Well, thanks, Mark, and good afternoon. I wanted to thank Terry and Mary for inviting me to come back. I was here at GM 5 when this program was just kind of a twinkle in my eye. And now I'm back at GM 10, and hopefully can share with you some of our successes as well as challenges. So Mission Health is a designated rural health care system in Western North Carolina, or a non-profit system. Here you can see the mountains. Our footprint is in 18 rural counties in Western North Carolina. Here you can see the whole state. This is basically our population mission hospital, which is the main flagship hospital, is basically in the center in Buncombe County. The system is composed of a tertiary care hospital to a large hospital, 750-bed hospital. It is the only tertiary care center in that region. There is five smaller hospitals around, adding about another 400 beds. Our patient demographic is we serve a largely underserved population. There is an increased number of retirees coming in. The demographic is mostly Caucasian, Irish and Scottish, and some Russian-Ukraine. It's a very stable population. One of the interesting components of this is people that are born in this area generally stay there, and people who retire here stay there as well. We have a challenging pair mix of 75% Medicare, Medicaid, or self-pay, and a very highly rated health system and hospital. One of the reasons for me taking on this responsibility of trying to develop a personalized medicine program at this community health system is that they already had really excellent resources upon which we could build. And I think the innovative leadership of our CEO, Ron Paulus, who was a previous director of innovation at Geisinger, speaks volumes. We also had a very established health information technology system with clinical decision support alerts being built in our Surner system. A genetics program of 20 years, the only genetics program in the region. And just a few years before I came, we had developed a new cancer center. Good primary care network. And I'll just add that in 2015, we started an ACO Mission Health Partners. So the personalized medicine program at Mission in 2013 and to the present, the vision has stayed the same. It is to utilize genetic and genomic information to minimize adverse drug response and maximize drug effectiveness in both cancer and non-cancer in cancer, where we already have many standards of care for testing for tumor markers and also new avenues of exploration, especially in response to immunotherapy. In the non-cancer areas, we wanted to focus on those drug gene associations with the highest level of evidence through CPIC as well as through FDA black box drugs, where I consider it's emerging as a best practice. Not everyone may share that consideration. When I first came there, I did an assessment of, OK, let's look into the non-cancer arena. I felt like cancer was a home run and that I wanted to make some kind of an impact in the non-cancer world and looked at the levels of use of the different drugs that were an FDA black box drug. And as you can see at Mission, and we have a large cardiology group that does over 1,400 PCI procedures on ACS patients. And I thought that this would be an ideal group to start with to have clinical implementation. And much of what I'll talk to you today about is clinical implementation. We have some research implementation going on. And as many others can attest to in this room, we did meet challenges in trying to promote pharmacogenetic testing in our cardiology practice. This is not new. In 2013 and 2014, when I came to the cardiologists and said, hey, we're here. We can do CYP2C-19 testing. Here's an auditorable. I can help you with clinical decision support. They basically said, we don't really have a problem in Plavix failures. And so thank you, but this isn't something that we feel is going to help us right now. And in addition to all of the other issues that may be present in cardiology, we also looked at a research project, an observational study, looking at ACS-PCI patients who had been readmitted to the hospital due to a MACE condition and looked up in those patients, those that might be due to a Plavix failure. And again, just an observational study, but about 4% of those patients in looking in their medical records may have not responded well to their Plavix. Unfortunately, at the time, and still now, I didn't have funding to go back and do a case control study, although that's what the cardiologist, I think, really wanted to see. We had many efforts going on, including Jeff Ginsburg coming down and giving grand rounds. As we are approaching another phase of information dissemination and through IGNITE especially, we have new cardiology leadership. And I have readdressed the question of the position on CYP2C-19 testing. We had Rick Stoffer from UNC come down and give a grand rounds talk and also talk about some of the IGNITE data. And that was really very impressive. And I think it started a swell of interest and information. And unfortunately, one of our interventionalists experienced a patient readmitted within eight days. He did the CYP2C-19 testing at that time, found to be a poor metabolizer. So we are in the process of reconsidering this. So in the interim, I was working with other groups and especially the group in pediatrics. I had gone to our VP, our head of pediatrics, and said, what are we doing about codeine and children? And she said, well, I'm really concerned about narcotics use in children overall. Now, most of the kids that come to our hospital are Medicaid patients. So we weren't in a position to be able to test every single kid that came to the door. And following many other children's hospitals around the country, we decided to take codeine off the pediatric formulary back in 2015. And as Todd has mentioned, when I went around to all the pediatricians in the area, everyone said, oh, we don't use it. We don't use it. And yet our database showed, yes, we do use it. And we use it a lot in the EDs when a kid comes in with a broken arm. So having data was very helpful to show that we were using it. And now we're doing some quality improvement studies to just check about how often this policy change and this removal from the pediatric formulary has been consistent. There are still some sites that are not connected to our CERNR system, which is an inpatient and an outpatient system. So we have basically walked up through this list recently developed clinical decision support for carbamazepine in the process with digitize of doing this for a back of year. Each one of these require submission to the P&T committee and also a clinical champion for each one of those areas. So the strategy in trying to develop this program continues to change based on really where the interest is and where the support is. But when I step back, I was really focusing a lot initially on the inpatient mission health system to try to develop point of care decision support tools when a drug was being prescribed. And in that process, making sure that there was an orderable, making sure that there were drug alternatives while you were either waiting for a test to come back or deciding against using that drug. In other words, in coding, we had alternatives at different age groups. And then realizing that there's this huge primary care network throughout the region, we have a very strong AHEC called the Mountain Area AHEC. And what I was trying to do then was to try to develop some pilot feasibility studies in the outpatient setting to try to push preemptive testing in the outpatient setting and still have point of care clinical decision support for those on the mission EMR. Not everyone has a mission site. We do have an accountable care organization, but there are still many primary care practices that are not part of mission. So let me just step back a minute, and these are our current services that we provide as well as our team. I can't stress enough the raising awareness and education and training and being a resource. And this continues to be a challenge for both educating clinicians in the region as well as patients and communities. We help to develop policy and implement those policies and best practices. We work with the informatics groups to develop the actual language in the clinical decision support, and thank you to Mary and many others who have helped in this regard. We also, especially in cancer, conduct QI outcome studies, which is done mostly manually to ensure that we are complying with the policies we've put into place. And recently, in 2016, we started with a clinical research study that was funded by the North Carolina Biotech Consortium, in which we were hoping to bring pharmacogenetics into primary care. And I will show you a few slides in just a minute about that clinical research study. But these are feasibility pilots. So the pilot in primary care, bringing pharmacogenetics to primary care is about a year into the study. And we just started a supportive care study in cancer looking at pharmacogenetics for cancer supportive care. And both of these studies are basically just to get physicians used to using pharmacogenetic testing, when especially the major barriers are removed. So we have funding to cover the cost of testing for a limited number of patients in the primary care study. It's directed at patients that are 65 years of age or older on Medicare polypharmacy, where one of the drugs is one of the CPIC guideline, High Evidence-Based Drugs. And we also provide education and training. And we have a clinical interpretation summary that goes along with it. So it's basically a way for physicians who have said to me in the past, Lynn, you're not even on my radar. I can't even think about pharmacogenomics to just try it and see what the real barriers are when cost and education are taken off the table. And since the arrival of our clinical pharmacist, Dr. Jillian Bell in 2015, we can now offer clinical consultation in both cancer for genomic profiling and in non-cancer as we have a clinic that we started last year. A lot of our work is really moving silos into a matrixed integration philosophy as everyone is working in their individual areas, and yet our program cuts across all the different service lines. We have a small but efficient group of people. My VP, a hospital administrator, is very supportive of the program. I have three full-time people. Myself, the clinical pharmacist and our program coordinator, through some of our research efforts, we've been able to get funding for a half-time research nurse and a pediatric pharmacist who's been the NICU pharmacist for 10 years and wanted to do some professional development. And so he's actually learning pharmacogenetics spending a day a week in our facility. Trainees come through and do rotations in our program, and they're very valuable resources