Introducing the Next-Gen Patient Safety Organization

Michael Barton:            I’ll say good morning to our West Coast participants and good afternoon to our Midwest and East Coast participants. We’re excited to share a little bit about our journey here at Health Catalyst as we became a certified patient safety organization. To start out, we’d like to talk a little bit about some learning objectives.

We have a sophisticated audience today, so I’ll try to go briefly on some of these areas not to bore people. Just some patient safety terminology and why PSO participation matters. Evaluating some ongoing challenges that PSO participation really may not totally solve for you related to safety. Gain an understanding of what active safety surveillance for all-cause harm can bring to your safety system and why we believe it’s essential. Discover the advantage of housing you’re all-cause harm surveillance system data and your PSO together and learn some key criteria for selecting a PSO partner.

Here at Health Catalyst, our goal is to create a data driven culture of safety. We really believe in our mission to transform healthcare that patient safety and culture of safety are essential to becoming high reliability organizations. When we talk about transforming healthcare, that high reliability organization is what we’re trying to achieve.

Now, I’m going to talk a little bit of history now for just a minute. On July 17th of this year, our patient safety product team, an outstanding product team in my opinion launched a new product called Patient Safety Monitor Suite. I’m just going to do a very brief review of essentially what that is because it really provides some context for our PSO offering. Here we’re looking at some data out our enterprise data warehouse, some clinical data.

That clinical data really needs to be assessed and really applying some analytics to reduce all those discrete data points, and some of them non-discrete data points into a coherent story about what’s going on with that patient. Then, generating some actual knowledge, having some automated triggers that runs. Any of you that are familiar with the IHI Global Trigger Tool, and I suspect many of you are doing some sort of trigger based surveillance to augment your patient safety system.

This does it electronically, taking data and identifying patients who are at risk of potential harm. In this case, we see this patient has reduced glucose, they developed a hematoma after a surgery or procedure, their creatinine has jumped up possibly related to a dye that was used during their angiography and maybe they were exposed to it nephrotoxic medication because of that. Those events are then presented, those positive triggers are presented to a clinical reviewer.

The clinical review work and then go through a workflow process of assessing those events. Did harm actually occur? What was the severity of that harm? And, what was the level of harm that was caused in the NCC MERP categorization methodology. Then from going through that process, they can identify opportunities for learning and improvement, but also for patient specific intervention. It really provides an opportunity to help prevent further harm for this individual patient, but it also provides learning that help us improve our care delivery system to reduce harm events and protect patients in the future.

This is just an example of some of the literature based trigger libraries. I appreciate the product team sharing this and coming up with a compelling product offering. But you can see, we really try to cover a lot of the areas within the care delivery system. These are going to continue to expand as this product has been in the market. I know they’ve already started working on some additional triggers for cancer patients is one example, but this library will continue to expand.

I share this with you because this tool, this patient safety monitor tool really was the impetus for us becoming a patient safety organization. Our patient safety organization is a wrapper that delivers the services related to this tool, both deployment, training, et cetera.

I’m going to go through this quickly because I suspect many if not most of our participants today are familiar with this. In 1999, the To Err Is Human Report from the IOM came out and we identified up to 100,000 preventable deaths annually as a result of patient safety issues in healthcare. Since then, we’ve actually seen that number do nothing but climb up to about estimates of about 400,000. The government when looking into why some of this was happening really identified a barrier where healthcare organizations were not feeling really comfortable to collaborate to drive improvement because of the fear for litigation risk.

So we in 2005, the Patient Safety Quality Improvement Act was passed that formed the concept of a patient safety organization, which is a certified protected space for patient safety work where that patient safety work product is protected from litigation. The Final Patient Safety Rule that really defined the framework for PSOs and their handling of patient safety work product was final in 2008.

They deal with some key terms like patient safety work product, which is essentially those safety artifacts that are protected under the PSQIA and Final Safety Rule, and then the Patient Safety Evaluation System, which is the system, it could be technology, it could be tools it could be processes that all support the Patient Safety evaluation System and the production of that patient safety work product.

I’ll just add one caveat here. Health Catalyst was listed as a patient safety organization in July 24th of this year. That journey took us the better part of the year. We started in late January, early February of this year, so it’s a significant process to go through. I do want to point out that legally protected means that not only are the safety data protected, but the deliberations on those safety data are protected. Essentially, derivative works are protected. I would recommend though, checking with your house counsel how that applies in your state. I am aware that in Florida the patient safety PSO protection has been challenged and has been overturned, so there’s really a question right now how much a facility in Florida can benefit from the participation, at least from the protection aspect.

