Elaine Huggins and Pamela Leonard share how Kaiser Permanente's National Program Office works the challenge of mindfully employing the High Reliability principles in multi-level, multi-organizational, enterprise-wide improvement that ties together the accountability of leadership commitment to no patient harm with the sensitivity to operations and deference to expertise they desire. They will share their experience of the 8-step problem solving journey using an A3 in a cascading manner that resists the temptation to simplify yet retains clarity of the work. While not at the end of the 8-steps, they will share their insights to date and their continuing resolution.
Hello and welcome back. My name is Jody Woodward. I am A P. P. I. Consultant at Barnes jewish hospital and I want to just really quickly thank the patient safety and quality symposium committee. In addition Vicky Pack and Robin Gray with the work with the abstract and partnership with my co chair that you heard from earlier dr Emily fondant who is RBgh assistant CMO and associate professor um at Washington at Washington the division of Medicine. I'm really excited to present or introduce our next two speakers. Elaine Huggins whose lead principal consultant for high reliability. Both ladies come from Kaiser Permanente. Elaine comes to us with 20 years experience as an army nurse with a master's in nursing and administration and education and has a very broad and varied clinical experience background. Just has 10 years in the department of defense, civilian corpse as a certified professional and healthcare quality and an additional 10 years of lean six sigma master black belt training. Her co presenter is Pamela Leonard also from Kaiser Permanente and she is a senior director of quality safety and experience and Pamela is accountable for driving the nursing strategy to deliver industry, leading performances and member experience and nursing outcomes. Um She previously served in leadership roles and risk and patient safety and prior to that she led the simulation innovation Centers for Medstar health in Washington D. C. As one of the directors in the Institute of Innovation ladies take it away. Thank you so welcome everyone. Elena and I are um honored to be presenting here and sharing our story. You can see our bios here. So let's get to the next slide. Mhm. So Elena and I have no relevant financial interest to disclose and Elaine put a little um teaser here. Yeah we wish. So today our title is mindfully addressing high reliability is robust. P. I. Multi level multi organizational enterprise wide improvement. Sounds like a mouthful but we are happy to share our experience across key P. So I'm just going to introduce who we are for those of you who may not have heard of Kaiser Permanente for an integrated health care system made up of our health plan, our hospitals and our Permanente medical group. We serve approximately 2.12.5 million members across the US located in several states. You can see our regions there um We have uh focusing on our nurses because this is kind of in scope that we're talking about our nursing practice, Over 63,000 nurses that were proudly representing next side. Alright so I'm just gonna run through the objectives and then I'll try some over to Elaine's Today. We really want to highlight the, identify the three prerequisites and five principles of high reliability and organizations. We're going to analyze the classic eight step problem solving lean approach and how this meets the needs of a robust H. R. O. Process improvement in a mindful manner which Elaine describes beautifully describe the use of the cascading a three's in the alignment of key stakeholders that highlights accountability of leadership, commitment to know patient harm. This was new for us to really cascade a system level A three. So you'll hear some stories about that and consider the roadblocks and challenges. We all know these come with any large project that you undertake for P. I. So we'll talk about how we address those. I'm just gonna level set about our journey here. Uh we were always on on this road for improvement and of course um to reduce patient harm. So we are making great progress over the last several years towards our hospital patient safety balls. And then as you know, I can't believe it's been three years now that we're talking about uh pandemic or two years. Exactly. Uh then we had to really regroup and our leaders asked us to really come together and huddle to look at our um just our current state during this pandemic and we became mindful that we really needed to go back and use high reliability. So our focus today when we talk about our R. P. I work in this space is on very specific adverse events. We tracked and monitored our progress with our H. A. I. S. R. Labs ecologies and CDF as well as our adversity met metrics of falls and hospital fire pressure injuries and what was in scope for this particular project was our hospital market. So Kaiser Permanente is represented across the nation as you can see in colorado Georgia, mid atlantic states, hawaii but really our hospital markets are in the in Oregon and California and Hawaii. Okay, so I think I'm going to transition this over to Elaine too. No one more. So again stepping back, this is just another kind of slide to tell you how we address things at a system level. We are a very matrix organization. We do not have line of direct reporting for our national Nursing Chief Nurse Executive to our Enterprise Chief Nurse Executive, but we have a lot of relationships and influencing. So how do we do this? We have a national nursing structure which looks at the data across the system. We look at our progress towards our goals. Where do we get all this information while we get it from our partners that are working in our markets or regions. So those are our strategic partners which we call patient care services. They bring all the data together up to the our umbrella of National nursing Pcs. Then what do we do with this information? How do we know? We're on target. How do we get our progress