Hello and good afternoon. Welcome to today's. Webex today, we're joined by our guests from safe and reliable. I'll be introducing our speakers and momentarily today we're going to cover. For the 1st, part of a 2 part, uh, series called the learning system. So we welcome you today. If you joined early. Or if you joined us before, it's old hat for you, but we'll cover a couple of details about how to make your Webex experience a little bit better. And hopefully, uh, you'll enjoy your time that you are sharing with us today. We want you to participate in the conversation today and hopefully you brought your questions along to ask our experts be sure to watch your chat for links and, uh, certainly use that to type in your questions. You'll be prompted to answer some questions also. Um. So go ahead and explore that if you don't see chat in your participant panel on the right hand side of your screen, you can go ahead and click on those 3 little dots at, um, excuse me, the chat bubble to the left of the 3 little dots. Uh, and it will add it to your participant panel. We also want you to participate verbally if you're the chatty type, uh, like our guests today, you can certainly do that by raising your hand, you'll find it located just to the right of your name click on it. I will find you unmute your line and at the appropriate time, you'll be able to join the conversation. Well, as I said, we are honored to be joined by our guests today from safe and reliable and it is my pleasure to welcome them and introduce them. So. Let's begin with Dr so Dr kelly's a physician leader who has focused half of his 35 year career on improving the quality and safety of patient care after medical school and residency training. He served as a full time faculty member in the Department of internal medicine at University of Texas, Southwestern Medical Center, where he taught students in residence, and did basic science research. He brought the concepts of patient, centered disease management, in the redesign of ambulatory care for 20,000 patients in the parkland health and hospital system in Dallas, Texas, seeing both the power and failing. So, healthcare led to executive work at the Baylor healthcare system where he developed office of patient safety and oversee diverse portfolio of programs across. It's 12 hospitals and 100+ambulatory care sites. He contributed to the national literature related, measuring injury during inpatient care, and guided a variety of other quality and business intelligence activities at Baylor as its chief quality officer. After leaving executive work Dr kennel, he has spent the last 3 years sharing lessons learned with consulting clients committed to the journey of delivering care that we all want for our own families. Dr. Kelly received a BA from Harvard College and M. D. M. PhD degrees from Washington University in St Louis where he also did his internal medicine residency, he has published 50 papers or book chapters received a variety of awards served on federal and regional advisory committees and served as a founding board member of 2 patients centered nonprofit organizations. He's joined by expert Jeff Dunaway. Jeff joins safe and reliable in March of 2020 is has a primary focus of supporting a variety of healthcare organizations on their journey to high reliability. He has participated as a registered nurse for 2007 years with the last decade dedicated to the high reliability and continuous improvement. He holds a black belt in lean 6 Sigma from Villanova University, any certification in change management. Jeff is passionate about helping healthcare at both a national and local level through the empowerment of frontline workers and training of executives. He brings a servant leadership model to all his engagements and has a deep understanding that culture each strategy for lunch every time. I love that line, gentlemen. Welcome to today's call. We appreciate you sharing your time with and knowledge with us today. Thank you victor. Uh, we appreciate it. We're excited that you're here, uh, with us today, Don, and I are always excited to come and and present. Uh, it's it's very fun for us. Our, our passion it is high reliability. Uh. And for tonight, it's it's just a fun experience. Uh, the, the real hard work is behind the scenes. Uh, so, Victor, thank you so much for everything you do to organize this and and put it together. Uh, Don, and I could not do this without you. Uh, I can promise you, we would never get this event off the ground. So so thank you so much. Um, let's look at the next. Uh, slide real quick. So. The learning system, uh, this month is part 1 it it's it's too big for, uh, 160 minute session so next month, we will have part 2. the learning system is a crucial part of any organizations journey to high reliability. Uh, today we will discuss at a high level how to build a learning system, what goes into the learn and improve domains of that system and, and then tie this into the framework for high reliability. Let's look at the next slide. It's important to define and and remember what high reliability is and and what it seeks. So high reliability can be applied to any industry, but we happen to practice in healthcare as such. We want our organization, our hospital, our units to be failure free. Meaning we want to do no harm and we won't no harm to reach our patients or we seek to minimize errors that contain any effects of errors in the space of clinical, cultural and operational areas. And when we achieve this. We want this to be stable over time without dramatic shifts in our abilities to execute