in Uh, for those of you who don't know me, uh, my name is Sean Rangel, and I'm one of the general surgeons here at Children's and also the senior surgical advisor, uh, for quality and safety. And so on behalf of all of our presenters today, uh, I want to thank you for, for joining, although we know probably Crico has a little bit to do with why you're all here this morning. Um, and so in that regard, uh, I do want to quickly touch over today's goals and agenda, and of course the, the overarching goal is to, for all of us to satisfy our cricodidactic requirements for a premium reduction. And so there's the didactic part, there's the part, but everyone needs the didactic part and so the, your participation today, uh, checks that off and at the end there will be a QR code, um, and we'll talk a little bit more about, um, the logistics of, of, of, uh, dealing with that, particularly for your faculty who may not be here this morning. Now that's the overarching goal, but what we do hope to do today. Is, uh, leave you with a couple of pieces of important information as kind of subgoals. And the first is to promote awareness of our recurrent perioperative safety threats at BCH. And so these are pretty substantial, and awareness is just part of, uh, any, um, you know, initiative to try to prevent them. If you know about them, then you might be more vigilant, and that might also, um, you know, really kind of get people to think more and talk more in the OR and if we can reduce, And mitigate errors in that regard, then we're doing part of our job now. In addition to that, we're also going to talk about our checklist and some proposed strategies and how we can make this better to address some of these pervasive safety threats that we do see that are very contemporary and recurrent. And in that regard, there are really three things we wanted to cover. First is to cover some proposed changes in the checklist to address these specifically, these safety threats, and also, um, some ideas on how we can make them, the checklist better. You know, one of these has to do with how do we make it, uh, uh, more effective in terms of implementing human factors and performance improvement principles in that regard. And the other is how, We make it better in terms of active and effective auditing, which has always been a bit of a challenge for us. And so I'm going to talk a little bit about the proposed changes and what the checklist may look like over the next year. And then luckily we have some experts in the latter regard as well. We have Marrette Dubey and Matt Taylor who have been talking about the human factors and performance improvement implications for designing or redesigning our checklist. And then Megan Nolan is going to talk about some really exciting AI based software that is really designed to record in the OR but also use AI technology, uh, for team dynamics assessment, which not only can improve the way we use the checklist, but also things like improve efficiency. and throughput on things that might affect the bottom line as well. So, some really exciting stuff that might be coming down the pike. And then we're going to finish by Julia Finkelstein is going to talk about the implications and relevance of these changes to the overall high reliability mission of the organization, and then we'll have some time for Q&A. And so just quickly, uh, none of the speakers have disclosures. As I mentioned before, um, this will be, this will be able to satisfy our CRICA requirements. At the end of the talk, we'll put this QR code back up and tell you a little bit more about what you need to do with it. Um, and again, for your faculty who aren't here today, uh, let them know that this will be recorded, but they have to, uh, scan this QR code and take the survey within 7 days in order to get that credit. So kind of jumping right into the checklist, it's probably best to go down memory lane a little bit, and this is the first checklist we implemented here about 14 years ago, and there was nothing really too fancy about it. We took the WHO checklist. We put together a committee, and which included the leadership of Beth Kingsbury as well as Bill Sparks. We implemented some pediatric focused elements. We tried to make it more kid focused, and then we just turned it loose. And over a period of time, you know, like most places, it was challenging to get buy-in. There was some resistance. People rolled their eyes, you know, we already do this stuff. I don't need this to tell me how to run my cases. But the good news is after 2 or 3 years we did make inroads and in Beth Kingsbury at that time, Beth Norton did some great work. I really kind of digging in with the survey and demonstrated that we actually changed the culture. People did believe, and this was with anesthesia surgery and nursing, that it was making a difference. It was making surgery safer. It was breaking down the hierarchy and communication silos, and so we were pretty happy that at least it was something that was adopted and valued. What we didn't have, however, at that time is really good data regarding perioperative safety events, and we really didn't have that data until later on in 2018 and 2019 when we had to collect this data in a standardized fashion for our verification requirements. And what we were surprised to find is that despite using the checklist pretty well, we had many recurrent safety events including equipment-related issues, tons of medication related issues. We had specimen related issues where patients actually had to go back and get rebiopsied. Because of issues with communication between the primary team and the surgical team with in terms of what specimens needed to be collected and how they were processed. And then we had a lot of events with, um, with botched or delayed MTB activation simply because we didn't have guidance readily available. And so what the, the other thing that we, that we found, which was probably even more concerning is that we had a high concentration of never events in which increased over time, particularly as we started tracking these things more closely, and these events were largely concentrated on placing the wrong device, or expired devices. We had GJs and G tubes, which were, we had errors in placement of those with CVLs and ports. Uh, but again, a lot of wrong implants in, in, um, uh, expired implants, and who would have thought that implants were like milk, right? They do expire, but we didn't really have a standardized way, uh, to check that. And so at that time, Jim Casser was the surgeon in chief, and this was really our first kind of PIPS endeavor when we became verified is to try to go back and try to fix this. And so, We put together the old band, the folks who put together the initial checklist again with leadership under Beth Kingsbury and Bill Sparks, and we sat down and looked at the checklist and really came to the conclusion that it was missing a lot of really important prescriptive elements that were