Here are just a few PSO facts that I thought I would share. These came from the HRQ website that’s listed there. There are currently 84 listed PSOs in the US. I think it’s interesting that approximately 83 have been delisted. Over the lifespan here, there’ve been 167 PSOs and there are just about as many currently active as have been delisted because they weren’t accomplishing the work or change in business. There are various reasons why organizations would be delisted as a PSO. But once you’re delisted, it’s very difficult to come back from that.

The national PSOs which essentially cover anybody in any state that wants to participate, there are 47 of those. There are 37 that are categorized as regional or state organizations, and those are all direct numbers off of the HRQ website. This next number is just from an analysis that I did because we really see as we look at PSO offerings that are available today, we really see a difference.

One key difference is there’s what I’ve termed umbrella PSOs, which essentially they can offer a full line of services for everything you need from a PSO. Then there are specialty PSOs that focus in a particular area. You can see some examples down there below, and honestly that long list could’ve been a whole lot longer if I’d continued to fill that out. But, specialty PSOs do bring special knowledge and expertise to a particular, perhaps population of patients or a particular knowledge or experience with a safety domain or a safety technology. This is the area where Health Catalyst’s offering fits in. We are a specialty PSO. We are a specialty PSO that focuses on active real time surveillance for all-cause harm.

Sarah Stokes:                Okay, thanks for that a primer so far Michael. Our first poll question, sorry. Let me launch this for you. Our first poll question, we’d like you to tell us about your organizational approach to patient safety organization participation. Your first option is, we partner with a single umbrella PSO. Second option is, we partner with multiple PSOs, both umbrella and specialty. Three, we have formed our own PSO within our healthcare system. Four, we have elected to not participate in a PSO, but may participate in one in the future. And five, I have no idea what’s a PSO anyway.

All right, we’re seeing the votes come in. We appreciate you participating there. As a reminder if you came late, we will be providing access to the slides and recording of this webinar once it has concluded and we do encourage you to ask questions throughout the presentation. We will address those in a Q&A at the end. The votes are still coming in. We’ll leave this open for just one more moment. Okay, let me go ahead and close that and share the results.

We had 7% reported that they partner with a single umbrella PSO, 7% reported they partnered with multiple PSOs, both umbrella and specialty. 18% reported they had formed their own PSO within their healthcare system. 45% reported that they do not participate in a PSO but may in the future, so that’s your majority today. Then 22% reported that they had no idea and were unsure of what a PSO does or is. What do you think about that?

Michael Barton:            Well, I find those results pretty interesting. I honestly would’ve expected a lot more in the partnering with a single PSO or partnering with multiple PSO option. What we’ve found in our communications with health systems that we’ve talked with to date is roughly in that 10% to 20% range are not participating in a PSO, but this honestly is a broader cross section across the market. I personally find that number pretty interesting and it makes me kind of wonder why. Some of the reasons that we’ve heard is the complexity of participating. Some organizations don’t feel that it’s going to add much for them. Those are some of the reasons that we’ve heard, but I do find those results interesting.

CMS did establish some reporting requirements for PSOs in 2017. For hospitals participating or contracting with health plans in the insurance exchanges, you should be participating in a PSO. There basically is … There are two options that were provided by CMS. One option is to participate with a list of PSO and to report safety data into that PSO. If that’s the path you choose, your data is protected from subpoena or legal discovery. On that protection I’ll say that it’s really the safety work product that’s protected, the actual safety event data that may be reflected in the EMR, those data are not protected since they are part of the system of record. That’s just one thing to keep in mind. This really protects what your organization learned from the event and what your organization did to prevent future events.

Then option two is really to implement a system to essentially accomplished the same thing. These are my words, not CMS’s words. They, of course took a paragraph or two to say that. But in that case, you don’t have any additional protection from the Patient Safety and Quality Improvement Act.

We’ve established the PSOs help protect your safety data, but what else do they do? Because, that in and of itself may not really change that much in our patient safety across our country. Patient safety organizations are required by HRQ to complete a collection of patient safety activities. I’ve abridged their list of eight to a list of six here. They’re really responsible for improving patient safety and quality of healthcare delivery, so improvement is one of the key areas that they’re responsible for.

They need to collect and analyze a patient safety work product and look at trends and look for opportunities for improvement. They need to develop and share best practices for patient safety. Encouraging a culture of safety and providing feedback to minimize patient risk. Preserve confidentiality and security, and to utilize qualified staff.

As we looked, there were a couple of areas that we think are necessary for a really successful safety system that we didn’t see addressed in this, or we didn’t see PSOs fully addressing in their offerings. The improvement of patient safety we think is a key. That’s how you know that the water’s getting to the end of the row. If you’re not decreasing your number of harm events, if you’re not decreasing readmissions and mortality, how are you really making an effective intervention?

