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Welcome to Episode #56 of Habitual Excellence, presented by Value Capture.

donna prosserIn today's episode, our guest is Dr. Donna Prosser, the Chief Clinical Officer for the Patient Safety Movement Foundation, an organization that Value Capture is proud to partner with, given our shared interests in improving healthcare.

Donna has been in the healthcare industry for more than 30 years and is currently the Chief Clinical Officer at the Patient Safety Movement Foundation. She spent the first fifteen years of her career at the bedside and transitioned into administration after a personal experience helped her to understand just how fragmented and unsafe patient care can be. This experience ignited a passion to improve healthcare quality and safety in her that continues to burn to this day.

She previously worked as a healthcare consultant, helping organizations across the United States and previously had leadership roles and/or clinical roles at Martin Health System, Carteret Health Care, and the Washington Hospital Center.

Dr. Prosser received a Doctorate in Nursing Practice at the University of Central Florida, a Master of Science in Nursing at Duke University, and a Bachelor of Science in Nursing at George Mason University.

In the episode, Donna discusses efforts to improve patient safety and healthcare quality — and her personal motivations for doing so — with our host, Mark Graban. Topics and questions include:

  • What inspired you to get so involved in patient safety? A personal experience...
  • How can we help advocates and patients be partners and not adversarial?
  • Two stories — helped STOP the errors
  • Fixing errors vs. focusing on culture, systems, etc.
  • Fragmented care, system issues -- or systemless?
  • Covid era - lack of visitation, impact on errors??
  • What’s the scale of the problem? It’s been 20+ years since To Err is Human… is it getting better?? Are we seeing results?
  • Goal of Zero Harm by 2030? How do we get there?
  • Making a commitment to zero harm
  • PSMF resources that can help?
  • Coaching support for organizations that commit to zero harm
  • Creating a foundation for safe and reliable care
  • Previous episode with Dr. David Mayer, former CEO of the Foundation 

Watch the Episode:


"The first thing we say is always have somebody with you have somebody who's going to be your advocate [in the hospital]. But more than that, the advocate needs to know what to look for. They need to know what questions to ask.""What I noticed was all of us were working really, really hard for the right reasons. We didn't not fix things yet because of lack of trying.""We're also talking with the general public and concerned citizens and helping them to understand how important this is, because if they don't demand high reliability in healthcare, it's not going to happen."

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Mark Graban (2s):
Welcome to Habitual Excellence, presented by Value Capture. This podcast, and our firm, is all about helping you and your organization achieve habitual excellence. Be a one unifying focus, one value based structure and one performance system. In other words, it's about helping you capture dramatically more value through achieving perfect care and perfect safety for patients and staff. To learn more about Value Capture and our services visit Well, hi everybody. Welcome to habitual excellence. I'm Mark Graban from Value Capture and our guest today is Donna Prosser.

Mark Graban (43s):
She is the chief clinical officer of the Patient Safety Movement Foundation and organization that we really like and respect within the Value Capture team. So before I tell you more about Donna, let me first say welcome. Thank you for joining us today.

Donna Prosser (58s):
Thanks Mark. Really, really great to be here today. Thanks so much,

Mark Graban (1m 3s):
Dr. Donna Prosser has been in the healthcare industry for more than 30 years and is apparently the chief clinical officer at the Patient Safety Movement Foundation. Like I said before that she spent the first 15 years of her career at the bedside and then transitioned into administration after a personal experience, helped her understand just how fragmented and unsafe patient care can be. Unfortunately, so those experiences, as we'll hear about today really helped light a fire and a passion in Donna for improving healthcare quality and safety. Previously, Donna worked as a health care consultant, helping organizations across the United States and previously had leadership roles and or clinical roles at Martin Health System, Carteret HealthcCare and Washington Hospital Center.

Mark Graban (1m 51s):
So Donna received a doctorate in nursing practice at the university of central Florida, a master of science and nursing at duke university and a bachelor of science in nursing at George Mason university. So Donna you've seen the healthcare, the provision of care from so many different perspectives, clinician and administrator as somebody who is at the bedside with loved ones. So from all of that background, first question for you, what inspired you? What were some of these personal experiences that really got you so involved in patient safety?