specifically geared for the events that I just showed you, and those are listed on the screen here. There was a lot of issues with again not being prescriptive enough, but probably just as importantly, there was really nothing in the checklist that really drove toward a shared awareness of when and how certain procedures were at high risk. The team really collectively just didn't have a good appreciation for that. And so then we went back to the drawing board. We spent about 3 months again with this checklist revision group and used those factors I just mentioned as kind of a template to restructure the checklist and address issues where it wasn't prescriptive enough, and this had to do with more specific specimen discussion. Uh, MTP activation, discussion of high risk procedures and situations, and of course in factors to check things like, uh, whether or not implants were expired and making sure that there was adequate communication when specimens were going to be obtained early on, what needs to happen to them. And so we're pretty pleased over the next 3 years to see that those never events I mentioned before dramatically decreased, and so the number of expired implants or overall wrong devices dropped tremendously. And when we also looked at some of those other safety events, those also dropped considerably as well. Um, medication related errors, you'll notice here that there wasn't a change, and that's specifically because we didn't address those through the checklist. At that time, and probably erroneously so, um, we decided that probably these would best be addressed by SBs and re-education, making sure folks were individually, uh, following protocol, but what we really didn't understand at that time was the complexity and how these medication errors were actually happening. So, we made all these changes, and so is the OR now a safer place? Well, yes and no. Um, what we found out in many situations is that it's a bit like whack a mole, you fix one thing and other things pop up. And the interesting thing here is this is an AI generated image, and so I got on chat GPT and put in a lot of the, um, basically the elements that we're dealing with at BCH with our checklist, and it popped this up as the representative image, which I thought was pretty clever. Um, no matter how clever AI is though, you can see that it still fails a 3rd grade spelling test on a number of different occasions, and so I guess, you know, AI is literally, but there is a lot of promise to it. So where are we now? So these are the most recent. This is kind of the most recent portfolio of recurrent safety events that we deal with uh in our OR, and you can see this is between 2023 and 2024, and the errors listed on the screen are those that are pervasive and recurrent. They happen over and over and over again, and they impact most of our services. Uh, medication errors are by far the most common, and a few of these do deserve special mention. Uh, we've had multiple patients with chlorhexidine allergies get chlorhexidine skin preps, and luckily, these have all not been true allergies, because in cases where there are true allergies, uh, there can be really severe chemical burns, and, um, and so this is something that somehow continues to somehow, uh, get through our allergy, um, uh, assessment during the sign in and during the timeout. Uh, clindamycin, so second line prophylaxis given to patients with penicillin allergies, is also a recurrent theme. And again, this is really important because if you give these second line agents, ironically, it does increase your risk of an SSI and it does ironically, increase your risk of an adverse reaction. Errors in dosing of a local anesthesia are by far our most common event in the OR, and this happens sometimes 4 or 5 times per month, and it's invariably an issue with communication failure between the surgeon, between the circulator, and sometimes between the anesthesiologist in terms of a common shared understanding about how much local can be given, how much actually was drawn up. How much was passed off in that syringe to the field and how much was actually given. And this has affected every single, every single service and just about every procedure we do. Handoffs and ownership are also, um, a pretty substantial issue over the last couple of years, particularly as we've dealt with more complex patients. And these are kids typically where the primary service is not the same as the operating service. Common situation is the triple scope, and, uh, these have been issues where there have been a, either a misunderstanding. Our lack of consensus about who's gonna take ownership for the sign out, who's gonna take ownership in terms of the pack you sign out to the sign out back to the primary team, and who's gonna write the orders. And so, these have resulted in multiple times, uh, delays in PACU care. Delays in ward care, but just as importantly, not only are there issues with patient care, but there are also issues with throughput inefficiency, because remember these things back up when they back up or turnover slows down, and of course that impacts efficiency in the bottom line as well. So specimen handling errors are another thing we continue to, continues to challenge us. Before it was an issue with communication with the primary team and the surgical team with exactly what specimens need to be obtained. Now the issues are really what happens to the specimens after they've been obtained at the correct specimens, but due to handling or or miscommunication at the end of the case, they don't get to where they need to be or they're not prepped in the correct manner. So with this kind of set of new issues, we have again restructured a checklist revision team to take this back and think about further changes with the checklist that made it may address these issues. These have to do with, again, making things a bit more prescriptive, and also thinking about how we can standardize things in a better fashion, such as a formal formalized medication pause, a specific discussion either in the time on our sign up with ownership and disposition in the handoff plan, and of course, more specific specimen reconciliation as well. Now, again, these are just issues and considerations that are being proposed. There are a lot of important considerations we have to think about with any changes that we make. We definitely do not want to make the checklist longer, right? We want to make it better, we want to make it more efficient, but we also want to make sure that it stays relevant in the majority of cases that uh it is really meant to help. Um, the changes must be relevant to different situations and environments, particularly with the satellites. And when we think about these checklist strategies, in addition to making them, you know, the change in the content, we also need to think about things about how to make it work well in terms of, again, compliance and optimizing those team dynamics to make sure that it's