Culture of safety is essential. You can think of culture of safety as the bundle of everything about how we deliver care. It’s the work processes, it’s the people, it’s the attitudes, it’s the communication, it’s the leadership, it’s sort of everything there. Under leadership, we also think that one of the particular needs for safety is safety governance.

What we’ve seen is, we’ve seen some organizations participating with PSOs and feeling like they’re doing so successfully, but then we also hear from some of those organizations that there are still some barriers for them. Complicated manual systems for reporting data into the PSO where they’re essentially taking data that they’re aware of, formatting it, organizing it and submitting it into the PSO.

That leads us to number two of limited new insights. A lot of organizations feel like as they’re participating with their PSO, that they’re identifying the same harm events that they were already aware of, and maybe the PSO can help generate some insight into those harm advance, but they’re not actually finding other harm events that they weren’t aware of. We think that’s an opportunity for PSOs and something that the surveillance really helps with. This is, I think, universal in healthcare, that struggle for meaningful, sustainable improvement. Every healthcare organization out there we’ve interacted with has participating improvement, and I would say a majority of the organizations that we interact with have some struggles and some frustrations with making it sustainable. Once they take their eyes off an area where they’ve been made meaningful improvement and go on to another area, that previous area tends to just gravitate back to the mean.

That governance aspect of senior leadership and safety leadership being connected to the front line of the organization, and not just vertical in terms of frontline to a senior leadership, but also across the organization horizontally. As organizations make that journey with an acquisition or whatever to moving to more of a health system based approach, a lot of organizations find that they’re struggling to connect across the organizations horizontally, across the care environments horizontally. How do you know that your intensive care unit at hospital A and hospital D are providing a similar level of care, similar care processes, and consistency in that level of care?

The last one that we hear about, and this is a name that we’ve ascribed to it, which is what we call the safety glass ceiling. And the safety glass ceiling is we will interact with organizations that are a little frustrated, quite honestly, because they see best practices, they see other organizations being successful in reducing harm, and they have done it, they’ve tried, and they haven’t really felt like they’ve been successful doing it.

So let’s go to our next poll question here and hear back from the audience what their observations are.

Sarah Stokes:                Great, thanks Michael. Alright everyone, so we’re onto our second poll question here. In this question we’d like to know which safety challenge do you wish your PSO would address? The first option is complicated manual, align many manual processes and reporting. Number two is limited new insights, you need a better understanding of hidden safety vulnerabilities. Number three is struggle for meaningful or sustainable improvement. Number four is senior safety leadership connection to the front line. This includes governance and/or culture challenges. And number five, the safety glass ceiling. How do we make it work here?

And we’ll give you just a minute to get your votes in there. We see them pouring in. We’ve had some great questions coming in so far, we encourage you to keep asking those. And we will get to those in the Q&A session at the end of the presentation.

Alright the votes are still coming in, we’ll leave the poll open for just one more moment.

Okay, I’m going to go ahead and close the poll and share the results. So for the most part we have a pretty even spread, you can see here. 16% reported complicated or manual. 17% reported limited new insights. The majority though said, 41%, was the struggle for meaningful or sustainable improvement. 16% reported senior safety leadership connection to frontline. And 10% reported that safety glass ceiling. What do you think about that?

Michael Barton:            I think this is interesting, and actually kind of aligned with my expectations in this area and what we’ve seen as we’ve interacted with health systems across the country. I think that struggle for meaningful sustainable improvement is present pretty widely, and what we see as we work with organizations is sometimes organizations that feel like they’re doing it successfully actually can really even improve and accelerate that improvement more. So we do think this is one of the key challenges facing safety as a whole.

But it’s encouraging to see sort of a broad spectrum of some of the challenges. I wish we could have kind of a fill in the blank option here to see what other barriers organizations are facing. I think the safety glass ceiling, that is something that is probably more the minority, and I think we have a pretty good representation of that.

Thank you for your insights there. We’re not going to be able to address all of those areas, I mean we could have multiple webinars on improvement, and we do. So we will send out some links that help share some of our thinking in both governance and in the improvement area, and I would encourage you also to look to a culture of safety presentation that we’ll reference later in this presentation, that was made on November 7th here and one of our webinars by safe and reliable.

As we’re moving to catalyze high reliability we really tried to look at a value chain so to speak, that can … a virtuous cycle. And I think you can see, any of you from the quality and safety space can see and what we’ve put here as a similar to a PDCA type process. Little different terminology. You need to detect your harm events. You need to be able to intervene on those harm events to help those individual patients. You need to be able learn from the pattern of those harm events, and then you need to apply those learnings to actually prevent harm in the future in your care process. So, we’ve tried to map what we’re offering in our health catalyst patient safety organization offering, into this kind of a construct.

