The relationship you develop with the patient is one of the most loving, giving, honest relationships you can have. That person has entrusted you. You've shared the worst and you share the best. I grew up wanting to be a nurse, never wanted to be anything else. I was probably three years out of nursing school and I was working in a cardiac intensive care unit. One of my patients had suffered a large heart attack and I was in her bedroom, which was open to her nurse's station. And I was laughing and talking with my co-workers and not really paying a lot of attention to what I was drawing up in this range. I went into her room and started injecting the medication and one of the nurses from the desk called out and said, when look at your monitor and her blood pressure had just plummeted. I looked down at my syringe and I realized I had double-dosed her on this very powerful blood pressure medication. I was crying and the patient actually took my hand and comforted me and said, honey, everything will be okay. I'm standing there in the back of the room watching my teammates try to salvage a patient that I harmed. I had potentially killed another human being simply because I wasn't paying attention.  I'll never forget it. We were able to stabilize her. It took about four hours. Stayed there about six days and then she did go home. I questioned whether I was fit to be a nurse. You know, was I morally fit to take care of other human beings if I could be so careless? So I went into grief counseling. I felt renewed. I felt like, okay, this is my fate to be not only a nurse but a champion for patient safety. We built one of the first quality circles in my unit and we looked at medication administration, how we cared for patients, fatigue in nurses. And when a nurse made a mistake, we had a team that would talk with her. We experienced less errors. We developed more processes around checking. We built in redundancy into our systems that we didn't normally have. It took about three years to get all of that set up. She came back to our unit about six months later and she was dying. Her heart was so damaged that it just could not sustain her. And I said, remember we in the hospital before? I'm the nurse that gave you too much medicine.  But I also want to tell you how much I learned. And she reached up and kind of cupped my hands and hers and said, honey, I told you it was going to be okay. And as long as you learned something, that was great. You know, her name was Shirley. And every time I start a new project, I think about Shirley. She has inspired me for a lot of my 30 years in nursing. Good morning, everybody. I'm Marty Hatley. I'm the CEO and president of Project Patient Care, a Chicago-based coalition that brings the voice of the patient into quality improvement work. I also serve as the co-director of the MedStar Institute for Quality and Safety. And I've had the great honor to serve on the Patient Safety Movement Foundation Board of Directors. The video that you just saw is something we wanted to start with today. It's the Gwen Cox video. That's what we're going to refer to it as. Because everybody in the US right now is talking about the criminal conviction of Nurse Thironda Botte for a deadly medication error at Vanderbilt University. And much of that commentary has focused on the fact that while that error was unintentional, Nurse Botte was terminated from her employment and lost her license. In contrast, the error that Nurse Cox made in the video we just saw had a very different trajectory. That nurse, Gwen Cox, was not fired, terminated, or prosecuted. And it appears to have motivated her to become a better nurse in her organization to become much more focused on prioritizing patient safety. The event led to improvements such as quality circles and teams that looked at medication administration and fatigue. So I'm joined today in this discussion about regulation and the role of regulation in improving patient safety by just a fantastic panel. We've just had the chance to catch up and talk about what we want to talk about today. We could barely stop ourselves from commenting. But I want to introduce them to you here today. And I'm going to do it in alphabetical order. So starting with my friend, Karen Feinstein, who is the president and chief executive officer of the Jewish Health Care Foundation, a long veteran in the patient safety, shaping and programming and thinking in this country, a lot of that work has been done through the Pittsburgh Regional Health Initiative, a program of the Jewish Health Care Foundation, where a lot of your quality and safety improvement work has happened over the years. Welcome, Karen. It's so wonderful to be with you today. Second is Michelle Schreiber, a physician who's the director of quality measurement and value-based incentives group at the Centers for Medicare and Medicaid Services. I get to work with Michelle as she on an annual basis kind of takes CMS's measures under consideration through the NQF process and gets the feedback from that group about what we measure. Karen or Michelle's job at CMS really is about measurement and looking at how CMS can improve safety. And she's a real leader in this space with a deep background before you went to CMS as well. And then Robin Betz is the vice chair of the Patient Safety Movement Foundation board of directors, also vice president of safety, quality, and regulatory services at the Kaiser Foundation hospitals and health plan for the Kaiser Permanente section in Northern California. So welcome, Robin. It's wonderful to have you here with us as well. So let's get back to that Tennessee case that seems to be all anyone is talking about in the patient safety movement. Wherever you go now, it's very, very top of mind. I just want to throw this question open to everyone on the panel about what are your thoughts about the impact of that Tennessee case on both patient safety and the profession of nursing? Why do we think that the responses of the two organizations were so different? Robin, why don't we start with you? I know you're passionate about this issue. Thank you. Well, Marty, the criminalization of medical errors could really have a chilling effect on reporting and process improvement for all of us. The safety of our patients and our employees is really our highest priority. And we're all committed to maintaining an environment where processes, procedures, and technology are really focused on providing the safest possible care. And it's really essential that medical errors are reported in a transparent and timely manner so that they can be appropriately addressed. And that systems and processes can be continually improved. Redonda did the right thing. She immediately reported. And she continued sharing throughout the organizational investigation her actions and mindset so the organization could surface any system issues of which there were many. And it wasn't until criminal actions were taken that Redonda had to consider the notion that she should take action to protect herself. And unfortunately, her transparency was treated by the prosecution as an admission of guilt at a time when all health care professionals have felt the stress of providing safe, high-quality, compassionate care during this historic pandemic. It's more important than ever that these same professionals feel supported by systems and practices that promote accountability, fairness, transparency, and continual process improvement. We need their voices more than ever versus having an environment that instills fear of transparency. Thank you, Robin. I think I mispronounced Ms. Vot's name, too. It's Redonda, not Deronda. So I apologize to that. I mean, we want to acknowledge her as a colleague and a whole person and get her name right in the process. Karen, you've got your thoughts on the impact of this case. Well, I was struck by one thing. I read the chats and all the online articles. And among nurses, there's been a mixed reaction, which I didn't expect. I think this is going to do a lot of damage. I don't want to, in any way, minimize that. Bringing criminal charges for a mistake is not something that is going to reassure nurses who are on the borderline of retiring. So I'm a little concerned about that. I will say, though, looking at the two different cases and the responses of these systems, there is a big difference in Nurse Cox's case. It was one mistake by one nurse. And it wasn't one that necessarily violated all the protocols and procedures. It was a mistake. In the case of Redonda, you have a much more complicated issue because there were so many failures in the system by so many people. It wasn't just one nurse, which makes her criminalization, to me, a little more bizarre. But also, maybe a system didn't even know how to deal with the fact that their procedures and protocols were violated all along the way. And it made it much more complicated. And maybe less easy to deal with. So before I turn to you, I just do want to remind us all that this is a case that's still in process. Ms. Vought has not been sentenced yet to our knowledge. There's likely to be an appeal. I know CMS has been involved in an investigation of this event, but it's not over. And I don't know how much you can say, but I would welcome your thoughts about the impact of the case in general. Thanks, Marty. I really appreciate that. So it is true, CMS did an investigation. It's been posted online. And I think what's important to remember is that in that CMS investigation, there were multiple errors that were found, as Karen pointed out. There were problems within the hospital systems. There were problems along multiple places. And that is what is common in health care. It is rarely just a problem of one person doing one thing. But most of the issues that lead to serious patient events and arm events, they're systematic. And we really need to take a systematic and deeply embedded approach to this. CMS really is committed to deeply embedded safety systems that operate where people feel comfortable speaking up and being transparent for reporting because that's the only way we will learn of events and be able to prevent them. And operate where leadership and governance also prioritize and really lead for safety and quality. So thanks. Sure. Thank you. Another surprising dimension of this case is that the health care organization at least allegedly failed to report this to regulators or to accreditors. And it's alleged that the coroner was led to believe that the patient in this case, Charlene Murphy, died from natural causes. So Michelle, I'm going to turn to you again. I know you can't comment about the specifics, but you and your colleagues, Lee Fleischer and colleagues from CDC, published a powerful piece in the New England Journal in February of this year, really calling for increased accountability and transparency in the health care system as a safety solution. What can you say about what CMS will be doing to really walk that talk of accountability and transparency? That's true that during the COVID pandemic, we really noticed a decline in patient safety. Health care acquired infections, for example, went up 40% that was published by the CDC. And our own internal data showed a rise in complications, increasing patient falls, increasing pressure ulcers, as well as a decline in patient experience scores. And so that's why CDC and CMS really felt compelled to put out a call to action for a refocus on patient safety. It feels like we lost some of the gains that we've had in the last decades. And we hope that everybody will join in this recommitment to safety. Our safety systems, this is getting back to what I was speaking about before. It isn't just one thing. It isn't one person. It is an entire system of safety, communications