designed in such a way where It is easy to use. And then finally, and this is something that comes up over and over again and is a very important consideration, is that it's not going to be the one size fits all right. The checklist isn't going to address everything, and we have to think about other ways that we can optimize preoperative safety practices before they even reach the OR, things like pre-op holding checklists, huddles, the things that we already are starting to think about. And so this is my last slide, and it kind of summarizes these different team-based approaches and how we're going to come together and try to develop a set of recommendations by the spring of 2025. This is also my segue. To introducing the next set of speakers again, we mentioned before that we have developed a surgery checklist revision team. You can see by the team members it is multidisciplinary. It involves perspectives from all sorts of different aspects of care in addition to the satellites. In addition to that, we have two other teams. We have our immersive design systems team, which is really going to help us think through the human factors and performance principles that are going to be important in this endeavor. And then, of course, the live analytics team who are gonna really uh talk to us about the really exciting AI technology that can help us really uh impact and improve team dynamics in the OR. And so with that, I am gonna stop sharing my screen and then turn it over to uh Marrette and Matt to tell us a little bit more about uh how human factors, uh, factors into all of these efforts. OK. Um, good morning and uh thanks Sean, for providing the context, uh, for us today. Um, the majority of you are familiar with the CRICA OR safety program, um, that provides, uh, premium reductions for staff and, um, high-risk OR specialties. Um, every year about 120 surgeons and anesthesiologists complete one of three activities that are aimed at meeting the following, uh, CRICO objectives, right? Ah Um, the specific focus of these sessions has been at the discretion of each specialty, uh, specialty, but this year, PPSQ is using CRICO, um, to align all specialties to address the most pressing safety issues across the perioperative area, which is, uh, medication errors. Um, traditionally, our approach to meeting this requirement has focused on training staff and crisis resource management principles, um, but these activities only address one element within a complex system, uh, and therefore, in order to make systemic changes, CRICO is now supporting our efforts, um, to reach our patient safety goals by including human factors and system design as, uh, qualifying initiatives, uh, Moreto. Um, the scientific approach to addressing systemic and process challenges will, um, in the future identify gaps in safety that moving forward will allow for targeted, uh, interventions utilizing our training and performance team and our VR device design service lines. So. Um, so, um, here's a quick, um, summary of each service line at Immersive Design Systems before I turn it over to Marrette. Um, she recently joined Immersive Design Systems as a director of Human Factors and System, uh, Design. So I've worked with many of you in developing individual and team activities, uh, using, um, simulation under our uh training and performance umbrella, um, which has been augmented by our device and PR solutions team that developed custom trainers and devices. And then thirdly, we have our HFSD service line that uh practively tests systems and processes using simulation and human factors methodology and I'm gonna turn it over to Marret now who's gonna speak a little bit more about that. Thank you. Thank you, Matt. Good morning, everybody. It is wonderful to be here representing the human factors and systems design team. So people often ask us what is human factors, especially human factors in healthcare, and it really is a science and application of how we as healthcare providers and our patients and families interact with this constantly changing dynamic healthcare system that we work in. So how we interact with our technology, our tasks, the physical environment that surrounds us, and our organizations, so things like our policies and and our culture. This informs our processes and our outcomes as, as it relates to safety, efficiency, and quality. And so we spend a lot of time doing systems thinking and taking that approach and, and we want to apply a lot of our methods to be able to test the system and by doing that we really do uncover all sorts of hidden safety threats within the system so that we can identify them early and mitigate them proactively. So then there's a really wonderful synergy between human factors, applications and system-based simulation. This may be different than some of the stimulations you've probably been in before where you might be discussing medical management or building, you know, honing your skills, but rather this is simulation. We really use it to recreate the Healthcare system and then get feedback on it from the participants around the system and process that surrounds them really and how we can design that better to make their jobs easier and most importantly again identifying those hidden safety threats that we don't even realize are there so that we can improve the system that way. So there's many broad applications to our work in healthcare, and so I just picked a couple to highlight. One is workspace design. This is a very expensive hybrid operating room from many years ago that I worked on, and we can mock this up very early in the design phase and then do simulations to look at workflow utilization of the room, so where people are actually moving about the room and looking at the bumps within the sterile aerials as well, so we can make much better sort of design and build decisions early by by doing this work as early as possible. Another is eSafety. We worked with many of you during EPIC in testing out Epic prior to Go Live, and we literally, you know, found hundreds of opportunities there to better align Epic with your workflows. But most importantly, what many of you might not know is there are many critical safety threats we found prior to GoLive, such as the consent forms not populating the way they should, and many even med dosing errors as well that we were able to catch early. So there's much evidence, of course, on HROs and safety and checklists. I won't speak to. I know others are going to be talking to that later. But importantly, the checklists can give us this opportunity obviously to create time and space for people to speak up if they feel like something isn't right. And in my experience, debriefing teams over the past many decades, we hear this a lot, that it can be really challenging, of course, for folks to speak up, especially in hierarchical situations. And this checklist can really help us with that if it's used well. And of course if it's designed and implemented and adopted well, it