I’m not going to go into too much detail here on the services that we’re offering, but maybe some of the things that are a little bit unique. Because we’re offering a technology that helps detect all cause harm and promote an active surveillance strategy for safety, we meet with our partner organizations that within our PSO twice a month. We are reviewing, at health catalyst, in the PSO, we are reviewing the safety events in parallel to your team, and we come to the table with some feedback in terms of how they can improve consistency of their documentation, of observations that we’re having in terms of trends or patterns, or new findings that might be of interest. And then we can discuss them with your team and share any best practices that we’re aware of to help with that.

We do offer patient safety governance coaching. This is an area that we participate in with most every client we work in, not only for patient safety but for more broadly improvement. And I think most of us will agree that with the evolving definition of safety, all improvement fits under that umbrella these days. And then we also help with improvement coaching, where we can actually put an improvement expert on the ground, side by side with your improvement team, working, seeing how you’re managing your improvement, and then seeing what we can do from our learnings to augment or accelerate that work. And I think those are some of our unique offerings.

I now pass it off to Elaine St. James, for her to delve into these areas a little bit more. Elaine?

Elaine St. James:           Great. Thank you Michael. Appreciate such a great introduction and PSO foundation. Let’s start by grounding ourselves in why we are interested in this. And we’re going to just take a moment to think about how patient safety and harm prevention might touch each of us. Whether you are a provider, the patient, or a loved one, patient harm affects you. I’ll just give you a moment because I know I could tell several stories, and I’m sure most of us could as well. The reason we’re here today is to look at ways to prevent that harm. So detecting and intervening is crucial in doing that, but it’s been found to be elusive.

In my career, as Sarah said, spanning over 30 years, critical care, clinical risk, quality and patient safety, I’ve certainly handled and dealt with my share of events that reach patients, and those are all despite our best intentions, excellent training, and our efforts to create safe processes to support patient care. And chances are you, like me, have family member stories that you could tell. So I think that establishes the why are we here, and what we’re really excited about is that at Catalyst we decided some months ago, as Michael mentioned, the patient safety monitor launched in July. It was time to leverage our industry-leading analytical technologies, and our widely known improvement capabilities, to create a data driven culture of safety. Next please.

Next slide please. Thank you.

So what do we mean by data driven culture of safety? Simply put we use data analytics to get upstream of harm so it can be detected, activating intervention from that and learning is all culminating in prevention, mitigation, and outcomes improvement. So we believe that our patients and our colleagues need an integrated solution, such as our all cause harm surveillance tool, patient safety monitor, which is hand in glove with our patient safety organization services. Next slide please.

So to enable this upstream intervention, we’ve built a next-generation solution to activate the data driven culture of safety and to fire up those three domains of the three systems that we talked about on the previous slide. So how do we get to that? Let’s start at number one on the bottom, our data operating system, we fondly refer to DOS, is the next generation data warehouse and application development platform. DOS integrates many distinct sources of robust patient data for all cause home surveillance. So in addition to the electronic health record, other sources that you might be familiar with can be brought into the DOS and expressed through the application as well.

So if you go to the middle row, number two, our patient safety monitor suite is the active all cause harm surveillance application, and it leverages all of the capabilities of our DOS platform. And then when we go to the top, number three, the professional services, really that’s that integrated point where the application is built by patient safety experts for patient safety experts, to support user workflow, and that would include clinical reviewers, managers of nursing units or other types of clinical care, and then also medical directors, people responsible for patient safety and quality leaders. Just to name a few. The use cases are pretty much endless. Go ahead and advance please. Thanks.

So, Michael did such a fabulous job at setting the foundation, we’re going to get into the weeds here a little bit in the next few minutes. And what I really want to call out is the synergism between the blending of the patient safety monitor as a technology and an application, and the health tablets patient safety services, and the user experience that’s built into the blending of both of those.

So when we think about the integrated tools we’re looking towards promoting adoption. There are practice changes that are needed related to applying this technology and these methodologies, and so we want to make sure to support that improvement and reach those patient safety outcomes that you’re targeting. So when we think about trigger selection, we want to make sure those align with your high level patient safety goals, and all along that goal cascade at different levels, making sure that those are aligned so that you have data driven insight to achieve your outcomes.