training, leadership, governance, deeply embedded processes that don't evaporate under times of stress. And so CMS as well as CDC is looking to take much more of a leadership role in terms of promoting patient safety. We know that IHI and AHRQ have a wonderful guideline out around patient safety. World Health Organization has another one out. And we're looking to promote those activities and really again, refocus organizations so that we're all recommitting to safety. I do wanna say another way of doing that that we haven't spoken of yet is how do we engage the patients in safety? How do we allow for patients, for example, to be able to report safety errors and patients to be able to hear about this and be engaged in the conversations and to be allowed to have their medical records so that they can look at them and comment on them. So engaging the patients, I think is another critical aspect of patient safety. Sean, I'm so glad you mentioned that because as you know, I'm very active in that patient engagement space, including being a co-founder of an organization, a network of patient advocates called Patients for Patient Safety US. And when we look at the landscape now, we've spent so much of our time trying to be a good partner, trying to be a partner during the patient care journey, trying to be a partner in improvement work, we haven't done as much in advocacy. And that's, I think, where you're really gonna see patients stand up now and already are seeing it as advocates for change because we can sometimes just say things that people in organizations, whether it's government or private sector, can't say. Michelle, Robin, I wanna, I'm sorry, Karen and Robin, I wanna turn to you because as we know, CMS has a lot of tools to make things happen. Conditions of participation, payment, just among others, contracts. But your thoughts on whether there are things that CMS can do, we'll give Michelle some feedback here or additional things they might do to better motivate organizational leaders to report the way we expect them to do. What more can we use regulation to do to get the kind of transparency and accountability we want? I would love to see, I like what Michelle had to say, we're all cheering in the patient safety world. I think we have to get better among regulators and accreditors at understanding whether the boards are really governing and the C-suite is really leading to create a safe organization. I think if you wait for a whistleblower, a random whistleblower, which happened in the case of Vanderbilt to come forward, that's not the best way to do this. You wanna prevent something from happening. And that is, I think there has to be a way the governing board, the regulators and accreditors talk directly to people on the front lines privately and find out what worries them, what seems hypocritical. Look at all the overrides of good practice that happened at Vanderbilt, all the procedural discrepancies. And I think we have to find a better way such as the simple regulation, but how do we understand what is really happening in an organization, both at the governing board level because they're responsible, but also for the regulators and accreditors. It's something more profound than hoping that a whistleblower will come forward one year after the incident. Yeah, I really appreciate that, Karen. I think those are all great things to say, but how do you operationalize it? And as a person who works in that healthcare system, you really have to, and what we do is we establish various standard work and protocols and workflows so that information does flow up to our board. And I don't know that that exists everywhere. We have a very engaged board that do hold us accountable to quality and safety, and we have a notification policy and the things that have to be escalated to the board. And we have systems that make it easy, for instance, critical issues with our medical staff go into the system and we have a process so that they can clearly see how our credentialing and privilege and gene committees followed up. And for serious safety events, the same thing, what is the protocol within your organization to escalate information to your board because they are the ones who can assure that your efforts are resourced, evaluated, and wanted to, for sustainment, hold everyone accountable. And they are very powerful if they're used and empowered to govern the way that they need to. So Robin, I wanna pick up on this because you mentioned, and actually Karen did too, governance. So governance, I guess, is a kind of regulation for what happens within an organization. And what I wanna probe with you is just the culture of safety because we've been talking about a culture of safety in this country for at least two decades, maybe closer to three and how crucial it is to preventing harm. I mean, your organization has really invested in a culture of safety. You talk about it a lot. People like you represented in the world, I think you're known for it. So what is the role, I mean, you've spoken a bit about governance, but is there anything regulation can do from your point of view to kind of incentivize or require or catalyze the culture of safety work that some organizations seem to do and others not so well? I think it's a great question. And I think we can't forget that our regulators have been with us all along the way. I'm kind of sad that healthcare required the push it did from regulators versus establishing our own self-regulation that we've seen in other industries. So, you know, when you look back at Teaira's Human, when that was published now to now, our regulators have funded performance improvement, aggregated safety performance data at a really broad scale so we can benchmark against each other and established well-vetted industry-based evidence-based safety operation standards and really ensure that we have the governance structures. It is a requirement. Our governing boards are responsible for the quality and safety of the organization and when our regulators come in, they look for that accountability. They trace through the activities of activities up to the board. And when those don't exist, we are held accountable. I think that, you know, I think we can continue to have that partnership and on, you know, there's the regulation side and then there's the collaborative side with we have our regulators and continuing to promote education, especially of our boards is really critical. Karen, I'm gonna get to you about culture of safety in a second, but I'm remembering that Michelle, before you went to CMS, you were at Henry Ford and you were one of the developers, one of the reviewers or developers that worked to develop the latest IHI guidance on optimal practices, best practices for boards in healthcare. Is there anything, you know, that you can think of given that expertise that boards can do more of or do better? There are many things that boards can do to be engaged in quality and safety. I think the first one, frankly is willpower and actually a commitment in placing that as one of their highest priorities, if not my own personal opinion, the highest priority in healthcare. What is more important than taking care of our individuals and our patients in the safest, highest quality, most equitable way? Beyond willpower, you know, there are lots and lots of best practices around high reliability processes that can be put in place, daily safety huddles, deeply embedded communication structures. There are many things that can be put in place, but boards have to make sure that those are placed and make sure that there are resources that are allocated to the organization and that they're hearing about what is going on so that that in and of itself promotes these activities. So I think there's a great deal that it can do. And I have a deep belief that leadership and governance really is absolutely essential in establishing the culture of safety, even tracking the culture of safety, doing those culture of safety feedbacks. I think that's where it starts, but it has to permeate to the front line. So this culture of safety has to go from leadership to the front line and frankly back. Yeah, I'm gonna add to that too. One of the most wonderful things from my point of view about the partnership of patients is the metrics they put into place for person and family engagement. One of which was do you have people who identify primarily as a patient or family member on your board of directors? And when we surveyed, baseline surveyed about that, there was massive variation in the country. There were some communities, some states where everyone had a patient on there. It was just part of the culture and then others where it just wasn't. So I'm personally rooting for that to be a metric at some point in time. But Karen, I now need to turn to you because you and I have had this conversation a couple times over the last couple of weeks about the culture of safety and how long we've been waiting for it and how, I don't wanna pick just on Tennessee because these cases, we get a blockbuster kind of case like this every year or every year or two that hits the papers where you just see an organization not stepping up the way. We think they would be after 20 years of encouraging a culture of safety to be adopted. So what do you have to say? I don't wanna steal your thunder. You're on mute, Karen. Totally cynical. I've been waiting two and a half decades for this culture to emerge. So first of all, payment. You want a culture of safety. You'll get a culture of safety when we pay for healthcare differently. We all could talk about value-based payment but I'm sure that's another panel. But it is, it is in, it is so intrinsic to the culture of safety that I can't separate them. But quite aside from that, surprising to all of you, I'm gonna come down on the side of some regulations. Some things shouldn't be allowed. An example, we regulated crash carts and people adhere to that. We haven't regulated the fibrillators. There were so many, and you know, there were so many things in this particular incident that should have been regulated. But one is, how can you be administering a paralytic high alert agent and not have the rescue med there? I mean, I don't understand that. And how can you be monitoring the waiting room when that agent's been already administered when you can't tell whether the patient is in cardiac distress or brain failure? So, you know, I look at some things that I think at this point, I'll take the fibrillators. That's actually my favorite. Every year our system deals with the fibrillator deaths. Standardize them for heaven's sakes. Standardize things that should be standardized. So you may be surprised. I'm coming down on the side of the regulators here. Thanks, Karen. I wanna get back to that technology point in just a second. But before we leave this sort of culture segment, I'm just cognizant that everybody on our panel today is from the United States. And we do have an audience that is global. And one of the global vectors right now that's very prominent in patient safety is a new global patient safety action plan put up by the World Health Organization last May. So just about a year ago. And it really, you know, it looked at the continuing challenges. It looked at what we've learned over the last 20 years and they come down really hard on, not hard, but really strongly, I should say on national governments really having to step up and lead to create that culture and to create the systems. Michelle, you're our representative from the federal government today. What more do you wanna say about what CMS can do or DHHS can do to really kind of create that culture, not just in the innovators and the early adopters and the organizations like Robbins with really committed