has, you know, huge potential to improve safety, as I know many of you know. But we also know that this checklist isn't a standalone thing, and in Human Factors we really call this a people-focused tool, meaning it still really relies on us to figure out sort of how and when and where we're going to use it. And if we truly want to make meaningful system change, we need to understand all the complex factors that surround the use of the checklist in our environment here at BCH. So I'm just gonna stop sharing while Crystal pulls up a video for us and I'm going to introduce Jeff Durney, who was kind enough to record this for us. Jeff is the director of quality and safety in the department of pediatrics at BCH. Uh, he's been a pilot for 10 years, and a flight instructor for 25, and he has deep experience as a surgical safety checklist coach working in facilities across the country. So if you can go ahead and play that, thanks, Crystal. Thank you, Marrette. Uh, the airline industry's connection to healthcare is well known, uh, when it comes to checklists. Uh, people often ask me, you know, how, how aviation became the go to model for high reliability and how healthcare can follow suit. And the truth is, Commercial aviation's success didn't, didn't happen by chance, and it wasn't just because airplanes became more advanced and reliable. In the 70s and 80s, many fatal accidents resulted from chains of human errors and not because of technical problems with the airplanes. Uh, themselves, but by embracing human factors and crew training, the industry really turned things around, uh, leading to an unprecedented error of safety. It's been more than 15 years now since we've had a fatal plane crash in the United States, which is really remarkable. Uh, in 2014, I worked with surgeons Atul Gawande, Bill Berry, and Alex Haines at Ariadne Labs. where the power of checklists to make healthcare safer was really embraced, and their work that was published in the New England Journal of Medicine in 2009 showed a nearly 50% reduction in surgical mortality when checklists were used correctly. However, poor checklist implementation can lead to accidents, as we've seen in other high risk industries. Checklists, when used to foster teamwork, communication, and situational awareness can profoundly impact safety. And from my own experience working with surgical facilities, the most successful transformations happen when checklists are seen not as box checking exercises, but as tools to unite teams. And one pivotal experience was with a facility that experienced a wrong site surgery just as I was beginning my engagement with them. The nurse director there called me to share the story of the investigation, and fighting back tears, she recounted how a surgical tech shared that he had suspected an error was about to happen. But he didn't speak up or intervene in any way. And when asked why he didn't speak up, he shared some thoughts that we hear time and time again when someone holds back information that could be critical to safety. He said, I'm just a surgical tech. What do I know? This is a, this was a senior surgeon performing this procedure, so he must know what he's doing. I was worried, you know, if I opened my mouth, I would be shot down, ridiculed, embarrassed, or worse. I second guessed myself into silence. So this tragic event spurred the facility really to to to fully embrace meaningful checklist use, fostering a culture where everyone was encouraged to speak up. And as a result, they experienced improved team communication and overall safer practices in their operating rooms. Their culture really began to change, much like the changes that we witnessed in the airline industry when they experienced their safety renaissance 30 to 40 years ago. Now, it's impossible to know with any degree of certainty, you know, what might have been prevented in this facility or others, uh, through robust implementation efforts like these. But as my mentor, Doctor Bill Berry once said, uh, you know, we shouldn't let the lack of perfect data stop us from doing what we know is right. So, thank you for allowing me to share some of these insights and I'm always happy to, uh, to discuss my experiences further. Thank you. Thank you, Marrette. Uh, the airline industry's connection to healthcare was OK. So thanks, Crystal, and thanks again, Jeff, for, uh, for recording that for us and sharing your messages. So where do we begin from here? Uh, Sean and Crystal had sent out a survey, and I think about 30 folks or so have filled that out so far. Uh, and I just pulled out a couple of the responses, um, from a human factors perspective that I thought I'd pull out. One was around multitasking and distractions, and we think of this like sort of texting and driving. The more that we try to do at the same time, the higher chance it is that we're going to miss something. Another one is having the right people in the room, and I'll have everyone just really take a systems thinking approach to this and get curious around how we've designed our system and the way that we use the checklist currently. And then policy interpretations, definitely something we hear quite a bit is that often when we're writing these policies and things in healthcare, they're not always interpreted in the way that that are intended. So now we'd like to hear from all of you to continue to build this sort of current state and understanding of, of our um roles here at, at, at BCH. So if I could have you enter into the chat. Something you or your team have seen, heard, or feel are current barriers to the effective and routine use of the surgical safety checklist. We would love to hear from you. We're going to save this, uh, chat entry so we can start theming some of the feedback we're getting from folks. So please take a minute to reflect and, and go ahead and do that. I'm going to keep chatting just to stay on time, but, uh, but we hope that everyone will, will take the time to enter that in. I'll also mention um to take a systems approach as well um while you're doing this uh and just thinking about, thinking about those barriers. You're not alone in the fact that there's lots of published evidence out there around challenges in other centers from implementation to organizational or cultural factors, uh, when, uh, when implementing their, their checklist as well. So as this quote says, we really want to seek to understand how to ground this checklist in present day, your present day operational environment, and of course simulation is an incredible tool of many, but it really is an incredible tool to help us do that, especially when used with real teams in the real environment. So here's a couple of ways in which human factors and systems design can be involved. One is around usability. This is of the checklist of itself, and it's really do a deep dive into the content, the layout, the usability of the checklist, what should stay, what should go, all that kind of thing. Then we can also