Now just to be specific, we want to make sure that you understand that a surveillance trigger is a leading indicator of potential or actual harm, which is different than some of the adverse event definitions that you might be using. And again that’s just a fine point to make sure that we don’t cause any confusion. Sometimes in organizations, if you don’t currently have a technology of this type, the clinical reviewer role may be new, so it might be a modification to an existing role or someone who does quality measures. And so there is definitely a knowledge transfer and a competence, and that again is part of our services to make sure that we are interacting with your new staff or for your staff who are doing this work frequently, and that we set a really great solid foundation for the ongoing surveillance, making sure that surveillance data is consistent and meets the expectations so that as it’s aggregated it can form the improvement work that we want to build on top of that.

So just to call out the workflow, really in the application without leaving it you can do some level of chart review. We pull in clinical data that supports event review. We can bring forward event analysis and documentation, so the clinical reviewer in the application provides that information, and then communication can be facilitated between reviewers or reviewer and manager, that type of thing. Someone for a secondary review. And then we begin the process of looking at patterns and trends by dynamic charts showing adverse events.

So if you could advance please. Thank you.

So if we fast forward a little bit, and imagine with me that the surveillance team has mastered the process, we continue our side by side work with our surveillance review sessions. So those include having the reviewers share any clinical interventions that were made to prevent or mitigate harm. So back to the creatinine that Michael spoke of earlier, potentially if there’s a trigger that fires around that, an intervention at that point could really spare some long term renal function for someone. So documentation and data analysis, I mentioned that we want to make sure that we have consistency and interrater reliability so that as the data aggregates and starts to feed more advanced analytics, that those are really stable processes on which other processes can be built.

Then we begin to identify opportunities for improvement and connect those to either a standing an improvement team or go back to the leadership team to talk about how that’s going to be prioritized. We’ll talk in a few more minutes about our methodology for how that can be done, and what our recommendations would be.

So if you look on the left at the screenshot, and I know you probably can’t see it so part of this might be to inspire you to get a little more information about what the application has in it, but this highlights the risk prediction. And the reason I wanted to speak to this is it starts to touch the clinical workflow. So risk prediction begins to bring up modifiable risk factors, and that clinical decision support, so that your frontline on the sharp end staff can actually decide what the most important interventions would be, and what the timeline is for getting those done. Also very helpful for oversight for larger units, so that a unit manager would know where to focus their attention.

So we work together with the clinical reviewers and all those involved in this, and additionally into the clinical workflow, to make sure that this amazingly intelligent information is available and used in the daily workflow.

Then when we look at the right lower quadrant, the quarterly patient safety leadership meeting is … our initial steps to make sure that this work is linked with governance and leadership so that it continues to be resourced, understood, used to drive decisions, and really to align, manage, and enable leaders at multiple levels to be able to have insight quickly and easily into what’s going on in the patient safety all cause harm reduction arena. Next slide please.

So in summary, the patient safety monitor intuitive user experience is if we start at the top where it says new trigger, integrates early detection of potential harm, event review, communication, analysis of detected events for patterns and trends, and then again all wrapped in the patient safety organization, both protection and the services. And if you’ll follow me to the bottom of this slide, the chevron starting from left to right, and it’s high level, you don’t have to read the small print. The point being that as we develop the analytics, there’s the data-driven part and the lyrics then feed the review process which then gives opportunities for it to the outcome improvement, we expand the services by adding in collaborative learning, making sure that governance is in place, and intervening if the governance needs some support or consultation. And then eventually all that driving toward improving the safety culture.

So what does all add up to are the building blocks for sustainable improvements in harm reduction and patient safety, and you could probably also link that back to your outcome improvement governance and methodology globally as well. And you’ll see a little bit more about that in a moment. Next slide please.

So this slide is intended to get your thoughts going around what are the either things you’re interested in 19. Do you have really hot areas? Do you have penalties coming down related to harm? Or maybe you’re in the hey we’re going for high reliability. So, what I’d like to have you do is respond to our poll question, and I’m going to have Sarah help us with that, so that we can drive our conversation from what you’re interested in and what you’re thinking about.

Sarah Stokes:                Great, thanks Elaine. So we will launch another poll question here. So I’d like to know which description best captures your organization’s patient safety vision for 2019. Your first option is high reliability organization, quest for zero harm. Two is decrease or avoid penalties for defective care, including HAC, VBC, readmission. Three is the joint commission 2019 national patient safety goal compliance. Four is creating a culture of safety. And five is you’re not quite sure or it’s not a priority. And we’ll give you just a few moments here to cast your votes. There they are, pouring in.

Okay they’re starting to slow down. I’ll give you one more moment. Okay we’re going to go on and close that poll and share the results.

