Pathology Quality and Safety: Managing Mistakes, Mentality and Methods

February 04, 2022

Information

Feb. 3, 2022

Yale Pathology Grand Rounds

Yael Kushner Heher, MD, PhD

ID7413

To CiteDCA Citation Guide

00:00So I will go ahead and introduce our speaker.
00:03So good afternoon everybody.
00:04I am thrilled today to host our ground
00:07speaker, Doctor Yael Kushner Hager of
00:09interest to some in the audience is,
00:12as already noted, is that Doctor Hayhurst.
00:14Currently the head of renal pathology at MGH.
00:17But the reason I extended the Grand
00:19Rapids invitation is her really
00:21impressive expertise in the field
00:23of quality and patient safety.
00:24And just as a way of background,
00:26Doctor Hager received her medical training
00:28at McGill University in Montreal.
00:30Which is one of my favorite cities in the
00:32world and she completed her residency there.
00:34Anatomic pathology in 2010 or so she
00:37arrived in Boston where she did a
00:39fellowship in renal pathology at MGH.
00:42Afterwards she pursued an MPH at Harvard
00:44School of Public Health and also as
00:46a graduate of the inaugural class of
00:48the Harvard Medical School Fellowship
00:50and Quality and Patient Safety.
00:52So there's this huge background of
00:55education inequality she stayed
00:56on as a faculty at Harvard,
00:59first at both Israel where she served.
01:01For many years as a director
01:02of quality and patient safety,
01:03there and later joined Boston
01:05Children's Hospital and then moved
01:07to MGH as well where she is again a
01:09director of quality and Patient Safety.
01:11Doctor Hager has become nationally and
01:14internationally sought after speaker
01:15and she has amassed a broad array of
01:17scholarship and pathology specific
01:19quality initiatives such as implementation
01:21of high reliability principles,
01:22safety culture,
01:23systems engineering,
01:24effective change in leadership,
01:26so on behalf of the department,
01:29I would love to welcome Doctor.
01:31Better to give her presentations
01:33and you know one of the small things
01:35that the COVID pandemic has changed,
01:36is that the required zoom platform
01:38does not allow for the warm applause.
01:40I'm sure you would get if you were
01:42here in person and so I really do
01:45hope that we get to meet in person
01:47in the future soon.
01:48So welcome and please go ahead.
01:52Give some. Thank you so much.
01:54That was an incredibly warm welcome,
01:56especially hard to do on zoom.
01:57I'm gonna share my screen
02:00and it makes it sound like I.
02:02I've been at it sounds much more
02:04impressive when you list it like that.
02:05I actually was at.
02:06I was in Montreal for 10 years and then
02:08I was at the Buy for about 10 years.
02:09That's pretty much it.
02:11I haven't moved around that much.
02:12I do cover Boston children,
02:14some work there,
02:14but I just do the renal service,
02:16which isn't the very high volume
02:18service as kind of a in in a sort
02:21of consultant neighborly capacity.
02:22So then I came back to MGH about
02:25a year and a half ago after having
02:27been away for about a decade after
02:30my when I mentor is retired so.
02:32Today I'm going to speak with you about
02:34things no one wants to speak about,
02:36so hopefully you guys have some lunch the
02:38the the worst part about zoom is I really do.
02:41I really do Miss meeting in person.
02:43I'm sure everybody is sick
02:44of hearing that already,
02:44but it is really different,
02:45especially when talking
02:47about these difficult things.
02:48Having a interpersonal
02:50connection is always nicer,
02:52so feel free to reach
02:54out to me after or doing.
02:57After you know the talk,
02:58if there's anything you want us to discuss,
03:00can you see my screen OK?
03:03Alright,
03:03I'll keep nodding,
03:04so I have a friend who's a
03:06professor at the Business School.
03:08He told me people take 2 minutes
03:09to decide whether they're
03:10going to listen to or not,
03:12so this is my two minutes and
03:14and you're competing with.
03:15I used to have this thing where we
03:17were competing with people phones
03:18like everyone is sitting in the room
03:19likes checking their phones and now
03:20I feel like you're just look out at
03:22a sea of like black boxes of people names,
03:24which is so hard,
03:25but I know everyone's so busy.
03:27So what I'm gonna do to compel you is tell
03:31you about real disasters that happened.
03:33At in hospital in the hospital I worked
03:37at due to errors in our department
03:39and their different flavors of error.
03:41So I thought that might be compelling to you
03:43to sort of if any of them rang true to you,
03:45I'd be very interested to hear about it.
03:49So here we go.
03:50Case one is entitled.
03:52Are you sure this is the right patient?
03:54So I hope your blood pressure isn't going up,
03:57and it's of course it's a prostate biopsy.
03:58It's always either a
03:59prostate biopsy or GI biopsy.
04:01I, by the way,
04:02I don't have any disclosures.
04:03Maybe my disclosure should be that I.
04:05That I'm not a Geo pathologist but
04:08I am very familiar with this case,
04:09so this is a case that showed
04:12prostate cancer.
04:13Do we have some trainees on the call to?
04:15Should we maybe?
04:17Maybe we can make it a little
04:20interactive? People are awake,
04:22so this shows prostate cancer.
04:23I'm going to ask a question about it,
04:25but not about the diagnosis,
04:26so hopefully folks are caffeinated.
04:29It showed cancer really,
04:31very routine diagnosis.
04:32No one thought anything about it.
04:34The patient underwent a prostatectomy.
04:36You can see by the year that these
04:39harmful errors don't happen so often,
04:41which is like nice. But then again
04:43I would say then we're sort of.
04:45We're not very nimble in knowing
04:46how to deal with them, right?
04:47So the patient underwent a prostatectomy
04:50and the prostatectomy was entirely benign.
04:53Totally benign.
04:55And no masses, no cancer.
04:57The entire specimen was submitted,
04:59much to the chagrin of the Sino pathologist,
05:0253 blocks. That's almost twice the alphabet.
05:06So invasive cancer, and so.
05:09I guess if any of the trainees,
05:10what what would you do if that was your case?
05:12What's the next step?
05:13Of course,
05:14you're worried that it's the wrong case,
05:15right?
05:16But so how do you figure that out,
05:19maybe?
05:23So I guess the first question would be,
05:26is that the only cord that was positive?
05:30And then the other question would be.
05:34Look at the cases that were gross
05:37and I guess accessioned before
05:39it to see if there was some
05:41kind of crossover event
05:43that's exactly perfect,
05:44so I think looking at the grossing
05:46log from that day is probably the
05:47first step 'cause you automatically
05:49are like jumping to a OK,
05:50we messed it up at the grossing bench.
05:52Of course it could be in
05:53the urologist office.
05:54It could be a lot of different
05:55places where that can happen,
05:56but of course the gross thing
05:57log is easy to look at,
05:58so we actually did do that and
06:02we found that it was mislabeled.
06:03It was pretty. Easy,
06:04it was just a mix up at the microtome, right?
06:06So we could tell when we re cut
06:08from the block that was wrong.
06:10So that patient had had surgery.
06:12He didn't need.
06:13This was his actual core,
06:15which was totally negative.
06:17Interestingly,
06:18you know he was quite young and
06:22he had all a lot of the you know,
06:25bad things that happen when you
06:27have a a radical prostatectomy,
06:29so that was pretty awful and
06:30pretty traumatic for all the
06:32care care members as well.
06:34The other patient,
06:35the one who was told that he was
06:38fine but actually had cancer.
06:40He opted for watchful waiting
06:41and this is an interesting part
06:43about the patient safety movement.
06:44So if you go by the strictest
06:46definitions of harm.
06:47Nothing happened to him right?
06:48'cause he was just gonna wait anyway
06:51and so it didn't have an impact
06:52like the way you might sort of do
06:54wrong site surgery or something like that.
06:56But and he was followed up with biopsies,
06:58they all showed the same thing and confirmed.
07:02You know his most recent biopsy
07:03was the exact same grading.
07:04You know, uh,
07:05five years later,
07:06but in reviewing his chart for QA,
07:09he actually had had a bunch of
07:12anxiety events in the in the years
07:14following this medical mix up.
07:16And he got better with medication.
07:18But I just thought it was interesting,
07:20and it's a good side note on how
07:22these types of psychological events
07:24can really can harm people and can
07:26make them distrustful of medical
07:28system and just generally anxious.
07:30So I thought that was interesting,
07:31and it hinges on some some other
07:33academic work that's been done
07:35around extending the patient
07:37safety movement to things like
07:39psychological harm and we're getting
07:40into that a little bit again now,
07:42with the Cures Act,
07:43which I'll talk about at the end in
07:45terms of reporting results and whether
07:47psychological harm is a real thing.
07:49So Creek?
07:50Oh,
07:50that's our malpractice insurer in
07:51the car captive Harvard system
07:53settle the suit on our behalf.
07:55The Department Public Health CMS came to us,
07:57which is, like, you know,
07:58not relaxing,
07:59and we did a border registration
08:01and medicine report and we had
08:03some Qi related changes.
08:05Interestingly,
08:05one of our QA related changes,
08:08which is just that you all
08:09know that we're human,
08:10was that on every requisition 'cause
08:11this was in the in the time when
08:13we still had paper requisitions,
08:14we used to write our right,
08:15our diagnosis on it,
08:17and someone would transcribe it.
08:18We had to sign the little
08:20thing saying, you know,
08:21we attest slides match the requisition,
08:24and you know what happened.
08:25If you months after, people would just
08:26sign that as part of their sign out,
08:27and they wouldn't actually
08:28be checking it anymore.
08:29And anyway it wouldn't have helped in
08:31this case 'cause it was labeled wrong.
08:32So I was thinking about this when
08:34I was reading the New York Times.
08:35A couple years ago and I saw and if the
08:38exact same case reported exactly the same,
08:41it was a 69 year old prostate cancer mix up,
08:44so I don't know.
08:45Maybe I don't know if you've
08:46ever had mix UPS in your lab,
08:47but it certainly happens with
08:50these small batched biopsies.