communicated to our executives. We have a national nursing steering committee uh that is comprised of our quality and safety partners are infection prevention partners. We also have risk finance HR I thi represented in our steering committee and that helps us drive our strategy. So after we we look at our strategy, then we we need to take action if we need to make improvements. So that is where decisions are made and then again it goes back down to really where the work is being done, which is our regional operations. So that was again a level set for overview and now I'm sure I'm going to turn it over to Elaine, right, so um thanks pam. So when I was called into this, we um you know, I realized that we really needed to take a look again at these principles of high reliability and see how we could use those to better I understand and support our markets in their work with the H II's and falls and happy. So we went back really to the beginning to um what seemed to us to be the seminal article on high reliability by chasing and low band great article and they said basically Um in 2011 we faced the intersection of two interrelated trends. So hospitals house patients who are increasingly vulnerable to harm due to error and the complexity of the care hospitals now provide increases the likelihood of those errors. So they concluded that the only way to go forward was to seek high reliability and healthcare. So they did a great review the quality journey and then they came up with something that was eye opening, they said um there were three prerequisites that needed to be established first in order to bring forth those five principles of high reliability by wick and Sutcliffe. So those three prerequisites were leadership engagement, safety, culture and robust process improvement. So we took a look at those first, this is a kind of a driver diagram so that first one leadership's commitment, it was really commitment to the ultimate goal of zero patient harm and that meant like a complete alignment of the governing body is what they were calling for. So starting at the top of the board of trustees or directors all the way down to senior management and then physician and nurse leaders and down you know, into what they call the constituencies of leadership. So sort of the official and unofficial leaders, everybody had to agree that zero patient harm was what we were working towards when they talked about the culture of safety. They were really talking about the model of reason and Hobbs which was that um sort of three part trust report and improve where you know um employees and staff feel comfortable um you know, speaking up and reporting and things weren't going well and then that they could see the organization was interested in improvement so they would improve and that would then increase the trust and reporting. So it was cyclical. They also noted that we needed to apply the principles of crew resource management. So we know that now as team steps and then this third prerequisite, The one I love robust process improvement and their point on that will identify any particular methodology, the methodology that would look at the very specific causes of failure. So we're talking about root cause analysis. So any methodology that employed root cause analysis to really understand um where the failures of our safety processes were coming from. The this is what they were talking about and they noted that it um this helped to support this. The one principle we'll talk about reluctance to simplify so with that, then um bringing those in then an organization they said was ready to begin working on the principles of high reliability. Okay, so that's a lot of information here. So let's give you a chance to sort of digest that we're going to do a little poll here. So if I could only implement and spread one prerequisite at a time, which one would I choose to go first? So we're going to launch that, give you folks a chance to uh ponder that again, there's no right answer. This is just more for our interest. Okay. And let's take a look at what we have here. So, well, this isn't too surprising is that the leadership engagement has always been the one that it seems like people really focus on and it's kind of cool to see that um safety culture is right up there, which is kind of what you'd expect, right, is if we can't do much if we don't have the leaders engaged, it just won't have. Yeah, we actually see these hand in hand. Yeah, okay, very good. So so let's continue with this driver diagram. So we've got our three prerequisites in process. Let's look at these um five principles again, just to remind ourselves where we are. So the first one preoccupation with failure. Now that just means that an organization is never satisfied that they have not had an accident or an incident, they continually remain alert to the smallest signal that a new threat might be developing, even to the point of proactively imagining worst case scenarios and assessing that risk and actually planning for it. So, you know, Amelia spoke to us earlier about that um that perpetual mindfulness, this is what she's talking about, is that preoccupation with failure. And and honestly, dr Reichman also spoke about it, you know, when he was talking about um they thought that their hospital was kind of like the titanic, that it would never sink. Well, that's not a preoccupation with failure, that is um you might say, as he he pointed out kind of resting on their laurels laurels. So this preoccupation with failure is a mindset of always looking and assuming that something is going to go wrong, The 2nd 1 resisting the temptation to simplify. So um now this is not talking about simplifying processes. Yes, we want to simplify processes, but this is about um simplifying observation and experiences of the environment. So the key here is actually being able to have a diversity in looking at what is happening in a daily way and being able to be aware when subtle differences occur. So, you know, Dr Reitman's um example of that smelling the alcohol in the O. R. This is a this is