So it looks like 35% reported high reliability organization with the quest for zero harm. 5% reported decrease or avoid penalties for defective care. 7% reported the joint commission 2019 national patient safety goal compliance. 44%, which is the majority in this poll, voted for culture of safety. And 9% were not totally sure and weren’t sure it was a priority. What do you think about that Elaine?

Elaine St. James:           Well I find the responses around high reliability and culture of safety really exciting, and so I think the next few minutes of the presentation might give you some both high-level ideas and then some concrete ideas. And then for those who are doing more regulatory and compliance-related things. We certain have ideas for you as well, so that sounds great, and let’s go ahead and move into the next section. Thank you. Thanks so much for everyone participating in the poll. It’s really helpful.

So as you think about your vision, and now I have a better idea of what you’re thinking about and where you’re heading, so, what would it take to really feel that you have a plan and traction to move forward? In the next segment of our presentation. Michael and I have several things that hopefully you can take away and think about, that could give you some new ideas in what you might do to move forward.

The slide we’re looking at right now is really in this area of your vision and how you might achieve it. I’ve got three suggestions or recommendations for you, that you can think about and see if they apply. They’re all geared around that idea of driving and sustaining outcome improvement, and in this case we’re applying that to patient safety specifically, but they come from our broader structure, within Catalyst around outcome improvement.

This image that we’re looking at is really what we have used and then tailored to clients, and we’ve observed that clients who create this kind of clear structure to drive change really do show in their outcomes that they benefit from the discipline of doing this. So, what this approach does is give you the opportunity to align your priorities and then create a sustainable framework and methodology to continue to drive those changes forward, and to continue to sustain those changes, which as many of us know, is in some ways the tricky part.

Effective outcome improvement governance helps organizations balance accountabilities, involve the right people, and maintain disciplined focus on your goals. Next slide, please. So, the second recommendation, and this is just images from our examples of this, is really to make sure that you have a grounding in an evidence-based improvement methodology. And these handbooks that we have created is that they are a distillation of our cumulative knowledge. I don’t even know how many people years we have involved in this kind of work. That might be an interesting number. But, these are both to share with you the evidence base, and then have how to involved as well. So, they’re both evidence base and how to guides. These three examples are around outcome improvement governance, the framework we have for outcomes improvement, and then data governance. That’s its own topic, for sure.

We would encourage you, whether you use our knowledge resources or some other, that that is a truly very important aspect of this work. Next slide, please. Then, the third recommendation, and this is just a picture of our team, is to engage your experts and other experts to accelerate your progress and hold your gains. This is a great example of just the richness, both of our team, but within healthcare across the board. There are so many excellent resources and experts that have been working on this, and in this journey, for many years. But for us, our core patient safety team starts on the left, and this is going to be really quick. It’s Holly, Michael, myself, and then Stan, and then Kathy Merkley, the fourth from the left, and Stephen Grossbart, he’s a couple more slots over. They are experts in quality and patient safety outcomes improvement.

Then, we want to highlight around governance we have David Grauer available to us, who you may be aware is a former CEO of Intermountain Medical Center. And you can advance, please. So, putting your team together. If we think about the recommendations, it’s really, make sure you tap into as much expertise as you can, make sure you have an evidence base, and then, what is your governance structure? What is that sustainability model for you? And then, as Health Catalyst PSO looks at ’19, we wanted to share with you a couple of things that we’re developing for the next year. These are pretty big undertakings, and I’m sure we’ll be working on it for a while, and look forward to participation from our patient safety monitor clients, and our PSO clients.

The Collaborative, you may be familiar with that concept. It certainly is part of the idea behind a PSO. We find value in that because of the rapid learning, and in this case, it’s around underlying causes of all-cause harm, and risks, but then that proceeds to sharing findings and best practices, and then all resulting in improved patient outcomes. That’ll be launching in ’19, and we look forward to really robust conversations and learning opportunities. Next slide, please.

Then, Michael, just some foreshadowing on this, which is great, we will also be focusing on culture of safety in ’19. I just want to tie this back to one of the first comments and slides that Michael had. To truly improve patient safety, we must cultivate a culture of safety and become high-reliability organizations. Your poll answers tell us that many of you are on that journey. This particular slide is from the work of two people that I and we admire greatly in this space, Doctors Allan Frankel and Michael Leonard of Safe & Reliable Healthcare.

While this model may appear simple, the framework behind it is really important. Again, speaking of practical tools and insights, if you haven’t had a chance to take advantage of the webinars that they did, I think you might get some ideas out of it. So, I think we’re up to four or five ideas of what you could do as a result of this conversation today. Michael, did you want to talk just a little bit about the model and the tipping point?

