Selected Podcast
The “Black Hole” of Event Reporting: Lessons Learned From Providing Feedback on Patient Safety Events
In our journey to create a highly reliable, safety-focused organization using insights from risk and patient safety events to drive change, we faced a long-standing challenge: “Is anyone reading these event reports and doing something about them?” At Milton S. Hershey Medical Center, we set out to remove this “black hole” perception by leveraging existing technology in our risk management software to collect individualized feedback entered at the time of our review and to automate emails to the reporter the next day.
Featuring:
Andy Moyer, BSN, RN-BC, CPPS
Andy Moyer is a certified patient safety professional with over three decades of experience as a registered nurse and certified informatics nurse. Integrating his professional nursing experiences and interest in information technology, Andy created a successful pre-hospital electronic medical record software company. After spending nearly 20 years in corporate health informatics, he accepted a position as an autonomous informatics nurse for a newly formed patient safety department in the Milton S. Hershey Medical Center. In this role, Andy is able to help lead the hospital campus’ journey to becoming a highly reliable organization with a safety-focused culture. Transcription:
Michael Carrese: Welcome to the ASHRM podcast made possible by the American society for healthcare risk management to support efforts to advance safe and trusted health care through enterprise risk management. Visit astrum.org/membership to learn more and become a national member. I'm Michael Carrese, one strategy that healthcare risk management professionals employee in their efforts to create highly relaxed.
The safety focused organizations is using insights from risk and patient safety events to drive change. But for that to work, you have to be sure the event reports are being read and acted upon. Well, our guest today is here to tell us how Penn state health Milton S Hershey medical center set out to remove this black hole perception about.
Event reports by leveraging existing technology to collect and share feedback. Andy Moyer is a certified patient safety professional with over three decades of experience as a registered nurse and certified informatics nurse in his current role as informatics specialist for patient safety at the medical center, he's helping to lead their journey to becoming a highly reliable organization with a safety focused culture.
And Andy, welcome to the ASHRM.
Andy Moyer: Thank you, Michael, for having me.
Michael Carrese: And before we dig into the questions I wanted to thank Conduent for sponsoring this episode and supporting ASHRM in providing this content to its members. So, just off the top, why is this particular topic so near and dear to your heart?
Andy Moyer: So Michael, most of the listeners are acutely aware of the staggering estimate of the annual numbers of medical errors. And we know preventable medical mistakes are now the third leading cause of deaths in America, somewhere around 250,000 deaths annually. So most everyone, again, listening probably is aware of a friend, a family member, or even themselves who have been affected by this either receiving or giving help. So I was introduced to a healthcare culture of no harm, no foul reporting 35 years ago. So it wasn't, it was kind of don't report unless you absolutely had to, because administration will use it to fire you. And this perception was further promoted that it was bad news when you got that call from risk.
So, you know, my experience was don't tattle on yourself. I was fortunate to come in on the ground level on the spin-off of a patient safety department out of our risk department at the medical center or at the time or chief quality officer and some other leaders at the medical center saw the need to raise our patients safety awareness and change our culture.
Back in 2015, what brought me was I kind of had my interest peaked because. Kind of had that culture background that I mentioned, I was aware of the ILMS to err, is human report that came out in 2000 and I also had a background in systems improvement. So it kind of looked like a really neat opportunity to join.
Now during the early months of this new department creation, we had that Seminole public relations event where we had a preventable death of a young child, and this empowered our leaders even more to say, look, we want to go further and we want to take the steps of becoming a high reliability organization and start teaching error prevention techniques to our whole campus.
Not just nursing, not just the patients that had direct clinical care. But to the whole campus. And as I got exposed to those HRO or high reliable organization techniques, the error prevention techniques, the fair and just culture. And the eyeopening impact of system issues and how it affects the decisions our healthcare makers or healthcare workers make.
I became passionate for it and our safe and reliable culture journey became a great interest. Having a background as a previous flight nurse, a lot of these techniques were informally taught to me by our pilots, which aviation is an HRO. They are known for having that type of environment. So it just became natural.
Why wouldn't I want to share this with all these other.
Michael Carrese: And you have gone out and deliver presentations on this black hole concept that you talk about. So tell us more about what you mean by
Andy Moyer: So early in our journey we raise the awareness to report more patient safety events and try to knock down this perception of no harm, no foul reports. That.
I experienced myself. And the first year we raised our patient safety event reporting by 70%. And over the next three years, we raised it up to 25,000 events annually.