08:51So many people come to me and they say,
08:54well, we just need barcoding.
08:55What we need is barcoding.
08:56We need RFID codes.
08:57We need to barcode everything,
08:59and I guess what I would say to that is,
09:01yeah, it makes things better.
09:03But remember that Pete.
09:04There's still a person.
09:05It has to affix the label to a specimen,
09:08right?
09:08So, for example,
09:09we reported a case where there
09:12was a frameshift error in our
09:14cytology specimens where he had 20.
09:16Someone batched out all the labels
09:18and started one specimen off,
09:20so we misdiagnosed 25 patients that day,
09:24and online cytology.
09:25So it's not perfect,
09:26right?
09:26You have to think about how you're doing it,
09:28so that's the first case that
09:30was a preanalytic error case.
09:31The second case is actually
09:33not really an error,
09:34and I'm interested in your thoughts about it.
09:36These are all real.
09:38These are all real cases so
09:41so haven't gotten fired yet,
09:43but I'll let you know if that type.
09:45I'm looking for a job,
09:46so this is a case where it was
09:48reported out on the treating clinician
09:50actually misunderstood the report.
09:52OK,
09:52which I'm sure has never happened
09:54to anyone in your department.
09:56So it was a very young man
09:57and he had neck swelling.
09:59He was noted to have a submandibular
10:00mass and he was referred to
10:02a surgeon to get it biopsied.
10:03He had an SNA totally routine by this
10:06surgeon and and the SNA showed many,
10:09many fragments that looked
10:11exactly the same of.
10:13Do we have any site of
10:14pathologists on the call?
10:15Anyone interested in?
10:17Thinking of a word to describe these cells.
10:21Another disclosure I don't do
10:22that I don't do psychopathology.
10:29Joe, I saw your name.
10:34He's like I had my camera off and I
10:36left message and also leave me alone.
10:39Form their bland.
10:40They have brown nuclei on the right.
10:43It looks almost like it has
10:45asked their architecture.
10:45Now wonder if it's normal last
10:47night I'd like to see more and
10:49see if they have this little
10:51aster architecture or if it's
10:53neoplastic with a very uniform.
10:55Population of epithelial cells. Yep,
10:58here's another section or another
11:00photo of another aggregate.
11:03So I mean, I guess the main
11:04thing was you can't really tell.
11:06I think that's what you're getting at, right?
11:07So then it gets to the point of like,
11:09how do you express uncertainty in a
11:11differential diagnosis in a report,
11:13which is a real challenge in
11:15all of anatomic pathology,
11:16but certainly in psychopathology,
11:18which probably in our community does
11:20the best of anyone in standardizing,
11:22reporting and categorizing risk right?
11:25Joe feel free to to jump in.
11:27This is how it was signed out.
11:29Basaloid proliferation with stromal
11:30fragments cannot exclude celebrate
11:32glenlea plasm so any pathologist
11:34knows that's kind of like.
11:35OK, it's like a descriptive thing where
11:37they're like we don't know whatever,
11:39and we're thinking you know, could it be?
11:42There's a long list of things that could be.
11:44Some of them are malignant and
11:45some of them are benign, right?
11:46And that's what we think when we look
11:47at it and it gets to the point of,
11:49you know, in the note.
11:50Do you list all the things it could be,
11:52but then people will get worried if they
11:53see things that are sort of low risk.
11:55So this went back to the primary care
11:57physician open to any comments in real time.
12:00By the way,
12:01feel free to unmute very and very flexible,
12:04and they decided look,
12:05I don't know what this is, I don't know.
12:07It means we're going to watch and wait.
12:08It's probably nothing, alright.
12:11So they did that and six years later
12:15he came back with neurologic symptoms.
12:17Alright,
12:17this is a real patient.
12:18He's 45 at this point here,
12:20which I consider very young since
12:22that's my current age.
12:24And
12:26there's one comment that came up
12:27at asking is this a way of saying
12:30specimen in inadequate for diagnosis?
12:31No, I don't actually think it is.
12:33I think it was more than
12:35adequate for diagnosis.
12:35To me, adequacy is more about like
12:37the amount of cells and the types
12:40of tissue that's there, right?
12:41So like if you have a myocardial biopsy,
12:44you need like four to six fragments
12:46of actual myocardium renal biopsies.
12:48You need like 10 to 20 glomeruli.
12:49You can do it unless it's not
12:51that there wasn't enough tissue.
12:52It's that in that issue that you saw.
12:54There's a pattern,
12:55and there's a differential.
12:56That pattern,
12:57so it's not that it's inadequate,
12:58it's that.
13:00I mean, I guess it gets it gets
13:02to the interesting philosophical
13:03question of adequacy, right?
13:04Like if you need architecture,
13:05does that make it inadequate?
13:06I don't think it's inadequate.
13:07I think it's just like this is what
13:09we can tell from this specimen,
13:10and maybe you should excise it if you want.
13:12If you wanna really know, right?
13:15But that kind of gets to the point
13:17of maybe the better term would be
13:19the limitation of the technique.
13:21Yeah, maybe? Sure.
13:27That's an option.
13:28I don't know if I've considered a limitation,
13:31it's it's just that's the type of test.
13:33It is right that and, and there are some.
13:36It's sort of like in radiology.
13:37There are certain certain tests that
13:39are better for different things,
13:40and if you get into a certain category
13:42of diagnosis you need to do additional
13:43tests or you need to sort of understand
13:45what risk you're getting into.
13:47And I think the problem here was
13:48that they didn't understand what
13:49risk they were getting into,
13:51so the patient came back and
13:53they had brain Mets.
13:55And metastases throughout the body,
13:57they excised a submandibular and,
13:59of course it showed adenoid cystic carcinoma,
14:01which was like a tiny chance of
14:03what that would that showed up,
14:06and it was scary, right.
14:07It was widely metastatic,
14:09and and what's interesting about
14:10this case is when we went back to
14:12talk to the pathologist they were.
14:14They were sort of like look,
14:15I didn't do anything wrong like
14:17I described it,
14:17and I released the case and it was right.
14:20So, like if they didn't understand,
14:21that's not my problem,
14:22so I don't know how people feel about that.
14:25But I think interestingly,
14:26there was an Institute of Medicine,
14:29now called the National Academy of
14:31Medicine report in 2015 called around
14:34diagnostic error for the first time
14:36and they define diagnostic error
14:38for the first time and interest
14:41for pathologists and and for and
14:43for someone wrote.
14:44That's why we have the Milan system
14:46which I love as a as a as a fan of
14:48the team behind the Milan system.
14:50But that's right, right?
14:51Like standardized reporting is really clear.
14:54Anyway, it diagnostic error.
14:55About the definition actually
14:57include commute,
14:57proper communication of the results
14:59in the definition for the first time,
15:01and that was a report written for
15:02pathologists and radiologists,
15:03which really changed things for us
15:05like we had never really considered
15:07that before.
15:08So anyway,
15:09I'm going to shift to something more current.
15:11I don't know how you guys are doing
15:13with open notes and with the Cures
15:15Act and with whether or not you
15:18hold EM atomic pathology results,
15:20you must not,
15:20because it's the Cures Act went
15:22live right about a couple a year
15:24or two ago and now, for example,
15:26all the mass General Brigham
15:28patients get immediate access to
15:30their anatomic pathology reports
15:31like the the literally the second
15:33you click finalize or release,
15:35or whatever it is in your system.
15:37It comes to their portal.
15:38And it's created a lot of thanks,
15:40so let me tell you a story
15:42that started with us.
15:42This is again a real real story.
15:44A young ish woman who presented
15:46to the Ed with new ascites.
15:48She had a diagnostic tap.
15:51Some paracentesis that showed
15:54metastatic adenocarcinoma.
15:55What's really kind of is interesting
15:57from a systems perspective,
15:58is it?
15:59It came actually under hematology
16:01because the CP people actually noticed
16:03in the tap that there was metastatic
16:06adeno and put it in the comment
16:08and the patient actually received
16:10this diagnosis via text like on
16:12her in her hospital bed right?
16:14'cause she got a notification
16:15that something was finalized.
16:16She clicked on it and that's how she
16:18found out and the clinician when
16:20they went to go search them in epic.
16:22Actually couldn't even find out where
16:23it was and the patient was really
16:25distraught and it was kind of a
16:27disaster so we were able to take a
16:29screenshot of how it appeared on her phone.
16:32And it was sort of like a loophole
16:34like it was a it was a smear
16:36review right of a hematology where
16:37they put it in the comment.
16:39And so when the when the clinician
16:41went to go search it out and the
16:43cytology had been withheld was held.
16:45At that point they couldn't even find it.
16:46So it's really sort of a Swiss cheese
16:49of like what could go wrong in in an IT
16:52system and and then you know there's so
16:54many other things that can go wrong for us.
16:57It's amazing things go right,
16:58the the amount they do,
17:00you know we lose things all the time.
17:02I know your separate AP and CP,
17:04but I'm sure there's a lot of shared
17:05specimens that are really difficult.
17:06Those unknown lesions that could
17:08be micro or AP auto verification,
17:11Miss process assessments,
17:12critical values,
17:13people argue about what is what
17:14should get a call.
17:15What shouldn't get a call,
17:16challenges with interface, right?
17:17Like you format something in a specific
17:19way because you think it's safe,
17:21and then when it goes to the portal
17:22it's like completely unformatted
17:24and then some of the issues
17:25we've talked about open notes.
17:27So I think interestingly,
17:28from a safety perspective you know when
17:31do we actually analyze these cases.
17:32We do a class analysis.
17:34When do we tell people about
17:35it and to whom by whom?
17:37Meaning like is it the
17:38pathologist calling the patient?
17:39Is the pathologist called the treating
17:40clinician like how do we manage this?
17:42And I think one of the main problems
17:44we have in pathology is we're so
17:46overwhelmed and many of our issues are
17:48so complicated and shared with so many
17:50different non pathology team members.