do some systems testing right in your real environment with simulation again to help inform and look at some of those other system factors that we are talking about. And then finally it's really looking at our safety data ongoing and saying, you know, are we actually making a difference after going through this? Are we getting better? And if not, do we need to do further rounds of testing or PDSA cycles to continue our improvement efforts. So just to wrap up, Human factors really does recognize that to err is human, and no matter how great any of us are at our skills, that we still will make mistakes. And so this checklist is really meant to be that structured teamwork and communication tool that helps create the space for folks to speak up and trigger important safety issues or steps. That can be missed. We hope one day we'll get to this goal of 100% compliance where everyone is engaged and we have a pause when we're using it. And more than anything, just on behalf of the human factors and Systems design team, we are here certainly to, uh, to do this with you and to help you. So thanks very much for having us, and I will hand off to the next speaker. Thanks so much. Great, thank you, Marre. So, our next speaker is gonna be Megan Nolan, and again to remind folks, she's gonna talk to us about some really cool and exciting technology in the OR which has implications again, not only for better understanding how we work together for safety and checklist uh fidelity, but also what we can do to become more efficient. So. Uh, thank you all. I'm really excited to be part of this team and working on this project. We're now gonna transition from thinking about our processes to evaluating our processes on the back end and, and with a tool of live analytics. So we're really working from that work as simulated to the work as done. We talked a little bit already about live analytics and aviation, but it's everywhere. It's in law enforcement, it's in sports, healthcare, we have patient monitors, we have digital twinning like they do in the, in the cardiac, um, space. So, live analytics is in use in our daily lives. Here's it, we're putting together our team, but here's kind of a brief overview of our, our team. Um, myself, Peter, Sean, Crystal, uh, Chris Viney, and, um, Peter Lawson's our executive sponsor. So, I know, um, the idea of live analytics can make people a little bit anxious, and we really want this tool to be a partner and be supportive to the great work that we're already doing. So, here are our north of the live analytics, um, and our core principles. So, the goal is for The technology to be supportive, enabling, empowering, focusing on what's important, a co-pilot and partner. So, it's a value add for our organization. And we want to do that with integrity, relevance, security, and most importantly, psychological safety, as we've already discussed. So, it's for the advancement of our profession, and that's interdisciplinary professions and our system excellence at BCH. This project is a continuation of Peter Waters' work from orthopedics where they were doing an audio audio visual recording to improve safety for for operating room patients in orthopedic surgery. They focused on team dynamics in the orthopedic space, and the partners with IDS simulation, orthopedics, anesthesia, and nursing. So part of this project um is a tool called OR Black Box, and that is part of this group called Surgical Safety Network. See, these are some of the, um, key stakeholders that already have um this tool in, in their hospital. So you'll see on their sick kids, um, UT Southwest is a big user, uh, Brigham and Women's at the Faulkner location, and, um, we also have this tool installed in the simulation space. Here are the advisors that we have discussed this project with. So we have surgical chiefs from across the country and down the street. We're also working with Luke Sato and Crio, and Patricia Trovich um is also working heavily on this project with us, um, for, to, for some bespoke analytics, um, on the back end so we can evaluate our work. The tool itself um is called OR Black Box. It's by Surgical Safety Technologies. The tool is um AI generated. It has video recording within the operating room, so that's cameras and audio recording. There's a full analysis piece, so it's 95% analysis in the background with AI and then the last 5% is human analysis. Um, it can collect things like flags and outliers, um, adverse event detection, and OR case optimization. The output, um, is de-identified videos, audio clips, um, and checklist compliance. So here's a little bit more deep dive into the OR Black Box platform. So as we already discussed, it can evaluate um the outcomes of our surgical safety checklist and our compliance to ensure that we're doing it appropriately, but also give us insights as to where we're, um, could have some opportunities. The, uh, the platform also has some other pieces that are really helpful for our organization. Room State is an AI optimization piece, case discovery is, uh, surgical videos, and explore is, um, surgical training playbacks that can be used for teaching in the future. A little bit more about surgical safety checklists as we've talked about today. Um, we've addressed that there's opportunities for improvement in our surgical safety checklist. Um, and so, we're, we're having a little, um, a sense of compliance, but because we're not auditing in all the rooms all of the time, I think you guys have in the chat with some inconsistency in the checklist. And lack of engagement. And then the other piece is analysis of the checklist, um, the components. So, are we doing all of the components all of the time? And I think, um, many of us would say that we don't always consistently do the debrief, for example. Um, so, this tool will capture it and assess it with AI and then, like I said, that last human factors piece of 5%, um, review of the data. Room state is another great tool that I think, um, as we're looking into the chat about time pressure and turnover time will be really helpful for us. And so this um can streamline operations, um, and providing real-time insights to what's happening at a high level. I think you, you often the charge nurse has to walk to the room to see where they are in the turnover and if there's a delay, and this will be, uh, more of an air traffic controller, um, kind of eyes in the sky to really give us some insights as to how we can improve. There's a lot of opportunity there. Case discovery, this piece um could help us um if there's an adverse event or something um that went really well in the operating room. Um, staff in the room can flag it. There's also flags within the system. Um, as we're setting up our metrics, we can have things automatically flagged, like, if the patient's temperature went too low or if the patient desatted, for example. So that'll kind of, the AI will automatically flag things that we're, um, agreed to look for. And then we can review