to learn from and also to conduct a lot of our smaller studies. We really couldn't do this without our consultants, Howard McLeod and Mark Dunnenberger, and without all the partners that have been really so responsive and so generous with their time that are listed here and many others not. So let me just go over a little bit what we're doing in cancer. When I came in 2013, we were still bringing in disparate oncology practices under one umbrella. And so what I tried to do is have a way to more or so bring people in for a consistent way of using tumor markers, developing the first kind of integrated tumor marker program at Mission Cancer Center. And it was basically to walk through each of the major disease sites for which NCCN had guidelines for tumor markers, make sure we were all doing it the same way, and make sure that this was common among all the different oncology groups. And also to bring together the different disciplines oncology, pathology, genetics, pharmacy, whomever was appropriate, to develop our internal guidelines. And that was something that people really hadn't done together. We've instituted quality improvement studies for tumor markers to ensure compliance with evidence-based guidelines. So for example, when I first came, we were looking at our non-small cell lung cancer patients of the adenocarcinoma variety and looking to see if we were doing EGFR-mutational analysis, ALC, and ROS on all our eligible patients. Well, we did a QI study after we implemented that policy of doing that and saw that 62% of the eligible patients got tested for at least EGFR mutation, if not the others, if there was sufficient tissue. And that the 32% of those patients who didn't get tested, there were really good clinical reasons why not. They refused therapy, they went to hospice early, or they left and went to a different institution. So a lot of what we do in personalized medicine is operationalizing process from the point of test ordering to sample submission to an interdisciplinary problem-solving, which also includes interpretation of results. And that's something that Dr. Bell is doing as we have advanced to have a lot of different genomic profiling laboratories and opportunities that we interact with. One of the things that Dr. Bell does is provide a clinical summary of these 20-page reports that's specific to the individual patient and actually looks up if there is a drug that matches their mutation to make sure that that patient, based on their other clinical characteristics, is able to not only take the drug, but if there's a clinical trial, is actually eligible for the clinical trial and that that clinical trial is really open somewhere in North Carolina. When needed, she also helps the physicians with some of the appeal process. The other research study that we're just starting right now is really to look at the feasibility of providing pharmacogenetic information to physicians, to patients, at the time when patients are starting on chemotherapy. This is for moderate or highly emetogenic chemotherapies in which at the time of education about their chemotherapy, the patient is asked if they'd like to participate in this study. Again, the testing is done free of charge. The physicians now get exposed to more of the germline orientation. So I've listed here some of the challenges in coordination and communication. A lot of the data is not in discrete fields, so manual data abstraction is quite cumbersome. I'm just going to go through some of these other challenges. In the CDS for drug gene pairs, we don't have a pharmacogenetic subcommittee of our PNT. Our group is very alert averse. We do have a personalized medicine clinic that we started last April. And most of the referrals, and it requires a physician referral, most of these are patient driven. And these are generally patients who are very complex cases that have heard about personalized medicine and are coming to their physicians. We are hoping with more awareness and some of these feasibility studies that we'll be able to improve that referral rate. Funding is another challenge for us as a community hospital. I really don't have startup funds and work on smaller grants as well as philanthropic donations. So I'm just going to end here. I had this slide and one other just to let you know that one year into this pharmacogenetic feasibility study in primary care, we have four practices, 10 clinicians, 32 patients who have had their pharmacogenetic testing completed. We have recommended changes to current drugs that they were on in 38% of those. Now again, these are pretty targeted patients. And we can go later over some of the barriers in this, which are not uncommon to what other people have described. So in closing, our lessons learned, and they continue to keep coming, is that having a top down as well as bottom up physician support is needed in our system. Solving existing clinical problems was very important rather than just saying, hey, we have a personalized medicine program.  Timing is important in terms of responding to national concerns as well as new professional guidelines coming out. So the new tramadol and codeine, we will be updating our CDS in that. I'm hoping that a pilot try it kind of approach is a way to help clinicians who are uncertain of the clinical utility of this testing in their practice and are not willing to try this in a clinical setting, but would much rather do this in a research setting. And I wish I would have done more work on applying innovation theory and implementation and diffusion science as well as understood a little bit more about behavioral economics up front, but we learn as we go. And over four years, I think I'm getting to the point where we understand a little more about what motivates our organization, our community, and clinicians in terms of changing approaches to health care. It's a work in progress. So thank you. Thank you, Lynn.  We have time for one quick question, and I'm going to take it from Rob because you're going to have to come to the mic. We'll get you for the discussion period at the end. Not quick enough. OK, quickly. So I have a very nice talk and a very interesting approach. I'm from a physician or provider education standpoint. One of the challenges we have in designing training programs is understanding how well they're able to implement that information. So we can test their knowledge after we've given them a lecture. But that isn't guaranteed that there's going to be a behavioral change. So you had some things where you were able to go into the EHR and look at who had tested. And so with how hard were those to implement? Is that something that you think can be done generally to see after training what the difference is in how they actually take care of patients? Well, that part of the research study for the primary care, we're still in the process of finding out what the physicians are doing with this information. So for those that are in our EMR, we can go in and look to see what changes have actually been made. We make a clinical recommendation or suggestion into how to change care, whether or not they do that. That will be in the second year of the study to look to see what was done with the information that was given out. So I don't have that information, but that is exactly what we're trying to understand. Great, thanks very much. So our last talk before our discussion period is Josh Denney, Vanderbilt University, someone who needs no introduction. PGX implementation research programs at Vanderbilt.


This is our women's peace ski of the year. It's got something a little bit special about it. It's got the smoothest most consistent flex and it's the Nordica Bell 72 DC. Here's Mark to give you some details on it. Hi there, this is the Bell 72 DC. This is a great all-round peace ski for multi-radius turns, short swing, long swing, GS if you want them, for an intermediate through expert peace skier. By using the double quartet that we've had in the last couple of years, we split the wood layer in two.  And this is Ellis Brigham's peace ski of the year for women and we couldn't be more delighted.


Romantic walks to KFC, salutations brother. Can I ask your opinion on the Tate brothers? Anti-matrix or controlled opposition ever since Andrew converted to Islam? He's been targeted with imprisonment or is this all just a smokescreen? I don't know if it's all just a smokescreen. I don't know, I don't watch too much of Tate stuff. I'm taking the label off. I listened to some of the stuff Tate said, videos he put out. I liked it and I looked at some of his other videos and I didn't like it. Like for example video that I didn't like we were said, why you read books? Forget about reading books. Live life. No I disagree.  What part of living your life to as full as his reading books? Period. Some of the other things? Hell yeah. Leave your life.  Make your own way in life. Become physically fit, right?  Really?  They would want more power. 100% right? So I don't know if it's controlled opposition or not. All I know is I don't I don't want his lifestyle. I like my lifestyle and I agree with some of the things he says. I disagree with some of the other things. I don't know. I haven't dug down into him enough to know otherwise. Cheryl, a lot of urban garden farm systems in New York City in the early 2000s were based on systems using Cuba. Really? Very cool. Very cool. I'm glad both the Tate Brothers are free. Yeah for sure. Because free speech is incredibly important. Incredibly important. Some would argue the most important thing in this planet right now, right? Be me nice. I think the Tate Brothers are doing a great job with everything. The only thing I disagree with them are their views on women. But everything else is top notch. Work hard, question everything. Be strong. Don't depend on anyone else. 100% agreed with you. Their opinion is a woman. I don't know from what I understand. He gets into relationships with women that are like that type of relationship, right? So more power to them. People need to appreciate that everybody doesn't like what you like, right? If someone wants to be spanked hard, that's theirs as long as they're not being abused, right? Whatever. I tell you the truth. I don't know. I haven't, again, I haven't dug too deep into the and you Tate and haven't dug into his brother at all, right? Or and you Tate. But as far as I see it, he likes a certain style. He likes a certain certain something. And he finds people that like that certain something and appreciates it. What the fuck's wrong with that? What the fuck's wrong with that?  Are they now free from lawfare? Or are they still target of lawfare? I think I think they're still target. I think they're crazy staying where they are. It's like Gonzalo lira being in Ukraine.  Well, he's arrested now. Hopefully it makes it out alive. Right? Salute Ken.


