WEBVTT 00:00:00.590 --> 00:00:04.004 position:50% align:middle - [Female] Brendan Martin is the Director of Research for NCSBN. 00:00:04.004 --> 00:00:08.586 position:50% align:middle He has more than 13 years in quantitative modeling and consulting. 00:00:08.586 --> 00:00:13.778 position:50% align:middle Brendan has extensive graduate-level statistical training in the fields of 00:00:13.778 --> 00:00:16.981 position:50% align:middle mathematics and public health sciences. 00:00:16.981 --> 00:00:21.926 position:50% align:middle His research interests include post-secondary access, biostatistics, 00:00:21.926 --> 00:00:24.687 position:50% align:middle healthcare reform, and regulation. 00:00:31.000 --> 00:00:34.843 position:50% align:middle - [Brendan] Hello, my name is Brendan Martin, and I'm the director of NCSBN's 00:00:34.843 --> 00:00:39.020 position:50% align:middle Research Department. I'm here today to discuss the results of a recently completed 00:00:39.020 --> 00:00:44.380 position:50% align:middle international study evaluating the efficacy of the adverse event decision pathway. 00:00:44.380 --> 00:00:48.010 position:50% align:middle For today's presentation, we are going to cover a few major points. 00:00:48.010 --> 00:00:51.925 position:50% align:middle To start, I'll provide a bit of background on the study to give you all the necessary 00:00:51.925 --> 00:00:55.561 position:50% align:middle context for why we wanted to pursue this study in the first place and what we hope 00:00:55.561 --> 00:01:00.201 position:50% align:middle to achieve. I'll then share a brief overview of the study methodology so that you are 00:01:00.201 --> 00:01:04.047 position:50% align:middle clear on how we selected our sample, went about collecting the data, and how we 00:01:04.047 --> 00:01:08.614 position:50% align:middle analyze the responses. Then, we'll get into the meat of the presentation in which 00:01:08.614 --> 00:01:13.350 position:50% align:middle I'll cover the results in detail before wrapping up with a few key takeaways. 00:01:13.350 --> 00:01:17.078 position:50% align:middle As always, I'll attempt to leave ample time at the end for any follow-up questions or 00:01:17.078 --> 00:01:21.220 position:50% align:middle necessary clarification. So please feel free to use the chatbox to submit your 00:01:21.220 --> 00:01:27.758 position:50% align:middle comments as I go through the material. By way of background, in 2017, NCSBN 00:01:27.758 --> 00:01:31.422 position:50% align:middle partnered with the American Organization of Nursing Leadership and the National 00:01:31.422 --> 00:01:35.042 position:50% align:middle Association of Directors of Nursing Administration to conduct a survey 00:01:35.042 --> 00:01:37.530 position:50% align:middle of U.S. nursing leaders. 00:01:37.530 --> 00:01:41.893 position:50% align:middle The goal of this outreach was to identify the determinants of underreported adverse events 00:01:41.893 --> 00:01:44.330 position:50% align:middle of facilities across the country. 00:01:44.330 --> 00:01:48.698 position:50% align:middle The primary factors that emerged from this analysis were confusion as to what constituted a 00:01:48.698 --> 00:01:53.693 position:50% align:middle reportable offense, a lack of clarity over how to report to an external regulatory body, 00:01:53.693 --> 00:01:58.356 position:50% align:middle and various facility-level barriers including existing policy and culture. 00:01:58.356 --> 00:02:04.710 position:50% align:middle The results of this study were then published in the Journal of Nursing Regulation in mid-2018. 00:02:04.710 --> 00:02:08.170 position:50% align:middle Based on these findings, NCSBN went about the work of spearheading 00:02:08.170 --> 00:02:12.643 position:50% align:middle an international collaboration to test the efficacy of its new facility-reporting tool 00:02:12.643 --> 00:02:15.111 position:50% align:middle called the Adverse Event Decision Pathway. 00:02:16.270 --> 00:02:19.810 position:50% align:middle Here is a copy of the AEDP we used for the study. 