this. We begin this journey with our perpetual. Uh, mindfulness, understanding the current state. Our expertise and the complexity of the environment and the potential for risk and defects and, and all of this is on a continuous, uh, Infinity loop where we are constantly in a state of of reflection. Reflection and planning forward, uh. Then we will see our world through. The lens of this framework for how reliability to, to better determine, uh, where we are and and where we need to be. Given a presentation on the knowledge domain with data and transparency, and now we move into the learning system, uh, where the learning system can be broken down into sub components of learn, improve and implement. So, with these 3 distinct components, uh, today is, is part 1 of the learning system, and we're really going to dig a little deeper into, um, ARN and then we'll begin to dive into improve a little bit deeper. Uh, Don will start to walk us through how to build a, a learning system. Don, thanks, Jeff and, uh, again, I just wanna to to repeat, uh, Jeff's, uh, words about, uh, enjoying being here and, uh, we'll have some time for some, um, where we're gonna be encouraging some dialogue here. And, uh, so I think it'll be, uh, we really hope we get some participation along those lines next. Please. Okay, so I'm really glad to be starting this new, powerful domain of the framework. And the learning domain is big and very practical. So, as Jeff mentioned, we're going to break it up into 2 sessions, and That'll help you to participate in and also lead work in your hospitals. That really will move the needle on patient care. Also, there are a lot of parts of the learning system that are relevant to our personal lives. I think I've, I'm in my sort of I've had 5 different components in my career and 2 of those were things that I didn't go to school for. And it's just really about being open to learning and so we hope that you will find this helpful, not only in your work life, but also, perhaps in your personal life. So, this area really resonates with me a lot next. So, what I want to do, 1st, is to start with the quote in the Orange box here and it's we talked about we've talked in the past about accountability and the cultural domain. And the quote is the learning system only works. If I actively participate in it. And that's really true and it really there are many things in life that have a variety of cost benefit learned ratios. But fewer is strongly good is having a system that improves important, important parts of our lives. And this is not just for senior leaders. But as the quote says, we really must participate in the ways we participate, or shown down at the bottom of the slide. And I think it's really important that we all recognize that we need to be as part of a learning system need to report problems and suggest ideas or innovations all voices and ideas are very important. A major part of my job is improvement. So, I need to know how what we mean by that is that we encourage you to both learn if you don't know. But if you're a teacher, make sure that people who work in your organizations know, at least where where to start in terms of how they can participate in the learning system. When it comes time to making some changes, be willing to test changes in my work and when the better way emerges, I change my practice to match and I don't just get sort of ornery and about resisting that because it's not the way I was doing it before. Also, I'd like to suggest that your organization consider having an elevator speech or some sort of campaign along these lines that has to do with the focus on learning. Because it's so important an example was that a number of years ago when I worked at Baylor, we had our vision, was to be the best place to give and receive care. That saved quality and compassionate. And I guarantee you that. Everybody talked to would know that. Because, in fact, the leaders spent a lot of time on that elevator speech and the 2nd thing we said, was in order for us to get there. We have to have care. That is what we called steep and that's the acronym for safe, timely, effective, efficient, equitable and patient centered. So somewhere think about having this morph into a campaign for learning in your organization. Next slide, so, in addition to, um, again, the topics that we're, we're talking about here, the learn improve and implement these 3 activities, uh, will depend on having a conducive culture. And but before we get deeply into them, we need to consider 3 other, must haves and those are the ones listed on this slide energy ideas and action these 3 play roles and all of the framework topics. Actually, not just the 1 that we're talking about today. Let me give you a real world example of how that has worked. We had a post op cardiac that had marginal outcomes, high staff turnover, and the worst nursing survey data in the, uh, the whole system a young enthusiastic nurse manager was brought in and had some coaching from the patient safety team on, making her unit, What was called at the time, a custom unit or comprehensive unit based safety program and in 1 year, that unit went to almost the best scores in the system as far as was concerned with virtually no turnover. See, you. Did it was a free. The ideas and action, and the involvement of all others in that process. And so don't underestimate the importance of energy. It's really low in many units and understandably, so it's a tough time. But again, local leaders can absolutely build energy. And we'll talk about some of the tactics in a later slide, but