Good afternoon everybody. My name is Adam Chapter Lane. I work as the town manager for the town of Arlington and welcome to our first virtual town forum. This will hopefully be the first in a series where we'll focus on different topics. We may even repeat this topic to make sure that we're reaching as many people as possible. Today we want to talk, I want to talk very briefly about some of our general efforts in response to the COVID-19 pandemic, but we want to spend the bulk of our time having Jenny Ray talk about the programs that we are we're putting together as well as those that we're helping facilitate with other layers of government for small businesses and nonprofits. So generally I'll say we have really been following the guidance and working through our Board of Health and our Department of Health and Human Services in our response to this pandemic. All decisions we're making are based on the best public health information that we have in trying to respect, excuse me, protect as many residents as possible and break the lines of transmission of COVID-19. We of course understand that these decisions that have been made from the public health perspective are having significant economic ramifications and that's going to be a big focus of what we talk about today. So Jenny will talk a little bit about the agenda, but what I do want to mention is once we get through Jenny's presentation we will then allow a question and answer period and I'll be asking everybody to use the question and answer function through Zoom and we'll then go through those questions and answer as many as we can within the time allotted. So I will wrap up my remarks now and I will turn it over to Jenny to walk through the presentation. Thank you so much, Adam. If you would advance to that next slide. Our first technical difficulty, there we go. Afternoon everybody and thank you Adam for opening this discussion. I'm Jenny Raid, I'm the director of planning and community development for the town of Arlington and I just want to introduce you first to the agenda for this forum today. The first thing is just to explain the objectives. Really we want to be able to provide you with updates to Arlington small businesses and the nonprofit community on what the town has been doing in response to COVID-19. To be able to answer any questions and to hear from forum participants about the challenges that they are currently facing. We're hoping that we can gather a lot of information from the people who are participating today so that it will inform future forms that we hope to provide to you in the future. So the first part obviously was our opening remarks and an update on town operations from Adam. I'm going to provide you with an update on information resources that are available for small businesses and nonprofit organizations. We're going to have Q&A with and comments from the small business and nonprofit community. Then we'll wrap it up with the closing remarks and some discussion about potential future virtual meetings. So if you would go back to that first slide please Adam. So just a standing of my department we do planning and community development for the town. Members from my department have been actively working with the leadership team who've been working on this emergency response to carry out the town's COVID-19 response providing supports and information to the business community creating engagement opportunities and spaces for people to connect while they're at home and helping to ease the burden of the departments that are involved in the emergency response. The department will also be administering additional federal funds which I'll talk about that will be directed to initiatives to help address those most in need right now particularly those facing needs with rental and business assistance. Allie Carter who is actually on the line and will be joining us during our Q&A she's the town's Economic Development Coordinator and she'll be joining us so that she can also answer some of the questions as they emerge through this forum. I really want to thank her for all the work that she did in helping us to develop this forum and also developing the business resource page on the town's website. There are a few important points to note before I outline the resources that are available to Arlington businesses and nonprofits. The situation continues to be rapidly developing from both a public health and an economic perspective. The state and federal government continues to respond it is a bit slow but they are intending to provide increased resources and financial support in this response. There will be new sources of support to report at future forums including from the state so if you could now go to the website with the town's Economic Development Business Resources. For you who are familiar with the town's website on the main landing page there is a button that leads to the town's COVID response and also directly goes to the business resource support page. The online resources include a curated list of businesses that remain open for example retailers that are accepting online orders selling gift cards and other things and as you may know of course Governor Charlie Baker has issued an emergency order that required all businesses and organizations that do not provide COVID-19 essential services to close their physical workplaces and facilities to workers customers and to the public. These businesses are encouraged to continue operations remotely of course and some of them have continued to do that and others have made other business decisions. Governor Baker is to communicate with which essential businesses remain open the hours that they're open and the contact information that's available among other details if they have been provided as part of that. The town via the Department of Health and Human Services continues to provide detailed operational guidance to essential businesses Additionally a new initiative called Amazing Arlington which is a community engagement initiative primarily is launching new resources to help people maintain connections and support the local business community. It's here on this forum but continues to remain available by phone and email information will be made available for aid relief and economic security act known as CARES the CARES Act billion dollars available to small business administration loans. I want to highlight a couple of those opportunities that are available right as the paycheck protection program. This is a 100% federally guaranteed loan directed at supporting the retention of employees. Loans are up to 10 million dollars with a 0.5 interest rate and a two-year maturity. There are no payments for the first six months. There are many organizations not just businesses that qualify for this program support. Businesses, nonprofits, veterans organizations, sole proprietors, self-employed individuals and independent contractors with 500 or fewer employees are all eligible to apply. The program is now open and applications must be submitted by June 30th through any existing SBA 7A lender or through any participating federally insured institution or federally insured credit institution. The loan will be forgiven if all employees are kept on the payroll for eight weeks and the money is used for payroll, rent, mortgage interest or utilities. As I mentioned the program is currently active and it's retroactive from February 15th 2020 so employers can rehire recently laid off employees through June 30th. The other program is called the Economic Injury Disaster Loan which is a part of the Economic Injury Disaster Loan. The advance however is a $10,000 instructions on how to submit that application for both the loan and the loan can be used for any immediate business expenses and does not need to be repaid. Potential SBA opportunity is an emergency grant program that's available to provide a small infusion of cash less than the Economic Injury Disaster Loan Advance which is tied to the other loan program. Also the small business debt relief program can help businesses keep up with required payments or current or potential SBA loans. If you have not done so already we encourage you to register for updates through the SBA at sba.gov slash updates. Additionally the town locally is looking to develop an emergency program for micro enterprises serving low to moderate income employees. The town receives $1 million annually in community development block grant funds which come directly from the U.S. Department of Housing and Urban Development. The CARES Act as I mentioned earlier also provided supplemental funding to states and local governments in the form of CDBG funds. $2 million are expected for entitlement communities including Arlington. Arlington will be receiving an approximately $650,000 which will be available immediately upon the contract. A portion of these funds will be devoted to serving the small business community as well as nonprofit institutions for serving low to moderate income individuals. More details about this program will be forthcoming and we anticipate releasing them next week. We will be joining with Worcester, Fitchburg, Cambridge and Boston in this response to serve the small business community and institutions that provide critical infrastructure in normal times. Additional resources are available to nonprofit cultural and arts organizations that I also want to talk about. Last week the Massachusetts Cultural Council launched two COVID-19 relief efforts to help those individual artists and cultural organizations to address the economic impact associated with the coronavirus pandemic and associated social distancing measures. As we know from our arts and culture action plan there are many individual artists that operate in Arlington as well as host many cultural institutions and museums and other operations that we all treasure. The COVID-19 relief fund for individuals is the first of them that I want to talk about. This relief fund supports individuals whose creative practices and incomes are adversely impacted by the COVID-19 crisis. Unrestricted grants of $1,000 are available to individual artists and independent teaching artists, humanists and scientists in Massachusetts who have lost income derived from their work as a direct result of COVID-19 related cancellations and closures. The program guidelines and online application are available today and the application deadline is April 22nd. On the screen there are a couple of there are a few deadlines that are coming up that everybody should be aware of. The one that I just mentioned is also on the screen. The St. Parber's COVID-19 initiative for cultural organizations is more broadly available to support cultural nonprofits to encourage access to COVID-19 assistance offered through the federal government and to also help organizations understand their current financial challenges and craft a responsible strategy going forward. Additionally the gaming mitigation program which is also noted on the screen has a very very quick deadline that's this Friday April 17th and this is available to all performing arts organizations who present touring shows and artists are encouraged to review the program guidelines to determine if they may be eligible to apply. The non-profit finance fund is another opportunity providing webinars and online resources coupled with capacity building coaching services and many other opportunities to assist nonprofits in preparing plans and making decisions particularly during this very challenging financial and economic time. The National Council of Nonprofits is another entity that also provides these resources as well as the Massachusetts Nonprofit Network. Many of these resources are noted on the town's website in relationship to our business resource supports during COVID-19. Lastly the two sources that I wanted to mention would also be the COVID-19 relief fund which is a fund that is supporting frontline health care professionals, first responders and other essential workers who need assistance, households who are disproportionately affected by the impact of COVID-19, people facing food insecurity and others. I also want to note that there is currently a bill that is awaiting passage hopefully by the Senate which would enact an addiction and foreclosure moratorium which is really critical at this time especially given the fact that deadlines are coming up for people's rent and mortgage payments. There are many different elements to this bill and we are hoping that our delegation will act swiftly in order to address these measures and support people in the community. I will note that we have been working with our regional partners as well as our state and federal delegations in order to best