So I'm going to start out with what risk management can help you with. I have often talked with our risk management from the research perspective from the Armstrong Institute, but also operations. So when we do a training such as a cusp training or any kind of advanced patient safety training that we have, we make sure that what we are providing can be shared with them and that they can take it with them. So one of the first things I want to talk about is, when do we consult? Well, we have a very close relationship with our risk management. Before I send anything I actually send things to him first to see. If we spent a lot of information putting together let's say a tool kit for instance, and it's evidence-based, we feel very comfortable in sharing that. But what if the information is considered discoverable. So, let's say, we talk about why we're doing our evidence-based practice and it was because of the death of a patient, or because of a permanent disability of a patient. So that is something that is discoverable and could put the hospital at risk. So you have to make sure that you're actually talking to risk management to make sure that it's a case that is closed and they're happy with you share it. Further, when you're putting together an evidence-based practice bundle or tool kit, you want to make sure that you're not putting your intellectual property at risk. And when I say that, so if you've developed let's say a program to combat high glucose while patients are at home, or a program to reduce the Cubit assist in nursing homes that you have found to work very well. It involves different tool kits, it involves collation of the evidence, and it involves mechanisms in order to collect data. And you've gone ahead and you've copyrighted it. That is your intellectual property. You have to make sure that if you're going to share that with another front line tertiary care hospital or a long term care facility, that you're still given credit, that any copyright is on there, any logos that support the institute that you work on are left in place so that it can't be taken from you. And I think this is something that we never really thought about before. But programs in Patient Safety and Quality can often generate money that supports further Patient Safety and Quality effort. So you want to make sure that you're not diminishing your impact to support your quality improvement activities. The other thing that comes up a lot is people will ask us, can we share our policy and procedures? So we do something that we call a peer to peer assessment, and in that opportunity we'll send our experts in and we will review everything that they do. Let's say to prevent ventilator associated pneumonia. And in one of those things that we do is we review their policy and procedures. So what do they do for patients that are on the ventilator that limit the transmission of pneumonia? And what do we do to protect that information if it's protected and developed with the support of federal funds? So if it's supported by federal funds, it is often shared. If it is something that is supported by the institution and funded by the institution, if it is shared as an example for another hospital and is copyrighted under you, and it says let's say it says Johns Hopkins Hospital policy for prevention of ventilator associated pneumonia. And that policy gets out and is implemented at another hospital. No changes at all. It's implemented as it is written. And they have an adverse event. It does put the hospital at risk. We're very careful with the policies and procedures that we have shared, and we make sure that not only are they supported by guidelines but we have risk management's permission before we share the policy and procedure. Risk management has been extremely supportive of us sharing a lot of our material, and that is so that we can build relationships and build a network of other hospitals and healthcare facilities that are working in Patient Safety and Quality. But they don't hesitate to let us know when there's something that is not ready to be shared or that they feel puts the hospital at risk. Sometimes we do share and it goes well because we're trying to build a relationship. But it also means that some of what we do is help the other hospital develop their own policy and procedures rather than give them ours. And we never ask anybody to implement something that we've done directly as we have, because just because it worked at Johns Hopkins does not mean necessarily that it's going to work at another hospital. It needs to be tweaked for the local culture. The other thing that comes up often is, when we begin a program such as the Comprehensive Unit-Based Safety Program, the second step is to identify those defects. We use a staff safety assessment. When we're giving a talk people will say, "Well what kind of things can you fix?" So you might be able to say hospital-acquired infections, and they say, "Can you be more specific? So I work in psychiatry, what would I be able to fix?" And you've got somebody there on your panel that works in the Department of Psychiatry and they offer up a list. So does that list that they provided of potential adverse events, is it based on real events? If you're wholly sure that it is not, it's still unlikely that it's going to be shared because those are potential actionable items that are discoverable within your organization. Not only do you have to have permission when an adverse event is released to be talked about, but for potential adverse events especially if that event has occurred in the unit that you're working with. The other thing as I've said copyrighted material, it can be shared. What is important to know is that, if you develop a whole program, let alone a tool and you have it copyrighted that it is protected. If you're going to lend it out and some people charge a fee, we usually charge a fee for copyrighted materials. However, if the tool was developed during a federal grant funding, usually the federal government owns that grant so it could be Agency for Healthcare Research and Quality. If you keep the same program and further develop additional tools, additional methods of reducing harm and those are copyrighted to your hospital- You have to make sure that the person that you're giving them to, this is your intellectual property, and it cannot be changed and copied by somebody else because it is yours. They would have to have