00:02:19.810 --> 00:02:23.537 position:50% align:middle The AEDP was originally created in response to requests from nurse 00:02:23.537 --> 00:02:28.050 position:50% align:middle administrators and regulatory bodies for a tool to assist nursing leaders responsible 00:02:28.050 --> 00:02:32.707 position:50% align:middle for evaluation and reporting of adverse events. This tool was developed via a 00:02:32.707 --> 00:02:38.256 position:50% align:middle direct collaboration between NCSBN and AONL. Following principles of the system's 00:02:38.256 --> 00:02:42.464 position:50% align:middle approach and just culture, the AEDP suggestions include a complete 00:02:42.464 --> 00:02:47.042 position:50% align:middle investigation of the adverse event as well as the nurse's behavioral choices. 00:02:47.042 --> 00:02:49.960 position:50% align:middle While we initially designed the pathway for U.S. 00:02:49.960 --> 00:02:54.280 position:50% align:middle nursing leaders, the tool was updated and the language broadened for an international 00:02:54.280 --> 00:02:57.591 position:50% align:middle audience in anticipation of this study launch. 00:02:58.770 --> 00:03:05.275 position:50% align:middle We had two primary objectives for the AEDP study. First, we wanted to replicate U.S. findings. 00:03:05.350 --> 00:03:09.700 position:50% align:middle This would help us establish important context for interpreting the results and confirm, 00:03:09.700 --> 00:03:14.585 position:50% align:middle as the literature suggests, the existence of certain borderless barriers to adverse 00:03:14.585 --> 00:03:16.910 position:50% align:middle event reporting, so to speak. 00:03:16.910 --> 00:03:21.740 position:50% align:middle And second, we wanted to assess the efficacy of the AEDP tool itself. 00:03:21.740 --> 00:03:26.120 position:50% align:middle You'll see this was achieved both through design and modeling. 00:03:26.120 --> 00:03:30.460 position:50% align:middle Regarding the methodology, the study utilized a pre-post survey design. 00:03:30.460 --> 00:03:34.179 position:50% align:middle NCSBN partnered with the British Columbia College of Nursing professionals and the 00:03:34.179 --> 00:03:38.615 position:50% align:middle College of Nurses of Ontario to survey nursing leaders in both provinces between 00:03:38.615 --> 00:03:43.907 position:50% align:middle May and November of 2019. An initial 19-item confidential online survey was 00:03:43.907 --> 00:03:48.295 position:50% align:middle administered using Qualtrics. Questions were divided into three topic areas, 00:03:48.295 --> 00:03:53.432 position:50% align:middle demographic and professional information including sex, age, title, credentials, year 00:03:53.432 --> 00:03:58.625 position:50% align:middle and position, health facility information including size and location, and health 00:03:58.625 --> 00:04:03.651 position:50% align:middle facility practices with respect to adverse event tracking and reporting. After 00:04:03.651 --> 00:04:07.290 position:50% align:middle completion of the baseline survey, respondents who opted in to ongoing 00:04:07.290 --> 00:04:12.484 position:50% align:middle participation received a copy of the AEDP tool for their reference. To facilitate the 00:04:12.484 --> 00:04:17.366 position:50% align:middle review and use of the AEDP tool, NCSBN provided each participant with background 00:04:17.366 --> 00:04:23.160 position:50% align:middle on the pathway, detailed instructions on how to use it, and definitions for key terms. 00:04:23.160 --> 00:04:27.630 position:50% align:middle Six months later, the same individuals received a second 14-item confidential 00:04:27.630 --> 00:04:33.110 position:50% align:middle online survey specifically tailored to assess the efficacy of the AEDP tool itself. 