17:53Is we really only disclose when there's harm,
17:56right?
17:57So there's this like vast, you know,
18:00untapped risk of like you know,
18:02imagine you have two GI biopsies.
18:04And they're like switched.
18:05But you know they're both benign
18:07and you realize it, so you're like,
18:09alright, we switch it back.
18:10We relabel it.
18:11There's maybe like a day delay
18:12in the turn around time.
18:13But you haven't harmed anyone.
18:15And I bet you don't report that.
18:16Or if you do, you're surely not gonna do it.
18:18Complicated root cause analysis on it, right?
18:19'cause you just don't have the bandwidth.
18:21So how do we tap into that risk
18:23to make the systems better?
18:25You know,
18:26not just at the very top of the
18:28like when we're really harming people,
18:30like in this prostate case,
18:31like how can you get at
18:33the learning and I think.
18:34Part of the other issue is
18:35labs are different, right?
18:37Like all those systems,
18:38the hospital level, graphical quality,
18:40the RL solutions, all these things.
18:41They were all designed for clinical medicine.
18:44They were not designed like for
18:46our production line manufacturing
18:48type systems engineering and how
18:49we move back and forth from like
18:51automated systems to human systems.
18:53Very nuanced diagnosis like people.
18:55Think of it as right or wrong.
18:57And in anatomic pathology,
18:58anyone who's ever thought about how you
19:00cognitively come to a diagnosis knows
19:02that it can be much more Gray than that.
19:04The other thing that's different
19:05about us so is people really
19:07don't understand what we do like.
19:09We'll go to a, you know,
19:10some bad thing happens and you go to
19:12present it to the board or something
19:13and you have to spend 10 minutes
19:15explaining how it normally happens
19:16before you even talk about what went wrong,
19:19right?
19:19Like there's no understanding
19:21of our processes.
19:23We do have this production line
19:24type workflow batching is common,
19:26you know we do we just because that's
19:28the way we do things which everyone
19:29knows this dangerous but it's just
19:31how can you handle it otherwise,
19:32especially now with the national.
19:34Technologist shortage shortage that
19:36we're all facing incredibly high
19:39volume people don't understand right?
19:42And you know,
19:43I think the subjective versus the
19:45objective result. You know people.
19:47You'll see something that says
19:49like what are the results?
19:51You know the results are not finalized as
19:54if it's like a potassium you know not.
19:56So I think that's a really
19:59interesting perception right?
20:00And and it puts a lot of stress on
20:02us multiplicity of events right?
20:04Like so.
20:04In that case, best case scenario,
20:06it affects 2 patients.
20:08There's two swapped events,
20:09but you can imagine a scenario we
20:11had a case where we miss diluted
20:13our formalin for like six months.
20:15We were buying concentrated formalin
20:17and diluting it at the wrong
20:19concentration to say to save money
20:21like we weren't buying prefab 10%
20:23buffered formalin, which we now do anyway,
20:26we realize that none of the IHC had
20:28been validated for that concentration,
20:30and it was like a total.
20:31You know, it's like for six months,
20:33and if you think about it, even the most.
20:35Dedicated patient safety professional.
20:37Like the volume of events that happens
20:39in pathology is is really a challenge.
20:41We had another time.
20:44We had a vendor who was bringing us and
20:47GI endoscopy specimens from an offsite,
20:49like private endoscopy.
20:51Come, you know,
20:52practice and they just lost an entire.
20:56They threw it away by accident.
20:57An entire bag of specimens,
20:59and it was like 46 patients or something.
21:01You had to go through every single provider,
21:02figure out what was retrievable,
21:04what wasn't, so you know it's different.
21:06Labs are different.
21:07It's not the same kind of events.
21:09This new legislative transparency I see
21:11Vanita wrote in the chat that patients.
21:14Do not get immediate notification,
21:16so that's interesting.
21:17I wonder how that was circumvented,
21:20maybe maybe there's a slight delay,
21:22but so I think what's interesting about
21:24us is we do need special systems, right?
21:27And they need to be able to have the
21:29capacity to deal with this volume,
21:31and we also, you know we don't
21:33talk to people like we're sort of
21:35pathologists aren't exactly known as
21:37the most the best communicators, right?
21:40Susie Densis in Seattle did a
21:43bunch of studies like focus groups
21:45and things on disclosure.
21:46Of of of pathology error
21:48and she put quotes in it.
21:51It was an archives paper some years ago
21:52and one of them said something like
21:54we became pathologist 'cause we don't
21:55want to talk to people or something.
21:57So that's kind of very telling about
21:59how motivated we'd be as pathologists
22:01to have difficult conversations if we
22:03don't want to have like any conversations,
22:05right?
22:07So I'm going to shift gears a little.
22:12Johnson Art says I'm pretty sure they do now,
22:14but they didn't used to.
22:15Yeah, I think actually they do not
22:18since I've been in conversation with
22:21both Alan Shao and Harlan Krumholz.
22:24So when we went live we did
22:27for a brief period of time.
22:29But as has been reported in the literature,
22:32the number of communications
22:33to clinicians went up by 70%,
22:37and so the board made a decision to
22:39not send alerts to patients. Works
22:42are available in the chart,
22:44but the patient are not.
22:46Patients are not alerted,
22:48and so one of our discussions was
22:51about the disparity of care that this
22:54decision by the system results in,
22:57because obviously educated patients
22:59are eager and they jump to it
23:02and they check their reports,
23:03but those. You
23:05know, a lot of patients don't have access.
23:08Super interesting,
23:09and I think that's kind of where.
23:11So you have to make them
23:13available immediately,
23:13'cause otherwise you're sort of subject line,
23:15so that was sort of the legal
23:17sort of interpretive loophole,
23:20so to speak that we use.
23:23I think one is that what you're
23:24talking about is like a push
23:26system versus a full system,
23:27so you did away with the push,
23:28and you have the pull system,
23:29which I think we actually did too,
23:33at least for anatomic pathology results.
23:35For CP results we left it.
23:36And so this was a funny loophole.
23:38'cause it was a hematology result,
23:39but I don't wanna get too far into the weeds.
23:41I think it's really interesting,
23:42and I think your disparity
23:43comment is really timely.
23:44Tejal Gandhi has written about this.
23:46If you're interested in,
23:47then in the New England Journal
23:49and other places around how the
23:51Curious Act can widen disparities.
23:53And it is very interesting.
23:55But there's so much to talk about.
23:56I'm going to move on a little
23:58just to show you everyone knows
23:59the three phases of pathology,
24:01so I'm not going to harp on it
24:03except to say you know everything
24:05that we don't have access.
24:07We don't have control over its preanalytic.
24:10You know analytic is usually what
24:11we control in the lab and then post
24:14is everything about communicating
24:15and turn around time and that
24:17kind of thing and now cures act.
24:19What I think is really interesting is.
24:23Myself and many others roughneck land.
24:25Others have reported that up to
24:2790% of errors in or safety events
24:30in pathology are preanalytic and
24:32yet we spend all our time really
24:34focused on analytic error, right?
24:35Thinking like don't miss the Melanoma.
24:37Don't miss the signet ring cell,
24:38which is really important,
24:39but we don't get a lot of training
24:40and we certainly don't spend a
24:41lot of resources thinking about
24:43the preanalytic phase,
24:43so I think that's really critical.
24:46Why don't we?
24:47This was a patient safety event.
24:49As a study we did by severity.
24:52Which showed that we really don't hurt that
24:55many people like like I was saying before.
24:57Most of it is just risk,
24:58right?
24:58So if you don't have a lot of bandwidth,
25:00you're not going to investigate
25:01the no harm in near Miss events,
25:03so I think that's partially,
25:04you know we have this untapped risk
25:06at the bottom of what they call
25:07the Heinrich Pyramid and the way
25:09I teach this to our residence is,
25:11you know, let's say you're driving.
25:13The more you sort of speed
25:14and do unsafe things.
25:15And like the more near Miss Accidents,
25:17you're going to have and the more risk
25:19you're going to have to actually have,
25:20like a fatal or difficult accident.
25:22So what you wanna do is address.
25:23Your style of driving so that
25:25you you don't get to the
25:27top before you do anything,
25:28and so that kind of gets to what
25:30our culture is in the lab,
25:32right? I think patient safety alone is a
25:36relatively new concept and so you know,
25:40we used to really focus on not being sued,
25:43right? Risk management was a thing and
25:44now the patient safety movement in general
25:46is more about actually just optimizing
25:48things and thinking about patient
25:49safety as opposed to just like is there
25:52malpractice risk here, and if not like.
25:54Too bad kind of thing and in the
25:56lab we always had like QA QC, right?
25:58Like is the fridge at the right temperature,
26:01you know is did we do 20 her two neu?
26:04Did we you know the whole checklist for CAP
26:06or don't Commission or whatever you use?
26:08And I think one of the things we shift
26:10towards is changing the language to
26:12quality and safety to think about culture,
26:14which is not something we've thought
26:15about often in the lab.
26:16And to think about continuous
26:18improvement as opposed to compliance.
26:19Like I remember when I started,
26:21we started these meetings where
26:22they would show all the CAP.
26:24Sort of goals.
26:25Back in the day when they
26:26had more mandated goals,
26:27they've dropped a lot of those and
26:29it would just say like 100% a 100%
26:31compliance and then we were done
26:32with the meeting and I thought like,
26:34well,
26:34of course it's 100% 'cause otherwise
26:36our lab would be shut down like that's
26:38an accreditation metric like we're
26:39not learning anything here, you know.
26:41So I think the difficulty with getting
26:43people to shift to like let's look
26:45at the things we do poorly on, right?
26:47Like let's have all the boxes be red.
26:48So then we can make things better
26:50like our goal is the delta.
26:51Not like we're not going to just look
26:53at the things we're already good at.
26:54We're going to look at.