That's a 206% increase over that time. However, as are other stages of our journey, we started identifying the HRO principles and the error preventions had not been fully rolled. And as we move to those stages, we started having greater interactions. One-on-one with those frontline staff and providers, and we started to hear a theme.
Do people really read those events? We report and do anything about them. This was a questioning attitude that naturally comes from the sharp increase to report more. We had asked them to take additional time out of their hectic days. And kind of full of competing priorities and report these events and they weren't getting anything back.
So this perception of patient safety reporting, black hole is staff putting information in and nothing escaping out is not a new concept. It's been around for years. And staff have identified that a lack of feedback reinforces their beliefs. That reporting is just another thing that takes time away from their daily care, with no direct impact to. Now our team recognized that this black hole was going to greatly affect the great strides we had made in reporting, and we needed to get them.
Michael Carrese: One thing sounds like you've got to remove the culture of fear about being punished or something for reporting, but then also this a, this is just pointless paperwork kind of perspective that might
Andy Moyer: Correct. They had no idea they would right. We kind of started doing this fair and just culture to erode that, Hey, reporting is going to penalize you. You're going to do that. So we directly did that. One-on-one with the rolling out of that. But there also. More pointless paperwork. And you're you hit the spot on our frontline health workers spend a lot of time documenting in today's world and they don't see the impact.
It affects people downstream from them greatly, but they don't see it. So we needed to bring them into the fold and say, this is how your work upfront impacts what we do on the backend.
Michael Carrese: So, how did you do that at Penn state health, Milton S Hershey medical center. What were your strategies for addressing the black.
Andy Moyer: So we kind of approached it in an iterative way. We identified a method in our Midas patient safety event, reporting software to build a personalized response that we could email to the reporter. The first was to provide a thank you email for submitting the report. And at that time we invited them to reach back out to the patient safety department.
And ask us questions about that event. Really the vast majority never took advantage of that. And this was an automated response with limited information that was available the next day after reporting. So we most likely had not gone through reviewed it and resolved that case. So it really did knock down that perception.
The same time, our college of medicine was raising the awareness of patient safety and near curriculum. And they asked us to provide feedback to the residents on the quality of how they reported patient safety events. We went out, we identified a scoring method developed by the association of American medical colleges, integrating quality subcommittee. And we decided that, Hey, we could use that. And when our patient safety specialists are resolving the event and closing it out, they could provide that scoring as feedback to the residents.
As we looked at this and talked about it, we said, So why wouldn't we want to give that feedback to everyone? You know, Give them that constructive criticism, along with all the closure information that they've been yearning for years to say, you know, what happened to that event? Did that event make a difference in something that we did? So we look back that previous process that we used in our Midas event software, and we did a similar function.
But now we had that additional information to try to close that loop and the road that black.
hole percent.
Michael Carrese: So, what did you start saying? What resulted from.
Andy Moyer: So the idea and the need for feedback was created because we knew that one-on-one interaction that we had that greatly improved concept of. Couldn't be sustainable. So we, we did the feedback and in the first year of implementation, we maintained a 15% growth in our event reporting. So now we're up to 235% increase.
So it was really great. We hadn't. We hadn't dropped and we're continued to grow. We also looked at our patient safety culture surveys, and we saw a great rise in the numbers of positive responses in staff did not feel that event reporting was punitive. Staff felt leaders were engaged in. Patient safety was a priority staff felt we learned from our mistakes.
So again, culture safety survey showed a dramatic increase in those positive responses than what we had before. The second year we were tracking for a 6% increase, however, COVID. And with that we saw reduced admissions. Fortunately when we monitored this, we saw we, had the same decline rate in patient safety event reporting as we did in our patient census.
So we felt positive. We saw that. And when we rebounded in the summer, we came right back up in the same parallel movement with our patient census and our patient event reporting. However that didn't last. And we saw a sharp decline in the end of 2020 and patient safety event reporting even know our patient census returned to higher than pre COVID levels.
We were monitoring this we kind of looked at this and circulated out ideas and we really went back to our staff, have competing priorities. They're fatigued. Our leaders are the same way and that patient's safety communication and being in the forefront might not be there. And that might be leading to the cause.
So we've raised this awareness. We're going to continue to monitor this and see what happens, but that's where we're at now, but I'll tell you the true. is the contacts we received from the frontline workers.