00:04:33.110 --> 00:04:37.633 position:50% align:middle Questions were divided into two areas for follow up, health facility practices with 00:04:37.633 --> 00:04:44.250 position:50% align:middle respect to adverse event tracking and reporting and direct evaluation of the AEDP tool. 00:04:44.250 --> 00:04:48.298 position:50% align:middle Generalized estimating equation models were then used to assess changes in reporting 00:04:48.298 --> 00:04:52.820 position:50% align:middle frequency and type based on use of the AEDP guideline. 00:04:52.820 --> 00:04:57.034 position:50% align:middle This approach appropriately counted for intraobserver correlation that resulted 00:04:57.034 --> 00:05:01.701 position:50% align:middle from the longitudinal study design while also allowing for sufficient flexibility 00:05:01.701 --> 00:05:06.040 position:50% align:middle to assess a ranked outcome, meaning ordinal, and adjust for other important 00:05:06.040 --> 00:05:12.898 position:50% align:middle covariates as necessary. Turning now to the results, response patterns did not differ 00:05:12.898 --> 00:05:16.360 position:50% align:middle significantly by province so data were combined. 00:05:16.360 --> 00:05:21.504 position:50% align:middle The pre and post survey response rates were 21% and 34% respectively. 00:05:21.504 --> 00:05:27.310 position:50% align:middle A total of 663 participants responded to the pre-survey. 00:05:27.310 --> 00:05:32.420 position:50% align:middle Director of nursing, nurse manager, chief nursing executive or officer, 00:05:32.420 --> 00:05:37.370 position:50% align:middle and other director or manager were the most common professional titles reported. 00:05:37.370 --> 00:05:42.370 position:50% align:middle Respondents were, on average, 50 years old and predominantly female. 00:05:42.370 --> 00:05:46.793 position:50% align:middle A master's degree was the most frequent level of nursing education reported and 00:05:46.793 --> 00:05:51.943 position:50% align:middle long-term care, hospital, and community represented the three most common facility 00:05:51.943 --> 00:05:58.325 position:50% align:middle types. Overall, 7 in 10 participants were from Ontario while over half of nursing 00:05:58.325 --> 00:06:02.130 position:50% align:middle leaders reported working in an urban healthcare facility. 00:06:02.130 --> 00:06:05.960 position:50% align:middle The median number of beds per facility was 140. 00:06:05.960 --> 00:06:11.279 position:50% align:middle Given the match pre-post design, the 121 individuals who responded to the post-survey 00:06:11.279 --> 00:06:17.340 position:50% align:middle largely mirrored the demographic and professional profile of the pre-survey sample. 00:06:17.340 --> 00:06:21.482 position:50% align:middle At baseline, two-thirds of nursing leaders reported their facility had an existing 00:06:21.482 --> 00:06:26.508 position:50% align:middle policy, criteria, or set of guidelines to decide whether or not to report a nurse to 00:06:26.508 --> 00:06:34.032 position:50% align:middle the provincial College of Nursing. Of this cohort, 194 used established criteria, 138, 00:06:34.032 --> 00:06:41.070 position:50% align:middle facility policy, and 74, a decision-making tool. Further, about 64% indicated they 00:06:41.070 --> 00:06:45.293 position:50% align:middle were somewhat or extremely satisfied with the process their facility had in place. 00:06:45.710 --> 00:06:49.920 position:50% align:middle So right from the start, we realize this would likely be a pretty tough crowd. 00:06:49.920 --> 00:06:54.144 position:50% align:middle By and large, this group had access to an existing policy which they typically held in 00:06:54.144 --> 00:07:00.254 position:50% align:middle high regard. Director of nursing, nursing manager, and chief nursing officer were 00:07:00.254 --> 00:07:04.191 position:50% align:middle among the most frequently listed positions with authority to report a nurse to the 00:07:04.191 --> 00:07:08.163 position:50% align:middle provincial College of Nursing, which is important information and you'll see how 00:07:08.163 --> 00:07:13.823 position:50% align:middle that comes into play later. A plurality of participants reported no