Michael Barton:            Yes. So, I think you can look at this as, on the left at the bottom in the red, unmindful. We’re chronically complacent, we’re not really engaged in safety at all. That’s one extreme. And the other extreme, on the upper right, is the generative. The generative is really what we think about when we think of high-reliability organization. That’s where safety is how we do business. It’s always what we do.

I want to call out an important piece to think about, and that’s the tipping point. The tipping point, from Safe & Reliable’s experience, is psychological safety. I’m actually going to use one of our questions that came in as an example of psychological safety. Somebody asked about staff competence. You know, “If it’s not a culture problem, it’s a staff competence problem, how would we approach that?”

I’m going to use the example of psychological safety. If I’m caring for patients, and I don’t have confidence in my team member that’s working with me because they are not competent, I do not feel psychologically safe. And when I don’t feel psychologically safe, we’re never going to be able to get to that proactive or generative state of patient safety. I really think of culture of safety being virtually everything involved in how we care for patients, and staff competence being one of those. That needs to be addressed, because if your organization, if you’re having challenges with staff competence either in pockets or in units or however that’s distributed, you need to face that head-on, and address that, because the psychological safety and the whole culture of safety in that unit is going to suffer until you do. So, that’s my example to think about.

Elaine St. James:           Wow. Thank you. Wow, I … And thank you to whoever submitted the question.

Michael Barton:            Right.

Elaine St. James:           Great answer and perfect timing. Why don’t we go to the next slide? Yeah, it’s hard for me to leave that one. Before we close, and I’m going to make this very brief because I want to get into the Q and A, we’re going to link back to the early part on the left side of this slide. You know, we talked about challenges and pain points. And on the right, just a quick run-down, but these could be criteria that you could use for considering how you’re going to put together your patient safety solution. Back to that vision. So, high reliability safety culture.

Seamless data flow. So, how do you make sure the data is where you need it when you want it without a lot of work? Active surveillance, so how do you get line of sight into those potential harms? Broader definition than adverse event, doesn’t rely on voluntary reporting. You do need expertise and side-by-side partnership. So, thinking about how you want to build up your team and provide support for internal folks and also, potentially, access external consultants or experts. And then, governance. How do you create that structure to drive change? And access to peers. So, that goes to the idea of the Collaborative, and having a form to explore and learn together. With that, we’ll hand it back, and hopefully we’ll have a couple minutes for Q and A, and many thanks to all.

Michael Barton:            One more slide.

Elaine St. James:           Oh, I’m so sorry.

Michael Barton:            Just the next steps for you to consider in taking action. Giving some thought to where your organization fits on that maturity model. Maybe talking to some colleagues and get them to rate it. And keep in mind, as you do that, that you have to look at a unit level, because safety is really unit-based. If your organization has administered a Safety Attitudes Questionnaire, or the SOPS questionnaire before assessing culture safety in your organization, what are the results, and what are being done about those results? That’s a gap that we find in some organizations where they’re measuring it, but they’re not quite sure what to do with it after that. And I think that’s an area to dig into.

Then, just on the improvement and the sustainability, I think talking to front line colleagues and asking them to identify the organizational safety goals, what their unit is doing to accomplish them, and how those goals are connected to their daily work. Now we’ll go to the poll question.

Sarah Stokes:                Perfect. Thank you, everyone, for joining us today. Before we hop into the Q and A, we’re just going to launch this last poll question. Well, today’s topic was focused on patient safety organizations and the value that they can have to help care providers. Some of you may want to learn more about Health Catalyst and how we might partner with you in your journey to improve patient safety. If you’d like someone from Health Catalyst to follow up with you, please answer this poll question. We will actually just leave that open as we dive into our questions.

The first question that we had was, back to what you were talking about in the beginning, Michael, about the PSOs and delisting, how there were so many that were delisted. John wanted to know, “Is the delisting voluntary or done by an outside organization like AHRQ? He wanted to know more about that?

Michael Barton:            It actually could be either, John. That’s a good question. So, if we’re not able to meet the requirements or we determine that it was not a priority for our business to continue to be a PSO, we could voluntarily delist ourselves with AHRQ. But if AHRQ, doing their audits and ongoing follow-up on your PSO services, detects that there’s a problem, you could be involuntarily delisted. That would be after receiving feedback and not correcting, and taking appropriate corrective actions. So it could be either.

Sarah Stokes:                Okay. Great. Our next question comes from William, who asks, “What is the evidence that PSOs are actually effective?”

Michael Barton:            I think that is a very interesting question, William. I think when you look at what PSOs are doing, many focus on the protection of the data, and some of them bring great insights in terms of best practices. But we really do think there’s a gap that prevents them from being effective, and some of those gaps relate around the improvement experience, and knowing how to bring change into an organization, and the areas of governance and culture safety.