serve this community. We look forward to the conversation ahead with you and we are hoping to answer your questions. Thank you so much. Thank you Jenny. So I'll remind everybody for anybody who's joined since we started if they have questions if they could input those questions into the question and answer function we'll read those and between myself Jenny and Allie do our best to answer those questions. I did see one attendee had their hand raised but if they could please please write their question into the question and answer function we very much appreciate that. So the first question is can you talk about the best and worst case scenarios for gradual slash rollout opening of the town's larger small businesses specifically venues such as the region the capital and Arlington friends of the drama which rely on large public gatherings to survive it's becoming increasingly probably increasingly problematic to schedule reschedule postpone cancel future events with such uncertainty any information even if preliminary would be helpful. So I'm I'm happy to take my best crack that Jenny and Allie and if you want to follow up on my answer that would be great. So what I'll what I'll say to that is it's it is very hard for us to provide a substantive or fact-based answer to that question. I think the best answer I can give is as many of us probably read in the globe either yesterday or this morning that a group of northeastern governors as well as some west coast governors are beginning to collaborate on putting together a combined or a comprehensive plan for the gradual reopening of the economies in various states and in contiguous states and I think that makes a lot of sense because if it's one state acts faster or slower than another it could counteract the the good efforts that have already been put in place in terms of social distance. So I I can't honestly tell anybody when I think larger small businesses especially places that as described depend on larger gatherings when they might be able to reopen but what I can say is I think based on those discussions that will be starting at the state level that over the course of the next let's say 15 to 30 days especially leading up to May 4th which right now is the date the governor has the non-essential non-essential business closure in place we'll start to learn more and more so I don't I hate to not have an answer because I know how critical it is for some of our again larger small businesses in Arlington that are so critical and important to Arlington but as we learn more as more data becomes available and as state leaders begin to advise in regards to these measures we'll we'll do our best to keep the town and the business owners informed. So the next question is do we know if there are additional funds coming for EIDL it seems like the ten thousand dollar grants have already been greatly reduced. I can take that one Adam. Thanks Adam. Sure so I think though there's been some issues with how the various aspects of the CARES Act have rolled out and I think some of the messaging that came out initially was a little bit confusing to folks because I think many folks interpreted it and I did myself as that businesses could get a ten thousand dollar grant for applying when they applied and then you know then there was the rest of it. It more specifically is a cap at ten thousand dollars and it's one thousand dollars per employee up to ten thousand. I don't think that was a change I think that was actually a change only in language with the realization that people have misunderstood. I've heard that there's already a sense that folks know that what's happening is probably not enough and they're planning for more but right now there are no detailed proposals about any expansion of what is in the CARES Act as of right now. Thank you Allie. The next question is I'm hearing from my business owner that funds are not being made available yet specifically by leader bank or TD bank and he has had that cooperated by his account. Are we aware that any funds have been given to businesses locally yet? I can answer that one as well so I have been on calls at least once a week with the Massachusetts chapter of the SBA and they for the past two weeks have been saying that they are dispersing funds they're working through them so none of this is happening as quickly as anyone wants it to. Even speaking with local bank managers they are overwhelmed with the number of applications they have something on the order of like a hundred times more applications than they usually have in the pipeline is what they're working with and this isn't a national bank this is one of our small local banks so everyone is struggling to keep a pace with the level of need. Having said that I have not personally heard from any Arlington business owner that they have started receiving any of their funds from CARES Act support that they've requested but the SBA has been assuring us that it is starting and the money is flowing hopefully we'll see that on the local level soon. Thank you Allie. So there are no other questions in the Q&A form right now you've got plenty of time if anybody look at that one just came in so regarding the EIDL loans that were announced yesterday and that the cap per applicant would be 15,000 the loans were to be up to two million so it's clear that the demand has been far greater than the funds allocated to this program Allie would you like to comment on that as you share that sense? Yeah and there's been many of you've probably seen these articles but there's been some pushback a little bit too from people that it's not it's a sort of square peg in a round hole that you know particularly for PPP the paycheck protection program that people can't actually bring their employees back to work right now they could but then they may have to lay them off again in another eight weeks and since you're supposed to spend 75% of that funding on payroll and only 25% is meant for other expenses it's almost setting people up to misuse it and then therefore not have it be a loan I'm sorry a grant but to have it be a loan if you use it correctly the grant the loan is forgiven and turns into a grant so I think there are people working on correcting the programs that are out there and whatever comes next will be a little more responsive but the whole thing is moving so fast I think when these programs were being developed two or three weeks ago or maybe four they were responding to what they saw on the ground at that time and things have changed so much then but you're correct there's just there's more need out there thank you Allie I see uh someone in the q&a said they have two questions that I'm assuming they're typing them in right now if we want to hold on for just a moment I just could add the last question a little bit or just to expand on the fact that it is a very evolving situation and that once things do reopen there's going to be a new economic impact to think about and that we're going to have to be pivoting to think about the sources of support and the resources that are needed in order to be able to roll that out and reopen and I think that our state uh delegation as well as our federal delegation need to be aware of the issues that people are facing in order to be able to reopen essentially um so any any information or feedback that you can provide directly to Allie would be very useful to us and also be able to communicate that up um so that we can advocate on your behalf and get the resources more quickly and also be able to protect you as you reopen so two more uh two questions have come in uh uh a business owner saying no one I know has received any funds uh and I applied as early as possible for the PPP and over two weeks ago for the 10K EIDL grant could the town put out a request uh for any business owners to let the town know if any money does come through so that we can then share it with other business owners because it would be helpful for business owners to know if others are beginning to receive it yeah I would love to hear back from anyone if anyone's willing to share that information with me I'd be um so grateful for it um that's actually so much of what I've learned about these programs is through your experiences and hearing your stories about how it's been somewhat problematic applying for it uh waiting on hold forever for customer service and then getting disconnected at the end of you know an hour and a half wait um I cannot imagine how frustrating that is um so please share those stories with me and if I start hearing good things or helpful hints I can share that with other folks I want to apologize in advance because my cat is coming up on me I don't mean to make light of the situation but if you're watching this video I'm being approached from the rear by a cat who might jump on me sorry I just want to uh well while there's a cat interference um I just want to put a plug in actually for Ali's survey that it's still posted on the town's website um that was really something that we pulled together early on and it may not be as applicable or relevant right now but it's still important for us to understand what you're going through in as a local business owner or even a non-profit organization so we can better understand how to help you but also Ali will be working with Kelly Linema to help to update that that survey um to uh be a little bit more current and also future thinking thank you Jenny don't worry about the cat Ali it's all this is just part of this new world order we have here um so we have three more questions that have come in one is regarding the EIDL loan um do we know if one can accept uh up to the $10,000 grant but not accept the loan and also uh Jenny mentioned that the PPP loan had five percent interest um but I read that it was one percent uh could we clarify that um I don't believe I can check and confirm this but I do not believe that you can apply for the EIDL loan and then just take the grant I'm I'm not really sure I I know that you can get the grant even if you're rejected for the loan application um but I don't know if you get the grant and then you're offered the loan application you say no thanks I'm just gonna keep I'm not sure how that would work I can find out um but I early on um two or three weeks ago I was encouraging people that even if you didn't technically um qualify for the loan that it was good to apply for it anyway because it put you in the pipeline and if things were um opening up because there was more need then you know then the fund could serve that you might become eligible um so I can try and get a sense of folks from the SBA what's coming down the line and what would happen if you were got the grant were offered the loan but then rejected it so I can follow up about that and how about the interest rate I another participant has said that the PPP loan first came out at a half percent and then was changed to one percent um Allie or Jenny do you have that information in front of me I have said it's not supposed to be more than four percent but I think that it varies depending upon the lender that you go the lending institution that you go to I'm not I'm not um you know I'm reading basically a comparison between the economic injury disaster loan and the payment at paycheck protection loan program and the comparison is that the interest rate can go not more than four percent on the paycheck protection loan and for the economic injury disaster loan it's three point seven five percent for businesses and two point seven five percent for a non-profit organization qualifying I might add um there are there are certain eligible non-profit organization another question's come in um if this is a forum this this forum that we're holding right now that will continue will we have more information that we'll be willing to share about actual distribution of funds by banks to Arlington businesses and I think you know a similar question was asked and answered I think we're willing to do that right I think we'll do our best to gather that information talk with business owners talk with banks and when we offer another one of these forums possibly next week hopefully we could have more information it would be it would be nice if there was good news to share at that point I think that at a minimum what I would say that by next week and we can certainly speak with lenders in our community and perhaps beyond in greater Boston because Allie is participating in this regional initiative with other folks in similar positions in other communities in greater Boston um so I think at a minimum we could find out what types of activity have occurred with lending institution what kinds of inquiries they're seeing how quickly things are turning around and