Donna Prosser (2m 29s):
Well, mark, as you said, you know, I I've been on all different sides of the bed now. And so back in 1997, I was a critical care nurse, you know, working in the Washington DC area. And my first husband was diagnosed with cancer. And at the time I thought we had the best healthcare system in the world and I was so proud to be part of, of that system. And then for the next three and a half years, I sat on the other side of the bed after he had a bone marrow transplant and was ill. We experienced, you know, every segment of the continuum of health care during that time. And suddenly I realized, wow, how in the world do people do this?

Donna Prosser (3m 10s):
Who don't have the background and the knowledge that I have. And, and, you know, and I, I like to say that my husband did not die of medical error and that is great. We are so grateful that we had him for the three and a half years that we did before he passed away. He died of his disease process, but that's only because I was there to intervene so many times at the bedside because I knew what I was looking for. So that experience really made me think I've got to be part of the solution for this. And so I got into administrative roles starting in about 2002, right around the time that all of the quality and safety work really started taking hold.

Donna Prosser (3m 50s):
So I was really grateful that my leadership career grew right alongside the patient safety movement

Mark Graban (3m 58s):
And that leadership career has taken place in the context post, the IOM report of, to err, is human. Was, was that eye-opening and influential or is that just part of the context of the environment now of being able to work on these challenges?

Donna Prosser (4m 14s):
Yeah, I, you know, I really didn't know a whole lot about the IOM report before I started in leadership. I don't think a lot of us did on the front lines. And so as, you know, as soon as, as I had the opportunity, I, I read the report and I was checking the boxes going, yes, that happens to me. Yes. That happens to me. And so, you know, so I think that my personal experience really helps to put into context, the work that we had to do in healthcare to make it safer and more reliable. And interestingly, I worked for, for the next several years to on various improvement teams and two different hospital systems trying to improve health care, working with quality teams, risk management teams and so on.

Donna Prosser (5m 1s):
And we, you know, what I noticed was all of us were working really, really hard for the right reasons, you know, w this wasn't, we didn't w we, we didn't not fix things yet because of lack of trying. And in 2015, I kind of began to understand why that might be. So at the time I was the chief nursing officer and the site administrator for a hospital in the system down in Florida. And my husband, my second husband was admitted to my hospital as a patient. And prior to that time, I, and I could show you all of the graphs and all of the charts and everything that we were working on, we were doing everything that everybody else was doing to be able to say, yes, we are improving CLABSI.

Donna Prosser (5m 45s):
We're improving CAUTI. We're doing all of the right things. And then here I sat on the other side of the bed, again, nearly 20 years later and thought, huh, we have the same problems now, as we did the first around, which is the fragmented care with the system issues that we still hadn't addressed. Yes. We had done a lot to improve performance improvement. Yes. We had brought lean health care into our organization, and we were changing the way people thought about a culture of safety, but what we hadn't done yet was addressed that foundation of systemness that was still missing. And it's still missing today.

Mark Graban (6m 25s):
I think w w we can, it would be good to talk about that, that system and how do we, you know, break down silos and care, or even break down silos and our improvement efforts. But I was wondering if, you know, Donna, if you wouldn't mind going back to talking about your first husband and his cancer treatment, you, you, you said, you know, you posed the question, how do people do this? Well, this meaning being an advocate at the bedside, I was wondering if you could just share more about that role and what it means, or the importance of having someone there looking out for you, advocating for you.

Donna Prosser (7m 4s):
Yeah. And it's something that I tell people all the time when, you know, friends or people through the Patient Safety Movement Foundation will reach out and say, I have to go into the hospital. What do I do? The first thing we say is always have somebody with you have somebody who's going to be your advocate. But more than that, the advocate needs to know what to look for. They need to know what questions to ask. And I think that's what I learned more than anything was that I inherently knew the questions to ask, just because I'm in the industry, just because I've been a nurse for over 30 years. So I think, I think that is definitely something that I still worry about, that we have people in hospitals with advocates at their bedside, but if the advocates don't know what questions to ask, and they don't know what clues to look for, things are still going to fall through the cracks.

Mark Graban (7m 57s):
And when you talked about intervening many times, I mean, I think there are things that patients or loved ones would take for granted that if somebody is coming in with a medication that will, it must be the right medication and the right dose at the right time. I mean, what was it ever like that? Or what, what do you remember having to look out for intervening about,

Donna Prosser (8m 18s):
Oh, there were so many things. So it could be from the way that the dressing was changed on his central line catheter, which was done appropriately, it was absolutely medication reconciliation not being done appropriately so that he wasn't on their same medications in the hospital that he was on at home or vice versa. In some cases, it was me just knowing him and knowing how he responded to things and not being listened to when I raised concerns and said, I am concerned that he's going to react the same way to this medication as he did to that other medication that he was allergic to. And they assured me that it was, it was not going to happen the same way.