the case to see what happened. Explore, this is a really, a lot of the training piece. Um, this is a a picture of our simulate um simulation in our simulation center. It provides quick access to surgical videos. Um, if you're training a video on laparoscopy, or robot, for example, you can save those videos and use them for training in the future. Um, there's a lot of Literature out there that the OR black box has improved performance. Um, this article, it says that it improved performance and team engagement. Um, this article said that the surgical safety checklist, um, had higher, um, compliance and engagement. So, really tailored exactly to what we're working on now. Um, and then AI monitors more precisely evaluate the, the measures that we're trying to evaluate than a human person. Um, so I think that's, it takes the bias out of it for us, which I think is gonna also be very helpful. So we're gonna talk a little bit of our use cases, which we already did, the surgical safety checklist. So as we revise the surgical safety checklist, with our tool, we can set up the metrics so that the AI is evaluating our metrics um as we want to see them and, and give us feedback on an ongoing basis. And then operational efficiency, I've mentioned this a little bit, um, this is gonna give us some insights, um, to streamline our scheduling, to give us insights of what's happening during those turnovers, where is their downtime will be really like eyes in the operating room, but like also eyes in the sky with the with the platform and the technology, and they'll give us, um, automated insights as well, and it's data driven, um, for uh utilization. So we have done quite a bit of engaging with key stakeholders. Um, we've, um, IDS, EPMO, PIPS, IPC, OGC, we've met with Goer governance, we've met with a lot of different people. Um, so we're really still engaging that team, but we're really next moving on to defining those metrics, especially for the surgical safety checklist as that gets Refined. So we're really moving through this project. Um, in the future, we'll also pilot and then do an evaluation optimization. Really eager for any of you, um, to get involved, um, as, as you're, um, engaging with this work, and we'd love to have you join our project. Um, I know you're all a little bit worried about privacy and risk management, and so our goal for this is that this tool be a value add to the work as done in the OR. The access to the videos will only be to certain people. Um, as you can see in this picture, there's anonymization, so the, the faces are blurred out, the voices are changed, um, so you can't tell who's who. The storage of the data is encrypted, it follows HIPAA guidelines, and videos are purged within 30 days. Um, and that is all I have, so feel free to reach out to me if you're interested in getting, um, more involved in this project. Thank you so much. Great, thanks, Megan. That was awesome. And I, I'm personally really excited about this for so many different reasons. Um, I, I wanna encourage folks to continue to, to put their comments and thoughts in the chat, both, you know, the good and the bad, the ugly, uh, cause it's all valuable. We put it all together. It really provides an incredible source of, of insight that just we would never get without this Brady Bunch I'm seeing on, on the screen right now. Um, so our next, uh, speaker, uh, and our final speaker before, uh, we transition over to some Q&A, um, is Julia Finkelstein, who's going to tell us a little bit about high reliability and how this aligns with, uh, with these efforts in terms of the bigger picture of perioperative safety. Mm Thanks, Sean. On behalf of the whole HRO leadership team, I get a couple of minutes this morning after these fantastic presentations to demonstrate how all this work contributes to making every moment matter at BCH as a highly reliable organization. The vision is that we deliver the safest, highest quality care, and optimal patient and family experience, and superior outcomes through the shared commitment of our workforce, patients and families to high reliability, continuous improvement, and the transformation of healthcare. The approach to achieving this vision has been to embed high reliability into the fabric of the organization. An emphasis on a culture of safety and use of robust process improvement tools have been foundational to the journey towards HRO. We are committed to preventing errors and improving our performance through the application of the five principles shown in the yellow box, which allow us to consistently and reliably operate safely and effectively. Almost 10 years ago, Boston Children set out on the road to HRO with enterprise-wide training. To employ HRO principles and create a common language across BCH, there was focus on the use of three core high reliability behaviors. Speak up for safety, pay attention to detail, and communicate clearly. In 2021, HRO 2.0 was initiated to reinforce and re-energize the use of high reliability behaviors and principles across the hospital. This program refresh was designed to empower everyone from clinical to research to support staff, to practice high reliability in their everyday work. A lot has changed since our HRO journey began, and this 2.0 program also served as an opportunity to consider how the environment we create has an impact on how high reliability is operationalized. The HRO 2.8 toolbox was expanded to include a commitment to psychological safety. As we recognize that high reliability is dependent on team members feeling safe and supported to speak up, ask questions, and discuss errors. The meaningful efforts that you heard about this morning reflect examples of Boston Children's continued commitment to being a highly reliable organization. You heard a proposal for enacting revisions to surgical safety checklists to address recurrent perioperative errors. To effectively implement this change, there are complementary teams who will work to elevate and optimize our performance. The IDS team will incorporate human factors and stimulation to aid in the implementation of checklist revisions to strengthen system performance and drive sustainable change. Use of OR analytics and augmented technology will further facilitate optimal checklist use and efficiency, as well as better communication and team dynamics. Altogether, this work supports and further embeds HRO principles into the processes, systems, and culture of BCH enhancing psychological safety and advancing the quality of care for surgical patients. Thank you. Thank you, Julia. So, um, we're actually on time, which is great, and, uh, we have 18 minutes left either to give some back to your day, uh, but also, um, for some opportunity for Q&A for our speakers as well. So I do want to thank the speakers for taking the time to put together their content. Um, what I'm really excited about is we really have kind of a coordinated effort to, to do it right, um, when we make these revisions and to be