also maybe learn a little bit about the challenges that those institutions are having in just getting those programs initiated and deployed that's part of I think the challenges we're all learning how to do some new things and I think there's there's that part of the story as well I would say that later on it would be very helpful to have the information about who does receive the loans in the end and hopefully at some point in the future we would be able to report that very accurately thank you Jenny another question a small business uh is any business under 500 employees uh why don't they address small businesses with under 50 employees with funding have either of you heard any talk at the federal or state level about a more targeted smaller business funding um it starts at 500 because the sba is you know a federal program and it's building on the infrastructure they already have in place and so on at the federal level um I know this doesn't translate well here but on the federal level a small business has 500 or fewer employees so they've just actually um really lowered the floor a lot of who can be eligible for these funds um by opening it up to sole proprietors and very small micro businesses um with the cdbg funds that we have available or will be having available um through the town um those will go to micro enterprises which are businesses that have five or fewer employees and the business owner themselves is a low to moderate income earning individual so we're trying to do that on the local level great and either alley or jenny um I know we're meeting with the cdbg subcommittee on wednesday to discuss that program and make recommendations but can you talk a little bit about um how that process will play out and when we think we might have a program to actually roll out we are meeting tomorrow with the cdbg subcommittee to review the plan for how to rate how to um program those funds we also don't have a contract yet from HUD but we anticipate that we will receive that in the next couple of weeks um and electronically so that it can be expedited my sense is that we will go to the select board in the next couple of weeks and right after that be able to make funds available um that that's my expectation I would say though at the earliest date that we can really get things up and running is likely after the start of May um you know it's it's really contingent upon getting the contract having a review and filing you know having the necessary timeline for public input um which is still required of course as part of even though it is an emergency we do have a required timeline before we can make things final submit the paperwork to HUD and with all said and done I would guess um but that said we we anticipate having another one of these forms hopefully next week so we can share more details about how that program would operate and we would still be able to actually start thinking about um educating people about how they would fill out the paperwork what information would be needed so we can get things rolling right away as soon as possible for people so people essentially would be lined up and ready to go as soon as funds become available great thank you Jenny uh we have a comment um which I'll gladly read since thanks for doing this Adam uh God bless you and your staff stay safe and healthy and joyful and we will get through this hang on so I I second that thank you to to Jenny and Allie and Joan and ACMI and everybody who's been part of this so thank thank you for submitting that um another question perhaps at the end of today's session you could let us know if there will be other virtual town hall meetings their topics and how do we learn about them thank you so I guess as opposed to waiting till the end I'll say it now and I'll say it again when we close we do plan on having there be a series of these virtual town forums we were deciding to call them virtual town forums instead of town halls to be clear that we're not actually going to meet in town hall which is sad but the is the state of our reality right now so uh yeah our plan is to really try to focus on three subject matter areas small businesses and nonprofits like we're talking about today general public health uh slash town operations focused and then we're also having discussions with the school department about whether or not we could offer an education or school department focused town forum and what we would plan to do is try to schedule more of these likely for next week we'll post them on the town website we'll send them out via town notices we'll send them out to local media and try to make them as available to as wide a group of folks in town as possible so we've had a fairly good attendance here we actually have about 25 25 residents on our 25 residents and business owners on right now in addition to the panelists so we'll take that as a good start and yeah we definitely want to continue to do this to try to provide a back and forth between town government and residents and business owners as we go forward so there's two more questions have come in one is have you heard anything about grants that could become available for businesses carrying small business loans that are not federally backed um jenny you can correct me from wrong but the the cdbg uh grants that we're looking at doing we don't pay attention to people's um there's no consideration of people having outstanding loans with that application i would not work against you in order to receive this grant funding yep sorry i'm not aware of other sources of some which you know i think you'd have to go through the various grant guidelines to better understand how they view other source other loans or liabilities um in evaluating whether or not another question would we be willing to set up virtual meetings similar to the ones that ali does with central merchants so that business owners can talk to each other this question is saying she'd love to connect with other people so ali what do you think could we put together zoom meetings for the the business groups within town yes um yes i'm actually heartened to receive that question and that's not the first time i've gotten that in the past week um just for folks who may not be aware i meet on a monthly basis with business owners in all of our three main business districts um pretty informally just to keep up on things that are happening in town and have um just a regular exchange of information between what the business owners are seeing in the community issues they're confronted with anything from parking to you know public works type issues um just or if there's a major project we have going on we just get together and talk um and we need to start doing that again just in this new format so i plan on um this week scheduling those out um so stay tuned um to your email i've been emailing the business owners a lot i have a pretty comprehensive list um that said it's not complete so i hope um when this when we're wrapping up in my email addresses out there if you are not receiving emails for me email me and i will add you to the list go ahead jenny i just want to note that um we are actively working with the our linkedin chamber of commerce and i think that working in partnership with them the chamber has been reaching out to chamber members as well as non-members um very much so through their virtual forums that they've been hosting pretty much every monday um that content has been posted on their webpage for anybody who's interested in learning more about those resources um but i will also note that we do intend to have a state of the town which is something that we've done in the past um and that'll will be another forum where we're sharing information about where we are with current affairs as well as future affairs about the town in relationship to the business community thank you jenny so there are right now no other questions have come in so i think we can probably start to wrap up um jenny and ali do you have any closing thoughts you'd like to share um just that if uh if it's not too much trouble to put back on the screen the contact uh just to to again plug that ali is a wonderful resource in the community and is available to answer questions and guide people to resources and provide support as well as that lock the executive director at the chamber um there's also a nima hotline that might be of interest to people who have uh direct concerns and you know they may be redirected to another resource but um it's a it's a good opportunity right now during this crisis to reach out to that particular hotline as well and i just want to say thank you very much uh to adam and to ali and to acmi as well as joan roman for helping us to host this forum um and that we will continue to communicate additional information that becomes available both through the town's website through the town notices and any other social media that we can put out there as well as in a future forum and i look forward to talking with people in the future and seeing people again thank you jenny how about you ellie uh yeah um i just want to thank everyone who is participating today um and to jenny and adam joan and acmi and beth at the chamber and anyone who's called me or emailed me um feel free to contact me it really um is so helpful to keep the lines of communication open i i can't help you unless um you let me know what's going on so um thank you all i know it's a really hard time and just um please hang in there um and ask for help like i know we all need it but ask for help like right away um so we have time to try and figure something out for you or connect you with the right person or resource um or whatever but uh hang in there you guys are awesome i know you're working so hard um and i really appreciate you all thanks thank you ellie uh and i'll close uh really echoing the same uh thank you to jenny thank you to ellie thank you to jone thank you to the team at acmi who have just been amazing throughout this and helping us get public meetings aired and meetings like this available to the public through multiple multiple media channels uh and thank you to all of you who are joining today hopefully this can be the first of many hopefully we can continue to get more uh more and uh wider and more diverse audience um stimulate more questions more engagement and to echo what ellie just said um we do understand just how challenging these times are for you in the business community and um though our means might be limited we are definitely willing to do anything that we can do to try to help you get through these times so whether it be joining us with this next virtual town forum or emailing ellie or myself or beth or jenny or whoever might be please feel free to reach out we we're here to support as we best can um so that we all come out of this we all come out of this together so with that uh let's let's wrap up this first virtual town forum again thank you to our panelists as well as our participants and we'll be getting another one scheduled hopefully next week and we'll uh leave we look forward to connecting again thank you everybody


