In this presentation, Dr. Ryckman will share patient stories where system failures led to suboptimal outcomes and the work to improve using high reliability science. Examples come from inpatient, nursing and the operating room.
I have the honor to introduce our next speaker. Dr Frederick Reichman. Dr Reichman is a recently retired pediatric surgeon who specialized in pediatric liver and multi organ transplantation. He was the director of the solid organ transplantation for 30 years and also the initial director of the ECMO profusion program. He was the clinical director of the pediatric surgery division and the director of the A. C. G. M. E. Fellowship in pediatric surgery. His active clinical surgical practice continued until his retirement As an emeritus professor of surgery in July of 2017. During his 35 years at Cincinnati Children's pediatric hospital, he worked to help implement the safest and most reliable health care for Children. He directed medical operations for the last 10 years of his career and served as the Senior Vice President for Medical Operations and the Interim Chief Operating Officer in 2015. In addition as the peri operative service director, he led the o our management team, surgical site infection prevention and peri operative safety initiative. He also led the hospital wide efforts to address patient flow and capacity management throughout Cincinnati Children's Hospital's inpatient and outpatient environment. Dr Reichman has had the pleasure of presenting at many Institute for Healthcare Improvement, national forums, strategic partner summer camp and collaborating with both the Scottish and danish patient safety initiatives. He is part of the teaching faculty for the I. H. I. Hospital flow professional development program and serves as a consultant working with the I. H. I. On safer care victoria Australia in Doha Qatar. He is currently enjoying a well deserved retirement and we are very, very fortunate to have him share all his knowledge and experiences with me with us. So please help me welcome dr Reichman thanks so much joan. It's an absolute pleasure to join the symposium here. The reputation of all of the host organizations is spectacular and it's a privilege to be part of the faculty to talk today and I'm sure if you heard everything Amelia said and you can do all of that then maybe you can take a break for the next few minutes. But if not I I'm gonna share with you some of the lessons we learned on our high reliability journey and I'm gonna share them with you because they weren't necessarily always successes. So I'm gonna show you how we struggled to get where we needed to get. I have again nothing to disclose. You've seen the objectives just as a brief outline for you who may not be familiar with Cincinnati Children's. Although I'm going to talk to you From our experience in the hospital with very small Children. This is not a small medical center. Over 600 beds. Over 30,000 admissions. Well over 32,000 surgical cases and a very large research component as well. So um we are like an adult medical center. I think the lessons that we learned can be shared and one of the problems that we have to get past that in our high reliability journey is as we build a better and better system. We started to think like the chairman of the White Star line did about the type panic. This ship can't sink because we've built such a great infrastructure for the program and what we learned from. And some of the lessons I'm going to share with you today is what the designer thomas andrews said she's made of iron. Sir, I can assure you she can sink and I can assure you, no matter how hard you work on higher reliability, how much you think it can't think. Like Amelia said, it can be one of the early things we had to do was really follow, john Kelsch is um, quote here because to do things differently, we have to learn to see things differently. We had to approach the way we did work differently. And when we saw those things that we hadn't seen before, we started asking different questions that we never had asked before. And so this is part of the challenge of high reliability is figuring out how to do this differently because we're seeing what's happening through a different lens. So let me present you, I'm gonna give you four different stories here today quickly. Here's the first one. This is a they're all gonna be real patient stories of things we experienced. This is an eight year old who presented with diarrhea, nausea and vomiting and fever and diffuse abdominal pain really unremarkable X rays admitted on our pediatric service for hydration with a presumed diagnosis of viral gastroenteritis within 24 hours. He really hadn't improved a lot, but everybody just sort of said, well it's probably just a prolonged case, hopefully he'll be better tomorrow. But when tomorrow came around he had increased local pain, proved to have missed appendicitis and they had a laparoscopic appendectomy where he had a necrotic appendix. So what didn't work here? We had huddles, we had people rounding, we had multidisciplinary rounds taking place. What didn't work was we didn't really have a good system to clearly identify patients who were either not progressing or we're not improving. And there was no structured method in place to address that, that we built a model called what we call our situational awareness model. This has really worked by Jeff simmons and steve muting. Um and as you can see this was a model to try and set up a system where we could communicate better about who was potentially sick. And these patients became known as watchers in our system. And a watcher was defined as somebody that we didn't was not following the correct medical course and they could be identified as a watcher through all of the things that we're here along the left hand side of the slide. Uh but most importantly, there were people that either had risk warning scores. They had were on complex therapy or they were brought up because we felt they had an employee risk this. Sure, dr Reichman your slides aren't showing yet. Can we actually just get those pulled up really quick. Oh yeah, sorry uh what do you want me to do? I go to share screen? I don't have any. Are those? There