Selected Podcast
Managing Risk in a Pediatric Health Care Setting
Health care risk management is a very diverse field and when you meet one risk manager, you meet one risk manager. One size does not fit all. This podcast series will look to discuss risks inherent to a variety of areas in health care. The third of the series will explore the unique challenges of health care risk management in the pediatric health care setting.
Featuring:
Rebecca is a Distinguished Fellow of ASHRM as well as a Certified Professional Health Care Risk Manager (CPHRM). She is also a board certified healthcare executive, holding the FACHE designation from the American College of Healthcare Executives. Rebecca holds a Certificate in Strategic Decision and Risk Management from Stanford University. She has been an active volunteer with ASHRM, helping to write a variety of publications including Pearls on Medication Safety and Applying Enterprise Risk Management, and the Risk Financing Playbook and Healthcare Claims and Litigation Playbook. She has served on multiple ASHRM committees and task forces including Chair, ASHRM Federal Legislative Advocacy Task Force; Member, ASHRM Nominating Committee; Member, ASHRM Journal Review Board; Member, ASHRM ERM Committee; and Member, ASHRM Bylaws Committee.
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE is Vice President, Chief Risk Officer at Children’s National Medical Center in Washington, D.C. She is a Bachelor of Science in Nursing graduate of Georgetown University, and a graduate of the University of San Diego School of Law. Prior to coming to CNMC in 2008, Rebecca was a partner at Grace, Hollis, Lowe, Hanson and Schaeffer, a California law firm, where she practiced in the areas of malpractice defense, healthcare, and professional licensure law. She has published extensively in the area of nursing and the law, and is a frequent lecturer to healthcare providers. She was Editor in Chief of the Journal of Nursing Administration's Healthcare Law, Ethics, and Regulation from 2002-2013. She was named the 2018 Risk Manager of the Year by RIMS, the Risk and Insurance Management Society, a global professional organization of risk professionals from all industries. She was also named the 2018 Risk Manager of the Year by ASHRM, the American Society for Healthcare Risk Management. She was recognized as a 2018 Woman to Watch by Business Insurance Magazine in December, 2018.Rebecca is a Distinguished Fellow of ASHRM as well as a Certified Professional Health Care Risk Manager (CPHRM). She is also a board certified healthcare executive, holding the FACHE designation from the American College of Healthcare Executives. Rebecca holds a Certificate in Strategic Decision and Risk Management from Stanford University. She has been an active volunteer with ASHRM, helping to write a variety of publications including Pearls on Medication Safety and Applying Enterprise Risk Management, and the Risk Financing Playbook and Healthcare Claims and Litigation Playbook. She has served on multiple ASHRM committees and task forces including Chair, ASHRM Federal Legislative Advocacy Task Force; Member, ASHRM Nominating Committee; Member, ASHRM Journal Review Board; Member, ASHRM ERM Committee; and Member, ASHRM Bylaws Committee.
Transcription:
Prakash Chandran: Welcome to the ASHRM podcast 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 ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran.
Pediatric patients are among the most vulnerable in society. Children rely on parents, family members, and sometimes state-appointed caregivers to ensure that they receive appropriate medical attention. Some pediatric conditions are easily identified as requiring immediate evaluation. However, for many pediatric conditions, determining when to seek care, as well as identifying proper treatment can be challenging for caregivers, providers, and payers alike.
The multifaceted needs of young patients require a robust implementation of healthcare risk management to educate all of those involved in pediatric care and solidify strategies to improve outcomes for children's care. Joining us today is Rebecca Cady, Vice President and Chief Risk Officer at Children's National Medical Center in Washington, DC.
Rebecca, thank you so much for joining us today. I truly appreciate it. I'd love to get started by asking what risks are unique to children's hospitals?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Thanks, Prakash. Glad to be here with you today. So, children's hospitals have several unique things about them that make their risks different from those of adult facilities. I think the one that we come across the most often and that we deal with the most often is the fact that you don't just have a patient that you need to deal with. You've got a family, and sometimes that family is comprised of what we would consider, you know, a traditional nuclear family, and sometimes it's not. Sometimes the grandparents are raising the child. Sometimes an aunt or an uncle is raising the child. Sometimes, you know, just a friend is raising the child. And you can sometimes have family members who have differing opinions about, you know, what should be done or what's going on with the child, especially if you have a circumstance where, you know, you've got a very sick child or a child who's been the victim of some kind of violence or gun violence.