Okay, great. It is 8 59. So I believe that by the time I'm finished doing our intro side, it should be nine o'clock on the dot. This is Ariana Langley, vice president of the patient safety movement foundation. Before I get started, I just want to make sure that you all can hear me. I think, Ed, when you're off mute, can you hear me? Okay. I can't. Thank you very much. Communications, it's aligned with our actionable patient safety solution number six today is June 28th, 2018. And today we'll have expert presenters, Dr. Steven Barker and nice and clear so that everyone can hear presenters. We will open up questions and answers at the end. Please feel free to chat your questions along the way. And we can always bring those up at the end. There is a chat box. The first 10 minutes, I'll be introducing the patient safety movement foundation and our actionable patient safety solutions, which we're calling our app by Dr. Steven Barker and Edwin Lawson. And then we'll follow with 10 minutes Q and a about patient safety movement. Our mission is zero preventable deaths by 2020. And so we say zero X, two, zero, two, zero or zero by 2020 and we believe that zero is the only acceptable goal because one preventable patient deaths in the hospital is one too many. The patient safety movement foundation is fostering new efforts and building on existing patient safety programs through commitments to zero. We're trying not to reinvent the wheel. We're trying to use the momentum and make as many. Commitments as possible. So these are the groups that can make who can take action. They're organizations, the patient safety movement foundation encourage, encourage us to make an online public commitment to improving safety. This can be an initiative that they're already working on, but can publicly share through our network of over 4598 hospitals across 44 countries. And so those organizations publicly share how they're saving lives and how many lives they're saving if they have the methodology to show. We have committed partners and these are nonprofits, professional societies, associations, advocacy groups, and we call them our committed partners and they sign a customized commitment to action letter. All of these are publicly available. You can find them on our website and it just encourages connections between all the stakeholders in health care that are working on patient safety. We work together and work on partnerships to align. The 3rd group that we work with our health care technology companies. This is a really important group for us because we believe that in order to improve patient safety, we must have open and freely moving data. And so we encourage healthcare technology companies, so med tech companies, lab companies, anyone who's creating patient data or can transmit patient data to sign a letter that we call our open data pledge and it encourages interoperability by removing barriers. Basically, companies agree to not block data or knowingly interfere or charge for that data connection. We have 83 companies who sign that pledge to date. The 4th group that we work with our patients and family advocates. We believe strongly that sharing stories is a really great way to get momentum and to encourage change within health systems. We also create resources. We have a mobile app called patient eater, for example, and we also utilize resources that have been developed by a lot of these advocacy groups like checklists for families that are going into the hospital. Just we call them apps in 2012. We vote on new challenges to appear on this list and everyone who's at that meeting gets about it and we vote on what the leading causes of preventable deaths are. And so you can see these are 2 or 3. So, for example, the CAUTI, CLABSI, SSI, VAP, and these are really good examples that can use to make sure that they really are doing everything that they can to improve safety. Today, we're talking about app number 6, which is handoff communications. And so our presenters today will be specifically talking about the role of handoff communications as it relates to patient safety and how we've seen improvements in that. Area. So, just to remind you how the patient safety movement is measuring our impact since we launched in 2012 and first started getting measurable results in 2013. We've seen a huge increase in the number of hospitals that are participating by making these public commitments to improve safety and then most recently last year we announced 4598 hospitals are participating in our work across 44 countries. And so it's really a good opportunity for whether, you know, here locally where we're based in Irvine, California or Texas or Brazil, hospitals are really rallying together and sharing how they're improving safety and learn from those hospitals. As I mentioned, also have the possibility if they are measuring C3 lives were saved in 2015 that jumped up to 6,571 and last year, earlier this year in February, we announced 81,533 lives were saved during 2017 and we really believe that we have to focus in on every single life. So we love being able to share these very specific numbers that hospitals are reporting back to us patient safety movement foundation. Dr. Barker, who will spend the first 20 minutes on some basics about patient safety about pass it off to Dr. Excuse me to Edwin Lofton. So, Barker received his bachelor's science and physics from Harvey Mudd College in 1967, his PhD in aeronautical engineering from the California Institute of Technology in 1972 and his MD from the University of Miami in 1981. He's reached the rank of tenured professor in both engineering from UCLA and anesthesiology from UCI UCI and University of Arizona. He chairs the department of anesthesiology at UC Irvine from 1990 to 1995 and then at the University of Arizona from 1995 to 2013. He's published over 200 scholarly work. He's now professor emeritus of anesthesiology and aerospace engineering at the University of Arizona. Dr. Barker has been involved with Massimo Corporation, a world leader in medical technology since its beginnings in 1990 and he now serves as Massimo's chief science officer and member of the board of directors. Dr. Barker is also actively involved with the patient safety movement foundation and serves on its board of directors. In 2015, Dr. Barker received the lifetime achievement award from IMPOV, that's the innovations and applications of monitoring perfusion, oxygenation and ventilation for championing the development of vitally important monitoring technologies and assisting associated testing. In 2016, he received the JS Gravenstein award from the Society for Technology in Anesthesia for his visionary understanding of the role of technology in anesthesia care and lifetime commitment to patient safety. Also in 2016, he received the distinguished alumni award from Harvey Mudd College. He's the senior vice president of integrated and acute care services and chief nursing officer of Parish Mudd. He's a progressive senior health care executive who cultivates a culture of healing and person and family when led at the medical center's efforts to become the first in the nation to earn the joint commission's integrated care certification under his leadership, Parish health care has maintained an impeccable quality in patient safety records, including our five star Parish health care. He's also a member of the world renowned Mayo Clinic that Lofton's community service includes serving the South East and Truven advisory committee, board member of the state care group advisory boards for youth colleges of nursing, board chair of the Space Coast chapter of the American Red Cross, board member of the Brevard County Big Brothers and Big Sisters and serving as the United Way of Brevard employee campaign manager. Lofton earned his master of business administration degree from East Carolina, he's a fellow of the American College of health care executives and a member of the American organization of nurse executives. So we are so pleased to have these two amazing speakers with us today. So I will pass it on now to Dr. Steve Barker to take a step back about me. Then you ever wanted to know, but one thing I'll just that I was originally an aeronautical engineer and then went into anesthesiology. So that gives you a little bit of a hint of what my approach is going to be. I like to combine the two.  Our committee has done so far our work group. And then I'd like to get very much like to get your input with that in mind. I'm actually going to try to stay below a handoff. Is it a is it a coordinated carefully time precision transfer of care from one provider or health care team to another? Or is it can be I like to use graphics by the way I should warn you it can be either one and let's talk about what what distinguishes one from the other. We'll start with some definitions. They're simple and they're obvious. So I'll go through them quickly. But I want to make sure we're all starting at the at the same point. A patient handoff between caregivers is a transfer and acceptance of care response, effective communication of patient specific information to ensure continuity and safety of care. And I will stress over and over again that the receiver is an active participant. The handoff process involves senders, the caregivers who are transmitting the patient information and transitioning care to the next caregiver, who are of course the receivers. Those caregivers accept patient information. They must understand it and accept the care responsibility when clinicians failed to properly communicate the patient's condition, either communicate or understand. The therapies or actions taken or planned or any other special consideration about the patient, the agency of help eating root cause of the required ingredients of a proper handoff. Well, here are a few and this is this is my list just for starters. Why is the patient in the hospital? What's the chief complaint? What is the problem list? What are all of the men to this hospital admission, but they might become in part important during the hospitalization? And there've been a lot of handoff at detailed description, complications have occurred. What is the discharge plan? How are we going to get this patient home? That's kind of the should say to the receiver here are my recommendations here is what I think and what I suggest. And of course, the receiver not only receives that, here comes my orientation warning, warning. It's a list and we check this list frequently, right? We check it and it's a list. Hey, it's a checklist. Of course, it's a checklist for forgetting stuff. Why do we forget stuff? Increasing complexity. That applies to flying airplanes and handing off patients and pay the other extra ingredient that often results in these disasters is what I call distract. Maybe it may just be the noisy environment in the hospital ward where you're trying to accomplish the handoff. Maybe there are some distracting events. And these are the things that kind of make you skip stuff receiving the handoff information and lead to disaster. Aviation has learned this in spades. Here's a checklist for starting up a 747. This doesn't get you in the air. It just gets you to the point where you release the brakes and start your taxi. Obviously, nobody could remember all of this every every day and nobody would even try. It's the same in medicine. And I'm not the first to have made this argument, obviously. My hat's off to Dr. Atul Gawande, an endocrine surgeon at Brigham and Women's. First, he published this book, the checklist. We did a follow-up study where he has shown has actually caused reductions in surgical morbidity and mortality. That's quite impressive. And my hat is really off to Atul. I've had the opportunity to talk with him for actually getting surgeons to use this checklist approach. So what can we do? Again, going back to aviation for an example, if you don't use a checklist, and this is my one cartoon far side for this talk, the fuel light's on. Frank, we're all going to die. You need to be sure of what you are hearing, what you are saying, and that you understand it. Here's an example from aviation. This is the only one I'll use today, but it's dramatic. You've all flown in these high performance. When these airplanes take off, they're weighted the airplane at about 450 miles per hour. But the plane has to take off at about 120 miles an hour. And that wing that's designed to support the plane at 450 has to generate a lot of extra lift with a speed of only 120. How does it do that? By putting down these flaps on the back of the wing, and you can also see the leading edge slats. They have to be made for takeoff before takeoff. Otherwise, the plane would need so much airspeed to lift off the runway, which you don't have. It's part of the pre-takeoff checklist. In this flight in 1908, not that long ago, why did they miss it? We'll never know before death's only 18 survivors. So 18. I'm not going to read all these to you, but you can see that there are four categories of senders, the emergency department, the hospital ward unit, the operating room, and the paramedics, the ambulance. And they send their patients to all of these other receiving. And for each of these sender-receiver combinations, you need a handoff checklist. We started in 2016 in our work group with these six, and we actually, 17, we added four more. So we've got a total of 10 of these checklists I'll develop now. I will show you just three, but you can study these at your leisure. You will have access to this slideshow. Here's the handoff checklist for emergency room to the operating room. This is one that I wrote. And you can see it kind of has a logical order, starting with the cheap complaint. Why is the patient coming to the operating room? What is the plan? The special anesthesia needs, et cetera, et cetera. Now, this is one of the handoffs that has to take place in some of the, some of the manicure advice on that. Here's another handoff. This is more leisurely handoff. There's usually not an intense one that can take place at variation, or it may be at the patient's bedside. And so there's a high incidence at the time of the handoff. And here's a third example, which is another one that's under intense time pressure. And that's basically from the ambulance, the paramedics, to the emergency department. And we kept that in 10 ABCDs, airway