we go. It's at the bottom. Yeah, the green box share screen. Mhm. Presto Yeah. Do you have a presenter mode option? We have to play if you go to the where it says play up at the top the for the green arrow right in the middle of the screen, go down a little bit with your mouse right right above the word care, it's in the middle of the task. Are did that come through now? It's still in the non presenter mode which we can if we need to we can always just do it in this mode. Can you can you change that? I don't see where I'm supposed to change. So if you go to the middle bar kind of in the middle of your screen above the word care. If there's a green arrow that says play that's pointing to the move your mouse down a little bit and then over to the left and right there there. Yeah let's try that, yep. That do it. Okay, sorry about that, as I was saying in this situational awareness model, there are lots of ways that both from a patient or system point of view that these patients could be identified once they were identified as a watcher. These patients were then assigned a charge nurse and a senior resident who are responsible for this communication about their progress and how that communication took place is probably the important thing which allowed the escalation to occur. And for each patient that was a watcher we then filled out a very specific mitigation tool and you can see on the left side the six or five questions that were asked to be answered but they revolve around what is your concern? What is your plan going to be a very specific plan about what you're going to do? What is your expected outcome? So some is not a time, as soon as it is not a a time and you can say we're gonna have so and so outcome by this particular time and what are we going to do if it doesn't occur? So an escalation plan is built into this. This then allowed patients to be managed in a different way because we would have a periodic meeting that uh at this time goal that would discuss whether or not this had occurred as expected. This model has since been modified and tuned up a little bit and a couple of things you can see there are some new warning tools which were built into it to assist in identifying these patients but probably the most important thing that that was built in is family concerns. And when we set up this model we set a family at any point in time. Could ask to have A. M. R. T. Or have some medical discussion about their patients because we felt their patient needed to be a watcher because they were concerned their child wasn't doing what they should be doing. The other thing was this idea of a gut feeling because we all we all said that as providers were often on making grounds are on the floor and we say something's not right but we don't can't put our finger on what it is. But all these then come into this situational awareness model and if in fact at the time that the patient has reassessed things are not moving in the correct direction and they are automatically escalated for either an M. R. T. Or anything consult something else would allow us to then move forward on care with that patient. And from this uh model we came up with was called this shared mental model checklist. And everybody who was in the situational awareness discussion at the time these plans were devised had to walk through these six individual questions and say do I agree with all of these And if I don't agree with one of these then we need to discuss this. So we can be clear what is our assessment going to be or what's our model or what's our escalation. And this allowed us to then take these patients and very specifically identify them. Once they are identified on units. This entire bit of information went to the safety officer who then had a read on the entire service and who might potentially be at risk for becoming um ill during the course of the day which allowed us to better define their care. So what did we learn when we set this model up? We learned first of all that we have to be much more specific as a whole team on who was sick or who wasn't improving. It wasn't going to be okay any longer to say I really concerned johnny doesn't seem right. I sure hope he's better by this afternoon we now have to have a very specific plan and because of that we could build a hospital wide list of who we thought were high risk patients or or our watchers it also had to be action oriented time structured with reevaluation and escalation. If those characteristics work in the plan then we weren't going to be successful at both reevaluating and making decisions and we have to have a very low threshold for escalation consultation or M. R. T. S. Uh It was no longer okay to say well let's just see how we're doing in an hour or so. And the thing that surprised us when we set this up is the patients and the families were actually really reassured they weren't scared that their child was put on the watcher list. They know in advance already that their child is really sick and isn't getting better. They actually were reassured when people came and said we think you are your child is one of the sickest people on our service. And we're going to do all these extra things to be more specific to try and make sure that they're getting better fast. But the second story I'm gonna tell you is that we didn't always do that perfectly well in 2014 um after much work on our cancer and blood diseases institute where we did oncology and bone marrow transplant. The the CBD I organization was identified as the best cancer program for Children in the country on the U. S. News and World Report survey. And out of that we saw an significant increase in the amount of patients that we came both in terms of new oncology patients and new bone marrow transplant patients. And although we had always worked hard for years to achieve this sort of status, we had not grasped the complexity of what this was going to do to our care. We tried to simplify this and say well we think we're okay and we weren't sensitive to the operational aspects of what it was going to mean. So this is what occurred when that we saw those additional patients. We not only saw a lot more patients, we saw a lot more patients that had relapsed or