obstacles to 00:07:13.823 --> 00:07:18.952 position:50% align:middle external reporting at about 43%. For those that did encounter difficulties, however, 00:07:18.952 --> 00:07:23.549 position:50% align:middle concern over possible legal ramifications, knowing what constitutes a reportable 00:07:23.549 --> 00:07:28.694 position:50% align:middle offense and how to make a report as well as facility culture and policy emerged as 00:07:28.694 --> 00:07:33.829 position:50% align:middle the most significant challenges. Nursing leaders were also asked if the facility 00:07:33.829 --> 00:07:37.935 position:50% align:middle reports to the provincial College of Nursing when a nurse's employment is terminated 00:07:37.935 --> 00:07:43.592 position:50% align:middle due to their involvement in a serious adverse event. At baseline, only half of respondents, 00:07:43.592 --> 00:07:49.293 position:50% align:middle approximately 52%, indicated their facility would. Among the most common reportable 00:07:49.293 --> 00:07:55.054 position:50% align:middle workplace behaviors or issues were sexual abuse, repeated reckless behavior, fraud, 00:07:55.054 --> 00:08:02.088 position:50% align:middle and abuse. Six months after receiving the AEDP tool, nursing leaders were again 00:08:02.088 --> 00:08:05.590 position:50% align:middle asked to share details on the reporting tendencies. 00:08:05.590 --> 00:08:11.267 position:50% align:middle Nearly all respondents, about 90%, actively used the AEDP tool for at least three months, 00:08:11.267 --> 00:08:18.104 position:50% align:middle which was great. Similarly, 91% of participants reported encountering at least one disciplinary 00:08:18.104 --> 00:08:23.376 position:50% align:middle case during the reporting timeframe and all but two indicated they used the AEDP tool 00:08:23.376 --> 00:08:28.888 position:50% align:middle to determine if external reporting was necessary. Among those who used the AEDP 00:08:28.888 --> 00:08:35.483 position:50% align:middle tool, 95% thought it was moderately or very helpful and 82% reported it made 00:08:35.483 --> 00:08:41.779 position:50% align:middle a significant impact under disciplinary decisions. Over 80% of respondents also 00:08:41.779 --> 00:08:45.911 position:50% align:middle reported the AEDP tool made the reporting process more efficient, gave them more 00:08:45.911 --> 00:08:50.083 position:50% align:middle confidence in their final decision, helped them distinguish between nurse error and 00:08:50.083 --> 00:08:56.130 position:50% align:middle systems issues, and was useful when deciding whether or not to issue an external report. 00:08:56.130 --> 00:09:02.354 position:50% align:middle Overall, 82% of participants reported the AEDP tool was superior or very superior 00:09:02.354 --> 00:09:06.710 position:50% align:middle to other established criteria or guidelines their facility already used. 00:09:06.710 --> 00:09:11.260 position:50% align:middle We felt this was a particularly interesting and important finding given this group's initial high 00:09:11.260 --> 00:09:14.500 position:50% align:middle regard for their existing policies and guidelines. 00:09:14.500 --> 00:09:17.966 position:50% align:middle While the most common reportable workplace behaviors or issues remained largely 00:09:17.966 --> 00:09:23.063 position:50% align:middle unchanged upon follow up, there was a net gain of 10 percentage points or more among 00:09:23.063 --> 00:09:28.384 position:50% align:middle those who would now also report issues of diversion, you'll see that was up nearly 32%, 00:09:28.384 --> 00:09:35.378 position:50% align:middle reckless behavior, up 26%, termination, up 24%, and standard of care violations, now 00:09:35.378 --> 00:09:41.285 position:50% align:middle up 13%. For most other workplace incidents, there were more limited gains or decreases 00:09:41.285 --> 00:09:47.881 position:50% align:middle observed. Overall, after using the AEDP tool for several months, approximately 7 00:09:47.881 --> 00:09:52.985 position:50% align:middle in 10 respondents now indicated their facility would report a nurse whose employment was 00:09:52.985 --> 00:09:57.330 position:50% align:middle terminated due to their role in a serious adverse event. 