um if they had really had this principle in place, somebody would have noticed that that alcohol smell was there and would have said something, but you can see it's challenging this temptation to simplify, we fight against it in many ways because we tend to be very conceptual and and, you know, categorize things, so it's a challenge. But this is uh what's important here and sensitivity to operations. Again, this um is really focusing on the front line work and recognizing any early indications that um that there's questions as to how things might be operating. So, and this is really where that speak up culture comes in, because again, with Dr Reitman's excellent example, not only is it just noticing that there's a smell of alcohol in the operating room, but then it's been able to report, it's knowing who to report to its feeling safe enough to report. The other key thing about sensitivity to operations that Wiccan Sutcliffe pointed out is that we need to be very clear as to where the front line operations are happening. It's very easy to um start looking at other things besides the frontline work that's going on, but they're um they're very clear on this that the action is at the front line. So these three particular um perspectives. These principles are looking at the issue of prevention, but the last two are really more about mitigation. So the commitment to resilience is is recognizing um that no matter what you do something something's going to happen and so this is about preparing to respond or how do you respond. Um And I thought it was um really sort of important to point out that week and Sutcliffe talk about that the hallmark of an H. R. O. Is not that it's error free but that errors don't disable it. And they talked about um degrading gracefully rather than total breakdown. And again I think dr Reichman just shared with us what that commitment to resilience is like is that every time something happened that they didn't expect um even to the point of a of a death of a of a baby, they responded, they responded very resiliently, they figured out ways to um to interact and to do better and that's what this is about. And last but certainly not least deference to expertise so that there are mechanisms in place to identify um who are the people with the greatest expertise for that particular situation and being able to move this decision making authority to that. So it's really the recognition that the authority hierarchy does not necessarily correspond to the knowledge hierarchy and being able to be um comfortable in moving the right people to the right place to support the right things happening. Okay. So they went on to talk about them that these five principles um bring us to this collective mindfulness again that Amelia was talking about really and that the collective mindfulness that really um support this highly reliable healthcare organization. Okay, that's a lot of information again, so let's do another poll and then you need to drop down and you'll see a question too. Oh so click on question one and you'll see the menu. No, let's see. Oh I see what you're saying. Oh thank you for that. Okay, so if I could only implement and spread one. Hr Oh principle. Which one would have the most impact on decreasing patient harm. Now remember again this is purely based on your experience or your perception. There is no one right answer on this. We're just curious as to what you think about this. Alright, so right now it looks like preoccupation with failure is winning. Alrighty, got it. Okay, we got it. All right, so here we are. Preoccupation with failure one we've got resisting the temptation and simplify sensitivity operational fairly equal. Okay, good one. Um I think this is pretty much what we've seen before, isn't it? Pam That preoccupation with failure is definitely seems to me where you have to start? Okay. And that that was really what kind of drove us the the ask was really are we doing everything that we can during the covid time? Are we, are we really ensuring um that we are doing no more harm? So kind of links into that? Yeah, that's well, yes, absolutely and we we um when we did our HR oh look of course we went through all that and and these, this is really kind of where we felt our most emphasis needed to be placed as certainly on the robust process improvement. We needed a proven systematic method that really could align all of the different um root cause analysis that were being done and communicate um you know, between layers as to what the problems were and what sort of support was needed, resisting the temptation to simplify again, it, you know, it's easy to look at hospitals in bulk or markets in bulk and it was important that we that we really focused on the individuated Root cause analysis and try to align it rather than just um bucket everybody into a few categories the sensitivity to operations. Of course, we knew that the work was going on on the front line for these particular five areas that that we really needed to keep our focus on what was going on, you know, monday through friday day, evenings, nights, weekends and to support that coordination and the deference to expertise. We knew that our nursing partners are the are the experts and so we needed to support them and um have a well developed and um you know coordinated processes for evaluating and supporting them. So that's kind of where our H. R. O. Quentin when we were looking at how we were going to you know what P. I. Method we're gonna use. We we fell back into sort of the classic lean eight step problem solving and um we found that the A three tool that is commonly used with that would work very well for us. And again this is um this is Toyota's methodology, the Toyota production process and um they're a three is really what they develop and lucky for us, Kaiser Permanent E. R. Institute are Improvement institute teaches the eighth step problem solving. So we knew that we would be using something that we wouldn't necessarily have to teach people that there was a lot of familiar already with it um and our institute a