Donna Prosser (8m 59s):
And then it did. So, but again, I knew what signs to look for. So as soon as I began to see that there were that, that he was having some complications, I could intervene a lot earlier in a lot faster than, than others.

Mark Graban (9m 15s):
And so if a patient let's say is, you know, taking notes and checking things, or a loved on us, they're doing the same. What can healthcare organizations do to help that be a partnership as opposed to something that's viewed as maybe being somewhat adversarial?

Donna Prosser (9m 33s):
Yeah, I think, I think having that patient and family centered care concept is the number one thing that I learned during my time with both of my husbands being ill. And it's something that, that clinicians aren't really necessarily welcoming of. You know, I, I remember, you know, when I was at one hospital and I was talking with leaders and doing an assessment of what the current state was in terms of person centered care. And I had a physician say to me, I know what you're after you want me to say that we're going to include the patient and the family and everything that we do. And I know that that's the right thing to do.

Donna Prosser (10m 15s):
However, really at the end of the day, I just want them to do what I say and not. And I really, it, because it takes too much time and effort to include them on the team. So I think that, you know, I was grateful to him for being honest with me. And I think that is definitely the sentiment of most clinicians and administrators is because we just, we really are so incredibly busy that we don't have time to slow down and explain things at a level to help them understand so they can be a part of that team. And so I think that's where the administration comes in. Let's not leave it to the clinicians to be the ones that are, that are having to deal with that knowledge gap at the same time that we're trying to explain what is happening to a patient that should happen from the minute the patient walks in the door of the building and goes through the entire continuum of stay.

Mark Graban (11m 15s):
And I mean, I like how you phrase that, you know, being a little bit grateful that the, the, the physician was able to raise that concern, but, you know, you, you, you mentioned lean earlier as a methodology and an improvement system. You know, I think anytime we hear people say, we don't have time to do the right things the right way, you know, we can take a look at well, what is what's consuming time? How can we eliminate waste and frustration from the day to hopefully free up the time for people to participate that way?

Donna Prosser (11m 48s):
Yes. And there are so many things that we do in healthcare that are inefficient. And when I think the way that we do improvement, I take, you know, I talk all the time about how we have to have a holistic, continuous improvement framework, right? So you think about how most hospitals work, you've got a quality team and, you know, there's a falls team and a CLABSI team and a restraints team and so on and so on. And so on. There's 50 different teams that are all doing different things to improve. They're all working really hard, but the right hand doesn't know what the left hand is improving. And so what ends up happening is they end up competing for resources, competing for money for time.

Donna Prosser (12m 28s):
You know, if, if you have 10 different teams that all need to make a change in the medical record, and they all show up at it at the same time and say, please make my change. Somebody is not going to get their changes made at the right time. The other thing that happens is then that those 10 and, or, you know, 40 different teams are all rolling out, changes to the frontline in a different way. One team says let's make a change to a protocol. Another team says, let's write a new policy. Another team says nobody reads any policies. Let's just put a memo on the door of the bathroom, because then everybody will see it because everybody has to go to the bathroom. And so the front line is really struggling with all of these different ways that they're getting information about how it is that they're supposed to do their work.

Donna Prosser (13m 17s):
So I call those the six keys of clinical practice being, you know, protocols, policies, and procedures, practice guidelines, summaries, patient, education, material, patient care documentation, and then finally professional development, you know, because then those, those teams, they all then go and make PowerPoint presentations and put them on the computer based learning center and say, everybody, please go do all of these modules. And then everybody now knows what they're supposed to do. So I think, you know, so, so my two recommendations to healthcare systems is, you know, make that continuous improvement as holistic as you can be so that everybody knows what is happening and then also make it so that it's really easy for the frontline to know what to do after you've made those changes.

Mark Graban (14m 1s):
I think that's, that's great advice. And, and one other question I wanted to ask you, Donna, is, you know, for non-clinicians who are going to be at the bedside, what, what, what can we do? Like someone like myself, if I was at the hospital with a loved one, I don't know the clinical processes. I couldn't tell you what a good wound dressing change looked like, or didn't look like. I mean, do we, do we need to try to find somebody with a clinical background to be with us? Or, or what, what else can we do to help be a partner in safer care?