00:09:57.330 --> 00:10:02.120 position:50% align:middle That represented a net gain of 17 percentage points from baseline. 00:10:02.120 --> 00:10:06.341 position:50% align:middle Further, the proportion of participants who didn't know if their facility would report a 00:10:06.341 --> 00:10:11.350 position:50% align:middle terminated staff member decreased from about 13% to 2%. 00:10:11.350 --> 00:10:15.691 position:50% align:middle Basically, as you can see for yourselves, at every level, the reporting tendencies 00:10:15.691 --> 00:10:21.250 position:50% align:middle for serious adverse events requiring termination increased pre to post. 00:10:21.250 --> 00:10:25.560 position:50% align:middle To quantify these results further, after referencing the AEDP tool, 00:10:25.560 --> 00:10:30.622 position:50% align:middle respondents were 2.29 times more likely to report a nurse's involvement in a serious 00:10:30.622 --> 00:10:34.310 position:50% align:middle adverse event necessitating their termination. 00:10:34.310 --> 00:10:39.010 position:50% align:middle This represented a statistically significant increase in reporting frequency. 00:10:39.010 --> 00:10:43.489 position:50% align:middle In addition, adjusting for the other policies or guidance, that about 20% of respondents 00:10:43.489 --> 00:10:47.723 position:50% align:middle indicated their facilities had implemented during the same period, the effect of the 00:10:47.723 --> 00:10:53.629 position:50% align:middle AEDP tool remained largely unchanged. Nurse managers were identified as the 00:10:53.629 --> 00:10:58.987 position:50% align:middle most appropriate audience followed closely by director of nursing and chief nursing officer. 00:11:00.730 --> 00:11:02.600 position:50% align:middle So what are the key takeaways? 00:11:02.600 --> 00:11:06.312 position:50% align:middle First, it is critical that decision-making tools are tailored to meet the needs of 00:11:06.312 --> 00:11:11.380 position:50% align:middle their intended audience and can work in concert with other facility protocol. 00:11:11.380 --> 00:11:15.362 position:50% align:middle Respondents to this survey indicated the AEDP tool would be the most appropriate 00:11:15.362 --> 00:11:20.390 position:50% align:middle for nurse managers, directors of nursing, and chief nursing officers. 00:11:20.390 --> 00:11:24.503 position:50% align:middle This represented a near-complete overlap with those individuals respondents had 00:11:24.503 --> 00:11:28.970 position:50% align:middle indicated were tasked with making reporting decisions at their facilities. 00:11:28.970 --> 00:11:33.680 position:50% align:middle In addition, even for facilities that enacted other policies or issued other guidance 00:11:33.680 --> 00:11:38.139 position:50% align:middle related to adverse event reporting during the same timeframe, the positive effect 00:11:38.139 --> 00:11:43.246 position:50% align:middle of the AEDP tool was not diminished, highlighting its utility and durability in 00:11:43.246 --> 00:11:48.616 position:50% align:middle the face of other competing strategies. Importantly, for most workplace incidents, 00:11:48.616 --> 00:11:53.581 position:50% align:middle there was also minimal change in respondents reporting activities, meaning the AEDP tool 00:11:53.581 --> 00:11:57.864 position:50% align:middle was often utilized in a targeted fashion rather than increasing reporting across 00:11:57.864 --> 00:12:02.279 position:50% align:middle the board. Notable increases in reporting were typically limited to more serious 00:12:02.279 --> 00:12:07.675 position:50% align:middle circumstances involving issues of diversion, reckless behavior, termination, and standard 00:12:07.675 --> 00:12:13.427 position:50% align:middle of care violations. Further and perhaps more importantly, the proportion of participants 00:12:13.427 --> 00:12:17.112 position:50% align:middle who were initially unsure if they would report a staff who was terminated due 00:12:17.112 --> 00:12:22.091 position:50% align:middle to their role in a serious adverse event decreased from 13% to 2% as I noted 00:12:22.091 --> 00:12:27.224 position:50% align:middle earlier underscoring user's increased knowledge and confidence in the process. 