Occasionally there's a technical issue where they'll get a blank feedback and they'll contact us and they'll say, Hey I got a blank feedback. Can you tell me how I did? And when I go back and kind of compare the number of technical issues that I can find and the number of contacts they're very close.
So that tells me. It's not by chance that this one person got a blank one and they decided to reach out to us that the majority of people are reading them and reaching out to us when they don't get them. Occasionally we might get a response from a person that maybe got a little bit more constructive criticism than they felt was necessary.
So we'll reach out to that. We'll take the opportunity. Maybe it's via a phone. Maybe it's a director or one of our patient safety specialists going down and meeting them at Starbucks and having a little coffee chat with them to say, Hey let's explain what, why we said what we said, and you can explain how you feel.
And normally we walk away with win-win situations in that, but the one that we hang up, the one that we hang our hat on and hang up in the. Are the ones where we get the thank you where people say, thank you for reaching back to me and letting me know how this ended up. Thank you for doing this because I've worked at several facilities.
I've never seen anything like this, and this is really positive. I really feel like I'm part of the team by doing this.
Michael Carrese: Well, and I would think they feel like they're actually having an impact on improving. Because they're feeling heard.
Andy Moyer: Right. Exactly. They see that we notify them to say, Hey, that resulted in a apparent cause analysis that resulted in a FDA recall that resulted in a safety alert to the whole system, you know? So they're seeing that impact.
Michael Carrese: So tell us why changing the perception on the part of your frontline staff regarding the reporting and analyzing of these risk and safety events is so important.
Andy Moyer: you just kinda touched on it. They need that reassurance that someone is reading and acting on their information they're providing we needed to demonstrate that there's worth in using that error prevention skillset that we spent that time training them and a benefit and taking that time to write.
You know, they are hectic. They do have competing priorities. There's a big benefit. So sharing with the frontline staff on how events are reviewed, how events are acted upon. Is a way to also promote what we call near misreporting. These are events where no harm or it maybe didn't even reach to the patient.
And this allows us to transform our way of dealing with patient safety events by becoming a proactive approach instead of being reactive. If we can plug as many holes as possible in the James reason's cheese model we can start to reduce our harm to our patients and reach that ultimate goal of zero harm.
And that's what we all strive for. Zero.
Michael Carrese: Absolutely. So as we wrap up here, any final thoughts or advice to share with our listeners who are working in places that are on this journey to advance a culture of quality and patient safety.
Andy Moyer: So, the one is I'm sure everyone knows it's a marathon by no means. Is it a sprint? There is a lot of groundwork the first few years before you can even begin to reap the harvest of your effort. And, you know, you have to have strong patient safety advocate, strong risk advocates to keep this forefront into the senior leadership's mind.
It is easy for them to be distracted with all the things they have to deal with and because they don't necessarily see the law. Paul of this. They can quickly forget about it and not be speaking to speak. In that same way, senior leaders are the most impactful numerous reports have come out to say, staff will look to the senior leaders to see if they are using safety as a main consideration in what they're saying and doing.
If it's in their messaging, coming out from them and they see that sentence in there. It hits home to them and they start seeing if it's important to my CEO or my precedent or my SVPs. Maybe it should be important to me. As I mentioned, we saw that decline and we think Roundup. With an emphasis on patient safety.
by the clinical leader.
So the nurse managers, the respiratory therapy supervisors, the different clinical areas, along with that executive leadership coming down and rounding and saying to maybe a nurse or a provider. Hey, tell me about the last patient safety event that you see. Tell me about what you did about it or how you handled it, or did you use error prevention?
You know, it's kind of like that one sentence topic, and then you can move on and go to somebody else. But at that point you touch the tip of the spear and you said to them, I care about, you know, patient safety. I care about how it impacts you. And I want to hear from you what we can do as a system to improve it. The last part is when it makes sense, use technology to advance your messaging. A lot of times we shoe horn fixes with technology and at the end we create more problems. So we were able to use the technology with our. Conduit software to say, Hey, this is a real easy way to try to knock down that black hole perception.
And I think we've been successful with it. So Don Berwick you know, from IHI always says, Hey, we must accept human error is inevitable and design around that fact. And that's what we all should be looking at. Human error is not going to go away. We need to look better in our systems and our individual actions to say, how can.
Maybe get away from that or build around that.
Michael Carrese: Well, that's a really great. And on, and I want to thank you, Andy, for joining us today, sharing your story and also your lessons learned. I think that's going to be really useful for our listeners.