Donna Prosser (14m 35s):
Well, I think there are a lot of resources through the Patient Safety Movement Foundation that are very helpful for, for folks. So absolutely go to patient safety, We have some fabulous resources. We have a, an app is called patient aid, or that somebody can download onto their phone and use while they're in the hospital. For sure though, just knowing what questions to ask from the beginning, you know, what, what, what should I expect? You know, and, and, and once you're very clear on what the expectations should be, then you, you know, what to be looking out for. So, you know, obviously most people know who they can ask that information of and who they can't.

Donna Prosser (15m 18s):
So, you know, if you have a nurse that is very engaging, that you have a really great relationship with makes you ask that nurse, what are some of the things that you think that we need to be concerned about and, and, you know, and, and make friends find people in the, in the hospital who are going to be your friends and your allies throughout the hospital stay.

Mark Graban (15m 40s):
I had somebody a couple of months back ask a question and, you know, I tried referring it to someone else who may be able to just pass those questions along to you. Let's say, let's say as a patient, or as an advocate or a loved one at the bedside, you know, you try to raise a concern and you feel like it's not being listened to what would typically be an escalation path to try to, you know, you know, you know, in some contexts people would say, well, you know, let me speak to the manager, hopefully in a constructive way, like what, what paths are there in a hospital to try to make sure that your concerns or questions are being heard?

Donna Prosser (16m 20s):
There's a chain of command in every hospital. And, but I love how you, you know, how you mentioned that we need to be constructive in the way that we're asking. Very often the reason why people aren't getting the answers they're looking for is because they are perceived as being confrontational by the care team. You know, I have doctors telling me all the time they shouldn't con you know, confuse their Google search with my medical degree. Right. So absolutely we, we all need to be respectful of the role that each of us plays as part of the healthcare team. And so, you know, first asking questions respectfully of the attending physician and of the nurses on the team, if you're not getting what you need there, then definitely you can escalate to the manager of that unit or the director of that unit.

Donna Prosser (17m 9s):
If you're not getting the answers that you need there, you can escalate it to the quality department, or you can make a formal complaint usually through the risk management department. And, you know, if you, if you're still not feeling like you're being heard, continue on and, you know, go as far as the chief nursing officer, the chief medical officer, or even the chief executive officer of the organization.

Mark Graban (17m 32s):
All right. Well, thank you. Thank you for that, Donna. And cause it can be tough to navigate even, you know, people come into an academic medical center and they don't know terms like resident versus attending and that, that can I think get in the

Donna Prosser (17m 48s):
Way. Absolutely. And it's of course it depends on who you have on the care team. So in some organizations and in some, in some areas for cancer, for example, there's a care navigator very often that it, you know, or, or a care coordinator or a case manager that is somebody that you can reach out to. Not every patient has one of those, but if, you know, if you, if you are lucky enough to have one, then definitely reach out to them as well.

Mark Graban (18m 14s):
So Donna, you talked about the importance of having someone there at the bedside with you, but what, what, what have you seen or heard that's happened during the COVID era when there were limitations, if not complete, you know, inability to come in as a visitor, is, is that still the case or, you know, and in the context of that, what impact then does that have on the quality of care or patient safety?

Donna Prosser (18m 41s):
That's a huge impact on quality of care and patient safety, both. So, you know, and rightfully so, all of the, you know, all the hospitals limited visitor access, which meant that the patient advocate was no longer present at the bedside. We helped a lot of people through that very difficult time, because we were then learning how to have those conversations virtually. And how do you advocate for your loved one through zoom or through FaceTime or even on the phone? So we now a lot of organizations have allowed at minimum one person at the bedside to be that patient advocate because they saw that losing that advocate was a problem.

Donna Prosser (19m 23s):
We, you know, that the advocate is not there just to help the patient. The advocate is also there to help the care team, you're the eyes and the ears and, and, you know, and the, the assistance that patients need when the care team can't be present. So, you know, falls increased during the pandemic because people were trying to get out of bed by themselves, pressure ulcers increase because people couldn't necessarily readjust themselves in bed by themselves. So many different things happened that that made hospitals recognize the importance of having that advocate at the bedside. There's still, you know, areas where, where that is not necessarily.