leadership, but system-wide? I think that there are a lot of things that are in place already, maybe more deeply embedded and widely spread, but remember the conditions of participation do establish an absolute floor for quality and safety. That's the purpose of the conditions of participation and organizations have to participate in evaluating the quality and safety and they're surveyed for that as well. There's been the quality improvement organizations, the Partnership for Patients, for example, that has provided support across the country. In COVID in particular, provided incredible support to nursing homes for patient safety and have provided support in many activities and really helped drive patient safety as well as then the quality measures that we have that allow us to look and compare one hospital, one facility, one provider to the next with deeply vetted quality measures that have been embedded in now over 20 quality value-based programs that tie performance to payment. Now you could argue maybe we should tie more performance to payment, for example, you could argue that maybe there should be more regulation, more validation of the data, but others then will argue that we're already too intrusive and so there's a middle point in there somewhere. It can't just be government though that's going to solve this issue though. There has to be responsibility at all levels, both local and state governments, boards that we've already talked about, individual providers. So I can't say it can be just government, but we certainly have tried at CMS to be leaders in this role and we are working very hard to align, especially across CDC, AHRQ, CMS to continue to promote and lean in patient safety. And in fairness, I think the World Health Organization is just prescribing what you said about government leading, but multiple stakeholders all having roles, educators, product manufacturers, creditors, patients all having responsibilities to play. Okay, thank you. Karen, I'm gonna go back to you for this one too because I know you're really active in this space through your work at the regional, through your work through the regional, Pittsburgh Regional Health Initiative, but technology, we've seen technology really improve outcomes. I mean, I think the classic example is the pulse oximeter. I mean, when we look now at what's safer, everyone points to anesthesia, but it's been antiseptic hand gel, CPOE, EHRs, a number of tools that have come out of the technology development sector that are improving care. And I know you feel strongly about the fact that we have a lot of tools right now that can actually help us identify and prevent things before they happen. So we don't have situations like the Tennessee case. What more do you wanna say about that? Oh, you know you're hitting my button, one of my favorite topics, but you look at all the things that could have been prevented autonomously, that should never have happened because we have the technology and we have the data now to understand that these could have been prevented and to do something about it. It's also very frustrating to me, this is not an under-resourced center, but the year's 2022, we can land a little helicopter on Mars, little ingenuity hops around. And honestly, we could have prevented the override on the high alert paralytic medication. I think when you issue those meds, you should issue the counter med, the rescue med at the same time. We should have ongoing assessment and maintenance of critical equipment that can be automatic. That does not have to be done by humans. That can be done autonomously. So sort out this common and generic name problem in just what the nurse entered. I mean, that could be fixed. The alert system, we've gotta fix that. How many meetings do we go to?  Well, fix it. We have technologies and algorithms that could fix some of this. And I think of the many ways that we could have monitored that patient to know immediately that she was going in the wrong direction. This is all so possible now. So my sense is these autonomous technologies, you know, the way that anyone in our industry would look at safety, they would be in place, you wouldn't even think about it. They would be in place so that the frontline staff doesn't have to constantly be thinking and checking and rechecking. That can be done now. So that we build them a better airplane. We don't rebuild them. So let me invite Robin and Michelle to comment too. What role could regulation play in making what you just said happen? What more could we use our regulatory tools to really get every organization to be doing what you just outlined as possible? Michelle, Robin? Robin? Yeah, you know, I think we take too long. I look at tubing misconnections where a tube feeding is connected to an IV. The male and female connection points were identical. For years and years and years and people died from tubing misconnections. And we tried to put in standard work that would prevent that, such as, you know, when you do a nurse handoff, you trace the lines back to the, from the patient, from the device. But that's a lot of manual work. And of course there's elements of potential human error because of the human factors involved in that process. And, but now finally, the industry has responded and the tubing manufacturers were mandated to make those connections different, to make it easy to do the right thing and hard to do the wrong thing. I feel that, you know, that our government agencies have been good partners in many ways with performance improvement. We had, for instance, in the United States, the Center for Medicare and Medicaid Services had their partnership for patients and they funded activities that reduce hospital-acquired conditions and readmissions. And we had incredible response to that. And I think that we could organize in such a way that we have more prompt identification and then expectations of implementation of corrective actions that permanently protect patients from harm. I think we take too long in our processes. I can understand how people think that we take too long. On the other hand, I have to tell you, it's unusual for me to be on a panel where people are asking for more government intervention and more government regulation. There aren't a lot of people who necessarily vote for that. But I do think with all of these programs, we are trying to encourage and support through the QIOs and the conditions of participation, through public reporting and transparency and through payment policies. We're trying to support quality and safety. But again, it takes everybody to participate. And at the same time, look, I'm a big fan of standardization, please don't get me wrong, but we have to support innovation as well and allow organizations to do what is right for their organization. And so although a lot of us would like to see more standardization as Karen was talking about, we have to allow for innovation and we have to allow organizations to find their best way of doing things too. I just want to take this opportunity. Oh, go ahead, Robin. I just want to say, I don't know that necessarily takes regulation, but like I said, I've really appreciated the partnership and the support that we do get. And you commented on those. And I think just continued more of that is very welcome. And the investment of resources. I mean, we always want more resources, but the partnership for patients, 80% of the hospitals, of the country's hospitals participated in that. And it was a real driver. It was a collaborative on steroids. HRQ was the biggest funder of research on patient safety in the world. So we're doing, it's not like we're not doing anything here. We're actually stepping up in a number of ways and I'm appreciative also, Michelle for CMS leadership there. We have about 15 minutes left before this wonderful session. I will have to sadly come to a close, but I do want to turn to an idea that's out there in a couple of different formats. And that is the idea of a new national agency, a national patient safety board it's often referred to. The Patient Safety Movement Foundation has kind of a call for a moonshot complete model of a federal agency based on the FAA, Federal Aviation Administration. Karen, you've got a more tailored approach that I know you've built an entire coalition around through the facilitation that you've done and it's not a regulator. It would be an independent agency. You're referring to it as a national patient safety board. There's a coalition that would essentially be a home for reviewing patient safety events when they happen. What do you want to tell us about that agency and its role? Well, I do want to thank the Patient Safety Movement for being such good friends and partners along this journey. We've tried so many things at our end at the Regional Health Initiative for 22 years now. And I'm looking for something that is a national home that is an independent, nonpartisan national home, a think tank for ongoing research. Michelle, I love innovation. And by the way, the human factors, people would tell you standardization and innovation are not in conflict. You standardize so that you can innovate. But I'm not sure innovation has to take place unit by unit, hospital by hospital, system by system. I think that we've made a mistake in healthcare. I think we've entrusted a lot of safety innovation to the medical profession. I love my doctors. I love the medical profession, but we're not engaging enough human factors engineers, people who are expert in AI and artificial intelligence, machine learning, robotics, even advanced analytics, predictive analytics, there's so much we could be doing now to anticipate harm and make sure that we've eliminated as much harm as we can before it ever occurs. So the other problem you had, and you saw it in this case in Vanderbilt, we don't have a home with an open portal for patients and families who've encountered an error. So how many times have we seen in cases the family termed a litigation, they didn't want to turn to litigation, but they felt that the death of their loved one was in vain. And so the idea that there's a portal, a place where people can turn to say there's a serious problem. One thing we noted in Vanderbilt, there's nothing new about what happened there. And in fact, I just came from an academy health panel and I put that out there and everyone in the room was nodding their head. These two medications are confused. The problems they had are happening in other hospitals. What went on at Vanderbilt could go on and probably does go on in other places. But I think at the federal level, I'd like to have one home that could constantly, not distracted with a lot of other issues that aren't safety issues. Focus, the resources we have now in terms of technology and data on preventing harm before it occurs and working with the industry, working with the healthcare industry to come up with solutions that are so powerful that what happened at Vanderbilt couldn't happen. Karen, I'm gonna turn to Robin next because I can see her nodding her head, but before I do it quickly, how would an organization like the NPSB that has no regulatory power make a difference? I mean, what would be the mechanism for it actually creating change? Well, as you, Marty and Michelle and others who've been on this journey for years, no, there was nothing new under the sun about this idea. So I'm totally humble. It's been, for three decades now, someone has proposed or some organization something like a national home. We chose the National Patient Safety Board and PSB because the MTSB, the National Transportation Safety Board has been so powerful in terms of bringing about an ongoing trajectory of safety and transportation. They have no regulatory power. They don't penalize, they don't