very thoughtful, uh, that this is not going to be something that overburdens folks or results in a checklist that becomes more, more fatty, right, and, and less, uh, less meaty in terms of the, the impact it can make. And in the last couple of iterations, we've really tried to make this an evidence or event-based set of changes, and so that's going to continue to be our goal. Um, so with that, before I turn it over to questions, I'm going to reshare my screen so everyone can see the QR code. Can everyone see the slide you go with the QR code? Yes. Yeah, OK. So again, to remind folks, so in order to get um credit for today's session, you need to scan the code and fill out the survey, and again, for your constituents and, and colleagues who aren't here today, uh, this, you'll be able to to watch the uh presentation and to scan the code and get credit up until November 27th. Uh, and after that, I think it will no longer be um available. And so with that, um, why don't we go ahead and turn it over if anyone has any questions, uh, for any of the presenters. And I'm not sure people are gonna put their uh will uh will have people put their hand in the crystal if you can keep an eye out because I can't see all the Brady Bunch of wants here. I'm on it, right. And again, thanks everyone for all the insightful comments. I think we have about a quarter mile of comments, both good and bad, which is going to be very valuable to go through. Paul I don't see any questions or comments, Crystal, is that right? Can I say something? Steve just, Steve just raised his hand. OK, Steve. Uh, yeah, I, I just, uh, a, a comment. I, I, I wanna thank all of, uh, today's presenters, as well as the teams behind them. Um, this, um, grand rounds, which, which wasn't scheduled as like our Super Bowl grand rounds where we, we sort of present great cases to learn from each other or Um, sometimes, uh, for oral leadership to talk about sort of, uh, major system issues, sort of like we did during the, the pandemic and leadership changes. Um, uh, this evolved a little bit organically, um, when, when the departments of urology and surgery decided to team up together, uh, with, um, to see, see how we could develop some, um, activity that would be meaningful, that would also satisfy these, these crico-premium reduction. Um, requirements. Uh, but, but they took it much further than that. And, and, and, um, that's how we ended up inviting, uh, so, uh, everybody else in the peroperative, uh, uh, community, uh, because this is uh clearly a value to everybody. And there's so much that goes on behind the scenes, um, in, in, uh, safety and quality in, in PIPs, uh, things that, you know, a lot of people don't spend a lot of day thinking about, but, but some of us do, particularly, uh, some of today's speakers. Uh, and, uh, you know, when Sean says, we see medication errors all the time, like, we do see, I mean, every single month, we review every single one of them. And these are frequent occurrences. Um, we, we've definitely had improvements over the years and decades in, in, in, in, in our performance, but some of these things still happen. Fortunately, and as Sean presented the history, the things like wrong patient surgery, I mean, I remember that happening. Uh, wrong site surgery still happens occasionally. It's not a never event, but it's, it's getting close. Uh, but we do have these new things to focus on that have risen, uh, to prominence, and, and, and, uh, and, uh. Uh, the charge, uh, has been, and it's, and it's been organic from, from, from a larger group than you were able to meet today, has been to, to focus on the things that actually are problematic for us and for our patients, and for us as a system. How do we bring them into, um, into the vanguard of how we address them in things like, like the, the checklist without making the entire day a checklist, right? So there's, there's this, there's this continuous balance, and we see lots of Comments, uh, in, in, in the chat, um, which, which go both directions. We don't spend enough time, this is not enough attention given to it. To others saying it's taking too much time. It's alarm fatigue. So the charge that, that, that our governance has given us, find a way to make this, uh and Sean's uh phrase, we want to make it better, not longer. Uh, and, and, and they're really taking this on. And, and I have great optimism. Uh, and so, uh, we, we, we're, we I wanted to do this, not only for them to present their ideas and their thoughts, but to get feedback from a wide group, and, uh, with almost 400 people at the maximum during this, uh, hour, uh, and, and, uh, dozens and dozens of comments off the site, uh, and what will follow. Um, uh, I'm really appreciative of, of the group, uh, taking this on, uh, and, and I hope it was a meaningful hour for everybody besides just getting, uh, a reduction in malpractice, uh, because actually the overarching importance is It's actually prevent errors. So, so thanks to everybody. Thanks, Steve. And Ben, I see you have a question, but before, before we get to you, um, I, Steve did remind me to emphasize that, um, if anyone would be interested in becoming more involved in this process as it moves forward in the next couple of months, uh, by all means, uh, we would welcome more thoughts and perspectives, and, and that's not only to formally become part of any of these teams, and we would love to have more perspectives on our checklist revision team. Uh, but even just simply reaching out to us if you have ideas, um, you know, none of this has to be formal, but if you have ideas, particularly if they're novel things we haven't thought of, you know, please reach out to myself, uh, or, or, or anyone else and let us know your thoughts cause, cause we would love to hear them, uh, Ben. Thanks. I just wanted to echo what, what Steve had said. Um, unfortunately, I'm just gonna put on my hat as spokesperson for my department just to make sure that our members of the department kind of do the things that we do need to do. When I completed the survey, it doesn't really ask. For our um ID at any point. So just, Crystal or Sean, I just wanna make sure I give the right information to the faculty that couldn't participate today. How does this backend work from a Crico um perspective, if you don't mind me asking quickly? Yeah, I'm gonna have to defer to Matt Taylor. I don't know if Matt's still in the Brady Bunch in here. Um, I'm still here. Thanks. Um, yeah, so Ben, um, once you complete that, um, it automatically, um, is recorded in the, uh, on the back end. As long as you've got your name, uh, and your specialty, um, we will be good as far as, uh, providing that information to Crico. It just didn't ask us anywhere for that, Matt. That's my only concern from following the QR code, unless I'm doing something wrong. So that was my, usually I've done that before, but it just didn't ask us that. So I just wanna make sure we don't miss that. And then this might be a stupid question for