Sarah Stokes:                All right. Elaine, sorry, feel free to join in at any time. We have Michael in the office, so it’s easier for him to speak first.

Elaine St. James:           Yeah. Sure. You know, the only addition I was going to make to that, I think, in the children’s acute care arena, you could probably find, and I don’t have it to hand, but that’s an excellent question, and I think one that Health Catalyst needs to think about moving forward. How to be transparent with whether we’re being effective, but a look at some of the children’s work at SPS might be helpful, and we could always send a link to that.

Sarah Stokes:                Excellent. Thanks, Elaine. I just want to let our audience know, we do have a good amount of great questions here. We are probably going to run a little bit over the top of the hour, but we’ll keep moving along here. We have another question from John. He said, “Is there a well-established safety ontology that one can use to structure one’s RCA data?”

Michael Barton:            That is a good question. There have been some work in that area, but to my knowledge, there’s no one methodology that rules them all at this point. No preferred option. But I’d be really interested if anybody participating in the call has other insights there.

Sarah Stokes:                Okay. Our next question is from David, who says, “Misdiagnosis. How does that fit in a PSO?”

Michael Barton:            Misdiagnosis is definitely a safety event. Being able to identify those events when they happen, and then being able to manage those, either through clinical care process models or protocols or order sets is one way to potentially, some of the interventions that can be used to manage those. But I would definitely agree that that is a patient safety event that your PSO should be able to partner with you on.

Sarah Stokes:                Okay. This one’s more of a comment. Maybe you can comment on it, Michael or Elaine, from John who says, “We would like to pull our RCA data into our data warehouse. Our quality department is resistant because they are of the opinion that doing so risks the protected nature of the data. I am of the opinion that such a restriction goes against the whole purpose of entering these data in the first place.” You have any thoughts on that?

Michael Barton:            I think that’s a great perspective, John, and I understand your concern, but I also understand their concern in terms of risking the data. It is required, to enjoy that protection of PSO data, to have it logically or physically separated, but there are ways to do that where somebody working within the PSO could look at other data in the data warehouse and pull that data into an analysis. There’s no preventing pulling in your EDW data into that analysis. That protection could possibly be done with active directory, or some other methodology where it’s actually, physically located in your EDW, but only patient safety workers within the PSO can access it. And in those cases, in that approach, I think you could mitigate that risk that your PSO program is concerned about.

Elaine St. James:           With that, there’s also the overlap with your state laws and things like that. I think the summary is, and see if you agree with this, Michael, that it’s doable but you definitely want to understand the constraints around it, and how to continue to protect that data.

Sarah Stokes:                Okay. We have another question. Regarding the triggers, it says, “Does the trigger have to be a manual trigger or report? Is there any automation or AI that will cause a trigger?”

Michael Barton:            The triggers are definitely automated. So, that is running off of the data in your warehouse, and it is evaluating the logic of the trigger against those data, and it is firing those triggers for you to evaluate. They’re also, as Elaine talked about, there is a predictive methodology as well, because as you review those triggers and document actual harm, that data can be used to drive a machine learning model that can help you predict harm in the future.

Sarah Stokes:                All right. Now we have a question from David who says, about the zero harm goal, he says, “Given that that is impossible, just what should the target be? Every system and person has an intrinsic number needed to harm.”

Elaine St. James:           What I would suggest about that is behind the zero harm, absolutely aspirational, then the idea is that within your own organization, you continue to ask yourself, “Have we established that high-reliability organization, constantly vigilant, never finished,” let’s just say, and then you balance that with looking externally at benchmarks. But sometimes if we get too focused on external benchmarks, we can still have festering problems that are harming patients, and we try to tell ourselves maybe that, well, we’re better than the rest of our peers, so we can be okay with the fact that maybe there’s still preventable harm that we could address. Would you add anything to that, Michael?

Michael Barton:            No. I think you got it.

Sarah Stokes:                Okay. We have one final question that we’re going to ask, here, from Danelle, who says, “On one slide review by a single physician was labeled as an RCA. How is a one-person review able to be considered an RCA?”

Michael Barton:            I think that’s a great point, Danielle, in terms of the challenge of putting all of the detail necessary on a slide, because you’re absolutely right, a single person looking at a situation would not constitute an RCA, but that initial clinical review is part of the process that feeds into your RCA process. As a reminder, an RCA is a root cause analysis, just for folks that are thrown off-guard a little bit with that terminology.

Sarah Stokes:                Perfect. Well, thank you to everyone for joining us today, and to you, Michael and Elaine, for presenting for us. It was a wonderful presentation.