sanction, they don't expose, but they bring together experts whose qualifications are so extraordinary that it couldn't be challenged. And they bring them together and come up with solutions that are endorsed often by the industry, but these solutions are so powerful that they can't be ignored. They are required by Congress to present them to the regulators. The regulators have to respond in 90 days. And so I think it's 80 to 90% of the solutions that came out of the NTSB have been adopted by regulators and are now standard practice in the industry. Robin, your thoughts, I've seen you nodding here. Yeah, you know, I think an organization like this could really reduce administrative burden for one thing. If we could establish a single set of reporting criteria, regulators from federal state to county, as well as the, you know, the PFOs, right? They all have variable disparate taxonomies and this, and they kind of want their own slice and dice and this creates administrative burden that really takes away resource time from actual performance improvement activities. And it would be great to have a single reporting portal that could aggregate data and trends, surface industry vulnerabilities, especially considering the ever-changing environment of healthcare where we have new technologies, medicinal agents that are added to the environment that carry known and unknown risks. And this organization could provide also concurrent performance measurement versus the lagging data that much of our industry-wide data operates against. So I think like sunsetting the PSOs and moving towards a National Patient Safety Board model and then from a federal to county level, the responsibility would be not to report all these places that your responsibility is to participate in the National Patient Safety Board who becomes a strong collaborator and advocate with our regulators as we share across our learnings and promote the level of safety that we need for everyone. Thank you. Michelle, you might have a different opinion here. What are your thoughts about a new federal agency? I'm not sure that I can or will comment on the establishment of yet a new government agency. I will say that I think that there's opportunities even within the agencies that we have to do more standardized national reporting around error. AHRQ, for example, does have a patient safety organization and they get some reporting, but they don't really get all of the national reporting I think that we're talking about here. In providing deep analytic systems, once we have that reporting, so that we can really track trends, look at trends and come up with recommendations. Reporting in a standardized way, I know the CDC through their NHSN is a great portal for reporting healthcare acquired infections and they're looking to report more patient safety data as well. So I think that there are opportunities to use what we have even more efficiently and more effectively, but I don't know that I can comment on yet another agency. No, I understand. We actually did have Paul Yang on this conference last year talking about the 15 year look back at PSOs too with some recommendations about how they can perform better. So we'll wait to see what happens there. Michelle, I wanna stick with you. We're kind of, I wanna hit two more issues before we break today. One of them is the work that I know is a personal leadership effort of yours to look at the role of structural metrics and really advancing priorities of the administration. So you have been the leader in sort of guiding the NQF process on a structural metric on maternal and child health and most recently on health equity, really getting commitments from hospitals to be working in this space. Tell us more about that and can we hope that there might be some kind of approach like this on patient safety? Well, I will say that there are certainly thoughts and conversations around something like that. We recognize that there are people who don't really like structural measures including NQF doesn't always support structural measures. But the truth is a structural measure is a commitment. It's a commitment that an organization is generally engaged in quality improvement is actually looking at their data, their leadership and their governance is engaged. We're talking about maternal safety. We're also talking about equity and something similar for safety could be something that is considered. But we think structural measures actually change behavior and really they are the first commitment of any quality improvement process that any of us undertake is to ensure those things are already in place. It's the same almost PDSA model that involves a commitment from the beginning. I've sat in the hospital workgroup of NQF, the measures application partnership where these have come up. And I know there's skepticism because they can be gained. I mean, they're gonna be the check the box kinds of concerns, but they do send a powerful signal out there that this is what we're prioritizing in this country. This is what we hope that organizations will commit to and making that commitment, I think it would be really an important step, especially now where we see so much of the progress we've made on patient safety lost in the last few years. One last issue I'd like to get to before we close today is nursing homes. I mean, we're coming out of a pandemic where we've just seen the rates of death in nursing homes pointing to big failures in infection control processes and other systems approaches to safety. What should we expect in addressing this issue? Michelle, can we start with you again? Many of you probably saw President Biden's state of the union and that subsequently there's been a long document that has been put out by the White House and supported obviously our cross HHS of a real commitment to obviously advancing equity and driving high quality, but particular for nursing homes because we saw what happened in nursing homes. And there is a multi-pronged approach now to looking at nursing homes, to ensuring that nursing homes have adequate workforce and safety mechanisms in place, looking at staffing levels and staffing turnover, expanding the skilled nursing facility value-based purchasing programs so that payments are tied to performance. So there are multiple initiatives that are ongoing across CMS and HHS, including ramping up what we've talked about earlier quality improvement organization support, which was really vital during the COVID pandemic where not only did we have QIOs that were helping but surveyors were going out and providing guidance as well as oversight for best practices in nursing homes. So I think we can all expect to see a very robust focus on ensuring quality and safety in nursing homes. Thank you for that leadership. I know the quality conference that CMS does every year, that huge conference is happening soon. I hope to hear more there. We are close to the end of our time. We've got just a couple of minutes left. So I just wanted to see if any of you have any last comments that you'd like to make about the session or anything else we've talked about today. Robin, why don't we start with you? Thank you, Marty. I think there's a lot of policies in place and sanctions for failure and in reporting and to really incentivize us to mitigate issues. But so I don't know that we need more at this point, but thinking back to this Tennessee case, I hope our policymakers will evaluate that case and really look to establishing much stronger policy for quality protection. So we can continue to have the learning systems that we've had up to this point. Thank you. Thank you, Robin. I mean, that was so well said. Karen, final thoughts from you. I'm going to finish with a comment about nursing facilities. We did a documentary on what COVID exposed in long-term care. And I want to echo Michelle, we have a real crisis coming up when you look at our demographics. We have a shortage of nursing home beds and a tremendous challenge in keeping our best nursing homes going. And I'll only say that our foundation put $35 million into creating a great nursing home. And we closed it last year. We could not possibly, on the reimbursement we get, keep an excellent nursing home going. And we didn't want to run a low quality one. You cannot put all these requirements on nursing homes without changing the reimbursement. This isn't just a problem for our seniors. It's a problem for everybody of middle age who's going to have to find care for their parents. Michelle, I want to thank you first of all for just bringing the concept of equity into this discussion because we didn't spend much time on it. But the way in which CMS is connecting the issues of safety and equity, we're not going to be able to meet our equity goals unless we have safe systems. I think it's just admirable. Final, so thank you for that. And final thought that you want to leave our audience with today. My final thought is, as you know, over the next coming week, CMS will be unveiling the CMS National Quality Strategy. It really ties a lot of this together and focus on improving outcomes, equity, front and center, safety, innovation, including advanced analytics, digital and our operability of data in most of all, alignment and cooperation across the federal government and reaching out to all of our stakeholders. Because we recognize we can't do this alone, it has to be all of us together. Great. Well, thank you, everyone. I can't, I mean, it seems a little weird to say that I had fun today because our topics have been so serious, but it was just a great pleasure to work with you and talk with you today. And I'm sure it will be of real interest and very provocative and stimulating to our audience at large as well. So thank you very much.


Let's pray and it's just kind of this time in the God's hand Father we thank you for this for this day. We thank you for this time Lord but even as we We've been learning about life skills and communication and how to be effective communicators Lord I pray that even as you called each one of us Lord to communicate the gospel and to communicate the truth Lord, I pray that what we learn Lord will be useful and it'll be used for Not for the extension of your kingdom father God, and I just pray that each one of us Lord will be able to sharpen our skills a little more and Find out what needs to be done and carry that out in our own lives for the God so that we can do things effectively and for your glory That we will understand people a little more better Lord with all the skills that we That we are upgrading ourselves with Lord. We thank you and we ask that you would teach us That you would show us Lord and Spirit of God God even as you Lord imparted so many different skills Lord, right? We as we see in scripture God We pray that you will impart this skill as well to us. We thank you We give you all the praise and glory in Jesus matchless name. We pray amen Okay so last class we looked at interpersonal communication and We looked at several aspects of communication right, so Ken Anybody share what what is it? Maybe each person can Share about what is it that you took away? You know from last class What is that that you remembered and what is a learning that you took away from last class? Anyone anything specifically related to communication that That's a Stephen yeah, yeah It's just one point like how poor communication affects Relationship Just that one. Yeah. Yeah, so how poor communication Results and breakdown of you know relationship Be it official or personal Right, right Yeah, so so very true and so very significant because You know since it affects relationship Lack of communication or poor communication, you know, it destroys that so so yeah So the importance of good communication. Yes