Andy Moyer: Thank you, Michael. I appreciate.
Michael Carrese: Andy Moyer is informatic specialist for patient safety at Penn state health, Milton S Hershey medical center.
And we'd like to thank Conduent for sponsoring this episode and supporting ASHRM and providing this content to its members. This podcast series is made possible by the American society for healthcare risk management to support efforts to advance safe and trusted healthcare through enterprise risk management, you can visit astram.org/membership to learn more and become a national member.
I'm Michael Carrese. Thanks for listening.
Michael Carrese: Welcome to the ASHRM podcast made possible by the American society for healthcare risk management to support efforts to advance safe and trusted health care through enterprise risk management. Visit astrum.org/membership to learn more and become a national member. I'm Michael Carrese, one strategy that healthcare risk management professionals employee in their efforts to create highly relaxed.
The safety focused organizations is using insights from risk and patient safety events to drive change. But for that to work, you have to be sure the event reports are being read and acted upon. Well, our guest today is here to tell us how Penn state health Milton S Hershey medical center set out to remove this black hole perception about.
Event reports by leveraging existing technology to collect and share feedback. Andy Moyer is a certified patient safety professional with over three decades of experience as a registered nurse and certified informatics nurse in his current role as informatics specialist for patient safety at the medical center, he's helping to lead their journey to becoming a highly reliable organization with a safety focused culture.
And Andy, welcome to the ASHRM.
Andy Moyer: Thank you, Michael, for having me.
Michael Carrese: And before we dig into the questions I wanted to thank Conduent for sponsoring this episode and supporting ASHRM in providing this content to its members. So, just off the top, why is this particular topic so near and dear to your heart?
Andy Moyer: So Michael, most of the listeners are acutely aware of the staggering estimate of the annual numbers of medical errors. And we know preventable medical mistakes are now the third leading cause of deaths in America, somewhere around 250,000 deaths annually. So most everyone, again, listening probably is aware of a friend, a family member, or even themselves who have been affected by this either receiving or giving help. So I was introduced to a healthcare culture of no harm, no foul reporting 35 years ago. So it wasn't, it was kind of don't report unless you absolutely had to, because administration will use it to fire you. And this perception was further promoted that it was bad news when you got that call from risk.
So, you know, my experience was don't tattle on yourself. I was fortunate to come in on the ground level on the spin-off of a patient safety department out of our risk department at the medical center or at the time or chief quality officer and some other leaders at the medical center saw the need to raise our patients safety awareness and change our culture.
Back in 2015, what brought me was I kind of had my interest peaked because. Kind of had that culture background that I mentioned, I was aware of the ILMS to err, is human report that came out in 2000 and I also had a background in systems improvement. So it kind of looked like a really neat opportunity to join.
Now during the early months of this new department creation, we had that Seminole public relations event where we had a preventable death of a young child, and this empowered our leaders even more to say, look, we want to go further and we want to take the steps of becoming a high reliability organization and start teaching error prevention techniques to our whole campus.
Not just nursing, not just the patients that had direct clinical care. But to the whole campus. And as I got exposed to those HRO or high reliable organization techniques, the error prevention techniques, the fair and just culture. And the eyeopening impact of system issues and how it affects the decisions our healthcare makers or healthcare workers make.
I became passionate for it and our safe and reliable culture journey became a great interest. Having a background as a previous flight nurse, a lot of these techniques were informally taught to me by our pilots, which aviation is an HRO. They are known for having that type of environment. So it just became natural.
Why wouldn't I want to share this with all these other.
Michael Carrese: And you have gone out and deliver presentations on this black hole concept that you talk about. So tell us more about what you mean by
Andy Moyer: So early in our journey we raise the awareness to report more patient safety events and try to knock down this perception of no harm, no foul reports. That.
I experienced myself. And the first year we raised our patient safety event reporting by 70%. And over the next three years, we raised it up to 25,000 events annually.
That's a 206% increase over that time. However, as are other stages of our journey, we started identifying the HRO principles and the error preventions had not been fully rolled. And as we move to those stages, we started having greater interactions. One-on-one with those frontline staff and providers, and we started to hear a theme.
Do people really read those events? We report and do anything about them. This was a questioning attitude that naturally comes from the sharp increase to report more. We had asked them to take additional time out of their hectic days. And kind of full of competing priorities and report these events and they weren't getting anything back.