Donna Prosser (20m 5s):
So, so in those cases, we, we did come up with a, a document on patient safety,, it's called the plan of care forum. So if you are a loved one and you have somebody in the hospital and you can't be at the bedside, then you can use this, this document as a guide for the conversation that you have on a, on a, hopefully at least on a daily basis with the rest of the care team

Mark Graban (20m 30s):
And what, we'll talk more about some of the resources, a lot of the great resources that are available from Patient Safety Movement Foundation for, for patients for loved ones, for organizations. So as organizations, like you said earlier, there there's no lack of effort or intent to reduce, you know, the, the, the, the gaps in outcomes to work towards zero harm. You know, it's been more than 20 years since that an eyeopening Institute of Medicine report. And, you know, I think you, you know, anecdotally sort of referred to seeing problems with your first few husbands at different times.

Mark Graban (21m 12s):
I mean, this is a broad general question, but how, how do you articulate the scale of the problem when it comes to, to harm and even death in, in, in health care things that we would describe as patient safety problems? What, what's the scale of the problem in general? How, how much progress are we seeing?

Donna Prosser (21m 32s):
You know, we, we've done a lot of good things. We really have, we, we at least are, have this performance improvement focus. We have this culture of safety focus in most organizations. We didn't have that 20 years ago. So we are moving the needle a little bit. The problem is we really don't know the scope of the problem because we don't, we don't really count those statistics. So there've been several different publications that have talked about the estimates of current. We know that here in the United States, between 250,000 and 400,000 people die every year because of medical error, we know that number is greater than 3 million on a global scale.

Donna Prosser (22m 12s):
We don't know really how many, how many there are. And we do need to do a better job of calculating that data so that we can count those statistics. And we also don't know the number of people who were harmed, but didn't die. You know, I have family members that will call me and say, oh, you know, so-and-so had a complication after surgery. She had a blood clot. I'm like, that's not necessarily a complication. That's an it's entirely possible that that was a preventable medical error, getting an infection after surgery. People think, oh, well, that's a side effects that happens sometimes not true. Usually that's a preventable medical error.

Donna Prosser (22m 52s):
And so the public you know, those patients survive those complications, but they're still preventable errors and that they don't even know. So until we actually start counting those statistics, we're really not going to know the scope of the problem.

Mark Graban (23m 8s):
And like you said, I mean, there, there, there are estimates and, you know, people push back on the estimates, it's clinicians or other leaders in healthcare. And it seems like there's this to me, a frustrating Catch-22 of not doing enough to have real data. So then the best we can do is to estimates. And then, you know, poo-pooing the estimates or even arguing about the numbers. I don't think anyone's arguing that there's not a problem. I mean, if we're comparing against a goal of zero harm, we're clearly not there. I mean, how, how do you, if anyone is trying to argue the numbers, how do you help redirect the conversation to the real challenge, which is not, you know, which, which is getting towards.

Donna Prosser (23m 53s):
Yeah, absolutely. And that's what I, that's exactly how we talk about it is, you know, one is too many and, you know, the, the, the, usually the argument that I get is, you know, what, you, sometimes there's nothing you can do. Sometimes people get infected. Sometimes these things happen, which is true. Sometimes they do. And, you know, so I make it very clear that what we're talking about are preventable medical errors. So what that means to me is, for example, if I give a patient a medication and they've never received this medication before, and they have a reaction to that medication, that's not preventable. That's a, that's a terrible side effect.

Donna Prosser (24m 33s):
That's a terrible complication, but it's possible that we couldn't have prevented it because we had no way of knowing that that's how that patient would respond to that medication. However, if the patient has a documented allergy to that medication receives it anyway, that is a preventable medical error. And so I think that's really where if, if we are, when we not, if we, when we start really calculating these statistics and becoming transparent with the data and healthcare, we need to be really clear when it is preventable and when it's

Mark Graban (25m 5s):
Well, thank you. Thank you for that. You know, that's a clear comparison. I think one example of preventable versus non preventable, you know, I've, I've had people push back on the idea of aiming for zero. I mean, that's something we're Value Capture as a firm and the Patient Safety Movement Foundation are in very strong alignment. We do advocate for going toward whether you use phrases like zero harm or the theoretical limits or ideal care, you know, what do you Donna, and to the foundation, why, why is it so important to not just emphasize on, on, on better or progress? Why, why is it so important to commit to working towards zero harm?