it's essential that team members not only be energized, but also have enough bandwidth for this work. Most staff today are in gridlock with nearly 0, capacity for improvement. Why? Because organizations have just keep adding tasks to the front line later. Today. We'll talk about what we call a stop doing program that frees up their time, because heaven knows they need some time to be able to do some of this work next. Thanks, so one of the things that, uh, we'd like to do is to sort of shift a little bit into some participation here as far as, uh, you folks are concerned, the energy to learn and improve and implement requires, as we've talked about capacity personal accountability capability communication and importantly celebration. So 1 of the things. I, I will hope that you will do is to, uh, is to in the next, uh, couple of minutes to put into the chat. Uh, let's start with the 1st question. What limits your personal energy? Excuse me, what activates your personal industry we'll start with the 2nd, 1 and why for yourself and others in the organization, and I'll share some of my own in just a minute. So while you're putting those into the chat, I wanted to just tell you what we mean, by energy or at least what I think is kind of an operational definition of that, um, one of the things that I do when I visit organizations and do unit and organizational evaluations is, I asked staff there in in 1 on ones. What fraction of your colleagues are kind of heads up and leaning into their work and by contrast what percentage your heads down mostly trying to just get through the day. And I think the, the ratio of people who are leaning forward to those who are just getting through their day is a huge predictor of success and the amount of energy that's in a unit. So, Jeff, we got some folks. So, with some, some thoughts there. Yeah, uh, so Mary said, when a staff person comes to me with a problem, and it's been thinking about solutions. Nice. Yeah, that's wonderful. Yeah, I, you know, again, it's, uh, having them be engaged and have an idea, not just whining, but have an idea. That's terrific. Yeah, uh, Richard said, uh, when he sees the number of events of reporting, start to increase. Mm. Hmm. Yeah. And the reason we're happy about that is not cause. We think that, uh, we want to have more, uh, events or injuries, but people feeling comfortable at reporting because that is the, the premier, uh, sign of a good unit that people are willing to say, hey, it didn't always go. Right? So, that that really creates energy to work on those kinds of things. Cause people feel like they're psychologically safe. Some of the things that are, uh, were on my list is, uh, frankly, being thanks for doing my work group and letting people people letting me know that my work was important or having a leader come by to really listen to what's happening. We had 1, uh, CEO in our system who, whenever she went to a, had a conducted a, uh, a briefing for the whole organization, and, uh, feedback sessions, she would have a she'd ask people to put on a 3 by 5 card, which they thought was stupid about the work that they did and so she had it was called a stupid list and she made herself accountable for deciding to explain why either they didn't have to do it anymore or why it's not stupid. So loved the idea. Leaders aren't really understanding what's going on at the front line and having them be committed to making the work better. Um, another 1 is really having leaders, just be present and visible and seeming to care about what what's going on other thoughts from the chat. Do we have any others? Uh, Joe yeah. Uh, Stephanie said what what, uh, activates her energy is the autonomy to make improvements and Jill said accolades, uh, always promote energy. Yeah, absolutely Thank you is really, uh, those 2 words are a little under used in healthcare, I think a lot and so thank you really makes a big difference, doesn't it? Well, let's let's, let's move along and we'll, we'll deal with, uh, uh, the, the 1st question in just a minute, but let's go to the next slide. So, um, you know, what creates the will to participate. Well, we've talked about that, but here we've got some, I've got a 4 year old grandson, and he loves his LEGO characters and, uh, so, uh, let's turn to the things that take away energy to kind of suck the oxygen out of the room. And we hope you'll put some of those into, uh, into into the chat and I'll share a few of mine as well because there are lots of ways that, uh, energy goes away. But I think 1 of the things we can do is by understanding what kind of takes energy away, we can avoid doing them ourselves. And we can also try to discourage others potentially from, uh, from slowing us down by simply letting the air out of our tires. Have we got some thoughts there yet in this in the chat? Um, staffing shortages Kathy said. Yeah, now I think that's certainly true. And, you know, I think it's really hard having, uh, I think leaders often seeming to say it's always about doing more with less and, uh, and I think a, and that's hard cause our plates always get real full. Don, there's nothing else in the chat, but just to to add the things that that kind of pull. Mine away is it's just not filling hard. You know, I can, I can really get on board with almost anything. If I feel like, uh, I've been heard, uh, and and valued. Next slide so, let's talk a little bit about this term here, the depth of learning. Um, and what do we mean by this statement? Well, the 1st thing to think about is a, which issues or problems are actually worth improving said