permission from you and your legal department to make any changes to your intellectual property that you have. It doesn't mean that you can't change your own intellectual property. In fact as the literature changes, you might want to update some of the tools that you develop but to make sure that if you're giving it out, that they do adhere to the copyright that's in place and they give credit where credit is due. So, new tools under development and they really should not be shared. And there's an event that I can think of when we had people shadowing to make sure that they understood what we did in quality and safety. And we invited them in and they did everything they were supposed to, they signed the HIPAA format and a confidentiality statement. So, they were good to go as far as being here to observe. What was not okay with that as they said it on some of our meetings, they were taking notes and there was a tool that was under development and they copied the tool on their own paper and titled it something else and then wanted to implement it right away when if we had been a little farther along, we still would've known that the tool still needed work. We needed to pilot it, we needed to make changes, we needed to address barriers for implementation, we would have to talk to people that were dissenters, those people that viewed it is not being very helpful and asking them why. So, you have to really be careful about things in development because they're not copyrighted at that point. So, be very careful of who is around, who's observing in your area and how much information you disclose when you're talking about some of the things that you're doing within your department. Very important to make sure that if it's especially part of a program like a patient safety certificate program, the comprehensive in a safety based program or any type of educational program that you're going to use that helps fund your quality improvement work, that you protect your intellectual property. And I think it can be said that there are things on the Internet that you can find that may be similar and you see opportunities where people have taken things that are out there and made adjustments were truly you are supposed to get permission from the person who develop the tool before you move on. And those stories to engage our audience. We always say, in fact, there are even courses now on how to tell a story to engage our audience. One of the first steps of getting buy-in or engaging your audience, is to make sure that you've touched their, not only their heart but their mind as well. So, you're giving them all of the events that occurred in the timeline that they've happened. You're also talking about what actions were done and the potential sequela. The issue is that some of the cases are very familiar with you but they also may be similar to another case that's active and ongoing. So, even though Risk Management has said yes you can talk about this case, maybe you can't talk about a case that is very similar with just some differences and nuances because you want to make sure that you have been given permission. So, I never deviate from a scheduled talk, especially if I have a case that Risk Management has decided that I can go ahead and talk about it and use it to engage people. And it is one of the first steps that we say is, you need to engage your audience and that's best done with telling a story. But make sure the story that you're telling is not going to be a surprise to your Risk Management and the senior executives for your hospital that you do have permission. And if you're allowed to tell it, are there any restrictions? I think that's also very important because there are a lot of details that we've been allowed to give but there are some restrictions that have been put on us like the long-term consequences, outcomes and that kind of things. And things to consider, and I think this is really important and it's probably something that we don't think of. I think because we're in the business of improving quality and want people to learn from us. We allow a lot of people to shadow. So, I really want to make sure that if you do have people watching your work that they have signed a confidentiality agreement and they have signed the HIPAA permit for your organization. It's a quick phone call to Risk Management and they can send the forms to you and then make sure that they're signed and they're put away for future use. It's also always better to have permission. I know sometimes we say let's go ahead and do it, and then ask for mercy later. Well, in this situation, that will never be the opportunity that presents itself because not only are you putting yourself and your career in jeopardy, but you're also putting your hospital and you could be disclosing very personal information that maybe a patient doesn't want to have out there. So, make sure that you have permission before you share any of your hospital documents with outside providers because some of them are based on true events and true cases. And further would there be a loss if a tool was used to impact a program? And as I said, a lot of the things that we do are to enhance our current patient safety and quality programs. They fund some of the work that we do. And so what happens when one of those tools is hijacked and as in the example I said where somebody copied down some of our rough work and then tried to replicate it. It remains an issue because not only is it that they've taken some of your work, but we've not finished the process. We've not piloted it, we've not made any changes to it, and it's really not ready for implementation yet. So, be very careful with those things. And I think what we have always found to be helpful is whether we are researchers or we're in operations in quality and safety, is that we have a point of contact in Risk Management and that we keep them informed about what we're doing. We've run data that we're going to share by them, we run tools that we're going to share, and we definitely run any type of story that we're going to tell in any programs that we want to share. Because I think that in our overzealousness to make sure that every hospital is successful at making patient care as safe as possible and preventing that preventable harm, we do share a lot and although, it's a great thing to do, make sure that what you're sharing is not going to put you or your hospital at risk.