Donna Prosser (25m 50s):
'cause, you know, as you said, but what we're working towards it, right. That's what we're asking. Let's try, let's strive for zero. Let's not strive for 10,000 people to die, or 20,000 people to die. Let's strive to get to zero. So now whether or not that happens depends on a whole host of factors. So, but it doesn't mean we don't try. So, you know, I used to say, shoot for the moon, at least your land among the stars. And then somebody pointed out yes, but the stars are further away than the moon. So that analogy anymore. But that is exactly how we see it here at the patient safety movement.

Donna Prosser (26m 32s):
We want people to make a commitment to trying to get there.

Mark Graban (26m 36s):
Yeah, there's, there's another expression that gets thrown a lot thrown around a lot, nothing to do with astrology, but Vince Lombardi, the fan football coach is often quoted as saying if the, and I'm paraphrasing it, but if you aim for perfection, you might achieve excellence.

Donna Prosser (26m 51s):
Exactly, exactly. And that's it. That's exactly how we feel about that here at the Patient Safety Movement Foundation, you know, when we do performance improvement, but, you know, we all know that we're examining and assessing what is currently happening. And then we're also painting a picture for ourselves of what we want the future to be. Right. And when we paint that picture for ourselves of what we want the future to be, it's usually pie in the sky, best case scenario, what do we, you know, what do we want to see a CEO would say, we want to be the best hospital in the entire country. And we want excellent. You know, we want the best patient satisfaction and the best physicians. And so on.

Donna Prosser (27m 32s):
We, they don't say, well, you know, we'll, we'll accept, you know, 90% patient satisfaction rates. That's fine. You know, so if we can have that, that, that ideal, that picture of the future for everything in an organization, not just a financial implications, but also the, you know, the safety of everybody in that organization and not just patients, we need clinicians as well and visitors and vendors, and everybody that walks into the doors of that hospital.

Mark Graban (28m 3s):
So the Patient Safety Movement Foundation has articulated a goal zero harm by 2030. You, you mentioned the moon earlier. We, we did a previous episode with Dr. David Mayer talking about, you know, sort of, you know, some of the moonshot language that the foundation has been using. So in terms of that commitment to zero harm, what can organizations do? You know, if someone's listening, who's in leadership at a hospital or a health system, or if they want to talk to their leaders that, can you talk a little bit about the process for gaining these commitments to zero harm?

Mark Graban (28m 43s):
What, what, what can people do through the foundation to, to state that publicly and really, really try to accelerate that progress?

Donna Prosser (28m 52s):
Yeah. We want everybody to make a commitment to zero harm. So if you are a healthcare leader working in a healthcare organization and your organization has already made a commitment to zero harm, tell us about it. We're collecting the, you know, the names of every hospital across the world who is, is striving for zero. And, and we have a map on our, on our website that will display your information there, right alongside everybody else. If you're an organization that hasn't already made that commitment to zero, then you can access our free resources. We have what we call actionable patient safety solutions or apps for short access, that information, download it for free, share that with your leaders and, you know, help them to, to, to come to the realization that we can strive, but we can reach zero.

Donna Prosser (29m 43s):
If we do it together, it's really easy to make a commitment on our website as a simple form that, that you have to fill out, share your information with us. And then, and we'll give you a little badge that says that you're committed to zero. You put it on your website, you can put it on a billboard and tell the world because we're also, we're also talking with the, the public, the general public and concerned citizens and helping them to understand how important this is, because if they don't demand high reliability in healthcare, it's not going to happen. So there's going to come a time that patients are saying, where's your badge? Where's the badge that says that you're committed to zero, because I heard from the Patient Safety Movement Foundation, that, that I should be looking for organizations that have that.

Donna Prosser (30m 29s):
So be ahead of the curve, you know, don't wait until after patients are already asking for it and join us on our website.

Mark Graban (30m 37s):
Yeah. And I'll put a link in the show notes to that map of organizations. I mean, like you said, even as a patient or, you know, if you've got a parent going in for a joint replacement surgery or something like you can go look at that map and see, and maybe, maybe make choices based on those commitments or data that hopefully would be publicly available. Because I, I think maybe let me, let me throw this statue as a questionnaire here, your reaction. I think sometimes people assume all hospitals are equally good. I'll choose the one that's closest. I'll choose the one, or maybe it's say, well, I see billboards for these or this one has a good reputation. What are some other things from a patient perspective we can do to try to choose an organization.