Anyone else? Yes, different kinds of communication skills and also principle of communication So listening also one part of that when someone needs to speak to me Yeah, yeah Yeah, so we saw that communication is two ways It's not just one person downloading or dumping, you know, what I know what I'm saying You know just dumping that it's it's actually two ways. So So the other person is listening Taking time to receive whatever is being communicated And also, you know, the The other the person who's communicating or sharing information also taking time to listen to the other person in order to understand Better, you know, what is the person asking and what is the person saying? so that we understand and The next sharing of information would be even better because you understood What they need of the other person was and understood the query and so you're able to you know satisfy that With our communication with the sharing of information. So yeah So we looked at it as two ways and also the importance of listening like Kiran said and today in fact, we're going to look at a lot more spends some more time on Listening and why listening is important and how to be a effective listener and some of the barriers, right? Which come in the way of listening effectively Yeah Anyone else else maybe just one more person What was your takeaway? From last class anyone else Okay Okay, so what did you learn about verbal and non-verbal communication? anyone do you remember that we looked at verbal communication and we also looked at what is You know not spoken But it's at the same time. You are still communicating So any anything on that? that you remember verbal non-verbal Anyone can and said Thomas Dave Anything that you recall about verbal and non-verbal communication the importance of that Verbal is using the means of speech. Yes, what you speak what you Yeah, that's true And what about non-verbal is non-verbal communication? Is it effective non-verbal includes facial expression body language etc. Yes, non-verbal is more like actions. Yes That's true So we realize that Yeah, an expression so we realize that you know if verbal communication and I'm sorry verbal is not in sync with the non-verbal then or you know in other words like if I say something but my Facial expression or my gesture Is not in line with that, right? I'm saying something which is very very I'm giving a message maybe like an invitation or something but my Body language my facial expression is not friendly enough or No, it's it's giving us certain. It's a different message altogether Then there's a mismatch, right? I'm saying welcome but My body language is different. You know, I'm it's not welcoming. You know, I'm like saying welcome I'm you know probably crossed my hands and my tone of my voice There is no smile on my face then even if I say welcome Yes, I'm so glad that you are here. You know it Conveyes a different meaning altogether right the message Even though the words are welcome. We glad you're here But the non-verbal message that is going out is there's something else something different and many times non-verbal speaks louder right and So we need to To be effective communicators. We need to ensure that Not saying that you need to be You know be an actor and you don't do all those things but but really To make sure that the verbal and non-verbal now go hand in hand And it's authentic. It's real really mean it from your heart, right? Okay, so okay So we looked at all all that last last And I just want to encourage you to you know go through your notes also, you know once you finish the class Maybe during the week. It's just one week once a week, right? So you can just go through the notes and that will help you to kind of reinforce whatever we learnt in class Okay, of course now the videos are also available so you can go through that Okay, so today we're gonna look at listening skills or listening ability. Okay, so The ability to receive information understand information, you know comprehend it and And and and do that well. Okay, so listening skill now If I don't listen effectively then I cannot communicate effectively it affects my communication why because here I am down Downloading some information upon you and I'm not taking time to Understand what your actual need is Right, so maybe it it could be it could be in different scenarios It could be an accounting scenario It could be it could be a professional setting where you're with a client or with a customer It could be a ministry setting where you're you know listening to the needs of a person You know, maybe as a pastor or as a as a leader or it could be You know Leadership setting like maybe you're a team leader or you know and and you're not listening effectively listening actively and that is Causing certain Blocks in communication. Okay, so so first off Let's try to understand. So what is the difference between hearing and listening? Okay Anyone Okay, I'll just put it on the chat here hearing Versus listening is there a difference are there similarities? What do you think? Hearing and listening. What is hearing? What is listening? Anyone? What does it mean to hear? Can all of you hear me? Yeah, so so okay Dave so hearing is to be able to know the sensation of sound Okay, so hearing is is more mechanical. It's okay. It's auditory function where if your Organ of hearing is functioning properly, you're able to hear the sound that is being made, right? You're able to hear the speech everything so You're able to receive that information but listening It's a little different because we hear and we also making some effort in order to understand what is being said in order to Comprehend what is being said so that would be the key differentiator between you know Hearing and listening so listening would involve us focusing on Whoever's speaking Right. We're not turning away Because if it's just hearing we can just turn away and walk around I can just hearing the sound. Yeah, it's loud. It's soft and so on but We are focusing on the on the one who's a speaker and we are concentrating and they're putting in some effort in order to understand Make sense of what is the message that is being said you're paying attention and You're in doing so we are receiving a lot of information, right? We are the the non-verbal cues we are receiving and that the emotion of how What has been conveyed that is also something that we are receiving right so so Listening is a very active Process It's very active it involves effort That is why you know listening can be tiring Okay So you're listening you're because you're putting in a lot of effort You're focusing you're using your your mind You're you know Understanding what is being said so it can be you know tiring, right? And that is why you know, maybe even after classes, right? three-hour three hours and You feel a little tired. Okay, you want to You know take a stretch and take a break and so on so it's because it takes effort You're using up energy in order to listen so It takes focus it takes concentration and you do that. It's a very active process and therefore This phrase active listening is used in order to describe the process of Effective listening no active listening where you're involved in Receiving that information. Okay, so, you know, there's a lot of research and people say that And if you if you're following in your notes, you're looking at page 22 and you can see that You can see that the diagram which is there so it talks about how 45% is spent listening compared to 30% of speaking, right? So we spend While as adults we spend 70% of our time in in in engaging in some sort of communication 45% of it is spent listening compared to 30% Speaking 16% reading and 9% writing. Okay, so so which means that it is it is a lot. It's quite a bit that we are using In communication and we need to know what's going on and what's going on And we need to do it too well Okay, so why is it important? Why is listening important? Okay, we know that it aids communication, but specifically why is Listening important. Okay, so let's look at that some aspects of it. Okay Well, it is important because we can avoid distractions when we listen in a focused manner We avoid distractions to receiving the message. There could be other things happening and there could be other preconceived notions in our own mind Right about the person about the message, but we we can put all that aside when we and receive the the message In an effective manner Excuse me So to get an accurate understanding So that's the thing to put away distractions to get an accurate understanding of what is the person What is the speaker conveying? What are the views of the speaker? What are the ideas of the speaker? Okay, that'll happen only when we listen effectively and we actively listen Okay And also to critically assess what is being said. So so you okay, you're saying um Okay, this person is saying something now. I need to analyze it Okay, I need to assess it Excuse me. Um, give me a minute. So Sorry about that So, uh, let's say a person is saying something and you want to analyze the content of what is being said Now I cannot do that unless I listen effectively You just think about it, you know, you want to discern you want to analyze you want to come to your conclusion about that But you'd be able to do that only when we, um, you know, listen effectively. Okay Um, and also to observe the non-verbal signals, you know, the person might be saying something but we might miss out We might miss analyze something Okay, and make our own judgments Let's say an interview Okay, so you're the person who's You was interviewing the person and if you're not an effective listener and if you're not, um You know looking out for those Verbal cues and what is being said and how is the person person? Um, what is the person's body language? What is the person gesture if you're not if we are not, you know, receiving all that and not actively listening Then I might come to certain conclusions about that person right, uh Which might be wrong And which might actually the my decision whether to hire someone Whether to not hire someone Will be an impaired decision in the sense it's affected by my ineffective listening Right, so, um, so you see the importance of it, right? I might come to a decision Uh as a leader I might come to a decision as someone who's Uh, you know as uh, who's someone in a leadership position who's you know, who's interviewing someone Uh, the the other side was also true You know, maybe I am being interviewed and the person is asking me something And I might not Answer Effectively, I'm not be able to give this a correct answer if I did not listen You know, I maybe I heard the first line And then I was trying to figure out what to answer and I missed out the rest of the question Right and I begin to just so I might the answer that I give Will not be full and satisfactory to the person who's asking me the question. So that's that's also true So you see all this, uh, is linked to effective listening. Okay, so So and a few others as well So so the thing is this that uh, effective listening requires focus requires concentration Requires us effort from our sides from our side, okay from It is not the same as hearing which can be a little passive, but it's a very active effort Okay, so let's look at Some principles of listening. Okay, so we are Let's say if I want to Upskill or you know make my listening a little better I need to know what are some principles? Okay, now a good listener will listen to not only what is being said, but also what is left Unsaid or what is partially said? Okay, so What is not being said? I need to understand that also um, for example, uh, look at the body language look at some Uh, non-verbal messages and And and then, you know, you what are some expressions? right, um, if suppose somebody is uh, saying or sharing a message which is A happy message, but the tone Is very sad You know, like we were looking at the example like you know, you ask someone how they're doing and they're saying Uh, I'm doing great, but but really their tone Suggests that they are not doing So great, but the words are say words are like i'm doing great And especially, you know, if they have texted that message, you think that they're doing great Right, suppose they sent a text or sms Or what's that message and they're saying i'm doing great You would have thought okay this person is doing great, but Maybe when you're speaking to them face to face they are saying they are doing great But their tone indicates that They are actually sad They are not enthusiastic They are actually sad so so All this, uh, it's it helps us. So let's look at some Let's look at some pointers or some principles of effective listening something to help us to be effective listeners Okay, the first thing is Listen Okay, so first thing is to listen Listen In a focused manner and don't interrupt with your own talking Okay So that's that's something, you know, we Sometimes we You know in our in our we mean it in a sincere way You know, let's say for example, we ask somebody something and then they they are answering and You know, they are searching for words and you complete the sentence.  