breathing, circulation, and drug. Now, 10 of them, there are at least 18 to be done. In fact, the number is more large. Are there any of these that can be combined? Are there any that, frankly, can be eliminated that we could do without? That's what I'd like to discuss. What are the next steps? What do these checklists actually look like? Where are they physically? Are they 5x7 laminated plastic cards in the pocket of your white coat? Or are they something else? And I'll show you an idea, kind of an idea on that. Some of the checklists are time limited. Here's an example of, rather than a laminated plastic card. Maybe it's on your iPad or your iPhone. This is just a very crude iPad. I want to stress, receiver, these checklists are not forms to be filled out. And I don't want people to have that impression that we're creating more paperwork. It's quite the opposite. But if we did it on iPads, they might be able to enter data. The next item on the checklist might depend on the answers to the previous item. So there's a logic to it, not just a one-dimensional list. It can be updated either by the standard or the receiver and the updates would appear on both. And that's something very desirable. As I said several times already, the receiver is not a passive participant in this. And it would, as I said, connect with the electronic medical record, get updates on labs and everything else. How about voice recognition? A. Siri or A. Alexa? Why is this patient here? Sure, why not? And I think that's... In going to the electronic and digital versions of these checklists, we are limited only by our own image. I want us all to think of these as more than just pieces of paper or plastic cards. It would be probably different for each checklist. We are not alone. We, the patient's safety movement, are not alone in tackling handoff communications. We had an excellent meeting of the Anesthesia Patient's Safety Foundation last fall, the Stolkin Conference, which was devoted entirely to handoff communication flowchart. Now these are just the perioperative ones, perioperative holding room, the room that the patients are waiting in before they go to the operating room. Every one of these white arrows between all these boxes is another handoff. So APSF is working on that and plan to continue that this year. The Joint Commission is also actively involved, not only in their... I want to point out one thing from this newsletter that I think was a very good point. Common problem in the information and the receiver. That, I have to agree, is a key part. Sixth time I've said this, the receiver cannot just be a pass ending the communications. And the receiver wants more detail or doesn't understand. I don't think all of these are universally applicable, but it's worth reading these suggestions. Conclusions are, before I hand this off to the next provider, handoff communications are not rocket science, but in stressful environments like we work in every day. It is very easy to forget stuff. Same as those design aviation. We forget the obvious stuff because there are about 20 different inpatient handoff types. As I said, we have developed preliminary versions of paper or cards. Some may be better off. Institutional variability is definitely appropriate. Different patient populations, different procedures, different protocols. One size fits all. There will be at least a minor group of pilot programs actually implementing this. Let's try these handoff procedures and checklists in some real clinical settings. To my colleague and friend, Edwin Loftin, who's going to telethical center, which is an outstanding picture of the F-22 Raptor, my favorite airplane. Thank you very much. Edwin, I hand it off to you. Well, Dr. Barker, thank you so very much. An excellent background in setting the stage. And as Dr. Barker said, what I'll do is go through the actual implementation of one of these checklists. I've had the privilege of working with Dr. Barker and the Patient Safety Movement Foundation and the subgroup on handoff communications. And I've developed the current handoff for emergency department to inpatient medical surgical units. So next slide, please. So first, a little bit about who we are, Parrish Medical Center. Parrish Medical Center is located in an area called the Space Coast of Florida, Brevard County. We look out our window and we actually look at the launch pad for Kennedy Space Center. So as Dr. Barker said, handoff communication may not be rocket science, but actually rocket science needs checklists and appropriate handover and handoff communication. It's interesting when we listen to the countdowns from Kennedy Space Center and their attention to detail using the checklist of every component of safety until that launch actually occurs. We are a standalone not-for-profit community hospital. We are the largest employer in our part of the county at 1,200 care partners and volunteers and physicians. And as Arianna said in introductions, we are a member of the Mayo Clinic Care Network. We're very honored in that we were able to build a replacement facility in 2002 that is based on the principles of healing. So we've created a physical environment that is focused on person and family-centered care. And as we approach patient safety and safe practices, our philosophy and what we believe should be everybody's is to make sure that the person and the family are part of that handover and that transition. So we spent quite a bit of time over 2017 looking at the existing patient safety movement's handoff checklist and began researching and applying principles behind our development of the ED to Med Search handover checklist, which is what you see before you. We've used several evidence-based practices that Dr. Barker referred to in our development. One is we have the background of FR situations, background assessment and recommendations. We also looked at the research done by Tull Gawande and others. We use the eight tips of recommendations from the Joint Commission. We use literature from AHRQ and the National Patient Safety Foundation to come together and say what information is critical for zero harm in that transition of care. And again, like Dr. Barker, I'm not going to read every component of this for you, but as you can see on screen, we covered very, very specific components within there. A couple of things to point out is really looking at the recommendations and the last thing. The next to last thing you see is a statement that says, my story. And this is intended as we are doing a clinical handover in the care of a person. We have to remember that it's the person that we're partnering and care with. We're not here treating pneumonia. We are here partnering and care with Sam. So who is Sam? Is Sam a 26-year-old athletic football player in college and has a sports injury that may be ending his career? Is Sam a 88-year-old great-grandfather of five who all he wants to do is be able to go home and have his great-grandchild sit on his lap one more time? That is a driver in not only the clinical care, but in our approach to safety and our connection with the person and the family in making sure we do that. The very next item is face-to-face. The evidence is very, very strong that when three faces are together during that handover and the use of the checklist, that's where zero harm can be achieved. And those three faces are the sender, the receiver, and the patient or the person in the bed. We have to include them in the conversation and we have to use language in that checklist and that handover that they understand so that they can, in a very transparent manner, ask us questions, understand what their plan of care is, and have input into their plan of care. So this was the checklist that we created. During this timeframe, I also did some data analysis at Parrish Medical Center of what could our potential impact be. So from calendar year 2017, I actually did a review of event reports and I used a very broad definition of harm or injury and we had 48 events that either were harm or injury or could have led to. And I used definitions, everything from missed medications and correct medications, missed information if a patient fell during transition or if there was a rapid response call within 12 hours of transfer, those types of definitions. So we had 48 events. One is too many in our point of view. So then we went to implementation. Next slide, please. The flow chart you see here is the methodology that we have chosen to use in that handoff. And the checklist is in the background providing the guidance for information, making sure we're not losing anything. But this flow chart is that literal movement of information, of knowledge, of person and of materials from the ED to the med search floor. And as you see in the bottom part of that, the person is in the center of everything that we do. We have now implemented the, this checklist and an associated process with this flow chart since May 6 of this year. So we're coming up on two months of implementation. And last week, I'm sorry, earlier this week, I did a data run of events during that time frame and knock on wood, whether it's by dumb luck or what I hope is more true by intentional use of evidence. Based practices, the checklist and person and family centered care during that this trial period, we have had zero harm at the bedside from transitions of care from the ED to med search. Next slide, please. So again, that's sort of the summary of where we are. Now, in addition to at this point in time having zero harm, we've seen actually several side or additional benefits come to the organization by use of this flow process and handle checklist. And that is efficiencies and operations. We've seen a 30% reduction in time from the patient being ready to move out of the ED, having a clean bed until the patient actually gets into that bed. That 30% reduction opens up beds on the inpatient side decreases lags and holes in the ED. And again, even just within itself at that point in time decreases opportunities for errors during holds or misinformation within there. So our early analysis is the handoff, the evidence based handoff checklist does allow us to move to zero harm by 2020. So that's sort of where we are in our implementation. Dr. Barker, I appreciate any input or challenge to the process and look forward to questions and conversation. Great to have both you and Dr. Barker provided with some background and then actual implementation of an example of one of the checklist and actionable patient safety solutions. So we'll move on. Dr. Barker, did you have any comments before we move on? I just want to thank Edwin for an excellent presentation and this is exactly the kind of pilot implementation program that we learn from each one of these and make changes and refinements and make it better. You're very welcome. And again, this is what I think whatever organization has the opportunity to do and what our plans at Pierce Medical Center are is probably after another two months of truly hardwiring this process. We've already begun looking at how do we edit, modify this and adopt the other checklist for the additional transitions of care when we can see this kind of improvement in zero harm for one transition. Like you said, Dr. Barker, there's at least 20 if not more other types. It's our obligation to carry those forward as well. So that you have an opportunity to ask questions. I do see that there is one question that we've noticed on the chat so we can address that one first before we unmute everyone. This question comes from Linda Chansey. We've tried processes where the nurses go to the other nurses unit to hand off where the patient with the patient and family involved, but there's a desire to change the telephone handoff with a transporter that's in quotes pushing the patient to the floor. That's actually a great question and was was was and is one of our biggest challenges as everybody I'm sure in the webinar is very well, very well aware that a nurse leaving the unit is a challenge. It's a challenge for the ED because of other patients coming in. It's a challenge for the med surge unit because of assignments and what we did in developing this process is I had the entire leadership from clinical coordinators, managers and directors from med surge and ED together. We went through a very detailed lean six sigma to may it process. We kept the focus on zero harm and we had to culturally work through how we would do that and what we ended up with is a shared approach. We now have sometimes where the med surge nurse will come to the ED and get the patient. Sometimes the ED nurse will go upstairs. But what we've done is eliminated the majority of time required for that face to face. The face to face is really an acknowledgement of the patient in the new location and a warm handover with the person in the bed seeing that clear communication between the two nurses. The majority of the information, the checklist information is actually built into our electronic health record or our EMR and as our process goes through its system. Once the bed assignment is made that trigger goes to the med surge nurse that med surge nurse then looks up the EHR reviews the information. If they have any questions for clarity, they will contact the ED nurse. They will have that clinical clarification via phone.  