26:55Capacity for growth,
26:56and I think that's been a really
26:58tough in an environment where people
26:59were so focused on compliance,
27:01especially like in CP Blood Bank
27:04in AP psychology,
27:05those are the cultures that were like
27:07very compliance focused to think about
27:08we're actually gonna shine a light
27:10on the stuff that we feel vulnerable about,
27:12so that we can make it better that just took
27:14a lot of feeling of like it's going to be OK,
27:16and we're not going to be like written up,
27:18and it's actually that's our goal,
27:20right?
27:20And it it, it works.
27:22I think we're a little behind in part,
27:24you know, the rest of medicine.
27:26They never really used the word quality
27:28like it wasn't in the vernacular
27:31of like hospitalists, or actually,
27:32hospitals weren't even a thing,
27:33probably 10-15 years ago, so you know,
27:36just except for kind of like ID doctors,
27:39it wasn't in the vernacular,
27:41so the quality patient safety movement
27:43started with kind of like Libby Zion.
27:46For those of you who paid
27:47attention to New York at that time,
27:49Betsy Lehman,
27:50for those of you who know that
27:52that was the The Globe reporter
27:54who was who was killed at the.
27:56At the Dana Farber because of an overdose of
28:00chemotherapy because of a medication error,
28:03and ironically she was a medical globe
28:05reporter and there were a bunch of
28:08other pretty high profile medical error
28:10cases that led people to realize that,
28:12like you know the the there are other
28:15things besides the natural evolution
28:17of disease that kill patients right?
28:19And and one of those things is
28:21mistakes and so you know, accepting
28:24that and being transparent about it.
28:26Became part of the general
28:29culture of medicine.
28:30I think what was different about
28:32the labs is we use the word
28:34quality and safety forever, right?
28:35But for us it meant something different.
28:37It meant compliance and it
28:39meant like environmental safety,
28:41like the formalin levels.
28:42You know,
28:43the eyewash station and this and that,
28:45and so shifting that from thinking OK,
28:48we need to do all those things
28:49like to stay in business,
28:50but that's not what we're talking about when
28:52we talk about quality and safety, right?
28:53We're talking about the broader patient
28:55safety movement and how to apply it to labs.
28:57And the broader quality culture.
29:00So one thing we struggle with at Harvard.
29:02I mean if you do at Yale also.
29:06I'm not a football fan,
29:07but I do know that there's a
29:09deep rivalry between the two,
29:11at least the tailgating is worth going to
29:13alone is that we focus all of our energy on,
29:17sort of the few you know,
29:19translational and basic science research,
29:21and that's where we put a ton of resources.
29:25It's like sexy,
29:26it's you get tons of publications.
29:28It's what we're proud of, right?
29:29But I think what's really amazing to me is
29:32behind the wall of all this fabulousness,
29:35and these are.
29:36Publications from mass general faculty from
29:38cell from Nature from all kinds of things,
29:41the that issue that led to all these
29:43publications is still processed like this,
29:45right?
29:45Like it literally comes in Tupper
29:48Ware containers in plastic bags in,
29:50you know, labeled in with a label.
29:52Nothing about the preanalytic
29:53phase has changed,
29:54nothing right?
29:55And so all the risk that's
29:57there is still there.
29:59You know you can make it
30:00look pretty good afterwards,
30:01but you know very little has
30:04changed in in surgical pathology.
30:06So I think the overarching goal for
30:08us needs to be to change how we even
30:10think about quality and safety,
30:11which originally traditionally was
30:12like we're gonna just be compliant
30:14like we're gonna get cap.
30:15That's gonna give us the seal
30:17of approval to go forward.
30:19We're going to like take care of patients.
30:20And then we're going to.
30:21Yeah, maybe we'll like manage operations,
30:23will firefight.
30:23And then if we have any energy
30:25left whatsoever,
30:26we'll do quality improvement, right?
30:29And what I would say is it needs to
30:31change like the base needs to be.
30:33The culture, like people need to feel safe.
30:35They need to feel like they can
30:37bring forward.
30:37Those risks and that somebody
30:39will be there to,
30:40you, know, listen,
30:41they need to be involved in the solution.
30:43If they call it events,
30:44you actually have to follow up with them.
30:46Tools need to kind of be disseminated,
30:48like root, cause analysis,
30:50safety events, eminems,
30:51whatever you wanna do.
30:53Those tools need to sort of be pushed
30:54out to the front line and they need
30:57to feel comfortable using them or or,
30:58you know, get some assistance or
31:00standardized because obviously
31:01no one resource to create a
31:03division to assist every single
31:04person with every single risk.
31:05And I don't want you to think we are either.
31:09I think the other thing about labs
31:11that's kind of overwhelming is,
31:14you know, when I say, oh, you know,
31:15don't worry about the compliance.
31:17That should just be a
31:18small part of what you do.
31:19Well, easy for me to say, right?
31:20There's like 400 compliance
31:21agencies that you need to keep
31:23up with just to stay in business.
31:24Now I know AP and CPR separate at Yale,
31:28but you know, even if you just count
31:30cap and Joint Commission which you
31:32which you have to do, it's still.
31:35It's still like 400 checklist items, right?
31:37So I don't want to minimize that.
31:38I know it's hard to to keep up with.
31:41The other thing that's different,
31:43I think, is.
31:44People at the hospital level think of
31:46us as like the smaller labs in AP.
31:48You know, they think it's like lower volume.
31:51It's like a bunch of people
31:52and sometimes in the basement,
31:54sometimes in that window.
31:55What are they doing down there?
31:57But what's interesting about it?
31:58When you look at at risk the the
32:02proportion of error or of risk
32:04in anatomic pathology is way way
32:07way higher than in CP.
32:09And that's not because we're stupid, right?
32:12It's because everything we do is manual.
32:15Right, and so you know,
32:17if you put a thing in a machine and
32:19it sort of gets gives you a result,
32:21it's gonna fail at a very reliable rate,
32:24right?
32:24But humans,
32:25you know it's a combination
32:26of patient related factors,
32:28tissue diagnostics and everything.
32:30We just delete.
32:31Our job is hard and and I think
32:34people need to accept that so.
32:35I'm going to shift gears in the
32:37second half of my talk and speak
32:39a little bit about some of the
32:41tools we've used around culture.
32:43If that's OK and high reliability
32:45is something that the Trump
32:46Commission and others have written
32:48about in terms of there,
32:49are there are principles of high reliability
32:52which and here are the principles?
32:57So interestingly,
32:57the first one is the toughest for labs.
33:00The preoccupation with failure.
33:02You know. People think of us
33:04as the gold standard, right?
33:06They think of us as like the result,
33:08the answer and for us to focus instead
33:11on what we do poorly is really tough
33:13culturally and from a moral perspective,
33:16and certainly again in this after COVID.
33:19You know, the labs were just like you know,
33:21murdered during COVID from a you
33:23know everyone was between being
33:25sick and out the lab shortage.
33:27And just like you know,
33:28the actual testing platforms,
33:30it's been a terrible people say, oh,
33:32it's great people know what we do now,
33:34which is like a nice like
33:35it's a silver lining I guess,
33:37but everyone is exhausted, right?
33:38People are exhausted and in AP we had
33:41major financial hits because of shutdown
33:43of elective surgeries and things like that.
33:45So it's been tough.
33:49I think you know thinking about the
33:51bandwidth to make things better is really
33:52hard when you're just trying to survive,
33:54you know.
33:55So I just wanna put in a note about
33:56that and just make sure that you
33:58take that with a grain of salt while
34:00we're discussing this or reluctance
34:02to simplify interpretations is
34:03really hard when you're busy.
34:05So for you to say, oh, I know what happened.
34:07It got switched.
34:08The microtone like Susie Q was like
34:09talking and it's she takes all the
34:11stuff at the same time. And that's why.
34:13So that's not curious, right?
34:15That's like you just wanting
34:17to be done with it so.
34:19I think figuring out usually there's a lot
34:21of different reasons why something happens,
34:24and understanding the complexity
34:25of the reasons helps you be
34:27successful in solving the problem.
34:29Resilience is like your capacity
34:31to fail and then get up again.
34:33So that is to me that's a more valuable
34:38and more honorable and more successful
34:41trait than existing excellence, right?
34:44Which is really tough for
34:45an organization like mass,
34:47general or Harvard Medical School.
34:49To say,
34:49yeah,
34:49we actually fall down and we're
34:51going to share with you how we
34:52fall down and how we get better as
34:54opposed to like we're the best.
34:55You know people who are the best are not
34:57going to tell you how they messed up, right?
34:59But everyone messes up.
35:01And so if we can do it and we can
35:02share what we learned, isn't that?
35:04Isn't that valuable?
35:05You know?
35:06And the other thing that's useful.
35:07I think the deference to expertise
35:09has to do with deferring to
35:11the frontline order meaning,
35:12so I'll give you an example we had.
35:14We had a case where a patient died because
35:17they didn't get blood products in time.
35:20The pneumatic tube system failed,
35:23and so you know,
35:24we went through many different iterations
35:25where we couldn't figure out why it failed.
35:27We sent the blood,
35:28they never received it.
35:29We sent it again.
35:30They never received it,
35:30so we ended up having the
35:32buildings and grounds guys
35:33come through M&M.
35:34Turns out that one wing of the
35:36hospital where this patient was
35:38was built at a different time,
35:40and the pneumatic tube system
35:42was like 3 millimeter smaller
35:44than the rest of the hospital,
35:45and the lab techs were sort of
35:47overstuffing the pneumatic tube
35:49containers because the patient was
35:50crashing and needed massive amounts
35:52of blood and they were getting
35:53stuck and we actually had them
35:55present like a map of the different
35:57pneumatic tubes of the hospital,
35:58and they're different diameters which
36:00like talk about different expertise.
36:02There's no way anyone in the pathology
36:03department would ever know that, and.
36:04The the The Blood bank texts were
36:06blaming the nurses the nurses
36:07were going to the blood bank
36:09text and it turns out there was
36:10like a total system explanation.
36:11So that was really interesting for
36:14us and sort of reaching out to those
36:16buildings and grounds guys who normally
36:17don't get involved in anything clinical.