So managing the patient and their family is really part of the art of risk management in the pediatric setting, keeping in mind that those families tend to bring with them all the troubles that they have in the external world. Those troubles don't vanish when they walk through the hospital doors. And so a lot of times, the troubles that come with them, whether it's marital dispute or whether there's something else going on in the home, so a lot of socioeconomic factors really impact the care of children.
We know that there are social determinants of health really from before the child's even born that impact their healthcare. And so the family is such an important part of this that we really need to know how to manage, not just a patient, but the adults that surround that patient.
A couple of other things that are more kind of technical, I suppose you would say, are the fact that there's a really long tail for claims, right? And in most jurisdictions, a child has until the age majority, so 18 years plus whatever the normal statute of limitations is for a medical malpractice case. In most states, it's three years. So theoretically, you could be taking care of a newborn and that child can have until their 21st birthday to sue you for something that happens in the newborn period.
So it requires really good record keeping and institutional knowledge about cases and it requires you to have a good way to go back and look at old files. So this actually came up for us recently, where we had a case that occurred a number of years ago, I think something like 10 or 12 years ago and was while we were all on paper in terms of our incident reporting and risk management documentation. Luckily, we're very organized about our files and storage. This file had gone to storage, but we were able to retrieve it and it had some really important information in it that helped me to have frankly a pretty stern conversation with the attorney who had reached out to me to let him know that we did not believe that this was a case of liability and was very specific with him about why that was. This was very important because without the ability to go back and pull from that institutional knowledge and those older records, it would have been hard for us to really provide a meaningful response to this.
The other thing for children's cases is that almost every case potentially could be like a bad baby case. And what do I mean by that? So a birth injury case. No babies are bad, so sorry about that. So a birth injury case obviously can have very large amount of damages involved because you have a child who's injured at a very young age at birth, and you have a child then who's going to need significant amounts of care throughout the rest of their life. And the rest of their life could potentially be something like 30 or 40 years. So, although some pediatric hospitals do not deliver babies, they still have that potential big claim exposure because they're taking care of babies and young children. And so if there's some kind of a devastating injury, you're still going to be looking at a case that could be worth potentially millions and millions of dollars.
The other thing we see in terms of how we manage risks are the importance of the need to teach families about all kinds of things. More specific to our bailiwick is informed consent. So how do you really make sure that a family understands the risks, benefits, and alternatives of a procedure that you're about to do for their child? And how do you make them appreciate the seriousness of a case, especially if you're doing a surgery for a rare procedure or for an underlying condition, which doesn't tend to have very good outcomes no matter what you do? How do you appropriately educate those families without sort of scaring them off to the point that they decide they don't even want to do the procedure?
You really have to find a good balance there and that's a struggle. And so being able to counsel physicians and work with physicians and other LIPs who do informed consent about how do you get this across in the right way to make them really understand what the risks are without sort of making them run away from the care altogether, I think are really important and unique risks that we deal with in children's hospitals.
Prakash Chandran: So that's a really good summary and kind of leads me to my next question. With all of the nuances around injury, the family dynamics that you need to deal with, in addition to the detailed hygiene around record keeping, why exactly would someone want to be a risk manager in that type of environment.
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Three words: mission, mission, mission. Pediatric hospitals do miraculous things to help kids. And you're an important part of the team as a risk manager in a pediatric hospital. The clinical staff really need you because consent issues come up all the time. If you have somebody who comes in with the child who is not the parent and we have to help them sort out is that person allowed to consent to this office visit or this procedure, the clinical staff really needs you. And so you really get a great sense of fulfillment of helping the clinical staff clear up the questions that they have so that those questions are not a barrier to their providing good care for kids.