Thank you so much. This kind of leads into another question, which I think you may have already partially answered, but it's from Mitchell Goldstein and he asks, could you comment on EHR integration of handoff communication? I think both Dr. Barker and I can do that. As we, and I'll start with, we all have different EHRs, whether it is Surner, Epic, Meditech, whatever it is. I would beg that we need not get hung up in the integration, but instead how do we use clinical information that's already collected and already existing within the EMR and pull it to a common place so that in the review of the checklist in review of the preparation for handover, the sender and the receiver have a single source to look at and that's, we're working on that. We've got a pretty good process right now. It can be refined a little bit. And when you have that pull of information, it does not require double entry. It does not require rework. But again, the checklist and the process of the, of the handover is the foundation of how we began sorting and pulling that data to a single location. I'm glad you could join us. That one slide I showed, which was, I didn't spend a lot of time on that, but the idea was that, yeah, this would be something that was wirelessly connected to the EMR. And the pertinent results for this particular handoff would, would automatically show up in any results that either the sender or the receiver wanted that were not automatically showing up. They could demand, ultimately verbally, hey, Alexa, show me the MRI results, you know, that, that sort of thing. I think the sky is a limit on this now that we have integrated EMRs. And I, you know, I have my, my share of objections to EMRs, but the end result is going to be great because for the first time it ties all the different parts of the medical record together into one file. And you don't have to go to radiology and then back to pathology and then, you know, back to the clinical lab and it's all tied together. So it should all be accessible during the handoff. One other short comment I wanted to make, I'm a, I'm an anesthesiologist. So obviously my world is the operating room. I'm used to totally accustomed to handoffs being face to face in person. I got to admit, I have problems with handoffs by telephone. And I realize that in the real world, that's going to be at least partially necessary sometimes unavoidable, probably. But boy, there's so many advantages to face to face. And maybe we can learn from that and even make the telephone handoffs more like face to face by having do, you know, do them on something like Skype where you're actually looking at each other. And facial expressions are worth a lot. So I just wanted to put in a plug for that. Thanks. Great. This is Ariana from the patient safety movement foundation. So we have a monthly newsletter that comes out at the beginning of each month. So you can look forward to on July 2nd. If you subscribe to that, seeing a spotlight on handoff communications from UCI and parish medical center UCI talks about incorporating their handoffs and their EHR. So watch for that. And if you haven't subscribed, head to our website and join it's called follow our progress and you'll join our mailing list and you'll get that resource. Okay, we have lots of questions here on the chat room. So before we open and unmute, I'm going to continue going through some of these questions. We still have a lot of time. So how one question from us is actually used as intended and that staff aren't just science. That's in the culture. Great question again. From my perspective, that is in the culture of the organization. The organization and the individuals have to be committed to outcomes of zero harm. And if we're going to be committed to outcomes of zero harm, we have to use the performance improvement tools that are evidence based and drive that process. Healthcare is finally learning after many, many years that when we are person centered, when we are person dependent, we make errors just like Dr. Barker shared in some of the historical information, whether it be in the area industry or whatever else is when the person is there, we can make a mistake. When we use those evidence based systems such as checklist, that's when we can approach and achieve zero harm. Also, the existence of the checklist and the flow processes need to be a natural part of the EMR, a natural part of the visual of that planning for an actual transition in care. So we have it both in the EMR, we've got it hard copy and we review it on a regular basis as part of an expectation. That's a tough question to answer. Aviation obviously learned it the hard way and they are religious about it now. They do not ignore their checklist. We would obviously want to use both a carrot and stick approach. I like carrots a lot better than sticks. The carrot is that it's going to be best for the patient and you know that. The stick frankly is, I hate to sound like big brother, but, you know, we can listen to handoffs and audit them. It's like all these procedures that are being used to audit compliance with hand washing in the operating room. To coin George Orwell, big brother is watching you. Like I said, I like the carrots a lot better than the sticks, but yes, we do have to make sure that people do apply with what we're doing. And if they don't think they should, we want to hear reasons. We have a question from Kathleen O'Neill and I think it's posed directly to Edwin. So it says, how does the pilot hospital, so I'm assuming that's Parish Medical Center, have pre and post data on the length of time for handover using this new process? Yes, and as I stated earlier, we've seen a 30% reduction in that time frame. So industry best standard for clean bed assigned to patient in the bed, best practices at 30 minutes. We were not even near that world. We were greater than 60 minutes for that time frame, more in the 65 to 67 range, and almost immediately upon the implementation of this process and the checklist, we dropped that down to 40 minutes and are working on that timeframe now. So we've seen significant improvement in efficiencies. A new process with respect to handover communication. I think the answer is the potential is there. As I reported, we had 48, and again, I use a very broad term of potential harm. We had 48 events in the calendar year of 2017. Since this implementation, we have had zero events to date. And because of that, we will have the ability to intensely prevent those harm events from happening. Come studies, that's always holy grail. Is there a study that shows that your change has affected as improved outcome? Those studies are coming. And as Edwin said, we're going to see the results. I think the things I've read in the Joint Commission newsletters make it clear that the outcome of this will be positive. But we can't wait for outcome studies to be implementing this. I'll just remind everybody there are still no outcome studies showing that the use of pulse oximetry in the operating room improves mortality. And yet we wouldn't dream of doing surgery without a pulse oximeter. Great. So we still have plenty of questions coming in, so we're not going to unmute just quite yet. So keep the questions coming in the chat room. We have a question from Christina Hayes-Camp. She asks, how would you suggest that a hospital or unit of providers implement, measure, and sustain use of a handoff process in order to truly change the culture of handoff communication? I'll start, and Dr. Barker, please. For me, from my perspective, it starts with a organization's commitment to a culture of safety. The commitment to a culture of safety requires very strong, visible leadership involvement. It involves a culture that listens to the frontline staff members. It involves a culture that honors and respects the input from patients and their families. And a culture of safety requires a commitment to zero. For healthcare for years, there was pretty loud voices that zero was impossible, but we've proven. I mean, Arianna's first slide where we've saved 81,000 lives just this past year, zero is possible. And when we believe that, and we put this, and here's my soapbox for a minute, when we put the science and methodology of performance improvement, and we use Lean Six Sigma into the process, that's when a unit and an organization can intentionally implement handoff checklists and processes that achieve zero. I'll just add that this culture of safety issue, it is also one of the key emphasis areas of the patient safety movement, establishing the culture of safety. And I encourage all of you who haven't had a chance to yet to visit our website and look at all 16 of our actionable patient safety solutions attacking these different problems, one of which is handoff communications. And yeah, it's culture of safety, right. Perfect. We have another question from Lindsay Schwartz. She asks, what are some other measures of success or metrics utilized? Incidents reported on handoffs or patient satisfaction? Actually, I am tracking those items. I am looking for HCaPs data, which that obviously is lagging. I have seen, and I don't want to give numbers yet, in our vendor, I am seeing some early indicators of improvements in improved communications and improved transitions of care. We are looking at also indicators related to staff satisfaction and staff trust in each other. As I described, we've taken several months in building the team between the ED and med surge, and we've seen walls come down, virtual walls come down between those two teams. And I hope to see that as a measurable component in our next in the NQI or in satisfaction survey. A feature we've discussed of these handoffs that hadn't occurred to me is that in quite a few of them, not all, but in quite a few of them, the patient and or the family members can and should be participants. You can learn things from the patient that you can't learn from the doctor. Zeena Hayes-Camp, she says, in aviation, are takeoff checklists universal? Should there be a universal handoff communication method in medicine to ensure maximum benefit? Well, I can start with the first answer because the short answer is basically yes. Nobody in their right mind would take off in any airplane from a Piper Cub to a 7777 without going through a pre-takeoff checklist. Because when you push that throttle forward and pull that stick back, it's your life that's on the line, which is one place where the aviation analogy sort of breaks down a little bit. But yeah, the answer is yes. So why shouldn't it be universal in medical care and specifically in handoffs? I completely agree. And there is evidence-based practices such as SBAR, which provides us that starting point for universal process for developing and utilizing checklists and handoffs. And would rather ask their question by speaking. Can you hear me now? Okay, so yes, actually we use the IPAS and the research within the IPAS in developing our checklist. And we made an intentional choice to use SBAR as the format, but there are elements of IPAS within the both flow chart and content that we used. So I think making sure that we use all relevant evidence-based information is critical. I'm going to just do a quick shout-out newsletter, which is virtual. Our July issue is focused on handoff communications and does highlight successes from UC Irvine Health and Parish Medical Center. It will be released on Monday, January, excuse me, January, July 2nd. Our next quarterly webinar will be related to central line-associated bloodstream infections. We'll be announcing some speakers soon, but it's several, it'll be two speakers, hopefully, that will be speaking about how several units within our here at UC Irvine Health. You can request your invitation today. There still are some spots open, so we hope that you'll be able to join us there. And then our seventh annual World Patient Safety, Science and Technology Summit will be held January 18th and 19th at the Hyatt Regency Huntington Beach Resort and Spots and Registration Open soon. So we thank you so much for your... Thank you. Thanks, Edwin. Thank you all. Bye.