36:19Certainly not an Eminem
36:20was really interesting.
36:23So I was thinking about telling you
36:26about a couple of things we've done to
36:28try and address some of these things.
36:30One of them is create and implement
36:32pathology, Eminem Realms and the
36:33other is a new thing we're doing
36:35called diagnostic error or diagnostic
36:37learning opportunity grounds,
36:38and I hope we'll have time for another day.
36:42I can and I think I spoke with with
36:44some team members this morning,
36:47including Andrea and Carla to talk
36:49about some of our performance dashboards
36:51and patient safety dashboards.
36:54So and Chi in process redesign.
36:56But today we're going to talk
36:57more about M&M rounds and these
36:59other rounds we're doing.
37:00So if you think back on our cases that
37:02I showed you one was preanalytic,
37:05one was post analytic and one was
37:07this like it legislative problem.
37:09So you can tell I made a real effort not
37:11to focus on something that was like,
37:13oh look at this Melanoma that was missed,
37:15right?
37:15'cause that's something that
37:16you get a lot of.
37:18So I really think we have to extend beyond
37:21worrying about what we're taught to worry
37:23about and and develop some new tools.
37:26So we developed these Eminem rounds.
37:28It was partially in response.
37:30We were already doing it,
37:31but we integrated residents because of
37:33new AC GME guidelines and pathologists,
37:36you know,
37:38we love to go to other people's
37:39M&M's and like shame them.
37:41You know, like this is the answer,
37:43this is what you missed but we
37:45frequently don't have our own EMS right,
37:46do you?
37:47I should say I should pause and
37:48if I were there in person I would
37:50ask if you have your own eminems.
37:53We currently do not have.
37:55Departmental Eminem it's in the works of
37:58being developed and and we're you know,
38:00we're tasked by the hospital to develop
38:02such a program in our department.
38:04Awesome, and I really looking
38:06forward to the next few slides. Oh
38:08well, this is a very very.
38:09This is like headlines only so I'm happy to.
38:13I think I was telling you earlier.
38:14We have like an 8 to 10 year experience.
38:16That's about to come out and
38:18we're going to publish all the
38:19templates and tools so people can
38:21just download them and use them.
38:22I see Marcelo there.
38:23I don't want to call out Marcelo,
38:25but Marcelo participated in
38:26more than one M&M.
38:28He did a great job.
38:29He's not
38:30now that I know that I'm going
38:31to have to go after Marcelo
38:33to get his experience. He's
38:35like I'm done with that,
38:37but I don't know where. I'm happy to help.
38:40Yeah, I mean you were there when we
38:42when we did that for many years.
38:44And it it was a total game changer.
38:46I mean, I don't want to overstate
38:48people were really nervous about it,
38:50like they didn't want to do it,
38:51and we invited like the we invited
38:53everyone like the secretaries
38:54were there or the assistants,
38:56the transcriptionist, the residents,
38:59the technicians, the chairman.
39:01And it. It, it was.
39:03Really, I don't know. I didn't.
39:04I don't think I realized how unique
39:06it was at the time until I started
39:07working in a different organization,
39:09and I realized that it's just not
39:10the culture, right? I don't know.
39:12Marcello, if you have any,
39:12I'm sorry to call on you.
39:13But if you had any.
39:14Memories of it.
39:16Actually I I would point
39:17out that it it was it.
39:19It was great 'cause it didn't.
39:21It didn't feel putative and
39:23it didn't feel like you know.
39:26You know people were looking
39:27to assign blame, blame.
39:29It was really a clear exploration
39:32of system related factors.
39:35I I as a resident,
39:36I found it to be really.
39:38A good a great learning experience
39:40and like a confidence builder.
39:41Honestly I thought it was great.
39:44OK, not a planted comment.
39:46Thank you, Sir.
39:47Thank you so much. I think it was.
39:49We tried very very hard to have
39:52curiosity be our focus and to select
39:54cases that had the biggest capacity
39:57for systems learning and to really
39:59open things up like to take away the
40:01safety net review behind closed doors
40:03and among leadership and make it more open.
40:06And we found that also increased
40:08reporting events 'cause people felt like
40:09oh this is this would be a good Eminem right?
40:11So we openly and honestly looked at cases.
40:15Figured out what happened and tried to
40:17fix them and promoted open discussion
40:19and transparent culture.
40:21We had a model where how we identified
40:23cases very standardized.
40:25We did RCA's and as I said we have
40:28a whole conference guide.
40:30We had like a slide deck template which
40:32we're going to get out there and I'd
40:34be happy to share two and then we just
40:36did it the same way every time so it
40:38never felt sort of like a witch hunt.
40:40It always felt like this is what we're doing.
40:42This is our system and it
40:45became totally normalized.
40:46And we shifted things.
40:47I know in pathology we never
40:48had our traditional Eminem,
40:49but for those of you who who did
40:52grow up in clinical medicine
40:53and in pathology in Canada,
40:55you have to do a surgical and
40:57medical residency internship.
40:58So I remember like standing at the
41:01front of those amphitheatres and just
41:03feeling like completely grilled,
41:06right like it wasn't a friendly
41:09place and we really only looked
41:11at harmful events in.
41:12In our case,
41:13we really were trying to look
41:14at near misses or close calls.
41:16With the capacity for learning,
41:17I've been talking about.
41:19In the traditional Eminem,
41:20the case information is presented by
41:22a person for the new pathology ones
41:24it was like gathered from all stakeholders.
41:27More systems.
41:27You'll see.
41:28It's really just from like person
41:31to systems and the top down punitive
41:33goes from the bottom up curious right?
41:36Like where you have frontline
41:37people who are like yeah,
41:38we don't understand what happened
41:39or here's how we normally do it.
41:41That kind of thing.
41:43And so again shifting the
41:44culture from frustration,
41:46anxiety to learning the denied
41:48offensive to transparent just.
41:50Culture,
41:50which is a balance between
41:53accountability and systems and
41:54then the top down like go.
41:57Figure out what happened and get
41:58back to us to you know engagement
42:00and ownership from the bottom up.
42:02These are real fish bones from
42:04real eminems we showed we had
42:06a breast you're going to think
42:07we never got a case right?
42:09Ever this was a breast
42:11biopsy diagnosis mix up.
42:12I think we did catch it though so
42:14was a mere mess and you can see
42:16this was a very like our most senior
42:18breast pathologist at the bye.
42:20Who had probably done millions of
42:22cases over his career and look how
42:25many contributing factors there were.
42:27I mean,
42:27it just goes to show how
42:29complicated things are, right?
42:32And we tried to make the ones
42:34bigger that were, you know, more.
42:36And everyone knows don't put
42:37different flags on the same tray,
42:39but I don't know about you.
42:40But our Histology lab is
42:41always running out of trays.
42:43We had another case really
42:45unfortunate and all explain it to you.
42:47We had looking at the time we
42:50have time we had a case where
42:53there was a patient who went.
42:55It was a frozen,
42:56busy frozen day, lung cancer,
42:58lung adenocarcinoma and there was a
43:00junior resident learning how to do
43:01frozen so they were in the frozen lab.
43:03Just cutting all kinds of Frozen's
43:05to get it right onto blank slides and
43:08putting them on top of the cryostat.
43:10Then they stained one,
43:11finish the frozen whatever and they got
43:13called away to the OR for another emergency.
43:16So there was a neuro patient and
43:18our neuro workflow with separate.
43:20We had different neuropathologists
43:21covered their own cases who was called
43:24rule out metastatic lung cancer.
43:26So already you can see what's
43:27going to happen right?
43:28So another Rep trainee gets called
43:31in starts picking up what they think
43:33are blank slides off the top of the cryostat.
43:35But of course.
43:36They're unstained lung cancer
43:38slides and cuts.
43:39Little pieces of brain onto them stains.
43:42It looks under the microscope and says
43:43it's metastatic lung adenocarcinoma,
43:45and they do a pretty big resection of
43:47the patient's brain and they find out
43:50that actually it's not in the block
43:51and it was reactive gliosis and that
43:53tissue was from the previous patient
43:55and it was a different resident,
43:56different attending,
43:57different patients,
43:58same day and just 'cause they didn't
44:00label the slide right and look at.
44:02There were so many issues that led
44:03to that this is a real real story.
44:06All true stories.
44:08So we actually got the the Eminem
44:11conference at crowded at VHS.
44:15And we awarded risk management credits
44:17which improved attendance in the days when
44:20people could come in person and really
44:23thought carefully about how we moderated it.
44:27Encouragement of frontline workers
44:28and trainees and the other thing
44:30we did once we were comfortable is
44:32we started inviting guests.
44:33So let's say we had a case
44:36that like affected.
44:38You know the OB guy in team?
44:39We would have the OB guide people come
44:41and that really at the beginning people
44:43stress people out like they did not want.
44:46It was like inviting guests to
44:47the family dinner table and then
44:49talking about family problems.
44:50You know, like they didn't,
44:51they didn't.
44:51They like can we just talk about
44:53it and then tell them later?
44:55And they were worried like they were
44:57worried that our treating clinicians would
44:58think like we don't know what we're doing.
45:01I would say from our surveys and
45:03from feedback from those people
45:04over like a decade long period.
45:06It did just the opposite,
45:08like they were actually able to help
45:09us bake into our proposed solutions or
45:11poke holes in some of our pro solutions.
45:14Like, well,
45:14if you do that then when we order it,
45:15we're not gonna be able to
45:17see this or you know,
45:18and they were also able to just have
45:20empathy for how complicated our work
45:22is and feel like they were a team.
45:24So it really changed things
45:25for us having folks.
45:27Fair, so we created this guide which we sort
45:31of tweaked every time we had an Eminem.
45:34Which I'm happy to share,
45:35and that's kind of a.
45:36That's a very like 40,000 foot
45:38view of like a 10 year experience.
45:40So there was a lot of work that went
45:42into it and it was really transformative.