another way. What matters to you and your team deciding to put an issue in the parking lot is okay it, uh, it may be sensible. Think about it. Uh, we can't fix everything again. If we try to fix everything, we fix nothing. So, having some priorities, um, is important and, um, remember Einstein's quote about the 1 hour to save the world 55 minutes to understand the issue. A way of deeply understanding issues is the 5 Y, process that Toyota developed and, uh, let me share a brief example of something that I encountered when I was patient safety leader. We hit a terrible, uh, event, uh, where a patient who had pneumonia was in, getting a huge amount of oxygen and the oxygen tanks oxygen ran out a lot of finger pointing it. Whether it was the nurses job, or the, uh, the respiratory therapist job and, uh, and it just, uh, turned out that. There was a sort of a feeling like there was a trying to blame people for that. But, in fact, when we took the 5 wise of why this happened, it was a really busy night and they couldn't get folks to come in to take the extra shift. When it was really busy. And part of the reason for that was, there were 5 women who were on maternity leave and, uh, now that was a pretty known situation. So why didn't they have a better backup system? Um, and, uh, and then when we asked that it was because we had to, we didn't want to bring new people in. And it was going to cost extra money, so ultimately it became much more of a question of leadership and financial priorities that were driving poor decision making, and putting patients and their staff at risk. Because this was really an ugly situation, and they should have had more staff there that night. So, um, so in any case the other things that Einstein, uh, encourages, is, uh, or others like him is to understand the problem by going to the work site, and asking people, how they do their work, you're asking a subject matter expert, or checking the literature. No sense, and rediscovering the wheel and once we understand why something doesn't work, we can then apply improvement method and then Jeff is going to be covering that name. So I'll turn this back over to you, Jeff. Thanks, Don, and, you know, there's a series of of reflection and planning that we're doing. There's a series of of of looking at it from a broad sense and then getting deeper into the weeds with this. So so, what you've heard so far is the importance of having a learning system, uh, to high reliability and some of the components to think through, as you start to build a learning system, move forward with a slide. So. Earlier in the chat and and thank you all so much for using the chat you all are. Uh, uh, attendees, we, we appreciate it, uh, such such depth of answers. I appreciate it. Uh, earlier I asked where you sit in the organization. Um, so YOLANDA is the PR director in Puerto Rico. Uh, so as we move forward YOLANDA, uh, I'm gonna ask Victor, just to, uh, uh, uh, kind of set it up to to unmute. You and I, I'd love for you to just feel free to, to add to what you're hearing and what you're seeing here. Uh, because this is really a 1 of the areas of, of the framework that that you live and breathe daily. So I just want to give you that space to, uh, to join in. So. Here are some of the I want to bring out some of the basic tools that you use to grow, uh, the learning system in this section of the framework. Uh, all of these tools are designed to, to add to your knowledge of whatever area you're seeking to improve uh, once you have RnD and use these tools, you're better position to develop and informed hypothesis, uh, that you can then go test. So so, let's talk through some of these, uh, voice of the customer data, uh, failure, modes, affects analysis, process, mapping and gap analysis. Um, so let's go to the next slide. If you will victor. Voice of the customer to understand any process to understand expectations you have to capture you have to seek you have to want to hear the voice of your customer or or rather how your customer feels or what they expect. Uh. Therefore, the unit is the customer of the, the supplier department, the the ways in which you can better understand what your customers need from, you can be surveys huddles or simply rounding to ask them. Uh, unless you yourself understand what it is that your customers need. You'll never be able to meet their needs and in this program that that you're a part of a. Don't feel free to jump in with anything. You'd like to add around that. I, you know, we. Do surveys, and if you that is the end. Well, that's really the beginning. Um, we need to go down and talk to patients and families and find out what was important to them and so rounding on patients. And families is hugely important. Not just trying to sort of get better scores, but to really understand the work that's going on in the front line and what they appreciate and what they wish they had. Thanks Don next slide Victor please. So so, once we understand who the customer is and and what they need, we can begin to understand the process, uh, in in, which we interact with the customer. Uh, and once we start to define the process and its capabilities. We can see its limitations. Uh, and where the barriers are, where there's redundancy and waste and where there's bottlenecks and and the tool that helps to make all this visual to us is, is process mapping. So think of how you got to work this morning. This is a process define your starting point as the the point that your feet hit the floor this morning and your ending point as you're sitting at your desk, what are the high