habits these uh the order set recommendations are based on guidelines from the university of michigan um and um help standardize the the number of opioid morphine equivalents there that are given to a patient the discharge works that was developed has has a couple components one for patients who are um you know short stay less than two two days as inpatients and so for each operation there's a recommended number of tablets of oxycodone um and for patients who are beyond the two days the discharge order set specifies that the the amount of uh narcotics prescribed should be based on what the patient's required in the last 24 hours prior to discharge so in this way opioid prescription prescriptions at discharge or standardized said that they're reduced to an appropriate amount for what the patient needs based on their operation and in hospital opioid requirements next slide so um when we're teaching quality improvement you're faced with a number of different challenges and i'm talking specifically about the uh m3 and for medical students quality work as you you can imagine seeing especially after viewing dr kramer's presentation you can see the quality work is time consuming and it's really complex and most of the time the the the lifespan of a project is much much greater than the time a student spends on our rotations um and these issues are often very very complex and beyond the level of uh typical early m3 medical students level of experience on top of that a student has a lot to learn already you know just learning clinical patient care is is a big challenge and so there are other competing priorities um you know that that the student has to pay attention to as they go through in addition to trying to learn about quality improvement um it's important when when you teach anything to to to a medical student to to help convey a sense of relevance but also to not oversimplify the problem and you know make sure that the student grasps the the level complexity that's involved um there there's an opportunity to do it by theoretical scenarios um but some sometimes these lack realism using real world examples sometimes can be complex and messy and you know you have certain other limitations there uh depending on what is actually going on in in the the real world at the time uh of your um that you're trying to teach the student um ideally you want to be able to give we wanted to be able to give the students an opportunity to provide meaningful input to to do be involved in a quality improvement project and and provide input that's relevant um and and you know with that quality improvement like anything else the experience needs to be engaging and interactive to to you know draw the student in and keep their attention next so our approach has been to use a case study review approach we've developed case studies with each topic representing an actual quality improvement project within our department we provide slides with content from on our ongoing quality improvement work and i'll show you some examples uh template slides are provided to the students to develop a presentation um that's that fits within a certain time frame and you know has a a a limited scope an appropriately limited scope the students with the content above are asked to to work on a collaborative presentation um and as they work on this presentation uh we provide input from contact content experts and others uh and at the end of the session the students are asked to provide uh the the president to present the to the uh their work to the group uh for discussion next slide so our first um first version of this was uh with uh surgery domain day in june you can look at the schedule on the right side of the slide we started out with an introduction to health system sciences and surgical quality this is to to the this time it was to the m3 students who hadn't had much of a health sciences uh curriculum uh compared to some of their um their uh um [Music] other cohorts other classes um that are behind them who have already started health system sciences curriculum in their m1 year so after the initial initial introduction uh the students are broken up into to to groups the groups covered um opioid opioid prescription reduction colorectal sepsis reduction reducing low value testing and ssi each group covered one topic um and within these groups the students were divided in subgroups so that um they there was a smaller group working on each subsection of the the problem from defining the problems stakeholders intervention design team members monitor performance and then they were they were put in breakout rooms and this was all done by a zoom so we we had had great help from megan brogan to um you know provide breakout rooms and smooth transitions um but in each breakout room contest tent experts who rotate through and that each content expert had a scripted talking points that i'll show you in a bit and then afterwards the groups reconvened and gave their individual presentations to share what they've learned about each of their projects to the rest of the group next slide please so this is sample i know it's hard to read but i just want to give you a flavor for for what kind of information we're providing to the students this is uh these are actual slides from our opioid reduction work um you know as we did this work we um our team had to communicate you know all these concepts to um to stakeholders to everybody involved in the project so we had accumulated a volume of of these slides that we were able to share with students and we've broken it down into sections you can see there's a section on defining um defining the problem and potential barriers there's a section on stakeholders and key priorities intervention design etc um so next slide along with this we provided the student with a template slide set so they were instructed to to not exceed the number of the slides allotted for each section um so that you know the the slides would you know so everything would be on time and the scope would be appropriately limited um and so working within these templates the um the students you know populated the presentation in in their breakout session after the breakout session next this is a sample of our moderator guide it's broken down similarly into these sections of background defining the problem barriers and you can see in the right hand column talking points for each content expert each one of the moderators as as they came in like i for one example talked about under defining the problem the research about consumption of opioids recommended dosages under monitoring performance our informatics expert talked about how we track metrics and pull data from epic to uh to help us monitor our our intervention um so you know in we were able to deliver the content in with using the combinations the content slides and our moderator input in in the interactive q and a session during the breakout sessions next slide so in the end the students were able to to develop these presentations and presented the information to each other with in the end what what felt like a good um understanding of the project that was involved um you know we we did feed them information in the in the form of the content slides but um in order to understand what was going on they had to absorb the content and you know re-synthesize it for delivery to their peers and you know this is the feedback from our domain day and i think it was pretty well received that we had reasonable scores if you look at the the bottom right hand corner you can see that our domain day performed well you know slightly above above performance of other domain days of this year and prior domain days and i think this is telling despite the fact that this was done via a a virtual approach and we also had some scheduling issues but you can read some of the feedback there i think the students appreciated the approach and it seemed to work well for them you know personally at the end of the the session i had the feeling that the students got it that they understood what this meant uh and uh what does what's involved in doing this kind of work next slide so um under dr dr morrow and dr carp's leadership we've been developing a health system sciences curriculum and implementing it um we are transition we're at the point now where we're transitioning so that we can provide this education to the