45:45So since I got to MGH,
45:47I'll shift for my final little story
45:50about what we've done differently.
45:52To be quite honest,
45:53I didn't feel like MGH was
45:55ready for an M&M just yet.
45:56Culturally,
45:57that takes kind of a big feeling of
46:00psychological safety to get everyone
46:01in a room and start talking about that.
46:03So we started doing something different,
46:06which is we called the diagnostic
46:08Learning Opportunity Conference.
46:09And what we did was we took
46:11very senior people,
46:12full professors who were very
46:14well regarded in their fields
46:15and we went to them and we said,
46:17tell us about a time you missed a
46:19diagnosis and the interesting thing
46:20was these are like people in there.
46:2260s seventies, sometimes greater.
46:25Who literally were like in 1992.
46:28I had this case, you know,
46:30like it was like 2 seconds.
46:32They could remember exactly the case
46:34right and everything that happened.
46:36Which is kind of amazing and it
46:38goes to how powerfully emotional
46:39like you know how you remember
46:41things when they're traumatic.
46:42So we would have people come and talk
46:45about their mistakes and this was
46:48partially to strengthen safety culture,
46:50but also to teach trainees it was made.
46:52It's for trainees about what
46:54to do when this happens to you,
46:56'cause it's inevitably gonna happen to you.
46:58Maybe not in such a dramatic way,
47:00but like you're gonna miss something.
47:01How do you document it?
47:02How you disclose it? You know?
47:04How do you do in RCA?
47:05And we built it on this New England
47:07Journal article that came from Joe
47:08Shapiro where those of you who know
47:10did a lot of work on the second victim.
47:12She was a Brigham surgeon who
47:14basically invented peer support.
47:16Which is dumb.
47:18You know, I think clinicians do where
47:21they help each other after they've
47:23been involved in a harmful medical
47:24error and support one another and
47:26they call that the second victim.
47:28So this is the sort of circle app
47:30framework from that New England Journal
47:32that basically is a very fancy,
47:33sophisticated way of saying like you
47:35should talk about things after they
47:37go wrong and support one another
47:38like it's that's their whole like.
47:40I wish I could write a New England
47:42Journal paper that had that obvious tagline.
47:43Anyone who's ever been in therapy
47:45knows that's like obvious, but anyway,
47:46they they created this whole framework.
47:48It was great around speaking up teamwork,
47:50making things better and supporting each
47:52other, and also empowering people right?
47:54So letting people say this was
47:56a disaster and I'm going to
47:58be empowered to make change,
47:59and that happened during the pandemic.
48:02I think the interesting thing coming back
48:04to MGH for me as a Canadian who like didn't,
48:07I did a fellowship there for a year,
48:08but I didn't grow up there is I
48:10was looking back and there was a
48:12case records for those of you who
48:13read the CPC's and then we England
48:15Journal where they basically said
48:17you know this is a really famous.
48:20These are where they show
48:21famous case reports right?
48:22Like a 38 year old woman with renal
48:24failure and thrombocytopenia or
48:26whatever and incredibly famous.
48:28And then it took them 100 years.
48:32To present their first case of a mistake,
48:36and it's the most downloaded CPC
48:38in the history of the CPC's,
48:40and they haven't had one since,
48:43and I find that super interesting,
48:44it was a wrong site surgery.
48:46Greg Meyer came and he he was the
48:48discussant for this wrong site surgery
48:50and it's amazing to me that this is.
48:52It's just that that we haven't
48:53had more of those,
48:54but I'm thrilled they did and it
48:56sort of followed on the heels of
48:58many people quote the sort of to
49:00air is human and the patient safety.
49:02Kind of movement and it's our turn,
49:04which was a call to action for
49:06pathologists that I described to you
49:08earlier around diagnostic error.
49:10So I think as I said before and I
49:13might skip some of these slides is,
49:16I think in places like Yale and
49:18Harvard and others where we have
49:19this like idea of what we should be,
49:21it's almost harder for us to admit
49:24when we're wrong.
49:25I took I took a screenshot of my I do the
49:27New York Times crossword puzzle and it said,
49:30Boston flagship Medical Center
49:31and the answer was mass general.
49:33And I was like it didn't like that's hard
49:35when you think you're more the flagship,
49:37like really, so it's hard like.
49:40How do you then say,
49:41hey I missed this right?
49:43Like this is Harvard Medical School,
49:44it's Yale. It's whatever it is and
49:46I think in the end pathologists are
49:48that to treating clinicians right.
49:50You're like the answer giver.
49:52So how do you then admit that
49:53you made a mistake, right?
49:55Like when we're the gold standard and
49:56you're using, you're giving an opinion,
49:58you're not like an instrument or a machine.
50:01So we use the dlow terminology which
50:03we took from the Pediatrics literature,
50:06which we thought would be like more
50:08friendly than saying diagnostic error.
50:10I don't know if that worked.
50:11I have to ask people and and
50:12we really wanted to train our
50:14trainees on disclosure of events.
50:16So we have simulations.
50:19Think I'm gonna come.
50:20Looking at the time, no.
50:22I think I'll continue.
50:23So this was a case where we lost a part
50:26of a specimen and basically we couldn't.
50:29You know,
50:30we the clinicians sent it to us,
50:33not in formalin.
50:35We got to generate it and we couldn't do it,
50:37so it was a joint event.
50:38You know we didn't know how
50:40to investigate it.
50:40We didn't know what to people often call me.
50:42What should I put in the report
50:43like I need to finalize the report?
50:45What do I put it in and they want to sort of?
50:47They either don't want to write anything
50:49or they want to write like a 12 page
50:51summary of the root cause analysis right?
50:54Which is really tough and we don't
50:55train our trainees or pathologists
50:56on what to do in these situations.
50:58So that's what we.
51:01Aimed this deal.
51:02Oh conference,
51:03as creating more training around
51:04how to deal with these problems,
51:06which are inevitable and Susie and I
51:08wrote a paper about how to disclose in 2018.
51:11If you're interested,
51:12we created an algorithm of when to disclose.
51:17Which had to do a little bit with harm,
51:19but as you can see,
51:20even when there was no harm in
51:22a probable or possible error,
51:23we still wanted to capture
51:25opportunities for improvement, right?
51:27Root cause analysis or discussion
51:28with the patient.
51:29Even if there was no harm.
51:31And it's not just because we
51:33are sort of like open, honest,
51:34Kumbaya, it's kind of practical,
51:36like for example, a patient gets a biopsy,
51:38you realize something is wrong and
51:39it takes you three weeks to sign up
51:41the report 'cause you need to do
51:42fish in molecular and figure out if
51:43there's a mix up like in that case
51:45somebody's gonna have to tell the patient.
51:46Like why is it taking three
51:48weeks to sign out your GI biopsy?
51:49You might not have harmed them,
51:50but you know you might want to consider
51:54a conversation. OK, someone says I
51:55hope there's enough time for QA,
51:57so maybe I'll skip forward a little.
52:00Oh look takehomes perfect.
52:03So we I think we have to redefine quality and
52:06safety and join the patient safety movement.
52:08Better expanding our responsibility
52:10to involve all phases of testing and
52:13collaborate with those outside of the labs.
52:16We need standardized tools.
52:18Really bad beyond what's required
52:20for regulatory compliance,
52:21so much unexplored risk and opportunity.
52:26Especially challenging with
52:27events with joint ownership,
52:29which is very frequent in the labs.
52:31We need to figure out how to work up,
52:33document and communicate error and and
52:35we need to be trained on how to oversee,
52:37teach and publish in this area.
52:40And so this is kind of a wheel
52:42we create with like you know,
52:43pathology, quality and safety.
52:45It's all these things, right?
52:46It's it's compliance, it's AC health.
52:49It's patient safety,
52:50but there's also a scholarship
52:52and education piece.
52:53Lots of people on my team over the year,
52:55so I'm grateful to.
52:58And I will take questions now
53:00and hoping for the spring soon.
53:04Wow, thank you, that was fantastic.
53:07I I can tell that people are excited
53:10for questions so I will hold off on
53:13mine and open it up to to folks I
53:15and this is sort of file a I.
53:17I am at a pediatric pathologist but I
53:20am also associate director of autopsy.
53:22I want to clarify that what Joanna say
53:26actually is incorrect. We do have an
53:29M&M's. We do have
53:31M&M's for pediatric mainly but also
53:33in the past we have used autopsy.
53:36That being a. Hospital autopsy are
53:41the baseline for quality assurance.
53:44We have used this in the past
53:46and in very distinctive way.
53:48Contacting the Medicine Department
53:51or whatever to senior with
53:54possible error to be discussed.
53:56Unfortunately, the feedback was,
53:59you know, our resident are not interested
54:02anymore to participate in into this,
54:05molecular informatics is more interesting,
54:08so there is a little bit of pushback.
54:11Inviso older way to do quality
54:15assurance that you should be
54:17reinstated and we still use.
54:19Actually
54:19Raphael. I can I just thank
54:20you for the double check.
54:21I I was referring specifically to
54:24an Eminem within pathology only to
54:26discuss some of the types of errors
54:28that Doctor Hager just presented.
54:31Yes, we do have Eminem's and
54:33other departments for traditional
54:35sort of presentations.
54:36Let's let's ask Doctor.
54:38Lu raised his hand very politely so.
54:41Will will let him take the
54:43next comment about that.
54:45Yeah, yeah yeah, this is a fantastic lecture.
54:48I think this is, you know,
54:50I think it's right. You know this
54:52is exactly what we want to hear.
54:55You know, as a department store where you
54:57know we are thinking about this all along.
55:00But I think that you know we really
55:02want as Joanna is now taking the
55:04leadership role for the you know
55:06quality and safety in our department.
55:07Certainly there will be a lot
55:09of things we wanted to you know
55:11to do and this is really great.
55:12So I really like the concept.
55:14You know you were talking about them.
55:16Within the department,
55:17pathology literally is openly discussed.