The second thing that's really wonderful about it is there such a variety of work. No one day at work looks like any other day. You can have a set plan and agenda for the things you'd like to do that day. And the phone rings probably before you even get to the hospital and you're off and running with something else. So there's a really great variety of risk topics that we manage. We do enterprise risks, so that's important and helping the organization look at its strategic plan and make sure the organization can be successful and continue to fulfill its mission down to the intricacies of helping staff work through a situation with a family that's in crisis and how do you do that? Keeping your staff safe, keeping the patients safe and keeping the family intact. Those are really challenging situations, but they're very fulfilling when you can help the staff come to a successful resolution. And so at the end of the day, you can really be an important part of how the organization helps children and their families.
Prakash Chandran: Yeah, I think that makes a lot of sense. And it's such an important role to play, to remove barriers and constraints to providing children the best care possible. Could you perhaps share some of your successes there?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Yeah. So consents in particular used to be a thing that we spent a lot of time on. And by that, I mean, almost without a doubt every day at around six, the phone would start ringing for whoever was on call and people would have questions about, "Hey, this foster parent is in with the child" or "Hey, this grandmother has brought the child in," or "Hey, the aunt has brought the child in," and the child is scheduled for surgery. And we need to know whether this person can sign the consent and we can't reach the mom and so forth. So we almost never get those calls anymore now because we've created a system to have those questions asked well ahead of time.
So, how do we do that? Well, we met with the surgery schedulers and we gave them a script of how do they talk to the person that they're scheduling the case with and how do they tell them, like, if mom or dad, you're not going to be able to bring the child in. If you're sending somebody else with your child, you've got to let us know ahead of time and you have to send them with a document that will allow them to provide consent on your behalf. And we created a document for the parents so that all they had to do is enter the child's name, put in a date of expiration if they wanted it to expire and then sign it. And so we also trained our social work staff that, okay, these are the forms that we're going to ask the parents to fill out. And these are the standard. We created a lot of standard work around this process, so that we're asking these questions ahead of time. We're not asking them for the first time on the day of the procedure. And we're making sure that all the staff understand that they can always reach us if they have questions and that, you know, if there's an emergency that they should go ahead and proceed with two physicians consenting.
Our goal is to not have a kid come in, especially after having been NPO for part of the night, parents are having to drive a long way, we have patients coming from all over DC, Maryland, Virginia, West Virginia, and farther. And so we really don't want to have to cancel a surgery if at all possible. And so we've worked really hard with those teams and our surgery cancellation rate has gone way down. The staff understand the process. We have less pickups at the last minute. And everybody seems a lot happier. And at the end of the day, the kids get the surgery when they need to have the surgery and that's what's the best for the kids. So it's a win all the way around.
Prakash Chandran: Yeah, absolutely. So, you know, someone might be listening to this and is trying to assess whether working as a risk manager at a children's hospital is right for them. Do you have any advice or guidance for the people that are in that camp?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: So I would say again, it's all about the mission and you can be a really important part of how that mission gets delivered every day. And you can make sure that we give the right care to the right kid at the right time. You can also help keep your employees safe and your family members safe.
I would say in terms of deciding if it fits with your sort of personal job agendas or what your desired career path is, I think it's a great way to get a lot of exposure to a lot of different issues and become comfortable with building trust with others, that's a really big part of our success, is the trust that we've built with all of our clinical teams.
So learning how to cultivate those relationships, I think it's probably important anywhere you work as a risk manager, but especially because pediatric hospitals tend to be sort of like softer places in a sense where, you know, sometimes it's hard not to go through a day without getting a little misty-eyed when you think about all the children that are battling all the various things that they're battling in your building and thinking about what your part in that is. It's very, very meaningful work. But being able to have relationships and build trust with the clinical teams is important. Being able to listen. Sometimes we just need to listen to our clinical staff where they're venting about something, but being kind of an active listener so you can help the person who's called you really articulate what the problem is, that can be an important skill. It's very important in this setting not to be the department of no. Again, if our mission is to get the care to the children, then we need to figure out how we can get from point A to point B without putting anybody at unnecessary risk.