refractory disease Or patients that were on new Phase one clinical studies where we weren't really clear what their potential complications. We're gonna be so more patients sicker patients. And Emily pointed out, there were two posters that are in your top three posters that are all about blood and blood infections. And I think the people that wrote those posters already know what happened. This is what occurred in our Bs. I rate we find that as those that risk increased. We have much many more patients with B. S. I. S. More complications as a consequence of the fact that we had not modeled for extreme success and did not know exactly how that was gonna impact us. We did a lot of predictive modeling in our organization where we looked at growth and we looked at staffing needs but we never modeled extraordinary success. And we also didn't see the early stress signs in that system because the progression was very quick and the census increases were quick. But we we were slow to identify the fact that they were not only numbers but sicker that we're going to require more the type of care. We also housed our oncology patients in a single large primary unit. We had no backup unit or no cross training of staff so that we weren't resilient when we needed to be as well as we could have been had we anticipated that better. And this was complicated by the fact that we're an academic medical center so that we have every year, we have new residents. We have a lot of turnover. We do a lot of nurse teaching as well. The other thing that had pointed out to us as we started to look at risk of this was the conclusion from these two studies that were done pediatric cardiac surgical care. One was done in 38 hospitals. The other was done by the society of thoracic surgeons. And they looked at mortality outcome in Children in cardiac I. C. U. S. And compared it to experience. And they're painful conclusion was that their odds risk of mortality increased by about 10% for every time that there was less experience in the patient. And the nurses with less than two years experience had a significantly higher risk of their patients dying than patients who were cared for by what my partners used to refer to as nurses with mileage who had more experience where you can see their odds of having mortality were much lower. And it also improved as organizations increase the educational background of the nursing staff. And this happened to us on psychology because as we had to broaden our staffing, we were hiring more new people and we were bringing into risk the fact that there were people with less experience. So the implications for leadership were very significant and that we have to realize that this wasn't just finding nurses that was finding nurses with the right education the right experience if we're going to avoid mortality and complications. And the threshold of that was probably around two years. And that's what we saw in the operating room as well. That it took about two years to really bring somebody up to speed with good coaching, mentoring and ongoing education. So one of the things we have to focus on then was not just recruitment but was a retention of nursing talent because the cost of repetitive retraining was not only paid in dollars, but it was paid also unfortunately with patients lives and with patient complications. So what do we do to avoid or to mitigate that when we set up secondary care sites? That's an obvious thing and we broadened our staffing so that we could decrease our nurse patient ratios. But the most important thing was we identified as we looked at these B. S. I. S. That we had significant variation that had occurred in our processes because everybody was trying to work faster and do things better. And so we developed an intense focus on what we then call key processes. And this definition is important. I'm going to go back to it again when we talk about the operating room, but the intense focus on key process that occurred because the definition of a key process was a process where we had a clearly defined best practice and process steps to uniformly do that. So it's something we knew how to do and we knew we were the best practices and then the process is when flawlessly executed lead to safer patient care. So we know how to do it. We know if we do it correctly, we're going to get a better result. And what we found was we were not focusing on those key practices. We have developed a lot of practices that were the infrastructure for doing this well, but we hadn't focused on execution execution. So what we have to do is we have to build those key processes back so that we knew they were correct and we did that using flow maps and all of the improvements steps you would imagine and then also use lean to streamline them. But the most important thing was that we had to train on flawless execution. So what did we learn from from that experience? Obviously we need to model failure and growth but also extreme success. And we had to be really key what these processes were at each delivery sort of setting. So the key processes in every intensive care unit, the core five or six processes like bloodstream infection and and things are all similar. But on oncology there might be a unique one for chemotherapy, use on transplantation. There were unique key processes for delivering immuno suppression. So these are all built by the front line at the front line but have to be standardized and then put in place and then as an organization that is looking to deliver quality sort of care, you have to train and train and train for flawless execution because that's where things starting to fall apart. This will be the most painful example I want to share with you, which is the Trestle. Russell's a little baby here and he underwent cardiac surgery in our organization on the night. Trestle underwent cardiac surgery. We have done a multi organ donor, we have done a liver transplant, a heart transplant. We're in the process of doing two kidney transplants when the sun rose in the morning and we realized we had to change some of the staffing in to cardiac rooms that were doing relatively routine sort of cases. We replaced the circulating nurse with what we felt was a very