little plug for them, so they have literally taught thousands of people and so far as you know sort of the green belt level improvement advisors, we use the I. H. I. Methodology for that level of improvement. And then um we also have active black belts who are both boots on the ground and are able to do virtual problem solving support too. So this is the A. Three document that's used by the Improvement institute, we took a look at it and it's a great document especially when you're teaching people how to do it but we decided that since we were going to be working really with operational leaders that we would just go ahead and fall back the sort of the standard A three document, this is in essence a Job Aid that explains what goes on um in each of the steps, what we're looking forward, we're not going to go through this today, but we just wanted you to see what our format was and key to this is that it's possible to use this in a cascading way. So um we would start our a three at the enterprise level um working through our problems and um and uh performance gaps and targets and then by the time we would get to step five we would identify um we which markets we needed to do there a threes to be able to look at these problems from their perspective, so they would work through The steps and by the time they get to step five they had the opportunity to identify hospitals that they would want to do eight step problem solving with these particular areas. So I just um allowed for a tremendous amount of coordination for easy communication, the method that we were all pretty familiar with. So what we wanted to do now was to go through um and just identify sort of the basic um work if you will each step, but really wanted to share with you the roadblocks um that we ran into and how we attempted to counter them, um I think like dr Reichman said, you know, it's it's never smooth sailing and we wanted to share some of our not smooth sailing with you too. So on the problem statement development, this is really a journalistic attempt to identify your problem and five sentences or less. And for us, since we're coming from the high reliability, um, you know, we were looking at being able to state the issue from the standpoint of patient harm and that that was really our driver, but again, it's um, you know, in general, it's the who, what, where and when of um, of that problem state, um, just out of curiosity, you know, it's a lot easier to write a problem statement from this standpoint if if your organization has clearly identified that no patient harm is a goal at some level in the organization. So we're just curious about um, at what level, if you have a written goal of no patient harm, sort of, what level of the organization is that written at? So let me go ahead and launch this. So, if it's written down, what is the highest organizational level that you've seen written, the no patient harm goal or objective. So either it's your primary workgroup, your department or division, a working goal of the organization or perhaps it's part of your organization's mission and vision, or maybe it's not written down at all, it's just understood. So we're just curious as to where it fits, so looks like um for a good majority it is a working goal, a written working goal and some folks have it as um part of the organization's mission or vision, so let me share this with you, So we've got 42% have it as a working goal and 24% as part of the organization's mission or vision, And 21% have it, it's not written, but it's understood and um that's quite understandable too. There are so many things for an organization to um focus on, but it does make it easier for writing your problem statement if it is written down. Okay. So so the challenges that we face as you might expect when you're looking at a at a group of people, it's just getting consensus on the problem itself as to exactly what the problem is. And then for us it was getting the right enterprise stakeholders and um and then clearly identifying the scope, you know, who was gonna work on what, because we were looking at a two or three year project here and you know, how that scope creep goes anyway. So the key thing for us then was to get the support of our senior leadership, so this was formally chartered um with our Chief Nursing Officer and our Chief Quality Officer, they were our senior sponsors and then we began to form market teams and this was really interesting because um position wise, this these problems sort of fell in different buckets if you will, and so we really did have to do stakeholder mapping. So, you know, for some it was the quality department that took the lead for some, it was the infection prevention ist that took the lead for um for some it was nursing that took the lead, so we really had to support each market and um and who they decided their team was going to be and um and then support them as they worked on their problem statement. We were really lucky is that all the teams did have um either a green belt level or a black belt level that we're supporting and so that that um was definitely lovely for us. Elaine, I'll just chime in with one comment as we say our market, so it represents each distinct region in northern California As 21 hospitals. Southern California has 15, so you can imagine that scope of how drilling that down to one, One representative or a couple for that whole group of hospitals, the 21 and the 15 um that's where we really try to hone in um to to kind of work with those leaders. Um so we didn't have a lot of several different meetings and a lot of silence taking place. Absolutely, yes. And so then our step two challenges that is, you know, this is where they did deeper dives, you know, to really understand the situation that they were working from and this is where we really did have to resist the temptation to simplify, because it's easy at the enterprise level, um to think that sort of, you know, there's a certain similarity in what they're looking at, that we really had to uh listen deeply and develop a rapport with each one of the people