And then it's also important for our risk manager in pediatrics to really have the strategic picture in mind, understand what your organization's strategic plan is and how your work fits in to that and how you help to either make that happen or put it at risk, because especially freestanding pediatric hospitals don't tend to have gigantic endowments. They really are operating on very thin margins and fundraising is important and the reputation in the organization is super important. And so the risk team can really help deliver on all the things that are necessary to continue to support the mission and the strategic plan for the organization.
Prakash Chandran: Well, Rebecca, I think this has been a truly informative conversation. Is there anything else that you'd like to share before we close here today?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: I would say risk management in general is a great profession. I think that we can do much more and we do much more now in terms of strategic risk management and enterprise risk management than we used to do 20 years ago. We certainly do a lot more of it now since I came in house almost 14 years ago. And so, if you don't know much about enterprisers management, I would absolutely encourage you to learn. ASHRM has great resources for you and it really is the wave of the future in terms of risk management and so it'd be great for you to have a ticket on that train.
Prakash Chandran: Well, Rebecca, thank you so much for your time. We truly appreciate it.
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Thanks so much. It was lovely speaking with you.
Prakash Chandran: That was Rebecca Cady, Vice-president and Chief Risk Officer at Children's National Medical Center in Washington, DC. The ASHRM podcast was 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 ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. Thanks for listening, and we'll talk next time.
Prakash Chandran: Welcome to the ASHRM podcast 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 ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran.
Pediatric patients are among the most vulnerable in society. Children rely on parents, family members, and sometimes state-appointed caregivers to ensure that they receive appropriate medical attention. Some pediatric conditions are easily identified as requiring immediate evaluation. However, for many pediatric conditions, determining when to seek care, as well as identifying proper treatment can be challenging for caregivers, providers, and payers alike.
The multifaceted needs of young patients require a robust implementation of healthcare risk management to educate all of those involved in pediatric care and solidify strategies to improve outcomes for children's care. Joining us today is Rebecca Cady, Vice President and Chief Risk Officer at Children's National Medical Center in Washington, DC.
Rebecca, thank you so much for joining us today. I truly appreciate it. I'd love to get started by asking what risks are unique to children's hospitals?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Thanks, Prakash. Glad to be here with you today. So, children's hospitals have several unique things about them that make their risks different from those of adult facilities. I think the one that we come across the most often and that we deal with the most often is the fact that you don't just have a patient that you need to deal with. You've got a family, and sometimes that family is comprised of what we would consider, you know, a traditional nuclear family, and sometimes it's not. Sometimes the grandparents are raising the child. Sometimes an aunt or an uncle is raising the child. Sometimes, you know, just a friend is raising the child. And you can sometimes have family members who have differing opinions about, you know, what should be done or what's going on with the child, especially if you have a circumstance where, you know, you've got a very sick child or a child who's been the victim of some kind of violence or gun violence.
So managing the patient and their family is really part of the art of risk management in the pediatric setting, keeping in mind that those families tend to bring with them all the troubles that they have in the external world. Those troubles don't vanish when they walk through the hospital doors. And so a lot of times, the troubles that come with them, whether it's marital dispute or whether there's something else going on in the home, so a lot of socioeconomic factors really impact the care of children.
We know that there are social determinants of health really from before the child's even born that impact their healthcare. And so the family is such an important part of this that we really need to know how to manage, not just a patient, but the adults that surround that patient.
A couple of other things that are more kind of technical, I suppose you would say, are the fact that there's a really long tail for claims, right? And in most jurisdictions, a child has until the age majority, so 18 years plus whatever the normal statute of limitations is for a medical malpractice case. In most states, it's three years. So theoretically, you could be taking care of a newborn and that child can have until their 21st birthday to sue you for something that happens in the newborn period.