experienced nurse in the cardiac rooms that day. In the process of setting up these cases, that experienced nurse realized that she hadn't set up something we call a slush machine in several years and wasn't completely clear how to set this up. And this is a machine that makes what looks like snow cone slush so that you can use it for irrigation or Oregon cooling. And in the process of getting ready to set that up, she went to one of the technicians for equipment and asked them how to set it up in between the two of them. They confused where they should put the alcohol, which is a thermal transfer agent and put it on the wrong side of a plastic barrier, which allowed some of the alcohol to get into the sterile slush in the first room. None of the slush was used until the patient was off bypass. The patient did well. But when they were using this slush they noted that they thought it smelled a little bit too much like alcohol. Does it normally smith doesn't smell at all. They came in the other room, but in the second room they had already been using the slush to keep the heart cool while they were operating. The slush had been sucked some of that water had been sucked into the pump suckers and circulated into the patient patient got alcohol infused and died a day later in our intensive care unit because of the air that was made in our operating room. The tragedy of that was compounded by the fact that several people in the both rooms had noticed that the room smelled a little more like alcohol than it normally would and had written that off to the cleaning of the rooms and had never mentioned it as a concern and less than one hallway away. There were several uh nurses who work with our transplant team who set slush machines like that up every single day and could have effectively taught people or help people set those up. But nobody asked the right person for the information. Um So the failure to escalate decision making to the correct individuals and a failure to speak up for the team. And this is now, this strikes back to what Amelia was talking about, about building the culture that allows things to be better. As I said to start with, we thought this ship couldn't sink before this event occurred. When we looked at the operating room overnight, we said we could not be running a more efficient operating room and at a very high level to transplant and care for all these kids. Uh, and by afternoon we realized that we had a disaster. Uh, we were lulled in the feeling we're safe because we believe the absence of a rare really untoward event meant that we were safe and in fact the absence of those events happening only meant that we were fortunate were that we were lucky and we had to think differently. It really forced me to think differently about my job. I had recently become the director of the operating growth and I thought when I began that job that my job was keeping the trains running on time. So we did a lot of work on first case starts and turn around and case scheduling and case duration and things like that, that was keeping the trains running on time. That was not my job, I realized come the evening of trestle surgery, my job was making sure the trains never crashed. Whether they arrived 10 minutes late or they started 10 minutes late was not as important. And it forced me and enforced all of us in the R to completely rethink about what high reliability meant for our patients and for our system. Here's what we learned early on. We learned that we were really not clear about mission. We talked to everybody that went after our morning huddle that went back to the room and he said, be a safe surgical team, take good care of your patients. Be careful that nobody knew what that meant. Uh, we hadn't defined for them what the execution steps and the key processes were to be a safe surgical team. So although we were saying the right things, we were doing the right thing, We're also not clear about expected behaviors. We were very clear about what registered nurses or scrub nurses or scrub text we're supposed to do. But really we weren't that clear about position and anesthesia behavior and provider behavior across the board. We are also not clear on execution because we had some unclear roles and responsibilities. That's how an experienced nurse went and ask a technician how to set up a piece of equipment rather than asking an expert and we haven't defined personal accountability very well. So I know these are a lot of things that Amelia's address uh, in the oil. We then looked again at our processes that we call our key processes and we we have seven of them here that you can see, I'm not going to talk about these individually. But I just point out to you that we thought these were the essence of delivering what we thought was safe care and build a bundle where we then evaluated each patient and said did we successfully execute each of these seven steps in their care? But it was important how we also just talked about these. Let's look at the top one surgical consent integrity. This is work that was led by one of my partners ritual Conan and patty material, one of our uh scrub nurses. And we looked at consent integrity. And when we looked at that for 32,000 cases We were we had perfectly good consents, 97% of the time and we were all patting ourselves on the back saying wasn't that great. Were 97% of the time we got everything perfect. And then we did the math. If we look at the 3% that weren't done correctly with 32,000 cases, that was 1000 consents a year that we have to modify or do something to reconcile before the patient went to the art. So Discussing these sort of things with the people you work with, communicating as Amelia said, it's an important thing, communicating data. If what we communicated to my co providers who did the consents was were right, 97% of the time, everybody would have said, Oh that's not a problem. I don't need to work on that. if you went and said, did you know, last year we had 1000 consents that works correct or had to be corrected for patients to go to the O. R. That feels like a very different problems. So how you communicate these sort of things, it's going to become really important. The other thing is we realized