on each of the teams so that we could get a better picture of how, what they were looking at in their market. And as pam said, you know, some of the markets are pretty complicated. So Anyway, moving into step three, this is this is this is basically on the Step three of the A three, what we're looking at. So this was not a real challenging step, because the market's already pretty much had their targets uh in place, they kind of knew what they were working for, but I think that when you introduce an enterprise level, you know, sort of a corporate level, wanting to discuss this, then we did have some challenges, You know, first of all, there's this fear that, oh my gosh, how long is this project going to go on? And what happens if we don't meet the target? And um and what do you do with variations of target? And I think the underlying thing was, you know, when you have a sort of a corporate level coming in, you know, are they your friends or are they your fault? Are they for you? Are they against you? So we really came from the standpoint that um you know, for us, you know, we're not there with a whip, beating them to hit a target. We just really wanted to learn. We just really wanted to understand what was going, particularly with the different ways that were happening. We just wanted to have a sense of partnership and that if there was anything that we could do to support them and so a lot of it was just being able to understand and report up well this is what each market is doing, you know, for each one of these areas. And so it was key to really, um I say pedal partnership to really give a sense that we're in this together, we're not competing, were not whipping um were, you know, being able to, especially as covid continued, you know, to share with them some of the information that we were getting in so far as national trends so that they wouldn't feel like um that they were somehow out there by themselves. Yeah. And I'll just add, so keep in mind this performance improvement journey began september of year one of Covid we had is that many, you know, we had no idea um that this journey would take so long and the covid impact. I think there's there's five ways um that that are really documented and when we set our improvement targets in september we were above, we were not reaching reaching our performance goals for Cody and collapse the we're doing really well with c diff and that continued through the pandemic um that is consistent with natural trends but with covid with claudia and collapse. See we were pretty close and we really wanted to drive and and and see how close we could get to our goal, what we didn't realize and we talked about feel, you know, fear of reaching the target, That there's literature now that was just published that compared to 2019 nationally, 2020 clap. See When a 46% across the nation. So really we were leading this robust b I to get back to our baseline yet we had this huge sir surge in our infections but still we'll tell you the story of how really developed and we will continue to monitor progress and we we're coming back down to baseline now again, thankfully yes, but at that time we just, we had no idea. So we went ahead and step four was Where you determine your root causes. Step five, then you prioritize Those that identify countermeasures to your prioritized gaps and step six is where you implement countermeasures. So this is how we did Step four as we basically for each of the five problems we develop, you might say template ID fishbone diagrams and this was really just to um help sort of the market focus in on what might be true for them and what might not, we had the capability to go through and look at all the projects in this case, this was um county, we looked at all the projects that have been done over the last few years, um and put them together, sort of the root causes that other projects found were a problem. And so just again, um to help focus folks on what potential problems were and then step five, once they identified their problems, they prioritized what they felt um were sort of the greatest root causes and develop projects or countermeasures. And then this is again the standard um format for identifying what they were gonna work on, who was the leader, who was the facilitator and when they thought they might um have this finished. So the challenges we found in step four, remember we're working with operational folks. So their first, let's just fix it, it takes too long to do that Root cause analysis and then second is why prioritize we need to fix it all. And so we were able to slow that down a little bit, you know, first of all, um what we found was was it was important to try to make this fun, so as we went on, we learned how to use mural better insofar as being able to do root cause analysis and to um to use it for prioritization bringing a group together, developing the reports, it's really a great tool when you can use, well with teams, we template id like I said those um fishbone diagrams, just to cut down on the time that it would take for them to do their root cause analysis. We had our trained eyes and black belts that supported this and we found that having a central document manager, so I became sort of the holder of all of the most current A threes and I'd worked quite a bit with the teams to to actually um develop their A three. So they didn't have to work, worry too much about the admin side of it. We were, you know, they were the folks in the field, so we got information from them and develop their A three and they checked to make sure it was um a good representation of what they were doing Step five and 6. Um you know, like anything is when you start talking about reporting, you know, what do we need to report? When do we report to, who's going to see these results, you know, on our side, we just wanted to know who was going to be responsible for the work because often times in the past we would get these general reports as to what was happening, I had no idea who was doing it or when it was going to be done by. So having a report out