Mark Graban (31m 20s):
We can look for that commitment to zero harm. What else can we, or should we look for,

Donna Prosser (31m 25s):
You know, the, the Leapfrog grades are a really great place to start as well. So, you know, Leapfrog is a great organization that, that assigns a letter grade to hospitals twice a year, A, B, C, D, or F. And, you know, obviously you want to choose somebody who has an, a rating, but understand also that, that, that information is coming directly from the publicly reported data that hospitals have to disclose. So most hospitals are putting a lot of resources into, into, into improving the populations in those particular areas. But just because you have, you're doing really good on those scores that are publicly reported doesn't necessarily mean that you have the foundation for safety across the board to support that work.

Donna Prosser (32m 17s):
And so we see that a lot in hospitals where, you know, maybe there's a, you know, there's been a lot of effort on the part of a, of a, an improvement team. They've gotten some great results, let's say for falls, for example, and their falls rate re you know, decreased the, the team disbanded, moved on to doing something else. And then slowly over time that falls right. Creeps back up again. And that's again, because we have been so focused on that population, specific improvement instead of creating that foundation for safe and reliable care. So they can also ask questions when they get to a hospital and say, tell me what you're doing to improve the foundation and the state and the culture of safety in your organization.

Donna Prosser (33m 3s):
If the nurse says, I don't know what you're talking about, I've never heard those words before. That's a clue,

Mark Graban (33m 9s):
You know, to look out for. So thank you for mentioning Leapfrog Group. At Value Capture, we're also big fans of the work that they do. Their CEO, Leah Binder has been a guest previously on the Habitual Excellence podcast here. So I encourage people to go and find that episode. And there are a lot of great resources from Leapfrog Group and from the Patient Safety Movement Foundation. So from a patient perspective and from the Binder, and, and one of the thing know, just wanted to ask before, wrap up Donna... for the organizations that are making this commitment to zero harm, there are a number of resources then that people organizations are able to tap into from the Patient Safety Movement Foundation, which you can tell us about that.

Donna Prosser (33m 53s):
Absolutely. So once a month, we run a performance improvement workshop. So any organization that makes that commitment to zero can send the folks in their organization to that workshop free of charge. We also provide free coaching for improvement teams. So if, you know, if you want to teach your improvement teams, how to go through the PDSA process, step-by-step we can help them to do that. And it's a train the trainer approach. The idea is we'll train them and then help them to train others. So, so, you know, those are free to committed organizations, and we also will provide a social media toolkit to help those organizations to market the fact that you are committed to zero and share that with your community.

Mark Graban (34m 37s):
Well, thank you for doing that and thank you for making that available, you know, to, to organizations and all the work you're doing to help educate the public and provide resources for patients. There's, there's a lot of great work going on. So again, the organization is Patient Safety Movement Foundation. Their website is that patient safety We'll link to that in the show notes. So again, our guest today has been Donna Prosser. She's the chief clinical officer for the Patient Safety Movement Foundation. Donna, is there any final thought or anything else that you would want to share with the audience here before we go?

Donna Prosser (35m 14s):
No. You know, but individuals, we do, we don't necessarily collect commitments from individuals, but any individual that is interested can join the community on and sign up for an account. You'll get our updates as well as be able to, to network with other like-minded individuals across the world. There's lots of opportunities get involved as a volunteer. We are a nonprofit organization that relies heavily on our volunteer content matter experts. So please join us.

Mark Graban (35m 46s):
Well, I hope people will do that. So to the listeners, please go check out their website again, Patient Safety Movement Foundation, or no, I got that wrong. It's the Patient Safety Movement Foundation and the website is So Donna again, thank you for sharing, you know, not only, you know, some of your own personal story and inspiration, but thank you for sharing a lot of great tips and advice for, for patients for the loved ones, for clinicians, for healthcare leaders. Very helpful today. Thank

Donna Prosser (36m 15s):
You. Thanks for having me, mark.

Mark Graban (36m 18s):
Thanks for listening to habitual excellence presented by Value Capture. We hope you all subscribe to the podcast and please also rate and review it in your favorite podcast, directory or app. To learn more about Value Capture and how we can help your organization on this journey to habitual excellence, visit our website

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