55:19You know the the errors,
55:21and I mean as we know is you know you
55:24mentioned the word is not just the culture.
55:25Lots of things that you know error happen
55:28is not really individuals personal failure.
55:31It's a lot of time.
55:32It's a systemic failure, right?
55:33It's just the the way how you do this.
55:35So in your experience,
55:37in my question to you is.
55:39And when you do this,
55:40how what's your experience so far?
55:42For example, how open your faculty staff?
55:46Actually talking about the errors,
55:49I mean, you know, in a way,
55:50it's they themselves.
55:51We always want to try to find a
55:53way how people can be so she ate.
55:55Yeah people, person,
55:57that person versus event right?
55:59Because you know The thing is,
56:01you know,
56:02have you thought about developing develop
56:05like rewarding system to the people
56:08who actually openly talk about error?
56:11And mistakes, right?
56:12But that's hard.
56:13You know, I'm saying we are living
56:14in a very peer review system,
56:16and you know,
56:17people promotion people's
56:18reputation is dependent on.
56:20We always say how great a pathology,
56:22how great staff member is in the
56:24in the you know in this department,
56:26but we rarely talk about say how
56:28open how actually sharing those
56:30kind of mistakes actually probably
56:32more important than people going
56:34around and say how great I'm
56:36doing one thing or another.
56:37I just want to hear your perspective.
56:39I.
56:39Well, first of all the thing you need is an.
56:41Openly supportive leader,
56:43so already you're like that comment alone
56:46your you know or at least benevolent neglect.
56:49Like if you weren't here but
56:50you weren't obstructionist,
56:51that would be good too.
56:52But the fact that you're open,
56:54I would say so.
56:54I'll give you an example.
56:55People are a little nervous
56:57about talking about it.
56:58We started over the first two years of
57:00the 10 years of day identifying it,
57:02and I actually presented
57:03all the cases to begin with.
57:05And at the beginning people were nervous.
57:07But then when they saw the tone of the
57:09conference and they became more and more
57:11relaxed and they saw we were really.
57:13What our goal was.
57:14People started self identifying
57:15like they were like.
57:17Actually that was my case and
57:18can I tell you what happened?
57:19What actually you know?
57:20I mean so it's. But it took years.
57:23You know people had to see that it was.
57:25They had to see how the
57:27conference was moderated.
57:28They had to see what happened.
57:29They had to see what the culture
57:31was and they had to feel trust
57:32and they had to feel safe.
57:33So around your comment about promotions,
57:36I mean no one's more familiar
57:37with the pain of promotions than
57:39Harvard Medical School faculty, so.
57:43You know there's a.
57:44There's actually a promotion path for
57:46quality and safety now even at Harvard,
57:48so if that's your academic interest,
57:50you could potentially actually
57:51publish on changes in safety,
57:53culture or numbers of diagnostic
57:55error and that kind of thing.
57:57So that's a huge shift like that's
57:59not just we're going to talk about it,
58:01but in private,
58:02that's we're going to actually reward it.
58:03Now.
58:04When you say you couldn't reward it,
58:05you can be sort of glib and give,
58:07like you know, good catch ords or whatever.
58:09But I actually think that's not.
58:11I mean, we're professionals and.
58:13That kind of thing can be glib if,
58:15like the rest of your system doesn't
58:17take it seriously, you know.
58:19So I think the answer to rewarding
58:20it is making people feel like it's
58:22valuable and like it's making a difference.
58:24And then if you have people who where,
58:26it's their scholarly interest,
58:27promoting them on that track.
58:30But otherwise I think it just
58:31needs to be baked into the culture
58:33and people need to feel like part
58:35of our job as respected.
58:39As respected, you know leaders
58:42is to is to do this work.
58:45Doctor Prasad Prasad says
58:47you still have to publish.
58:48We promoted that's 100% correct and
58:50you can publish in this area and I'm
58:53working with multiple journals to
58:55sort of create new tracks and new
58:57areas to publish quality and safety.
58:59Jeez your hand up.
59:00Did you want to say something?
59:01Yeah I did wanna share a couple of thoughts.
59:05One is I really like your.
59:09You talk about moving it from blame.
59:12We do focus on the analytical factors and
59:16when we discuss quality QC conferences,
59:19we talk about who missed a carcinoma
59:23in frozen section,
59:24or a Melanoma and stuff like that.
59:26And it's it's very hard to separate
59:29blame from just curiosity and that
59:32would be on Joanne's plate to
59:35make sure we move and we are
59:37curious about how it happened.
59:39And how we can figure
59:41out how not to let it happen? I also like
59:46like what you presented about the deal.
59:49Sorry for one second, it's actually
59:50on everyones plate to do that right?
59:52Like it's a joint family decision
59:54to to sort of feel safe. Of course,
59:57it's up to the leaders to make to hold
59:59people accountable to that safety,
01:00:00but it's everyone, I'm sorry, go on.
01:00:03And also the pathology
01:00:05M&M. It seems
01:00:06like you decided to call
01:00:08it the. Or conference and
01:00:11invite the senior most people to
01:00:13talk about their mistakes or
01:00:15misses. And I was invited to
01:00:18and ask App Companion Society
01:00:22meeting where the entire head
01:00:23and neck platform was dedicated
01:00:26to things that you missed.
01:00:29And then I realized I was the only
01:00:32one who talked about something I
01:00:34really did miss and I started with.
01:00:37I'm really embarrassed about this case.
01:00:39But anyway, that's the topic I
01:00:41will share all the other speakers,
01:00:43talked about cases that someone
01:00:45else best and they got it.
01:00:47So that's just my generation
01:00:50where they would.
01:00:53They are used to
01:00:54catching other peoples missing stuff.
01:00:56Yeah, I want to just make 2.
01:00:58Thank you so much for that comment.
01:00:592 slight adjustments to your second comment.
01:01:02One is the M&M is different than the DLO.
01:01:05The Eminem was a systems based
01:01:0710 year experience where we went
01:01:09methodically through systems issues.
01:01:10In all parts of the lab,
01:01:11including transcription
01:01:12that like transport error,
01:01:14I told you about Dlo is a totally
01:01:16different conference that is
01:01:18focused on diagnostic error.
01:01:19But what's different about it than
01:01:21what you're describing is we focus on
01:01:22the management of the error rather
01:01:24than just preventing the error,
01:01:25so we don't focus on like what
01:01:27is it about a decimal plastic
01:01:29Melanoma that makes it hard?
01:01:30Or was it about Signet ring cell
01:01:31that you can do to avoid it?
01:01:33What we focus on is this is going to happen
01:01:36to you and when it happens, what do you do?
01:01:38How do you write up the report?
01:01:40How do you have a conversation
01:01:41with your clinician?
01:01:42How do you file safety report?
01:01:43What are the reporting
01:01:45requirements to DPH form?
01:01:47You know?
01:01:47How do you document it?
01:01:49What are the legal implications?
01:01:50So we focus on managing an error which
01:01:53no one gets any training on, right?
01:01:55And I I doubt that was
01:01:57discussed at the USCAP platform.
01:01:59We're really people focus more on on
01:02:01like preventing the diagnostic error,
01:02:02which is super important
01:02:03and we should all do that.
01:02:05But we're great on that training
01:02:07like that's what we do.
01:02:08So I just want to make a slight adjustment.
01:02:10It's a little bit different.
01:02:12Thank you.
01:02:18Any other we have?
01:02:20We have had some comments.
01:02:22I don't know if everybody saw Doctor Robert,
01:02:24Gary mentioned psychological safety
01:02:26in her comment and says that I think
01:02:29the benefits of such a culture are
01:02:30important and extent well beyond
01:02:32the realm of quality and safety
01:02:33to be beneficial for a larger
01:02:35educational training environment.
01:02:38And you know, we we have a another
01:02:43question came up from Doctor M.
01:02:44I'll let you go ahead. Terrific talk,
01:02:49I want to follow up a little
01:02:50bit on what Rafiella said.
01:02:52That is. How do you compete for interest
01:02:54with the residents when they
01:02:56want to do molecular analysis
01:02:57or next Gen sequencing
01:02:58or something like that?
01:02:59And do you have some pointers for us
01:03:01to how to sort of make it more sexy?
01:03:03Yeah, so the first of all,
01:03:05I just want to take a minute.
01:03:07Rafael mentioned.
01:03:07I think she was mentioning
01:03:09fetal autopsies basically,
01:03:10which in itself is incredibly difficult
01:03:14from a root cause analysis perspective.
01:03:16Like there's the patient who's brave.
01:03:18That social worker.
01:03:19The the the the legal weight cut offs
01:03:21at age cut offs like it's basically
01:03:22like an accident waiting for happen
01:03:24to happen in terms of safety events
01:03:26and autopsy is like on the other end
01:03:28of the spectrum from like molecular
01:03:30and all these like amazingly like
01:03:32and cool things like as a mass
01:03:34general person I get that right.
01:03:36What I would say about residents in
01:03:38general trainees is they're really
01:03:40frontline workers and as much as they're
01:03:43interested in that kind of work for research,
01:03:45they're pretty good at calling out problems
01:03:48like that's like part of their culture.
01:03:50Is like being frustrated with operational
01:03:52things or with cultural things,
01:03:55right?
01:03:55So how do you somehow like leverage
01:03:58that into learning and change for the
01:04:00system 'cause they're they're like?
01:04:02They get sort of a toxic dose of where the
01:04:05dysfunctions are in the workflow, right?
01:04:06'cause they're constantly trying
01:04:07to manage it, especially in AP.
01:04:09And so the Eminem was good
01:04:10for us in that regard,
01:04:12'cause they were able to have a
01:04:13place where they called that out.
01:04:15You know where they were like?
01:04:16Listen, I was on call and like XYZ
01:04:18happened and it was a disaster,
01:04:19you know or?
01:04:20I went to go do this thing and
01:04:22there was no X and it was a patient
01:04:25safety issue like they're actually
01:04:27pretty good at at doing that and so
01:04:29involving them in the root cause and
01:04:31involving them in the solution and
01:04:33actually making it easy for them to
01:04:34call it events like I was talking to.