Which means we need to be patient. We need to let the person speak and not really interrupt Okay, so Sometimes we we the person is speaking And they have not really finished Responding fully Right, they've not even finished the sentence, but we we come across and we we say, you know, our own Our own thoughts, okay, you know, but actually, you know, this is what happened or something like that Which means that we have not been listening Right, we have been thinking about what can I say next and we say that right, so So which means that we need to Listen, we need to stop Interrupting With our thoughts our ideas and let the other person Speak, you know mark twain's Come Court it's very, uh, you know, it's really significant. It's really Uh Brings that out. You're saying If we were supposed to talk more than we listen, we would have two tongues and one year The bible also talks about that right and in the james chapter one. We see that um, I think that references Let me read that first Okay, james one and verse 19 So then my beloved brethren, let every man be swift to hear slow to speak slow to Be quick to hear and that word here there Use there means to to actually understand To to comprehend Which is listening right so slow Slow to speak slow to wrath About quick to listen right, okay, so how can I Prepare okay, second thing is to first thing we saw. Okay, don't interrupt Um, don't share your own don't complete the sentences for the person let the person speak The second thing is prepare to listen, which means you relax Like sometimes we can be distracted by other things put all those distractions away You make up your mind. Okay. I'm going to listen to this person now You make up your mind and say, okay, all distracting thoughts all interrupting thoughts I'm going to put it away. I'm not going to think about those things. I'll deal with it later But here's this person in front of me and I'm going to Give my full attention and so so you you Uh, make up your mind to listen Okay, so there will be other interrupt interruptions like okay, maybe your phone ringing Maybe you need to put your phone on silent. Maybe you need to you know, Switch off those notifications. Maybe you need to maybe, you know turn your phone And put it face down Right, so you don't see what's coming up on the screen. Sometimes we need to do those things right the other thing is to Make the other person feel free. Don't intimidate that person Uh, encourage that person to speak, you know And sometimes what would help is when we look at the person when we nod our heads The person says, uh, you know today. I just thought I should share with you some difficulties that I'm going through And we can go on and yes Yeah, just tell me right so so the person feels encouraged to share Right, so suppose that person says, you know, I just felt that I Want to talk about some difficulties and then you're looking at your phone. Um, yeah, yeah, tell me What are you saying? And the person knows that you're not interested right just even your You're saying okay. Just tell me Indicate to the person that You're not giving them that importance And sometimes we do that with family Right most times we do it with them Either we're talking to our spouse or you talk to the kids and and you know, you're just doing this and tell me Yeah, what do you want? and and you know that Uh, that is not that is not helping so they are you're sending the Non-verbal message that whatever you're saying It's not that important Right now the work that I'm doing the texting that I'm doing now that is important Important than what you have to tell me so we learn to put this away You know, this is of course it is important work and etc. But then When we have these conversations, right put this away and say okay now I'm going to Give full attention, okay look into their eyes and and So that they know that okay this person is attentive and wants to speak Okay, maybe You know you need to put away certain things like if you're in an office situation, you know, they could be They could be loose paper. There could be stuff, you know So don't don't start arranging those things as you're speaking Like putting those things away, you know arranging books arranging things Um, you know just focus on the person. Okay. What happens is, you know, different people speak at a different rate Of speech right some people might speak very rapidly And get their views across some people might take their time And it might be very uh You might find it very impatient, especially if you're a person Who's used to you know doing things and and you're like, when will this person finish? Hey, the person is taking their own time and they're saying and there's a long pause and You know they I just thought I should tell you and and you know Just waiting. Oh man. So if you start, you know, like on the table if you're doing that That means that you're impatient, right?  If a person is slow to speak or maybe if they are pausing we need to Give them that time, you know, sometimes I I think I'm guilty of that, you know, I try to finish their sentence and So I'm just learning to be a good listener Sometimes I finish their sentence and I'm I'm impatient. I'm trying to help them like with with the ideas with thoughts And that's not really helping actually It's distracting them from what they want to share and sometimes they get influenced by that and say things that they don't want to say also Right, so we're not Being good listeners and we're not getting the actual truth The actual message of what that person wants to convey Okay, so um So yeah, so these are some things that to look at for avoid personal prejudice because of persons The way whatever they are dressing Maybe their mannerism You know, don't come to certain conclusions. Oh people with long hair. They are like this or people with You know Piercings body piercings people with tattoos. They are like this. Don't Let that influence you don't bring your personal prejudice And influence you so that that shuts down whatever they are trying to say, right? Um, so let it not distract you listen to the tone Very important You know, you're hearing a message What is the tone of their voice? Okay, is it um, is it a happy tone? Are they excited? Are they not excited? Are they sad? Are they agitated? fearful Right, all that is conveyed In the tone of their voice, right? Right, for example, if I'm if I'm using this kind of tone Like you hear my voice and I'm saying, I'm saying, you know, I'm really excited about what is happening right now That's a very excited tone. But at the same time if I say, you know, I am I'm really excited about what is happening And that's not a really excited tone. You know, that's that's like Low on energy and and so on. So what is the tone? Like, uh, is that person agitated angry? Or is the tone really conveying, you know, uh, what the message is so, uh Observe the tone listen to the tone, right? So You understand, okay, what is that person saying? What is the emphasis of what is being said? All that comes from the tone. Okay Then the other thing is To listen for ideas and not just the whole not just the words. Okay. So what is that? Okay um Because when people Now this is very subjective, of course um you know people are conveying certain informations in some information is being conveyed but It is in bits and pieces Right, it's bits and pieces maybe because the person is agitated. Maybe the person is angry They are conveying something And in the words, you're not getting the full picture Right in the words that they're saying, you know That's they're not conveying through what they're not being articulate But we who are listening Will be able to put it together based on the tone based on their Their expressions And the words that they are using so that would help us Get the full picture Right um And of course they were able, uh, I mean they are gestures and facial expressions and everything Eye movements also, you know would help Get the clear picture. Okay. Now, um Now there is something called a hurrier A hurrier model of listening. Okay. Now each This is uh developed by someone in Cornell University Judy Browner It's it's helpful to remember and to to understand. So let's let's look at that You know H-U-R-I-E-R each letter It's an acronym. So each letter talks about something something. So the first one H is hearing Okay, so It refers to the physical act of hearing. Okay, so make sure that you're hearing everything you're picking up everything On what the word is on the what words are being said and also other things, right? You understand Okay, understand what is heard. Okay, maybe there are some things that are being said that you don't understand You know make an attempt to understand uh Our stands for remembering. Okay. Sometimes what happens is uh, the person starts to say something and you've forgotten, you know this happens typically uh You know when a person gives too much information um Maybe about an introduction or about themselves And you uh, I'm sure you you had that experience where at the end of that particular line You've forgotten what? Maybe it's an introduction about themselves. You've forgotten the name of the person Right because you your mind drifted off and you looked at And you were thinking about what that person said what the person was doing and you forgot the name of the person And uh, you had to go back and you know ask them again. So I'm sorry What did you say your name was? Right, um, which is just good. We could do that. But the thing is that your main mind Trailed off and you forgot to actually remember the name of the person, right? So Our stands for remember. I uh, is interpreting Okay interpreting based on what the tone and everything interpret the message uh, e is evaluate Okay, evaluate what is being interpreted don't jump to conclusions about what is being said interpret it correctly And uh, e uh is into evaluate and R is respond Okay, so our response Helps in communication like where you can clarify Maybe a person says something and um our response to that could be to ask a question In order to clarify what is being said. So you're saying that um, let me just understand a little better So you're saying that, you know, is this what you're saying? Right, you're saying that you will meet me at this place at 10 o'clock. Right. So the person says no No, I didn't say that I said, you know, I'll your call at 10 o'clock. So you've clarified Um based on your response. Okay, so h u r i e r Uh, a hiria model is um is easy And to do this right So that is that is what we see. So there are some barriers to effective communication. Um, so Yeah, let me just look at it. Just give me a second one second one of the barriers is of course, um, you know being distracted Uh, we looked at it earlier, but it's something that we need to uh work on consciously being distracted by the person being distracted by Maybe what the person is, you know person said by their mannerisms So we forget or we lose out on what the person is saying, you know, um, so One of the things is to put that aside.  