level steps that occurred between your starting point? And your ending point, this is your process map. Then you can further drill down as needed in the areas that show opportunity for improvement. And it's, it's really just that simple. Let's look at the next tool in the next slide. Data collection, everything in life runs on data on numbers on math and in healthcare. This is, especially so we need to understand those numbers. What do they represent? Uh, how do we capture those and begin to organize them, um, tally, sheets, observation, assessments, understanding what type of data we're collecting, or need to be collecting is crucial. Uh, do we need to understand our data as a rate or as a percentage or a number of occurrences per 1000 patient days you need to think through your improvement what told you there was a problem to begin with and and led you. Um. You know, down this, this road, um, thinking about the type of data you need, and the amount of data you need to collect. Um, so so there's a lot of tools around data collection analysis. Uh, I just want to. Stress to you that this is a crucial and and often overlooked piece of the learning system, you know, in fact, it's it's such a a huge piece that it gets its own domain in the knowledge framework where we talk about data and transparency, uh, that we covered. I think a month or 2 ago. Let's look at the next slide. So, now that you've collected your data. Uh, you want to organize it and display it in a visual representation that helps you to understand it. It helps you to analyze it and it helps you to convey, uh, it to those who, who need to know run charts, control charts, fredo charts Instagrams. These are all tools at your disposal to, to organize the data and display it. Note here that we, we haven't really begun to start thinking. Yet of how to solve this problem, uh, just like Albert Einstein, he's still in the 55 minutes where he's trying to understand the problem. We are still in the learning section of the learning system. Remember there is, uh, learn, uh, improve and implement. So, we're still in the, the learning section, and we need to better understand the problem. You know why is it a problem who says, it's a problem? What is the scope of the problem? What resources will it take to address it? These are only a few of the questions that we need to answer before you start trying to solve it. This is why we 1st learn. In the learning system too often, there is a straight data point that someone interprets as a problem. And then a lot of resources are are thrown in that direction as a knee jerk reaction. Uh, and this really never solves anything. Uh, Don, did you ever see that in your career? Oh, my heavens. I mean, I, it's amazing how often people just raw on, uh, on what amounts to just a, you know, a 1 time bad thing, or somebody collected the data wrong or something like that. And all of a sudden everybody's panic goes. We're trying to fix something. That wasn't a problem. Yeah, exactly. Thanks, Don. I appreciate it. Nick next slide Don, kind of starting to allude to this earlier. Um, the, the 5 wise gap analysis is a step in the learning process where we begin to uncover root causes of issues. Um, 5 wise, a fish bone diagram, these can be great tools for issues that have a moral limited scope, uh, a formal root, cause analysis tool or or event is often used uh, when the issue is much more complex. Let's look at the last slot or the next slide. Feel free to call my attention to it. I will do Jeff. I don't see anything new. I did reach out to YOLANDA. See if she's, uh. Getting prepared to share. Yeah, we just want to, uh, offer that yon and not to put you on the spot, but that I'm sure you're sitting back saying, hey, they're really speaking my language here. Yeah, and that's true for anyone on, uh, you know, if you have something to share, I I know these 2 gentlemen would love to hear it in our, our, uh, attendees would as well. Thanks you can, you can roll on, uh, Victor has done. Takes up the next section yeah. Okay. Thanks, Jeff. And those are, you know, again, we have to, uh, understand what we want to improve and, uh, as a, as again professor Einstein said taking the right time to understand the problem digging down into it, uh, finding all those methods that Jeff was just sharing as well as, um, you know, driver diagrams those are all things that can potentially help us to understand why something is happening and what might be reasonable to work on but remember to that don't, we don't have to improve everything. And every, a number of it isn't exactly where we expect it to be doesn't make it a problem. So, start focusing on what matters to you and the team, and your colleagues and a, and the leaders of your organization. Because again, you have precious few resources and so, as a result, make sure that those resources are heading in a direction that it could be the greatest benefit once you've now got sort of a better sense of, uh, the, uh, what you're going to be working on then the next slide will show you a good initial, uh, tactic, uh, to be thinking about using. Next slide. Yeah, there we go. Is that really the drivers of human error here are human factors. These are, these are things that I think many of you have seen, or heard about, but nonetheless, when we don't follow the rules, if you will of human and understand and apply the knowledge of human factors, we are, uh, we had put ourselves at risk and, so 1 of the tactics of trying to decide what we're going to be, how we're going to approach a problem, used to be asking ourselves