you, but did you select the, go down to the drop-down list and select, uh, grand rounds? Yeah, the Crio monthly disciplinary grand rounds at 7 a.m. Right, um, let me follow up with you. I apologize. Um, there is gonna be a link sent out, and, um, within that link, I will, um, provide information to make sure that you guys are able to complete that, uh, appropriately. Matt, it does ask for our, our name and our, and our email address, but not our ID. No, we don't need that. Yeah, we don't need the ID, um, Sean, that's all we need, name and email. And, and, and, um, uh, and, uh, it's, it's, it's a shame to have all these people having a discussion about these logistics, but, you know, the, the, the questions ask things about where you were a participant, to, you know, we're observer, and those apply to simulation activities, not to this particular type of activity, sort of as we discussed before. So what does it matter what they check for that, uh, uh. Um, um, if you, um, you know, uh, checking this morning, it should, uh, be stripped down from what you had seen, uh, previously. Uh, there were 8 questions that were removed that related specifically to participation in simulation, and, uh, some of us just did it, mat, so we can take it offline, but I, you'll accept whatever they check, right? Yeah, I'm sorry that I asked. I just wanted to make sure we just didn't lose that. Yeah, we're, you're, you're correct, Ben. There's hundreds of people who, who are doing this, so we wanted to, we wanted it to be simple. But Hey, can folks see the QR code? Did I put it back up? Can you see it? Yes. OK, great. Um, other thoughts, questions, comments. Chris. Hi, hi, this is Nancy Webb, um, not Sheila. Um, this was a great presentation. Um, I have so many comments about this, but, um, I'll just pick one. I think a big factor is we need re-education. Um, one thing is orders are never written, um, before patients are coming in the OR, not never, but very frequently. And a lot of times the residents don't know what orders to write, so they write orders for everything, you know, not, you know, like when there's a CVL they'll write for 100 to 1 or like things that you're not going to need to cover all the bases. Um, also, when, uh, surgeons have their procedural days, um, GI, general surgery, oncology, they have all these patients that they don't know, and they're over here doing this and they're in this room and they're in this room, and they don't know these patients, and I, I just think it sets, it sets you up for failure or for a mistake to happen. And my last comment is um, We have a lot of new staff, nurses in the OR and they just aren't aware that a lap pyloric patient does not need antibiotics. We try to teach these things, but I agree with Doctor Holtzman's comment is a lot of times we're not teaching why. It's like, do this, do this, do this, do this. So, I have a lot more to say, but that was, I picked one area to talk about. Thank you. Thank you, Nancy. These are really important comments, and, and guess what, we know where to find you, so we'll be picking your brains. Mm. Sean, Sean, this is Matt again, and just to answer Ben's question, um, the second part of the survey, just, um, so you know, is, uh, from the DME which requires the questions, uh, at the second half of the, um, survey for folks to receive CME credits. So, unfortunately, I can't change those questions. They are required by, uh, the Department of Medical Education. I'm sorry, Matt, can you also clarify, so when you open the QR code, it gives two things to do. One is to register attendance, and one is to perform a survey. Um, all we're asking is the survey, um, to be completed because that'll serve as attendance. OK, so I, I hope I heard that because most of us have been doing the first one, and that's where the frustration has been coming about participants, which is a simulated thing. The, the QR code opens that. So you're telling us we can skip that and we can just. We could just do the survey, which actually from my experience, you actually have to rescan the QR code a second time to do that. Well, unfortunately we're trying to make it easier and it looks like we've actually complicated things, so I apologize. Just the survey needs to be completed. So you might have to scan the QR code again, guys. Apologize for that. Doctor Mayer, I think you have your hand up. Yeah, I, I just had two observations that might be worth emphasizing. One is there's the repeated reference to time pressures, and I think that's certainly something we need to think about at a system-wide level. I think the second comment that caught my attention was that team members don't know each other, which I think is A real problem, and we need to figure out ways to address that. And my last comment is just an admonition, and, you know, most of you know I'm not in the operating room much anymore, but, you know, I think we should embrace this black box, uh, video recording. Uh, I think it's going to be A remarkably rich source of information and I think will really help guide us to sort of get over the next hurdles. Thank you. Other comments or questions. Julia, yeah, hi, good morning, uh, Julia Galvez. My pronouns are she, her. I'm a pediatric anesthesiologist, and just in terms of black box, I think it's amazing. I've been following its development over years in the anesthesia space and love that it's entering the US. I know a barrier has been medical-legal things, um. But just in terms of having access to it, um, I would explore making sure that the teams in the room have access to whatever the recordings are because it would be incredibly helpful, especially if we're trying to pay attention to like post-event debriefs and things like that in real time. Uh, I think, um, you know, democratizing that, finding a way to do that, um, you know, with all the constraints and everything else would be helpful. Thanks, Julia. Yeah, I think one of our greatest advocates and probably resources are gonna be across the street. Uh, many of you on the screen know Doug Smiin, who's, uh, uh, really been integral over there, and, uh, since many of us know him well, I think he actually used to be Doctor Fishman's fellow at one time. Um, uh, we should have some inroads in, in learning all the ins and outs that we possibly can for them, particularly for these types of considerations. So, thanks, Julia. Other comments, questions. Crystal, you see any? Cause I don't. No, we've officially entered into the awkward pause for a minute. All right, well, in that case, we, we will give folks about 2.5 minutes back in their day. So again, thank you for, uh, joining the conference this morning. And again, if you have any ideas, thoughts, suggestions, criticisms, please don't hesitate to reach out and let us know cause we would love to learn more and, uh, implement any, any insight we can into this whole process. So thanks again. Enjoy the rest of your day.
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