So to be a effective listener is to put away all these distracting Manorisms of people. Um, that would really help us, right? Okay, and also, um, uh The other thing is also about the rate of speech. Okay rate of speech. Some people speak very fast um, especially if they're excited and And some people take their time to speak to communicate So They might take a long long time to finish a sentence So especially during such times it's We can drift off We can drift off we can we start thinking about certain things What you need to do maybe after this Uh, etc. And then suddenly you realize that Oh, I didn't pay attention to anything that was said And now I have to respond, right? And I think in today's day and time When you have these zoom meetings and you have these online things, you know, that's the danger, right? Okay, so this Saying I could relate to that.  I'll finish this I'll finish this person. I'll finish this email And you're very happily you're doing that And suddenly somebody asks you a question And uh, and your response is, um, yeah, can you just Ask that question again? Can you just repeat that question? I didn't get that but the fact is that you didn't get anything that was said, right? Uh, and you completely You're in the dark. Okay, so distractions These are things that can be barriers rate of speech This tries a barrier. Okay. Um Okay, um The other thing is, um What can be a barrier is our own body language Okay, so What can be a barrier to listening is our own body language in the sense you can easily Show or tell the person that we are Not interested because of our body language right, um, because, uh Uh, our body language could be very very defensive. You know, you're closed or you're like that Or you're turning your face away Because you're not interested even though you're saying Yeah, tell me something but you're you're not even looking at that person So that will be a barrier to the person To communicate further. So that again becomes a uh barrier Right, so our body language becomes a barrier for the person to open up and share and uh, You know, plea for people who are in ministry if you're in, uh, you know, let's say, um, your pastoral role or a counseling role It's it's so so important for us to learn to be effective listeners And uh, you know, I don't know if it's a if it's a if it's a case with men But really, uh, you want to solve right? As a person somebody's sharing information you want to solve that problem And the minute they start sharing your Thinking of you know solutions one two three. This is what that person should do But we are not really listening to what they are saying. Okay We're not really empathizing what they're saying. We're trying to solve so much the thinking of solutions that We're not really listening and we are, you know, and and the solutions can be great Or the solutions can be a complete mismatch because we have not listened to the whole um Whole problem what is being conveyed? Like we're not listening to that. So whatever we are suggesting You know can be a mismatch And it can be as serious as that whatever advice you're giving whatever solution you're Putting forth we are putting forth can be a mismatch to that because we have not listened fully you're not listened actively okay, so So So I just want to ask you, you know, how many of you think they're that you are good listeners You know, this is something that I need to work on You know personally for me Listening is something that I really need really need to work on because I can You know, my mind sometimes wonders and thinking of solutions all those things Um, so what about you on a scale of one to ten? How would you rate yourself as a listener? You know one is very poor 10 is very good Okay, seven Okay, even I just need your score. How would you rate yourself on a scale of one to ten? uh as a listener Thomas eight okay Kiran five Kanan 5.5. Where is the point five coming from? Okay, Aaron is six Dave is seven uh five maybe Okay Yeah Okay, so all of us, uh, I think we um We need to work on this area because many times we we think of communication as only speaking Right, and I told you that example of how in a group discussion for this for this management course Since it was it was part of a Admission process that everybody wanted to convey something and make themselves To be heard and so that the people will take notice of what they had to say And so everybody was speaking nobody was listening, right? Nobody was Listening to the other person. They just just going bang bang And and that can happen and if You know, it's a serious thing, you know, really because it can come across as something that is very very rude See, I think all of us we will deal with people Right at some point or the other We will deal with people and we will be um leading people You know, if we are not doing that already um If we are not effective listeners, we will be Seen as people who are rude Though though that is not the intention, you know, we will be seen as people who are rude because we are not Actually giving people importance to listen Right, we will be seen as people who are Not that effective very You know We'll be seen as people that Who who don't have the capacity to maybe Things fully we'll be seen as people who do not understand problems fully Right So That's another thing. That's another danger if we are not listening fully Listening effectively be seen as people who are You know, don't have that capacity Maybe even to solve because we are not listening, right? So apart from the fact that okay seen as rude, you know You know seen as people who don't have the capability to do some things Um and and over a period of time what will happen is that people will stop sharing information Right, you ask and people because people will think, you know, what's the point anyway He's not going to listen to what I have to say He's just going to share his own thoughts his own ideas.  You don't want to break down in, you know, like in a family Kind of relationship. You don't want to break down on that. Right. So so the importance of listening skills, so maybe this week, you know, you can take time to Try that out. Okay, how can I listen without Getting distracted By the person's appearance, person's mannerism and person's usage of language, etc How can I listen Without interrupting them frequently With my own thoughts my own ideas and how to listen to them fully till they are finished till they are done Okay, so Not being Impatient. Okay, so so let's try it out. Let's try that out. Okay, so we will go one notch and better our scores Right, seven can go to eight to nine five can go to seven maybe so and keep moving that direction. Right Okay, so we'll stop here Get back next class all the best and for your effective listening Okay, you take Thank you, sir You


Dragon Ball FighterZ may be my favorite game of all time, but unfortunately, it doesn't look like it's getting any new official DLC anytime soon. But as wild as it might sound, that doesn't mean your favorite Dragon Ball character won't end up in this game. And that's due entirely to the amazing modding community behind Dragon Ball FighterZ. In this video, I'm going to show two fully unique fan-made characters in the form of Beast Gohan and Raditz, just to show you what the community is able to do. If you enjoy these videos where I check out fan-made Dragon Ball content, definitely make sure to like and subscribe because we have a ton more to do. But with that said, let's go ahead and get into the matches. Look at that. The Raditz art is so good. Both characters are good, but the Raditz art is crazy. Yeah, it is. It is real good. I haven't even watched No Disrespect. I know you made a video on it, but I haven't even watched the video for like Beast Gohan. I have no idea what this man does. Yeah, he's just, you know, honestly, I really forget. So Beast Gohan is going to be kind of like that. Kevlar's just here to show off what the costumes could look like. Wait, what? Oh, damn. I was like, I was confused. So I guess it's my turn now. All right, let's see what Beast Gohan. Damn, my order kind of crazy, didn't he? Damn, that's a hug. Oh, are you learning? Yeah, bro, I don't know what you do, but I do know I can mash. Damn, bro, I stepped out of the staple center, bro. I just got off work. Let's go. Hey, chill. Chill. Kevlar beat down. Let's go. All right. So now we're just going into some standard Kevlar stuff. Tell me, what is Beast Gohan's answer for the Kevlar mix? Probably to just walk. All right, that works. Beast Gohan assist. Let's say go. Right, it's assist. Double Sunday. Yeah. My opener wasn't as good as my follow through, but I think we can all appreciate what it was. Damn. He's a weird. What does this man do? Beast Gohan is a weird character. I remember him being flipping good. Bro. Oh, you were learning, huh?  I scrapped my back. Let me show you a little something. Why is this 2H weird? His 5H is weird. Everything about him is weird. No, not everything's about him. We're like, uh, like, let's see. Oh, my second. I was saying what specials I got. No, no, no, no, no. Oh, special. See, I thought we was going to. I can't believe you did that. What? Yeah, bro. They made me, they made Beast Gohan broken. You didn't know that? Oh my God. What are you? Why did he pick you up and throw you like that? Bro threw me like I was a baby. All right. I guess I'll be over here if you need me. So you ain't going. Damn. I was channeling my beast rage. You're ugly. No. The Beast Gohan beat me. That is not a mess. Let's go. Bro said, let's go in line.  It's main, baby. The new character on the block. Let me show you a couple moves from Dragon Ball Z like am I near right? I should think maybe I like right.  Yeah. Yeah. Beast Gohan kind of feels like a boss. Raditz just feels like it. Oh my God. Oh my God. You were on. Oh, I thought it'd be like frozen electrocuted.  That's a mean glare. Bro, I just realized that's Piccolo's outro. Okay. Yeah, it is. Actually, I didn't realize it was Piccolo's until you said something. What is Beast Gohan doing back there? He's confused.   What? Bro looks shocked. He does look joy. He does look Juvio. I will say. I'm playing Raditz this game, man. Hi. And you mind if I just... Oh, hold on. So your beast going up. That's power level. Damn. Bro, I clicked my scouter one time. Bro, I beat you when I was four. I'll beat you when I'm alone. That is true. If I was Raditz, I would simply go to cardiac arrest. The world has so clearly moved on from me. Bullet. Oh. That's power level. Nice power level. Nice power level. Damn. I got four. I got four readings on here.  I got four readings on you and none of them are looking good. I got to be honest. Whoo. Take that! Double Sunday. I think go on. The worst part about that is I had to look up and see nothing but crotch as you fired down on me. Well, here, let me show you Raditz's level three as well. No. Man, I can't play. You kind of got me locked down right now. What do you mean you just killed a character with this idiot? I know, but I guess I just... I guess I always want more. What? That was a crazy hitbox. I was just doing that to get down to the ground faster. Back kick. Back kick. Oh, look at that vortex. Look at the vortex. He can't break them in. He broke it. You did it. You fast up. Come on, man. I forgot. You went double super.  