So this perception of patient safety reporting, black hole is staff putting information in and nothing escaping out is not a new concept. It's been around for years. And staff have identified that a lack of feedback reinforces their beliefs. That reporting is just another thing that takes time away from their daily care, with no direct impact to. Now our team recognized that this black hole was going to greatly affect the great strides we had made in reporting, and we needed to get them.
Michael Carrese: One thing sounds like you've got to remove the culture of fear about being punished or something for reporting, but then also this a, this is just pointless paperwork kind of perspective that might
Andy Moyer: Correct. They had no idea they would right. We kind of started doing this fair and just culture to erode that, Hey, reporting is going to penalize you. You're going to do that. So we directly did that. One-on-one with the rolling out of that. But there also. More pointless paperwork. And you're you hit the spot on our frontline health workers spend a lot of time documenting in today's world and they don't see the impact.
It affects people downstream from them greatly, but they don't see it. So we needed to bring them into the fold and say, this is how your work upfront impacts what we do on the backend.
Michael Carrese: So, how did you do that at Penn state health, Milton S Hershey medical center. What were your strategies for addressing the black.
Andy Moyer: So we kind of approached it in an iterative way. We identified a method in our Midas patient safety event, reporting software to build a personalized response that we could email to the reporter. The first was to provide a thank you email for submitting the report. And at that time we invited them to reach back out to the patient safety department.
And ask us questions about that event. Really the vast majority never took advantage of that. And this was an automated response with limited information that was available the next day after reporting. So we most likely had not gone through reviewed it and resolved that case. So it really did knock down that perception.
The same time, our college of medicine was raising the awareness of patient safety and near curriculum. And they asked us to provide feedback to the residents on the quality of how they reported patient safety events. We went out, we identified a scoring method developed by the association of American medical colleges, integrating quality subcommittee. And we decided that, Hey, we could use that. And when our patient safety specialists are resolving the event and closing it out, they could provide that scoring as feedback to the residents.
As we looked at this and talked about it, we said, So why wouldn't we want to give that feedback to everyone? You know, Give them that constructive criticism, along with all the closure information that they've been yearning for years to say, you know, what happened to that event? Did that event make a difference in something that we did? So we look back that previous process that we used in our Midas event software, and we did a similar function.
But now we had that additional information to try to close that loop and the road that black.
hole percent.
Michael Carrese: So, what did you start saying? What resulted from.
Andy Moyer: So the idea and the need for feedback was created because we knew that one-on-one interaction that we had that greatly improved concept of. Couldn't be sustainable. So we, we did the feedback and in the first year of implementation, we maintained a 15% growth in our event reporting. So now we're up to 235% increase.
So it was really great. We hadn't. We hadn't dropped and we're continued to grow. We also looked at our patient safety culture surveys, and we saw a great rise in the numbers of positive responses in staff did not feel that event reporting was punitive. Staff felt leaders were engaged in. Patient safety was a priority staff felt we learned from our mistakes.
So again, culture safety survey showed a dramatic increase in those positive responses than what we had before. The second year we were tracking for a 6% increase, however, COVID. And with that we saw reduced admissions. Fortunately when we monitored this, we saw we, had the same decline rate in patient safety event reporting as we did in our patient census.
So we felt positive. We saw that. And when we rebounded in the summer, we came right back up in the same parallel movement with our patient census and our patient event reporting. However that didn't last. And we saw a sharp decline in the end of 2020 and patient safety event reporting even know our patient census returned to higher than pre COVID levels.
We were monitoring this we kind of looked at this and circulated out ideas and we really went back to our staff, have competing priorities. They're fatigued. Our leaders are the same way and that patient's safety communication and being in the forefront might not be there. And that might be leading to the cause.
So we've raised this awareness. We're going to continue to monitor this and see what happens, but that's where we're at now, but I'll tell you the true. is the contacts we received from the frontline workers.
Occasionally there's a technical issue where they'll get a blank feedback and they'll contact us and they'll say, Hey I got a blank feedback. Can you tell me how I did? And when I go back and kind of compare the number of technical issues that I can find and the number of contacts they're very close.
So that tells me. It's not by chance that this one person got a blank one and they decided to reach out to us that the majority of people are reading them and reaching out to us when they don't get them. Occasionally we might get a response from a person that maybe got a little bit more constructive criticism than they felt was necessary.