schedule is important, but at the same time as, you know, as these waves kept coming, having the flexibility and moving implementation dates, of course, we um we were very flexible and that sort of support and you know, everyone who is doing the work um obtaining the accountability of who was going to do it. That was a little challenging at first. But we found that using a race teach art was really helpful and for some reason that seemed to ease the angst a little bit of, you know, of the accountability. So that Slight to work well. So words, step seven. Now this is the monitor and confirm resolve. Um this isn't real data, but this shows you the format that we use, that we use a run chart. We have a central repository of data that we can um pull our county and collapsing and you know, c diff and all of that and we add then for each one that we do for the market, we add um at what point they're starting from different implementation. Um we put a median on. So even if folks aren't reaching a target, we still are able to see um based on the patterning as to if they're making improvements, you know, up until they hit the target. So it's just a standard way that people get used to seeing how the data is displayed and monitored. So the challenges that we've had on here. Um first of all, of course we use organizational data, we have a 2-3 month lag time, which is, you know, it's just challenging when folks are working on stuff and they don't actually get to see the data results for months later. And of course we all experience these surges, you know, just, you know, folks had great plans and then another surge would happen and so they'd have to back off. So for us, you know, it's just keeping the focus and maintaining the momentum, We established routine contact with each of the teams. Even if there wasn't any new data, we would still get in touch, how's it going, you know, how's covid for you? Um and we really um we decided to do another relook and so far as where we are with the H R. O principles. Um so you remember initially it was robust process improvement, resistance to temptation to simplify sensitivity to operations, deference to expertise. We realized we needed to look at commitment to resilience and I think we're just at a point now again, this is about mitigation and response capabilities and so um we realize we need to start, you know, talking about the workarounds. So coming from the perspective, you might say the old days where, you know, if you have a policy or procedure boy, you better follow it, you better follow it right and you better, you know, if you don't get it right then do it again until you get it right. Yeah, we have to really look at the issue of workarounds and this is something that we learned from week and Sutcliffe that this resilience, it's just what dr Reichman was talking about is when things go wrong, let's see how we can fix it and share it. So this um resilient system that is spoken about in HR Oh this is really more about having a well developed response capability and this is what we realized we've started now to ask about, you know, what have you learned from all of this? You know, what what sorts of things are you trying or have you tried and and really um integrate that into our reporting structure and our celebration structure. And um I thought again, this is good to remember that it's better to degrade gracefully than to suffer total breakdown. So thank you. Yeah, amen to that. So anyway, that's really where we're at now, is that we're asking these questions about what have you learned, You know, what should we sort of standardize now and um and how would we deal with this in the future. So, um just one more poll, just to give you a sense to think about this commitment to resilience. So um so try to identify here which concept is not um consistent with the commitment to resilience, so whether paulie Elaine since we're not Next to each other, I'm just going to say we have 10 minutes, it's 9:00 at the top of the hour. Okay, I think we're getting there. All right, So remember we're looking at what concept is not consistent with commitment to resilience and you have to think about this, you know, it's funny, we don't we don't talk as much about resilience I think is as we do about um you know, some of the others. Mhm. I see it. Someone has their hand raised if you can put questions in the chat, if you have a question that would help. Okay, so here we are. Well again, sort of the school answer is maintaining standard procedures, no matter what is actually not considered part of the concept of organizational resilience. The the idea of resilience after you have um harm events or in this case, you know, when when we have covid have the the idea is actually you do look for workarounds, you do look for ways to work better with the current situation. Um So but it's good that we had a chance to kind of share this and this was a test question. We are getting some chats that they read the question wrong. Oh yeah. Which would be consistent with commitment to resilience? Oh yeah, instead of which would not that's a trick question. I guess so. All right, okay, so Step eight by definition, we are not actually at step eight because um Step eight is really might happens at the end when you hit your targets or you know, you develop new processes that really work, but we um we actually I don't want to wait for that, partly because, you know, we're looking at a 2-3 year project here. Um We've also had, you know, it's a change continually goes on, so we've had almost a complete change in our senior leader sponsorship and we certainly have had changes in our market leadership and of course we know we've had changes to staff that are working on the improvement. So rather than sort of wait till the end, um you know, hats off to to pam that you know, who's really moved in and so far as um you know, starting to talk about this or having talked about it over the last year in our communities of practice um and our enterprise nursing and you know, enterprise quality forums, we've done lunch and