So it requires really good record keeping and institutional knowledge about cases and it requires you to have a good way to go back and look at old files. So this actually came up for us recently, where we had a case that occurred a number of years ago, I think something like 10 or 12 years ago and was while we were all on paper in terms of our incident reporting and risk management documentation. Luckily, we're very organized about our files and storage. This file had gone to storage, but we were able to retrieve it and it had some really important information in it that helped me to have frankly a pretty stern conversation with the attorney who had reached out to me to let him know that we did not believe that this was a case of liability and was very specific with him about why that was. This was very important because without the ability to go back and pull from that institutional knowledge and those older records, it would have been hard for us to really provide a meaningful response to this.
The other thing for children's cases is that almost every case potentially could be like a bad baby case. And what do I mean by that? So a birth injury case. No babies are bad, so sorry about that. So a birth injury case obviously can have very large amount of damages involved because you have a child who's injured at a very young age at birth, and you have a child then who's going to need significant amounts of care throughout the rest of their life. And the rest of their life could potentially be something like 30 or 40 years. So, although some pediatric hospitals do not deliver babies, they still have that potential big claim exposure because they're taking care of babies and young children. And so if there's some kind of a devastating injury, you're still going to be looking at a case that could be worth potentially millions and millions of dollars.
The other thing we see in terms of how we manage risks are the importance of the need to teach families about all kinds of things. More specific to our bailiwick is informed consent. So how do you really make sure that a family understands the risks, benefits, and alternatives of a procedure that you're about to do for their child? And how do you make them appreciate the seriousness of a case, especially if you're doing a surgery for a rare procedure or for an underlying condition, which doesn't tend to have very good outcomes no matter what you do? How do you appropriately educate those families without sort of scaring them off to the point that they decide they don't even want to do the procedure?
You really have to find a good balance there and that's a struggle. And so being able to counsel physicians and work with physicians and other LIPs who do informed consent about how do you get this across in the right way to make them really understand what the risks are without sort of making them run away from the care altogether, I think are really important and unique risks that we deal with in children's hospitals.
Prakash Chandran: So that's a really good summary and kind of leads me to my next question. With all of the nuances around injury, the family dynamics that you need to deal with, in addition to the detailed hygiene around record keeping, why exactly would someone want to be a risk manager in that type of environment.
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Three words: mission, mission, mission. Pediatric hospitals do miraculous things to help kids. And you're an important part of the team as a risk manager in a pediatric hospital. The clinical staff really need you because consent issues come up all the time. If you have somebody who comes in with the child who is not the parent and we have to help them sort out is that person allowed to consent to this office visit or this procedure, the clinical staff really needs you. And so you really get a great sense of fulfillment of helping the clinical staff clear up the questions that they have so that those questions are not a barrier to their providing good care for kids.
The second thing that's really wonderful about it is there such a variety of work. No one day at work looks like any other day. You can have a set plan and agenda for the things you'd like to do that day. And the phone rings probably before you even get to the hospital and you're off and running with something else. So there's a really great variety of risk topics that we manage. We do enterprise risks, so that's important and helping the organization look at its strategic plan and make sure the organization can be successful and continue to fulfill its mission down to the intricacies of helping staff work through a situation with a family that's in crisis and how do you do that? Keeping your staff safe, keeping the patients safe and keeping the family intact. Those are really challenging situations, but they're very fulfilling when you can help the staff come to a successful resolution. And so at the end of the day, you can really be an important part of how the organization helps children and their families.
Prakash Chandran: Yeah, I think that makes a lot of sense. And it's such an important role to play, to remove barriers and constraints to providing children the best care possible. Could you perhaps share some of your successes there?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Yeah. So consents in particular used to be a thing that we spent a lot of time on. And by that, I mean, almost without a doubt every day at around six, the phone would start ringing for whoever was on call and people would have questions about, "Hey, this foster parent is in with the child" or "Hey, this grandmother has brought the child in," or "Hey, the aunt has brought the child in," and the child is scheduled for surgery. And we need to know whether this person can sign the consent and we can't reach the mom and so forth. So we almost never get those calls anymore now because we've created a system to have those questions asked well ahead of time.