that we had to deal with competency. We have made some assumptions in the O. R. That if you do it every day you must do it well. And so all these people are really good care providers and we reconciled after trestle that just because you're doing it every day and not necessarily mean you're doing it right. And if we said people were good nurses or good scrub tax or good equipment people, we thought that meant that everybody was probably doing good things pretty much the same way and we realized we had incredible variability and lack of consistency and standardization. But the most important thing, we realized that we had confused the experience, which is a time metric with competency, which is a skill metric just because you've been there a long time, doesn't necessarily mean you have the competency to do a particular job. And that is where we fell off the uh, the edge of the world here in this example because we had a very experienced person who was not particularly competent in one of the tasks that we asked them to do that day and we assume that expertise could be generalized and costs casts and rules. But just because you're good at one thing doesn't mean you're good at something else and this competency experience problem becomes really problematic if you're dealing with complex cases or new therapies or you're dealing with very difficult complications in the operating room. So what do we do to try and change that? We we we became very unpopular because we went back to every nurse, every text, every technician in our operating room. And we made everybody re certify in their skills and we classified people as a basic advanced or resource depending on their skill level and how confident were they were with equipment and devices and where they're problem solvers. And also were they the people that could lead and experience does count. I mean in order to be qualified as an advanced resource person in our system, you have to have experience and to be a resource person. The service specific leader, you also have to have successful leadership roles in your past. And this was very unpopular but allowed us to then do things differently. We began to build our teams and our staffing for rooms based on competency in case complexity, not on well johnny and susie like to work together and they're a good team that doesn't matter. Doesn't matter if you're dealing with competency, you say, do we have the right skills and experience in the room for that particular case. This also helped us because it helped us build bench strength because when we looked at teams, we could say do we have enough advanced to resource people to do these jobs in this complex team? And if not then those are the people we needed to grow and educate. So we could fill those gaps. We never understood where those gaps were before we started to really pay attention to competencies and most importantly, as a provider who went in the operating room at night, I could be assured after we did this that I had people in the room with me that had the skill sets that we're gonna be needed uh to do the type of case that I was going to do. The way we identify those skill sets that were needed was we built a situational awareness model that was very similar to the one I showed you for the floors, this was for the operating room and every day, the day before surgery we went through the box on the left hand side where we looked at it and we have the right team, right experience. Do we have any concerns that are risk and how do we mitigate them? And then we classified every case is green, yellow, orange or red. If it was a red case, that case would not get done until we solve the problem. Yellow and orange cases because they were more complex, required more advanced uh people or more resource people in that room taking care of that patient. Because we had already identified, they were going to need a higher skill set. And we used that green, yellow, orange red information to then build our teams and the next day, the day of surgery, if somebody called in sick or something changed, then that risk classification would have changed and we would rebuild that team. But if we substituted somebody in for someone that called in sick, they have to be the same competency level. So they have to have the same skill set. And then we had an escalation armed to this as well. The other thing we realized and this was very painful was we had to deal with this teamwork dilemma because as I told you in both of these rooms, somebody smelled something which they didn't think was right and nobody said anything about it. And surgeons and anesthesia providers, we often think we're the smartest person in the room and especially in the operating room at times when you look at that little part of that procedure or the technical aspect, we might be the smartest person about that particular thing in the room. But we are not smarter than the collective wisdom of everybody in that room combined. And that was the value of team vigilance that we have to bring to bear and to do that. We have to change the culture in the operating room. And if a pre requisite, the changing culture is perceiving a need to change having a child died because you made an error in the operating room is a pretty compelling way to get need for change. So what do we do while we were working on this? We had a pleasure meeting with paul O'neill, who was the former Alcoa Ceo and was known for running the safest system that you can imagine making aluminum. And we showed him this model, we said, we think we're okay with common purpose and vision. We're working on mutual respect to get collaborative teamwork and we think that's the next generation of very caring. And he said to us, well, do you know what? I expected Alcoa all the time was do I treat all my employees with respect and dignity? Do I give them the necessary resources to do their work? And do I show appreciation for their contributions? In other words, do I respect my staff? And we said, you know, we're really good at doing uh you know, family centered care and we're really good at trying to work on safety. But we had to admit that we weren't really that good at talking about what was necessary two for staff