So we'll reach out to that. We'll take the opportunity. Maybe it's via a phone. Maybe it's a director or one of our patient safety specialists going down and meeting them at Starbucks and having a little coffee chat with them to say, Hey let's explain what, why we said what we said, and you can explain how you feel.
And normally we walk away with win-win situations in that, but the one that we hang up, the one that we hang our hat on and hang up in the. Are the ones where we get the thank you where people say, thank you for reaching back to me and letting me know how this ended up. Thank you for doing this because I've worked at several facilities.
I've never seen anything like this, and this is really positive. I really feel like I'm part of the team by doing this.
Michael Carrese: Well, and I would think they feel like they're actually having an impact on improving. Because they're feeling heard.
Andy Moyer: Right. Exactly. They see that we notify them to say, Hey, that resulted in a apparent cause analysis that resulted in a FDA recall that resulted in a safety alert to the whole system, you know? So they're seeing that impact.
Michael Carrese: So tell us why changing the perception on the part of your frontline staff regarding the reporting and analyzing of these risk and safety events is so important.
Andy Moyer: you just kinda touched on it. They need that reassurance that someone is reading and acting on their information they're providing we needed to demonstrate that there's worth in using that error prevention skillset that we spent that time training them and a benefit and taking that time to write.
You know, they are hectic. They do have competing priorities. There's a big benefit. So sharing with the frontline staff on how events are reviewed, how events are acted upon. Is a way to also promote what we call near misreporting. These are events where no harm or it maybe didn't even reach to the patient.
And this allows us to transform our way of dealing with patient safety events by becoming a proactive approach instead of being reactive. If we can plug as many holes as possible in the James reason's cheese model we can start to reduce our harm to our patients and reach that ultimate goal of zero harm.
And that's what we all strive for. Zero.
Michael Carrese: Absolutely. So as we wrap up here, any final thoughts or advice to share with our listeners who are working in places that are on this journey to advance a culture of quality and patient safety.
Andy Moyer: So, the one is I'm sure everyone knows it's a marathon by no means. Is it a sprint? There is a lot of groundwork the first few years before you can even begin to reap the harvest of your effort. And, you know, you have to have strong patient safety advocate, strong risk advocates to keep this forefront into the senior leadership's mind.
It is easy for them to be distracted with all the things they have to deal with and because they don't necessarily see the law. Paul of this. They can quickly forget about it and not be speaking to speak. In that same way, senior leaders are the most impactful numerous reports have come out to say, staff will look to the senior leaders to see if they are using safety as a main consideration in what they're saying and doing.
If it's in their messaging, coming out from them and they see that sentence in there. It hits home to them and they start seeing if it's important to my CEO or my precedent or my SVPs. Maybe it should be important to me. As I mentioned, we saw that decline and we think Roundup. With an emphasis on patient safety.
by the clinical leader.
So the nurse managers, the respiratory therapy supervisors, the different clinical areas, along with that executive leadership coming down and rounding and saying to maybe a nurse or a provider. Hey, tell me about the last patient safety event that you see. Tell me about what you did about it or how you handled it, or did you use error prevention?
You know, it's kind of like that one sentence topic, and then you can move on and go to somebody else. But at that point you touch the tip of the spear and you said to them, I care about, you know, patient safety. I care about how it impacts you. And I want to hear from you what we can do as a system to improve it. The last part is when it makes sense, use technology to advance your messaging. A lot of times we shoe horn fixes with technology and at the end we create more problems. So we were able to use the technology with our. Conduit software to say, Hey, this is a real easy way to try to knock down that black hole perception.
And I think we've been successful with it. So Don Berwick you know, from IHI always says, Hey, we must accept human error is inevitable and design around that fact. And that's what we all should be looking at. Human error is not going to go away. We need to look better in our systems and our individual actions to say, how can.
Maybe get away from that or build around that.
Michael Carrese: Well, that's a really great. And on, and I want to thank you, Andy, for joining us today, sharing your story and also your lessons learned. I think that's going to be really useful for our listeners.
Andy Moyer: Thank you, Michael. I appreciate.
Michael Carrese: Andy Moyer is informatic specialist for patient safety at Penn state health, Milton S Hershey medical center.
And we'd like to thank Conduent for sponsoring this episode and supporting ASHRM and providing this content to its members. This podcast series is made possible by the American society for healthcare risk management to support efforts to advance safe and trusted healthcare through enterprise risk management, you can visit astram.org/membership to learn more and become a national member.
I'm Michael Carrese. Thanks for listening.