It's all right.  I'm whole on Saiyan saga dead. I always forget I threw the skin on there. For no reason. How's that even there? Well, it's just... It's like I have like 800 mods installed for fighters and this is one of them. 800. I've only seen like three videos on this thing. One of my videos was I downloaded every mod and played it. Oh, yeah. I do remember that. That one video took up all of my mod spots. Damn. So you just started playing all of a sudden? Bro, you're annoying. You just started playing all of a sudden. Take this. All right. Did she pelved you with that? Okay. If I lose Kepler now, I don't think...  Maybe we can lock up a 1v1 for him. We're locking it up. Actually, it's a 2v1. I'm outnumbered. You are outnumbered.  Okay. I'll be over here. Damn. I should have just let Kepler die. That Kepler moves a little underrated, I think, just dashing out of danger. Come here. Damn. Big-ass hitbox. Big hitbox. Hey, bro. You got to hold that. How do I unleash... No. No! I'm trying to find the... Release the Beast. I know there's a move where he... All right, I'm just going crazy. Oh, no shot. No shot, no shot, no shot. Damn, so much damage and for what? I'm beat. It's Gohan now.  Bro, here's what I'm going to do is I'm going to go back to the... I didn't mean to skip the outro like that. Yeah. I'm going back to the... I'm going back. I got to reduce my load to one DLC character. I'm going to be honest, Dotto. I don't really play this character. Whoa. Mix and roll. I'm getting a little thematic on him. I'm just going to go for thematic. Whoa. They look... Dude, that should be a real team. Arksis, what are you doing? It should be. It should be. And because I don't know how to play these characters, don't find me. Uh-huh. I'm looking forward to learning more about this Ultra Instinct. All right. Yeah. You can see who was replaced. Right? It does, in fact, replace UI Goku. Power. Oh, this is... Is there something wrong with my scout room? That's an interaction right there. DLC interaction? Other than you thinking I'm Ultra Instinct. Haha. Yeah. Okay. Well. Dirty fight. Yeah. Or drop me right now. Hey, chill. Chill. Oh my God. Look at the reach on those normals. Chill. It is actually. I'm trying to unleash the beast. I'm using all my abilities. Yeah, I can tell. Oh. That was on Nate. No, no. I guess it's my turn. How many times are you going to get kicked around like this? I don't know, bro. Oh, I'm purple now. What did I do? My power... My power's through the roof. No. Haha. Hey, these guys are picking you up. How do you play Netflix? Oh, you don't know. You never play this. I'm even a drop of Mavic... Damn, see, it's just... Why did the shades just brush me down like that? Oh, I'm going to get some revenge. I'm going to get some much needed revenge.   Yeah, I should have brought you to the dramatic finish spot. Hey, get some revenge, boys. Hey, chill. Let him know. Let him know. Hey, this is what we're being robbed by from ARCs is not getting more DLC. Oh, I had to drop it on them. That was a great reflex timing everything, bro. The timing was good. The Saiyans just weren't there quite yet. Stop all this. Stop running around. Bro, you're scary. I know I'm scary, but... Hold on a little destructive disc. Get his tail. My tail. Frillin is going through and just surgically removing Saiyan's tails right now. Ouch. Mix. Never mind. The only Vegeta I don't know how to play. Haha. You know, I'm surprised actually. You seem like you would be a base Vegeta player. Oh, nay. It's happening, dude. It's happening. The only reason is because I don't... If I don't do the loops once, I just don't want to deal with the back left. Haha. I don't want to deal with what comes after dropping the loop. Damn. I can't...  Part two. No way. We got renewed for a sequel. Bro, you're two feet tall. I am. And I'm proud. And I'm proud. I was rushing because I really want to play Raditz. What's going on? Is that you? Oh, wrong son. That is not the right son. I'd be pissed if my dad confused me for my brother. What was I going to say?  I like the idea of Raditz being like, Dad? What are you doing here? You died like six years ago. Anyway, hold on. Let me show you what you were missing back on Planet Vegeta. Bro, you're looking at this little delay, bro. If there wasn't this delay, I'd be beating Raditz right now. Hey, well, that's the power of steam remote play. Oh, my God. The kicks are clean. I like the elbow dash move a lot too. That move just looks good. Stop that.  Oh, hold on. Let me get... I can't act surprised anymore, can I? Oh, let me just... Let me get the whole family involved. Oh, my God. It's the son family. They're going crazy. I'm not leaving. All right. Nappa, fight back. No, Vegeta, please. What's your power level? Pathetic. Power level check. Pathetic. Oh, come on. Elbow drop. I don't like to leave. I keep doing the beam move. All right, I'll take it. Get the Raditz back out here. I'm taking him back. No. Stop. Oh, let me vacuum. Hold on. Hold on. Get the vacuum. I'm cleaning up. Damn, Vegeta just launched me. What was that? I don't know, but watch out for Nappa, too. I don't need to watch out for Nappa.  Let's be out. Damn. No shot. No shot. Leave me alone. No. I missed once or maybe twice. Yes. He's not a Raditz maid. He's not a Raditz maid. Oh, my God. Even on board? That hits not on that. It's insane. Oh, the whole family is getting involved.  Look at what. Oh, my God. I felt like I didn't get the setup I deserved for that. I felt like Nappa's thesis just kind of died halfway through. There's a little bit for me, a little bit from Raditz, and a little bit for... I didn't want to be here. I really would rather not be here right now. No, no, no. Damn, what's up fellas? Damn. Damn. Guys, we could have shared the dragon balls, guys. We could have shared. I didn't even want that.  Yes, actually. No! Spam Keyblast and you look like a base Vegeta maid.  That's really all you need to do. You can impress a lot of people by just jumping back and firing Keyblast. They don't know until you drop the loot. Don't I have like a DP or something? Nappa does not.  Allow me to breathe. Well, boy, do I got some news for you. No bounce. That's some good news.    Oh my God. Okay, I understand. I understand.     There is the thing. Don't ever call in Raditz or you'll regret it. Got you. Big mistake. Woo! I'm Goku! Damn. Don't even try. Oh, big mistake. Big mistake. Oh, wait. Beat it, beat it. Wait, wait, wait. No, that is not canonical. What did my eyes just win? Brother. Big mistake, Raditz. Leave my kid alone. Hey. Come here and grab it. Give your brother a hug. It's been years. Bro said hug me, brother. Don't even try it. How childless do you have to be? Damn. Where are you? You had my hair.  You're pretty f***ing... I need Raditz actually in this game now. I'm saying, bro. See, this is... I'm glad this mod is out. This is what's crazy. I'm one Raditz away from learning base Vegeta. Please. No, Bardock. It's Raditz. Your other son, man. He got mad. Why? I feel like that's actually... Look at that. I'm fine because that just means Bardock's a confused old man. Bro's the senile. He feels like he's in self-defense mode. Get out of my house. It runs in the son family line to be angry and punch stuff. Now come here, Raditz. I got to teach you a lesson. Bro. We'll just do a little something off the top. Yeah, you can go ahead and switch out now. Oh, you didn't. Oh, double. Double Sunday. This time, Raditz is actually here, too. That's not Raditz. Oh, right a bum where I needed you to be. Bro, okay. Do I need to backdash the heavy there? Because you're always just... You're always plus there. I'm plus. Now bring up Vegeta. Mix up. Mix up. Mix up. Mix up. Mix up. Bro, I'd be scamming in the air. I'm not going to lie to you. I'm not going to lie. I said I wasn't going to lie. So many. Saiyans. All right. So you reacted to that. You've seen that one online, huh? Damn. You know about that Bardock special? To hit him. Let me show you a real Saiyan. Why does he fall? Raditz just got insults. Take one of these. Nice power level. Damn it. Put me down this instant. Damn. Ain't no way. And there is a way. And it's because I'm Raditz. Double kick. Oh, no, no, no, no. Okay, I'll take it. Oh, my God. I dropped it. You got to get out of here. Don't run from me. That stun is crazy.  What happens when Raditz gets to level 7? I don't remember. I feel I've watched the video. I know I did. Damn, I wanted to hit my scouter a few times. Maybe once or twice. All right, how do I do Saibaman? There we go. There you go. Now, sadly, that was the Saibaman you had to program. Oh, he just killed himself. Damn. Damn, no way. He's going crazy. You know, I'm about as strong as a Saibaman. Oh, my God. Oh, my God. He got pissed. He's learning now, but he's having a good time. I am. You know how to just disrespect Raditz like that. You not blocking?  You blocking over there? Damn, Saibaman, stop. There's already too many people on the screen.  Oh, I was he waiting patiently for you. Oh, no shot. You clutched it up as Raditz? I don't know, bro. He kind of passed. This can't be happening. Luckily, I have Reed. Never mind. I was going to do the super that jumps above you. And I did do it. One editor playback. My bar went away, but it wasn't fast enough. Final match. This set determines everything. Whoever wins this game is the winner of the video. I like how Beast Gohan kind of disappeared into the echelon of history. We both just kind of vibe with Raditz. Yeah, bro. Oh, my God. Barok. Auto combo still impressing me to this day. Gita kind of popping off. Raditz combo route. Yeah, I guess it's a little impressive. Reset. That actually did suck. I looked away for one second. Not good enough. Tim. Oh, that was actually good.  Yeah, I got a piece of him. Yeah, I'm back. Oh, you thought I wasn't going to come back for you?  Sadly, I did.  Oh, my God, man. That's some Barok stuff.  Whoa, whoa, whoa. No, no, no. David, I got stuck in an innovation. What? Bro's CSS is a DP. It has DP properties. Bro is smiling ear to ear playing that. He's having a grand old time. Stop that. There you come in. Not nice. He died. Come on, brother combo. Brother's combo. Right. I got you, brother. Never mind.  No, I'm not. Yes, you are. No, I'm not.  There you return fire. I now see what they base right. It's just keep last off of God. That's embarrassing. I'm sorry. You can see. I'm not. I'm not too hit with the sides of me. I don't know when I should start swings. Hello. Damn. Short. You are. Was it worth it? It was a bit funny. Was it nice? Nice power level. Had a flick of bullet. Oh, he's stepping. Oh. No, no, no. Wait, wait, wait. I can change. I'm just a Raditz player. I play Raditz. He's not even in the game. I only get to enjoy him with mods. Mods. I love that. Early. I'm a saiyan. You got to put the pause on you for a second. Now we just have DLC one matchup.  No. I threw a key blast on that. It's not canonical actually, but you know, won the fight and Goku had to get help. That's true. I'm scared. But you're lucky. I did this whole video with a team. I didn't even know I'll beat you. Bro, then maybe we should run it back with including these two DLC characters, but we maybe we don't have to use them, but maybe it's on your channel. Gasp. That was not a good segue, but yes. Well, then like and subscribe on this one first and then go over there. Goodbye. Thank you. Oh, and modders keep adding more characters. Thank you. Who's next? Take me on next. Thanks.