So, how do we do that? Well, we met with the surgery schedulers and we gave them a script of how do they talk to the person that they're scheduling the case with and how do they tell them, like, if mom or dad, you're not going to be able to bring the child in. If you're sending somebody else with your child, you've got to let us know ahead of time and you have to send them with a document that will allow them to provide consent on your behalf. And we created a document for the parents so that all they had to do is enter the child's name, put in a date of expiration if they wanted it to expire and then sign it. And so we also trained our social work staff that, okay, these are the forms that we're going to ask the parents to fill out. And these are the standard. We created a lot of standard work around this process, so that we're asking these questions ahead of time. We're not asking them for the first time on the day of the procedure. And we're making sure that all the staff understand that they can always reach us if they have questions and that, you know, if there's an emergency that they should go ahead and proceed with two physicians consenting.
Our goal is to not have a kid come in, especially after having been NPO for part of the night, parents are having to drive a long way, we have patients coming from all over DC, Maryland, Virginia, West Virginia, and farther. And so we really don't want to have to cancel a surgery if at all possible. And so we've worked really hard with those teams and our surgery cancellation rate has gone way down. The staff understand the process. We have less pickups at the last minute. And everybody seems a lot happier. And at the end of the day, the kids get the surgery when they need to have the surgery and that's what's the best for the kids. So it's a win all the way around.
Prakash Chandran: Yeah, absolutely. So, you know, someone might be listening to this and is trying to assess whether working as a risk manager at a children's hospital is right for them. Do you have any advice or guidance for the people that are in that camp?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: So I would say again, it's all about the mission and you can be a really important part of how that mission gets delivered every day. And you can make sure that we give the right care to the right kid at the right time. You can also help keep your employees safe and your family members safe.
I would say in terms of deciding if it fits with your sort of personal job agendas or what your desired career path is, I think it's a great way to get a lot of exposure to a lot of different issues and become comfortable with building trust with others, that's a really big part of our success, is the trust that we've built with all of our clinical teams.
So learning how to cultivate those relationships, I think it's probably important anywhere you work as a risk manager, but especially because pediatric hospitals tend to be sort of like softer places in a sense where, you know, sometimes it's hard not to go through a day without getting a little misty-eyed when you think about all the children that are battling all the various things that they're battling in your building and thinking about what your part in that is. It's very, very meaningful work. But being able to have relationships and build trust with the clinical teams is important. Being able to listen. Sometimes we just need to listen to our clinical staff where they're venting about something, but being kind of an active listener so you can help the person who's called you really articulate what the problem is, that can be an important skill. It's very important in this setting not to be the department of no. Again, if our mission is to get the care to the children, then we need to figure out how we can get from point A to point B without putting anybody at unnecessary risk.
And then it's also important for our risk manager in pediatrics to really have the strategic picture in mind, understand what your organization's strategic plan is and how your work fits in to that and how you help to either make that happen or put it at risk, because especially freestanding pediatric hospitals don't tend to have gigantic endowments. They really are operating on very thin margins and fundraising is important and the reputation in the organization is super important. And so the risk team can really help deliver on all the things that are necessary to continue to support the mission and the strategic plan for the organization.
Prakash Chandran: Well, Rebecca, I think this has been a truly informative conversation. Is there anything else that you'd like to share before we close here today?
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: I would say risk management in general is a great profession. I think that we can do much more and we do much more now in terms of strategic risk management and enterprise risk management than we used to do 20 years ago. We certainly do a lot more of it now since I came in house almost 14 years ago. And so, if you don't know much about enterprisers management, I would absolutely encourage you to learn. ASHRM has great resources for you and it really is the wave of the future in terms of risk management and so it'd be great for you to have a ticket on that train.
Prakash Chandran: Well, Rebecca, thank you so much for your time. We truly appreciate it.
Rebecca Cady, Esq., BSN, CPHRM, DFASHRM, FACHE: Thanks so much. It was lovely speaking with you.
Prakash Chandran: That was Rebecca Cady, Vice-president and Chief Risk Officer at Children's National Medical Center in Washington, DC. The ASHRM podcast was 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 ashrm.org/membership to learn more and to become an ASHRM member. My name is Prakash Chandran. Thanks for listening, and we'll talk next time.