01:04:37Some of your folks before about like
01:04:40creating a distribution list instead of
01:04:42having residents file reports 'cause it just,
01:04:44it's like prohibitive.
01:04:47So they can just sort of
01:04:48email someone and say,
01:04:48hey,
01:04:49we notice this like we notice this
01:04:51risk and then having like an Eminem
01:04:54platform or or or something like
01:04:55that where they can be involved in
01:04:57the solution I think can be really
01:05:00transformative for them and quite healing.
01:05:01'cause it's it's a difficult
01:05:03period of your life.
01:05:03And remember you're only a couple
01:05:05years away from being a faculty member.
01:05:07So many of those folks as I was
01:05:08saying to some people earlier are
01:05:10like very very thoughtful and
01:05:11mature and and and allowing them
01:05:13to participate instead of sort
01:05:14of paternal ising or them can be.
01:05:17Really great for everyone and
01:05:18then the ones who do really well.
01:05:19Of course then you wanna recruit right so?
01:05:23I think it's about it's not just
01:05:26about making it sexy for them to
01:05:27use your term, it's about
01:05:28making it sexy for everyone.
01:05:29It's about making it so that you wanna
01:05:31do it because it actually results
01:05:33in change as opposed to like you
01:05:35just checking a box or you just like
01:05:37complaining into the ether, you know.
01:05:40Autopsies also, like you know,
01:05:42we could have a whole other
01:05:44conversation about autopsies.
01:05:44Maybe I won't, 'cause it's 137,
01:05:46but I have time.
01:05:49Let's say you've got 66 people
01:05:51still on and listening intently.
01:05:53We got what, let's take one last
01:05:55question from Doctor Shelburne,
01:05:56who raised his hand
01:05:57time. I can stay on like
01:05:58if I were with you guys.
01:05:59I would be at the podium hanging
01:06:01around like sipping coffee,
01:06:03so I may be driving an hour and a half home.
01:06:06So I'm my day is for you if
01:06:08you wanna hang on, hang on.
01:06:10Thank you very much for
01:06:11talking that I'm one question,
01:06:13you know that I have that I think
01:06:14ultimately it's all about priority.
01:06:16You know there's so
01:06:17many competing things that.
01:06:19That residents and faculty
01:06:20we don't know where to go.
01:06:21We have to prioritize.
01:06:23Do you have a a system or metric
01:06:26or how you can evaluate the impact
01:06:29of all everything you're doing
01:06:30so that you know we can make
01:06:32a claim and raise the priority
01:06:34and and and show real impact. So
01:06:35how are you evaluating
01:06:37the impact of all this?
01:06:39That's a great question,
01:06:40so there's different ways
01:06:41you can evaluate the impact,
01:06:43and I think you can't like boil the.
01:06:44That's a really insightful question,
01:06:46by the way, so I think you need to.
01:06:48Pick something like you can't when
01:06:50you say everything you're doing,
01:06:51I just I just shared with you like
01:06:53a 10 to 15 year experience, right?
01:06:55Like we didn't do that like overnight
01:06:57we did one thing at a time.
01:06:58Very slowly.
01:06:59First of all, second of all,
01:07:01we measured things like safety culture,
01:07:03but we also measured safety event reporting.
01:07:05We measured number of safety events in
01:07:07different areas and then we also even
01:07:09looked at things like financial metrics.
01:07:11So like,
01:07:12let's say we're looking at efficiency.
01:07:13I didn't talk about any of the projects,
01:07:15but we we looked at things.
01:07:17You know you have to think about.
01:07:19What's your outcome is?
01:07:20And then what you're measuring.
01:07:22I think that's exactly right,
01:07:23and you don't probably need to do that for
01:07:25everything like some things are no brainers,
01:07:27right?
01:07:28Like you know,
01:07:28you don't have to measure every single thing.
01:07:31If something is obviously better.
01:07:33But if you want to publish it,
01:07:34you probably do, and if you're not sure,
01:07:37you should baseline before you make an
01:07:39implementation and and and measure again.
01:07:41So I think you're absolutely right that you
01:07:44do need to create some kind of measurement.
01:07:46We usually we use the smart goals
01:07:49or the smart framework, which is.
01:07:51Specific, measurable, attainable?
01:07:53I forget what are is relevant and time bound,
01:07:56and that's widely published.
01:07:58I didn't. We didn't make that up.
01:07:59It's it's a very again motherhood and
01:08:01apple pie approach to like it's like
01:08:03when people say oh the answer to that
01:08:05is getting beaker and you're like OK
01:08:06great but that's like not gonna happen.
01:08:08You know you know what I mean.
01:08:09So that's like the you know,
01:08:11attainable section.
01:08:12It fails the attainable thing.
01:08:14Specific is like when you say
01:08:16we're going to reduce, you know,
01:08:18frozen section discrepancies
01:08:19by 10% over a one year period.
01:08:22Bubba,
01:08:22and then you make like an intervention
01:08:24and you measure before and after.
01:08:25So I think you're right that
01:08:27you should do that.
01:08:28The cultural pieces are a
01:08:29little tougher to measure,
01:08:30but there are safety culture surveys
01:08:32and you can get in RM&M package.
01:08:35We actually have a survey that we
01:08:37use for CMAS where we measured rates
01:08:39of like how comfortable people felt,
01:08:41how much they felt that they
01:08:43changed their practice and then
01:08:44we had a narrative comment.
01:08:45So we were measuring how
01:08:46we were doing overtime.
01:08:47It's a little qualitative research.
01:08:48It's like a little more tricky,
01:08:50but there are still
01:08:51validated tools that exist.
01:08:54Thank you, it's hard though. Alright,
01:08:58well in the interest of people needing
01:09:01to move on with the rest of their day,
01:09:04I would like to just give a very sincere
01:09:07thank you doctor here for coming to us and.
01:09:11Bringing an introduction to safety culture
01:09:14to us in such a understandable and clear way,
01:09:18and I thank everybody who asked questions and
01:09:22so I'll you know if people want to log off.
01:09:27That's fine, but if anybody wants
01:09:28to stay behind for a few more
01:09:31minutes and ask some more questions.
01:09:33Doctor Hager said she'd stay
01:09:34so thank you so much,
01:09:38really really appreciate this session.
01:09:41Megan honor I hope that we
01:09:42can do it in person one day.
01:09:45I hope so too.
01:09:48I actually would be really interested
01:09:51in getting that slide deck template that
01:09:54you mentioned for your M&M conference.
01:09:57No problem. I think it.
01:10:00I you know it is something that the
01:10:03hospital has cost us with to do,
01:10:05and I've been talking to the other
01:10:07departments at Yale to kind of gauge of
01:10:09what they're doing for their peer review.
01:10:11M&M conferences and.
01:10:15You know it's it's kind of a new concept.
01:10:18You know the traditional eminems are still,
01:10:20you know, obviously, how a place.
01:10:24For for doing this stuff,
01:10:25but this is something that's a little
01:10:27bit more introspective and looking,
01:10:30you know, internally into our own
01:10:33practices and discussing these things.
01:10:37So any remaining people
01:10:40have any other questions?
01:10:42But it looks like people ran it.
01:10:44Oh, there's Christine.
01:10:45Hi no, I'm I just wanted to
01:10:48say thank you again. I really
01:10:49have to get going because
01:10:50I'm severely behind.
01:10:51But thank you so much for this morning
01:10:54and for the great lecture today.
01:10:56So and then Joanne and I need to
01:10:58catch up because we haven't started.
01:11:01But it it really is.
01:11:02There is some great
01:11:03ideas in this
01:11:05that I think so.
01:11:07OK, take care. Thanks, Christine.
01:11:13No one has a question. I'm going
01:11:15to end with a story.
01:11:17It's not an error,
01:11:18but I just wanted to share.
01:11:19I forgot to tell I forgot to tell you.
01:11:21I love this. When we were
01:11:23talking earlier that it's
01:11:24really a problem coming to Yale and
01:11:27knowing Yale because my iPhone just
01:11:30can't get that straight.
01:11:32And every time I would tell someone
01:11:33by Yale, it would come up gaelle
01:11:36and I had to retrain my iPhone.
01:11:40Problem because people every
01:11:42time someone needs they're like,
01:11:44oh, Yale at Harvard. Haha, I'm like,
01:11:47yeah good one like never before.
01:11:49Also my name blood GAIL.
01:11:50Like every single time for like 30 years.
01:11:53Yeah well tell Apple that you because
01:11:55according to them your name is Yale.
01:11:58Perfect, I know.
01:11:59I named my kids like really boring
01:12:01things because like my husband like how
01:12:03about this day and I'm like no no no.
01:12:05It needs to be like the most obvious name
01:12:07possible and needs to be pronounceable
01:12:09in every language. He's like.
01:12:11Why do you care so much about this?
01:12:13Like because my whole life like
01:12:15what is it like? Yeah exactly.
01:12:17Joanna Joseph, that's a good one
01:12:19that can't go wrong with Joseph.
01:12:21Good biblical name. Pardon,
01:12:25yeah, no. I I got lucky 'cause you know,
01:12:27being Polish born at least Joana
01:12:30translates easily to English.
01:12:33Enough is that Polish
01:12:35it's pronounced you on now.
01:12:37But it's. It also lends itself to
01:12:43lots of good nicknames like Joe.
01:12:47Well, thanks so much. I was
01:12:49lovely seeing you and be well.
01:12:52Yeah, same to you all, be well,
01:12:54I'll definitely hound you with
01:12:57some emails for some details. I'll
01:13:00send you whatever templates
01:13:01I'm always happy to share.
01:13:03I'll, I'll send you like a
01:13:04like a downloadable package
01:13:06that would be wonderful.
01:13:07Thank you so much.
01:13:09So take care and have a
01:13:11safe rest of your February.
01:13:13Hopefully spring is coming.
01:13:18Bye bye bye.