satisfaction. And if we were gonna get collaborative teamwork and develop a satisfied staff, we had to work on a culture of mutual respect and this sort of opened our eyes because we said, we need to do things differently. This is Lucien leaps work and he had four categories of what he called disrespect, which I like to call lack of mutual respect. But he said there's different things that show up and we didn't have a lot of humiliating behavior or really bad passive aggressive behavior. But we had a lot of passive disrespect. We were tolerating what we called difficult people and they were often my surgical colleagues, although not always. And these people, they were difficult to work with because they didn't do the necessary safety behaviors. They didn't want to run checklists, They didn't want to do time outs, They didn't, sometimes they were griping about handwashing, they didn't like who was in the room with them or something and we tolerated them because a lot of times they were pretty high end surgeons. Um, but we realized that that wasn't gonna work. And those same people that were disrespectful of the staff oftentimes were disrespectful of the patients and they didn't partner well with people if they weren't listening to the other people in their, in their team, they probably weren't listening well to the parents and patients, they weren't asking the right questions and as a consequence they weren't getting the right information and oftentimes they would not be able to make the right decisions. So we realized this was a major barrier for us for both current safety and future safety because our entire safety model was built on the physician nurse partnership and the essential role that they played and safety behaviors and I am treatment. Um so we realized we had to make a major change in terms of this level of tolerance. I always used to say behaviors and infectious disease and I saw this when I was training. If there were residents that were training with people who were difficult people, they learned that it was okay to be a difficult person and often then became the exact became exactly what they worked with. We have to stop that process and part of it the entire thing. If you uh if you listen to Amelia's talk, our entire strategy was based on the fact as she said that behavior and culture is my personal responsibility. It's not the job of the operating room to do that, it's the job the operating room to support it and set the tone. But it's personal behavior. So what do we learn with this example? We learned that safety always trumps efficiency. Um working on making the trains run on time was important. But what was really important uh was building a safe and reliable or and you have to be very clear on how you create that, Make it clear what being a safe or where it looks like. So high reliability design had to be built around defining competencies defining key processes and then executing on those and the culture of mutual respect and employee satisfaction was absolutely accountable if you wanted. Really true teamwork and you wanted mutual accountability and I'm so delighted. Amelia talked before me because she talked about all of the things that we have to try and put in place in order to execute on that problem. Last case I want to share with you quickly is a child who had a mid mid shaft femur fracture from trauma was resuscitated and left in the emergency room. But we had multiple cases going in the operating room that evening and we did cases in a sequential fashion whenever you were scheduled we did you next. And so he sat in the in the E. D. For several hours waiting to get in the operating room. By the time he was put to sleep in the operating room several hours later he almost arrested because he had compensated shock. And then at induction his blood pressure fell out the bottom and he was fortunately resuscitated. But it forced us to understand how we ran surgical care was not addressing patient needs and it was not highly reliable obviously in his case. And it forced us to look at a couple of facts. First of all everybody no patient wants to be compromised in their care especially if they're the ones getting surgery. And I really believe everybody that worked in our periodic environment wanted to deliver great care. But unfortunately our entire solar system was based On the fact that we regularly structured care around efficient and revenue enhancing scheduling of elective cases and black time. We took 90% plus of all of our daytime block daytime hours in the operating room. And we assigned them for people to do elective surgery. And we then delayed urgent cases because we have no room to put the patient in even though we knew it was going to compromise outcome. Um So we had to realize we had two streams of care here. We have an urgent emergent surgical stream which is very predictable because this is natural variation. There's there's nothing that isn't predictable about identifying how many patients might get hit by a car or have some other trauma or need to come into the operating room. And we had a lot of these going on because we ran a transplant program, a high risk nursery. We ran multiple intensive care units, a very vigorous c'mon program. So we had these emergencies and we knew they were going to happen every day and they can be managed if only we took into account in the system they were going to occur. We also had elective surgery which is entirely unpredictable because like myself, we scheduled whatever we wanted on in our block time and some days are block might be really complicated. Some days it's very simple. So we redesigned this with the idea that we never wanted to do urgent cases in black eyed and we wanted to set aside appropriate time for urgent cases as best we could. So let me show you how we set the system up. This is what happened beforehand. We had Overall had everyday 15% of our cases were emergencies. And when they showed up we had to jam them into the elective schedule which pushed everybody else down. We oftentimes ended up working overtime or had the wrong team. Uh It was amazing that we were running this high risk hospital and this complex operating room. But we pretended like these emergencies, we're