the question, whether any of these things on the left, um, might be a problem. If we look on the right? Pardon me? We have, we can see that hey, you know, maybe we have a different perspective than the other person 1 person is looking at this number from 1 side and another and they say 6 or 9, uh, on the right oh, my heavens. Does look like a pretty similar, a spray cans and 1 is a deadly and a, and the other is and so trying to avoid things that are confusing and then the center the elephant is there because the people, uh, are in the old example here, you've got people who are trying to guess what that is. Uh, and if they don't talk to 1 another, they won't come to a common understanding of what the, uh, what does the real situation is and finally on the on the bottom. Uh, another is, uh, it shows that if we are, if things are messy or disorganized, it's very hard to make progress. So, uh, so having a way to, uh, work on, uh, these human factors components, and we'll cover those more in the next slide as well. Pardon me? So okay is this we have a number of things that we can do, and we're not going to go through all of these things, but a few that I think are, uh, important R. T address to try to undo human factors based problems. Um, and again, uh, Jeff, and I are big advocates for standardizing work so that we, at least know what's consistently being done, even if we aren't going to change it. So some of the process mapping things helps us just to understand what we're actually doing and mapping them out to see what things look like greater as full sources of error. 1 thing I, that I, you know, is really a pet peeve of mine is over relying on vigilance and it's really, kind of dangerous because, uh, when we're busy, we can't just expect everybody to be, uh, you know, um, vigilant all the time. Uh, you know, we, uh, we have to move on to things and so, uh, I think it's a, to do to be able to have, uh, some support from visual cues good labeling, checklists signs. How would we do in terms of driving if we didn't have warning signs on the side of the road? You know, so, uh, really trying to find ways to keep us in a sense on the road by, uh, by making sure that we have ways to, uh, avoid making mistakes. You don't have reminders. And, uh, although training is a, um. It is a weaker intervention. 1 thing that I would like to emphasize is that make having a program to make sure everyone has at least the foundational training they need and maintaining competence is very important. And as I mentioned before, some, some at least limited training, uh, in a performance improvement. So that they understand some of the basic techniques. So that they can be active participate Pinson, the learning process. So, uh, again, team, good team function, uh, is shown there as a as a tactic and it's really important because, in fact, uh, the, uh, if we are able to, uh, generate a, and support psych safety so people can ask questions and raise concerns and share good ideas, I mean, if we don't benefit from their contributions, we're likely to rediscover the wheel and keep making mistakes, closed loop communication like pilots use for critical information, asking clarifying questions when we're not sure and encouraging other people to do the same. Next slide, so I talked a little bit about the notion of of, uh, our troubled bandwidth and some of the things that we might want to be thinking about here and so. So, I got some things popping up all over my computer. I'll try to turn those off here. Um. I mentioned to stop doing program and. Has been guidance, old ways of. Yeah, they're not only inefficient. But also they might be risky. So, the quota that I'd like to harken to here is remove anything that creates waste instead of value. So always be thinking about that in the back of your mind as to whether something is really value added or? No, no. Or little value, or maybe even a risk so, uh, this process has a has been turned by some to be X innovation. So, you have innovation when you need to make changes, but when you stop needing to make changes, get rid of the old stuff. That's ECS innovation. A, 2nd, and professional work is full of tasks that have little or no value and I think we all would like to do less of this kind of work. Right? I mean, you know, why, we wouldn't want to do low value work. We want to work on high value work, but most of us are worried about stopping something that has been done for a long time. Maybe it's actually important. You worry or I might be accused of cutting corners. The stop doing program should start with executive leaders in their direct reports. And Here's how it works. Every 2 or 3 months have the direct reports of the senior leader proposed 3 low value things that they'd like to stop doing, or do less over delegate. The Baylor, the program identified an incredible number of love of low value work processes, and they were giant time wasters and I almost always said, yes, to the question of can I do less of this or stop it the few occasions where I didn't I realized that I hadn't done a great job at explaining my priorities and so it's a great opportunity to realign when, in fact something is important, but the folks who work for, you don't know that by giving them permission to stop doing something. It frees up their time. So, now they have time to do this, and when those people then did that same thing for the people who worked for them. That ultimately translated it into 150 people in the various hospitals I worked with being able to free up their bandwidth. It's a great opportunity to be able to