00:12:27.868 --> 00:12:32.661 position:50% align:middle And finally, overall, over 80% of participants reported the AEDP tool 00:12:32.661 --> 00:12:36.521 position:50% align:middle made the decision-making process more efficient, increased their confidence, 00:12:36.521 --> 00:12:41.030 position:50% align:middle and helped them distinguish between nurse error and systems issues. 00:12:41.030 --> 00:12:45.220 position:50% align:middle Perhaps most interestingly, despite the fact that nearly two-thirds of respondents 00:12:45.220 --> 00:12:50.180 position:50% align:middle reported using an existing facility policy with which they were somewhat extremely satisfied, 00:12:50.180 --> 00:12:55.383 position:50% align:middle an astounding 82% said the AEDP tool was superior or very superior to other 00:12:55.383 --> 00:12:57.810 position:50% align:middle established criteria or guidelines. 00:12:57.810 --> 00:13:02.158 position:50% align:middle Thus, we concluded and we hope you'll agree, the AEDP tool is an effective, 00:13:02.158 --> 00:13:06.910 position:50% align:middle evidence-based tool that can be used to support facility decision-making. 00:13:06.910 --> 00:13:10.810 position:50% align:middle With that, I will open the floor to discussion and any questions you might have. 00:13:32.300 --> 00:13:36.760 position:50% align:middle Hello, everyone. So the floor is now open for questions. 00:13:36.760 --> 00:13:41.745 position:50% align:middle As you gather your thoughts and submit your questions to the chatbox, I did just 00:13:41.745 --> 00:13:48.787 position:50% align:middle want to give you an update from the latest recording of this presentation and that is 00:13:48.787 --> 00:13:54.671 position:50% align:middle that the manuscript associated with this analysis is anticipated to be published 00:13:54.671 --> 00:13:58.707 position:50% align:middle probably in the next month or so in the Journal of Nursing Regulation. 00:13:58.790 --> 00:14:02.686 position:50% align:middle So for those of you who are interested in some of the more detailed takeaways and 00:14:02.686 --> 00:14:10.010 position:50% align:middle how they relate to the literature on this topic, that manuscript is forthcoming. 00:14:10.010 --> 00:14:15.826 position:50% align:middle So with that, I will hesitate here and see if any questions start to roll in. 00:14:18.200 --> 00:14:23.590 position:50% align:middle One of the things that I will mention too, just as everyone continues to think 00:14:23.590 --> 00:14:27.996 position:50% align:middle over some questions, is that should you have a question that occurs to you 00:14:27.996 --> 00:14:35.290 position:50% align:middle after this session, I would encourage you to reach out to me directly at bmartin@ncsbn.org. 00:14:35.290 --> 00:14:40.976 position:50% align:middle I'm happy to field questions today during the live Q&A session and/or after the 00:14:40.976 --> 00:14:47.289 position:50% align:middle event should something come to mind and you want clarification or you feel that 00:14:47.289 --> 00:14:52.620 position:50% align:middle follow-up would be helpful. So, please always just feel free to reach out. 00:14:52.620 --> 00:14:56.690 position:50% align:middle So one of the things, just again as we wait for some questions roll in, 00:14:56.690 --> 00:15:01.137 position:50% align:middle one of the things that was particularly, I think, interesting about this study was 00:15:01.137 --> 00:15:04.200 position:50% align:middle the opportunity for international collaboration. 