never gonna show up every time they came in. It was like a surprise. You know, today we're gonna actually have to do an emergency. And the way we worked around that was we set up a scheduling guideline for urgent emergent cases with by need to get in the operating room. We went to every surgical chief and every surgical division had them classify all of their cases into these five buckets. We then shared everybody's bucket with all the other chiefs so that we came up with a list and we said we're going to do cases based on urgency. Now, not based on who signed up first or who has the most seniority. And the important thing about this is you can see in the red boxes where guidelines at any point in time, any surgeon could Classified their case at any level of complexity, complexity they wanted. And we never questioned that at the our desk. If you said I have an a emergency you were going to get an operating room in 30 minutes. But if you're gaming the system to try and get your case in ahead of other people, we were going to review those and follow them well we we did a simulation modeling on this using discrete event simulation. And after running that we realized we needed to set aside two operating rooms to do emergencies and one to do cases that came in that had to be done in a very short time frame and we set all that aside so that now we were doing emergencies all day long as they came into the operating room. We had the staff with appropriate O. R. Staff and this is what happened. We went from doing about 80% of our BD cases which were needed to be in the operator between two and two hours and 12 hours instead of doing them at 80%. Our goal was to get these all done within 90% of the time and about 95%% of the time we hit that goal. Even though we increased the number of cases in the are from 26,000 to 34,000. While we're running this trial, the only time this didn't work is when we closed one of our add on emergency rooms to do renovations. In the er The a case is our target was 30 minutes. We were able to have a room available in 30 minutes for every single one of these cases when a case was delayed. It was because there was a medical need for either intubation, transfusion, something to stabilize the patient for transfer transport. So what this did is this decreased our waiting time significantly for patients both on the weekends and on the week days. So that was good for patients and better care. It decreased our overall overtime hours substantially because we were doing emergencies all day long when the patients needed to have that done. And we weren't stacking them up and doing well at the end of the day and into the night. So that was good for staff and it was good for the surgeons. And during that time we were able to increase the growth of our O. R. by uh the equivalent of 5-7%. And as you saw we ran that system for over 10 years and increased the volume from 28,000 to 34,000 cases. Uh without without having to change the system. So what did we learn when we learn that urgent case needs have to be addressed in the system that's designed around urgent access, not who signed up first to who's the most has the most seniority. And I would suggest that that the 800 some people on this call a lot of you have a system that's based on who signed up first for seniority. This is patient centered access. It's not surgeon centered access that's for sure. But what we had to build a little bit of what Amelia was talking about is build a collective, shared mental model about what our job was and what was that responsibility in the operating room. And that was to take care of sick people when they were sick as quickly as possible rather than to work around surgeon convenience. So I don't want to wrap this up just by saying, I go fishing every year and I fished with captain chuck and every year we go, we're going out on the river to salmon fish and I said chuck, are we gonna catch fish today or what do you think? And he always reminds me his job is to have the right to vote the right equipment, the right flies get me in the right position so that I can cast for the fish. He said that's my job and it is kind of like being administratively responsible for running high reliability. You need to put in place all of the things that are necessary so people can potentially be successful. But he would then look at me and say, but you have to cast the fly, you have to set the hook and you have to land the fish that's personal responsibility. And so I'm going to echo what Amelia said, which is part of our job building, high reliability is to go ahead and build the right systems. But as we saw in our example, especially in the operating room, the delivery is all about personal investment in doing what is right and also training and training and training for effective execution and if you do that you know every once in a while you actually get the big fish that you're looking for. So with that I wanna stop and I'll take a few minutes to answer some questions. Um om are what are the acronyms? I'm sorry MRT Medical response team as a huddle situational awareness huddle the huddle where you got together all of the part of our safety system. I'm sure you all use is a huddle system where every morning at all the little micro system levels like in the in the operating room and all the units and all the ice us. They have a they have a huddle and then a representative comes to an institution wide huddle where we deal with both patient flow and patient placement and we also deal with patient safety concerns. And out of that comes an institutional plan for both dealing with patient flow but also in institutional plan based on who are the watchers so that we have the right resources to take care of the kids. Um when I ran operations I also had once a week a huddle where we looked at what was coming up for the next couple of weeks so that we were able to proactively try and plan for potential emergencies. Another question it looked like in the other questions. Um One person asked when he went back to that original um story um with the the ice and the alcohol. I forget the name of the actual tool. Was there any follow up with the company about air proofing? It's that math