get more done. And we were able to do many more things as a regulators asked us to do new things, and we identified issues then we could have done if we didn't start clearing the plate off. Because there's always going to be something to add to the place. So, we got to clear off the plate some. So, next slide, so we're going to be a turning, uh, to this, uh, pretty complicated slide here and then gonna be, uh, working through just part of it because most organizations need to have a big picture model about actually how to deploy improvements. And this is complicated. So, we're only going to introduce the add car system here and we'll return to it next month in our 2nd, session on deploying the components of the learn improve and implement sections. Um, so, uh, again, we'll be covering these separately, but I wanted to emphasize these components that are shown in the upper right here. The acronym for add, car, awareness, desire, knowledge, ability and reinforcement and what that really means is that in in order to get started. This is really a change management system. Where are we with something. Uh, do, we need to have awareness. That there's a need to change. If we don't believe there's a need to change, we're not going to make any progress. And then if they feel like there are people feel like there's a, an awareness there needs to be an, a desire to be active participants and achieving the change. 3rd, they need to know what specific steps they need to do in order to be able to be made to get the results that they're aiming for. And that may involve the next thing. The AE has ability to implement the key steps. If someone doesn't know exactly what to do, then we need to teach them how to do it. And finally, the reinforcement is that we need to reinforce good behavior and to be monitoring it to make sure I should say behavior, but good processes and strong implementation. And, uh, this all comes out of a, uh, what's called the very well validated, uh, stages of change. Just like in the in the learn section. Uh, there's some basic tools that you can use to help you move forward. Um, you see some of those on the slide here. Um, having a, a hypothesis about what do you think you might want to do again? Data collection, voice of the customer, rapid cycle testing, whatever you call it, whatever version of it, you use plan do study act. It is a major part of the improved section. Um, so. From all the efforts around learning we, we now have a better understanding by which to form our hypothesis. Uh, and and what could ultimately solve our problem, you know, data exists and is needed at at every step in the learning system. The customer has a voice and an opinion and expectations at every step in the learning system and this never stops. So.1 of the primary tools that we use and we'll discuss today is the work horse of improvement. Um, and and it's found in some form in every improvement methodology that you'll ever use, whether it's lean 6 Sigma, uh, there's some version of a plan to study act. Uh, that that's that's there so let's go and and look at the next, uh, next slide please. So every hypothesis needs to be tested every route calls, uh. Needs a hypothesis to better understand how we can make it better, or how we can solve it. And every hypothesis has to be tested. The plan do study act cycle. The rapid cycle testing is how we do that. Uh. So, we start small we. Want to fail fast and we want to fail small, uh, if we fail and, and most often we will, because fail f. A. L. is our 1st attempt in learning. And we are a learning, even when we fail, we're learning so so we start with 1 patient and 1 variable at 1 time. And and then we study how that went, then we move. To to act, so we plan our, our efforts we do them. 1 patient, 1, variable, 1 time and then we, we study that, uh, how did it go and then we moved to act in act. Uh, that's where we either. Adopt the change because it worked so well. Or we abandon the change because it failed so spectacularly or more often than not, we adjust it because although it sort of worked it, it needs more refinement and it needs to be tested on a larger scale. We run multiple cycles of this, uh, until the data, the process, and the customer tells us that this is better than it was before. Didn't we, um, take a successful test and, and we start to scale it up with the intention and a, and a plan for moving forward. We, we systematically scale it up and spread from our pilot level to the department and facility and eventually a systems level. Uh, so that's kind of how the, the plan to study act works. Uh, let's look at the next slide because I know we're kind of starting to get short on time. Uh, so just a reminder our learning system is, is self reflecting, it's improvement capable and it's sustainable. That is the ultimate. Goal for any learning system, it fits into the larger picture of higher reliability as you see here on the slide. It's not a separate thing that we do but connected into our everyday work and we're constantly learning and we're constantly improving in service of failure free operations. That are stable over time. This is what we're seeking every day. Next lab, so so as a reminder, some of you may have opted into participation in the score survey. Last year. Some of you may have opted out everyone who's in this program will have the same opportunity this year to participate in the score survey. It's a, it's a survey design to better understand the culture of your environment. Um, and this survey can really reveal a lot of areas of strengths and areas of opportunities