learn. So we keep people apprised as to sort of what's going on, anything new that we've learned out of it, we keep people informed. Um I'll add just a couple of comments here, Elaine. So at the very beginning and thinking of the scope of this, we had a lot of angst about our our quality performance, particularly our nursing goals. So we did stakeholder Bath Elena and I said this is such a great opportunity to share as we get updates in this a three, it's it's a it's already made communication tool if you think about it. So we were able to give updates to our our board forums um by briefing our senior leadership at any point they would know what region, where they were on their performance, their countermeasures and who was accountable. So if we had a senior leader saying I want to know like southern California will just be honest, was completely hit um by covid in the L. A. Area as you know. So their performance did look worse than our northern California counterpart yet, you know, kind of have the same surges. So we were able to say this is what identified and this is what their countermeasures are. They are working, you know, with with this, this P I team to lead the improvements also were able to quickly get that transfer of knowledge or boots on the ground work. That was happening right at the time. If you think about the nurses were moving, you know, I? Ve pumps outside the rooms to mitigate PPE we're looking at the effect. Does that have any effect on the the collapse the rates? So this really became a very useful tool. I would say, I told Elaine I would love to partner with her on every project that I leave because it's ready there. The information is there. Um and we didn't have to redo board reports or executive summaries. So think about that if you if you're encouraged by this step, it really was helpful in the long term. Yes. And we shared some of our other learning, certainly the use of mural, we've been using that more. Um using these potential these uh pre developed fishbones was kind of a cool thing. The run shot format. Um, we've shared that. So, so yeah, I mean a lot of good has come out even though we continue to work on it. For sure. So alien. Thank you. I'm going to really wrap this up because I really, I think we need to leave The last four minutes for questions again, kudos to everyone. We just wanted to recognize that we know we're all in this together and that's what the next couple of slides say. But with your permission, I'd like to end Elaine now so we can get at least get a couple minutes of questions. There's one question in the chat that we can address and then if anyone else would like to to add additional questions, it's our pleasure to share our story with you all in this forum. And again, we're just so appreciative about this partnership, um using HR Oh, thank you very much. So questions it says in regards to work around is the thought that you would collect information on the workarounds and change the process such that it is no longer a workaround but becomes standard work, we always thought of workarounds as an indicator that the process has built is flawed. Well, both are true because when you think about it when we build a bundle or we build standard work, It's based on a certain environment and and it works in that environment. But what happens when you have something like, covid your environment changes, the rules, change, the situation changes. And so you do have to, you know, the front line are going to do workarounds in the moment. That's what you want and then yes, um, to be able to collect those and and look at them and see how they work. Then that becomes the new standard Shore. That's the concept really of resiliency. Thanks Elaine. And what is mural? Oh, mural is another application that um, you can use it with teams. It's similar to the, to the white board, but mural is actually a full blown application that allows you to um use sticky notes. You know, due process mapping, um, any sort of collaborative work. It's uh, it's a forum for doing it. It's fun. And then there's a question about are the template fish bones and other documents available online. Well, they're available, you know, within Kaiser, we use them. I don't think we've ever had anybody actually asked to use them outside, but I think if you contacted us individually, uh, you know, Yeah, if you look at it and I would say the template of fish bones, what we did is we we tried to make it as easy as possible for our region leaders to identify what their gaps are. So I looked at standard um, Kati and clap see Fishman's if you just google them, you'll find plenty of them there and the A three format is available online as well in many different forums. Yeah, someone just comment, I H I and they said he's a mirror M I R O. It's no it's it's mural M U R A L. Okay, so we are wrapping up, I want to thank you all again for your for listening to our story. I'm sure they will share um our contacts if you have any other questions speaking for myself and Elaine, another closing comments, Elaine? No, um I think we just really appreciate the opportunity to share our journey with you and uh and I think to point out nothing's perfect, you know, we we keep learning to I think that's about, you know, that's what it is, that it's a journey and we just keep on plugging and thank you so much. Well ladies, thank you so much for an excellent presentation. I just want to remind everyone that if you have questions later that didn't get answered. If you go into the meeting platform, which is what we're viewing this on now and click on the meeting calendar and you click on the uh session, then you can directly send that those will get directly emailed to the speakers and they can respond to you via email. So that's that reminder again. Thanks Elaine and Pamela for an excellent presentation. I have a few questions that we weren't able to get to, so I'll be sending those as well. And don't forget to complete the survey, view the posters And the next session link is available and it will start promptly at 11:25. Thank you so much.