state couldn't happen again to another patient Actually. Our error proofing was we got we had two types of machines. This was the one that required the alcohol was an older machine. And because we've been transplanting so much the night before we've used some of the new machines and they were still being turned over. We actually went to the old machines and we cut the electric cords off of all of them the next morning so that nobody could ever use that machine again. Um The new ones that we had did not require the alcohol. Okay. And then you also mentioned the initial unpopularity of the competency. Focus. Did it remain unpopular or how did you build frontline support for the O. R. Staff to have that training and have that more of that transparency around their competencies. Mhm. Part of it was that we had to become very clear about why we were we were questioning people's competencies. We were documenting their competency and the way we got around them being concerned about it was we said we want to make sure that we always put you in a situation where you're going to be comfortable and you're going to be safe and you're not gonna be asked to do something which is outside of your skill set. Um but the initial message, of course, when we said we're gonna have everybody read and this was not, it's not like a paper test, they have to demonstrate personally to a trainer that they had the right competency. Um A lot of people felt that that meant we were questioning whether they were skilled or not. And that wasn't the idea. The idea was trying to build the right teams and more importantly, being able to then proactively say, who do we need to train and how do we build a better, safer system because we build for competency rather than I just assumed that if people who worked there for two or three years, they obviously have developed that because that clearly was not happening. Um what would, so one of the other comments was, you know, the importance of that um comment you made about experience versus competency, you know, as we all know right now, we're in a lot of staffing shortages, you know, for both nurses, but, you know, a lot of other roles within the healthcare team. So what would be your thoughts about the best strategies um for the current climate where it's so difficult with employees staffing, you know, to start to think about experience versus competency and the documentation of that. Uh I think that, you know, we're obviously as we have staffing concerns and considerations, um we're having to try and teach people new skills and uh so a very specific training program to do that will will help them advance their skills in in a in a better, easier documented way. Um We actually kept a book at the front desk of the r that had everybody's skills documented in the book, so we knew exactly who was who. Um But I think part of part of staff satisfaction is being comfortable that the patients you're being asked to care for our people, that you feel like you have the right skill set for it. And as we are stress was staffing that may require that we have to teach more people different skills, which is what we have to do in our human example, we had to teach other complex care nurses to actually take care of a cancer patient or a bone marrow transplant patient. So those are new skills, but it made it helped them to feel like they were at least competent and comfortable doing the basic care for those patients when they were asked to fill in for somebody else. If we asked them to fill in when they weren't, they didn't feel like it adequately trained, then they were put in an unsafe environment for the patient and you're putting them in a difficult environment unsatisfied factory environment for them as well. So I think, I think they feed into each other. Um, but it's obviously much more complex now with the problems with coed and everything else in the world. I think one more last question um, with, especially with the physicians or the providers in the operating room when you were speaking to um, developing that culture and mutual respect, how did you start to get the surgeons and the anesthesiology providers engaged in those discussions into changing their behaviors? We did a lot of the things that Amelia was talking about, but probably one of the most powerful things to start the entire initiative is that everybody in the sort of top 10 leadership group of the hospital that was on the, that were functionally work directly with the Ceo had projects every year that they were accountable for bringing that project to fruition. And the Ceo himself took on culture within the institution as his primary project. And all of us had potential salary at risk if we did not achieve our goals and they were very specific goals. And um, Michael Fisher, Ceo took that on and was very clear. He had several hospital wide meetings with all of the uh, physician staff and spelled out very clearly what his expectations were about individual people's behavior. And we went out of our way to make sure everybody was modeling the right behavior in the place, they needed to be in the organization, but I'll be honest with you After the first couple of years of this, we had a I think the final tally in my mind was three people who came to the conclusion that they were not going to be able to function well within the system. We were asking him to work in and they're now somebody else's problem. Um but at some point in time you have to say this is a standard and if you're not gonna you're not gonna tone the line to this level of a standard, that's expected behavior, then you're gonna have to go somewhere where your behavior will be acceptable because you can't work here if you're not going to do these things and there's a lot of work before you get to that step. But you have to be clear that at some point in time there's some people that you have to make that step with and we have had several that were very, very skilled clinicians, but they we're beyond difficult people to work with. Thank you Dr Reichman and thank you for everyone for joining this great presentation and please be prepared to go out and view the abstracts and thanks again for joining us. Thanks again for the opportunity