that can then drive your improvement efforts. Um, so. If you did participate great, uh, I hope your a testimonial for the survey and, and you participate this year if you didn't, you can certainly understand more about that. Uh, from. The your TMF partner. Let's look at the next slide. I want to leave you with this. You will never know if change is actually an improvement. If you don't measure it, you have to measure it every. Every step on on the process and and Victor, it. I want to thank you for allowing Donna to come to you today and bring this, uh, this high reliability. Webinar. Um. To you, and and to the participants of the program, um, I think we've got enough time left over if you want to say anything about score B, you want to plug the, the communication that's going out about it. And and Don, and I'll be happy to answer any questions. Absolutely, thank you, Jeff, this is be with TMF and, um, just to reiterate the opportunity that just expressed that we are opening up the score, um, integrated survey as an option for your facilities you should have, uh, received the lead for your organization should have received an email explaining, um, the survey itself, what are the benefits of participating and the timeline that we're looking at for you all to return some mapping files. That are required in order for our partners. That's safe and reliable to set up these surveys for your facilities. And so, if you have any questions, or if you, um, wanna take, uh, an opportunity and benefit from this service, we ask you to reach out to us. Um, and we can kind of help and guide you along the process of what you need to do. You can email us directly at H, quick at dot org. And I'll drop that into. The the chat, uh, but you can also reach out to your consultant and they'll be able to give you more information on that. I don't know if you want to open it up for questions. Yeah, absolutely. We do have a couple of minutes left be and I appreciate the, uh, information and I want to say, thank you. Dr, generally, and Jeff or imparting their wisdom and sharing the, uh, those powerful experiences. I think we had a lot of activity in the chat, but we do still have an opportunity for some additional questions. I want to remind everybody that you can drop your question in chat, or if you'd like to participate verbally and you'd like to be unmuted. So you can do that just go ahead and click on the icon to the right of your name. Uh, there's little hand there, just click it. I will find you and unmute you and we'll bring you into the conversation as we're writing for comments and chat and, and perhaps hands to pop up. I want to mention that networks dot Org as B. Uh, mentioned is where you would, uh. Retrieve all of this information, uh, including, uh, the presentation that we recorded today. Along with that, um, I want to also let, you know that, uh, there's a quick, uh, tutorial here within this slide on how to set up your. Account it's very simple. It takes just a couple of, uh, seconds and just a quick, uh. Few a quick question and answer exchange and you'll be, uh, right in there to the wonderful content we have for, you. Yeah, and and as always there's always some questions about about the slides that we presented. Uh, I believe, uh, the TMF website, uh, will be the place to find this presentation. You're absolutely right. That's exactly where you want to do that. And if you want to get ahold of us, you can certainly send out an email. Uh, we'll be happy to connect with you. If you're not already working with a 1 of our consultants, you can also follow us on Twitter at TMF networks. We put a lot of information up there. So it'd be sure to do that. And I don't see any, I don't see any questions in chat, but I do see a lot of wonderful comments on the content that you shared today, along with the colorful slides and all the information available on those. There's 1 question, Don, this may go to you. Can you please repeat the s. T. E. P. acronym? Sure, I'd be glad to the Institute of medicine came out with, uh, a report, uh, in, uh, almost a, I guess, more than 20 years ago. And it said that high quality care, uh, could be described by care. That is. Uh, has the name of. Dave. Efficient. Equitable and patient centered, so it just makes, uh, for an easy way to, uh, think about that. And, frankly, um, you know, when I, I was working at Baylor, we had, uh, objectives in each 1 of those topics to make care safer, more efficient, more, equitable, more effective, more patient centered. Um, and it was, uh, it was really kind of the driving force for our work and I think you might find it helpful as well just to help people understand what we mean by high quality care. Thank you, Donna. You bet guys I hope everybody has a great day. We, we really enjoyed being with you today. Thank you. Bye. Bye. Thank you. Victor. You're very welcome. Thank you. Dr Kelly. And thank you Jeff. Uh, to our audience. Thank you for sharing your time with us. We know it's valuable. And, uh, we appreciate, uh, the time you spent with us as you disconnect, there will be a short survey. We ask you to it'd be redirected in fact, to take that survey. Uh, please take a moment to answer just a few quick questions on. How we did today. We do appreciate your feedback. Unfortunately, that is the top of the hour. That does conclude our call for today. That's all the time we have, we hope to host you on the next 1 and hope that you'll reach out to us. If you have any questions or concerns that concludes our call for today. You may now all disconnect. Thank you have a good day.