m3 students the current m3 students so what we've done in surgery is we've taken the the format that was uh effective in our domain day and transition it to uh teaching in the m3 block within the m3 block so each block has a single topic um and each block of students has a single single topic one of the things we've we learned as we did this is that our topics need to be adjusted according to learner stage you know the early m3 student is not well equipped to grasp some of the complexities of the the more difficult complex topics so we started out with something simpler earlier on for the early m3 um there's a introduction lecture early in the rotation where we talk about health system sciences and quality improvement and the we talked about the logistics of putting together this presentation the students different from from from how we did no mandate the students in the m3 block are encouraged as they developed their presentation to speak to stakeholders during during the rotation so while they're on the ground um you know working directly with frontline staff residents and others we we encourage them to speak about the topic they're assigned so that they understand it from from a frontline line staff perspective uh how well the things are working how things you know that we may not hear about that aren't working well we asked them to try and solicit that information through you know their their work their time on the clinical rotation um at late in the rotation the the students uh reconvene to uh do group presentation uh and discussion uh on the the project and we've asked that they provide within their presentation and a section where that's dedicated to student suggestions um for project improvement this is actually feedback from the domain date group because you know the the domain date group felt that you know once they got a grasp of the the project they had some ideas some some sometimes very useful ideas that they wanted to contribute to to the the project so we we're formally incorporating this into the uh the m3 pilot next slide so it's very very early in our experience uh with the m3 group but our preliminary feedback looks favorable you can see here that we've had um fairly high scores for um for what we're trying to do i i think that the one that struck me the most was the the one that's highlighted here you know we were able to uh you know inspire uh students to become involved in quality improvement of patient safety in the future and i think you know as as educators that's that's one of our our um you know biggest goals is to inspire people to to to do do the kind of work that we're teaching them about and get involved so hopefully that trend will continue as we move forward next slide please so our future plans are to develop further uh content for the uh the the m3 block right now we have ready-made content for um for four to five blocks and we need to add some more um so as we go along we're going to assign topics to future blocks we're going to adjust our um approach based on feedback and later in the year we're planning a presentation of all projects that are covered by each block with updates on um on the the project progress at a future system session formerly called domain day um eventually we would like to be able to incorporate this work the work that the students do into a formal student quality portfolio so that students can come away from the institution being able to say that they've been involved in quality improvement work next slide so that's that's all i have to share right now i'm happy to take any questions or discuss anything you'd like thank you both so much that was a fantastic information and appreciate the way that you uh shared out what you've learned and the work that you're doing um and and how health system science has integrated into that we do have a couple of questions in the chat so i'll go ahead and read these out for you caroline cox commented that a lot of unsafe systems issues take money to fix how does curling decide which problems to focus resources on the answer to that oh gosh there's a lot of content i could pull from my presentation to answer that but really the the root of the response goes back to one of those earlier slides where i had those four quadrants and it was the different sources of information and and it's truly a combination of using data you have available as matched with clinical observation um and as a clinician who works in the ambulatory space in the inpatient space often i would say 99 of the time clinical observations from your health care team predict what your data is going to tell you and that has been true every time that we've been looking at projects and so you you take that information you have and you also reflect on performance compared to how other organizations are performing you know how how far are we leading we are leading in central line very low rates of central line infection where we had a lot of opportunity in some of the other hospital card infections and so you have to have benchmarking you also have to have the mindset that much of this can be improved when you look at what's the structure involved in creating the the improvement um we're not going to get to um where we want to be just by you know throwing money and resources at the problem but we really have to study what is the structure for optimal performance and where are their gaps can we measure the opportunity to improve can we create that cadence and then ultimately it's about accountability it's no use to measure it if we don't have those individuals who can take the responsibility to drive the improvement we have introduced multiple low-tech solutions to lead to outstanding improvements um specifically i'll reference again hospital card infections it's also um also really relies on establishing relationships within a team interdisciplinary teams using that cusp model can solve multiple problems without additional resource and then the final response to that is you also have to understand how heavily something is weighted and how frequently it's occurring in your environment because there is a saying focus on everything accomplish nothing so you have to be very disciplined in those decisions on with at the system level on what you're going to really put on the quality plan for this year and and have that road map for the next three to five years through education of health system science is how we empower everyone to get better within your environment to make the change that you see whether it's part of cms measurement or leapfrog if it's an opportunity that you see that can lead to improvement many of the projects like dr lupton just shared when we're doing both really well is when we will be in a completely different way of approaching quality and safety here at carillion clinic that's when we'll know that we've really advanced on that journey and dr kramer and caroline had a another question if someone has an idea to improve quality for safety who should they tell or contact about that idea well first of all learn what you can on your rotations in your curriculum if you're a learner in the environment and there also are educational opportunities that our team provides you can suffer them on cornerstone on demand there are work shape workshop based sessions on project management and i probably should have put this in my talk but it's maybe the focus of another talk is a resource that truly transformed my career and realizing that you have to have more than ideas you actually have to have the ability to know what to do to lead to an improvement and there's a great book out there it's called the four disciplines of execution and it it does not oversimplify but it it really shares with lay people who aren't certified project managers those essential elements on how to drive improvement and how to manage it yourself whether you're in clinic or or or leading a larger team great thank you so much um i just wanted to again let everyone know if you are interested in seeing me credit we do have information for you in the chat i think we might be a slightly over time um if you have additional questions for either doctors creamer or luck tongue please feel free to reach out to them with your questions around this topic and again just want to thank everyone for your your attention today and look forward to seeing you next time.