00:15:04.200 --> 00:15:10.490 position:50% align:middle So that is something that we here at NCSBN are looking to do more and more. 00:15:10.490 --> 00:15:14.528 position:50% align:middle And so this was an opportunity to naturally build upon some of the research that we 00:15:14.528 --> 00:15:20.910 position:50% align:middle had conducted, you know, just a few short years ago, in which we looked at the barriers 00:15:20.910 --> 00:15:26.288 position:50% align:middle to adverse event reporting for U.S. nursing leaders and this was a natural extension 00:15:26.288 --> 00:15:30.618 position:50% align:middle and an opportunity for collaboration with our Canadian neighbors. 00:15:30.618 --> 00:15:35.480 position:50% align:middle And I think moving forward, this is something that we in the Research Department 00:15:35.480 --> 00:15:41.301 position:50% align:middle here at NCSBN really want to try to do more and more, and that is collaborate with our 00:15:41.301 --> 00:15:46.092 position:50% align:middle international partners and make sure that we're understanding the true impact and 00:15:46.092 --> 00:15:51.996 position:50% align:middle the issues related to nursing regulation across the global nursing community. 00:15:53.260 --> 00:15:59.000 position:50% align:middle You know, I'm not seeing any questions as they relate directly to this study. 00:15:59.000 --> 00:16:03.820 position:50% align:middle So one of the things, to give a little bit more space in case something comes 00:16:03.820 --> 00:16:07.468 position:50% align:middle to mind, one of the things that I will just reiterate, that if you have a question that 00:16:07.468 --> 00:16:12.471 position:50% align:middle comes to mind after this session is over or after the conference, please feel free to 00:16:12.471 --> 00:16:16.050 position:50% align:middle reach out to me directly at bmartin@ncsbn.org. 00:16:18.100 --> 00:16:21.430 position:50% align:middle And I think we're starting to get some questions coming in. 00:16:21.430 --> 00:16:26.672 position:50% align:middle So let's refresh the log, make sure that I'm not missing anything. 00:16:30.820 --> 00:16:36.730 position:50% align:middle So I am still not seeing. Here you go. Here you go. Okay. 00:16:36.730 --> 00:16:38.560 position:50% align:middle Yes, I am now seeing questions. 00:16:38.560 --> 00:16:42.670 position:50% align:middle So the first one is, you indicated that respondents were inclined to see 00:16:42.670 --> 00:16:46.841 position:50% align:middle the tool. Will there be any follow-up to see if the quality of reporting improves 00:16:46.841 --> 00:16:51.820 position:50% align:middle post this study? Yeah, I think that that's a really good point. 00:16:51.820 --> 00:16:56.933 position:50% align:middle I think continued follow-up with some of these folks really would shed further 00:16:56.933 --> 00:17:03.490 position:50% align:middle insight on kind of the longevity and how much legs this particular tool has for 00:17:03.490 --> 00:17:08.049 position:50% align:middle some of these facilities. One of the initial sources of disappointment, and 00:17:08.049 --> 00:17:11.616 position:50% align:middle disappointment might be a bit of a strong word in this context was that we had a 00:17:11.616 --> 00:17:15.677 position:50% align:middle number of individuals who hoped to participate in the follow-up study who, 00:17:15.677 --> 00:17:19.338 position:50% align:middle for various reasons, found that they didn't have time or weren't able to kind of share 00:17:19.338 --> 00:17:23.797 position:50% align:middle their full evaluation. So I think continued follow-up and making sure that essentially, 00:17:23.797 --> 00:17:30.109 position:50% align:middle we really do understand if and how this tool is built into the reporting process in 00:17:30.109 --> 00:17:34.169 position:50% align:middle kind of a durable fashion, I think that that's a very good idea. And then we 00:17:34.169 --> 00:17:38.460 position:50% align:middle have another question. Were there any indications of cultural or organizational 00:17:38.460 --> 00:17:41.820 position:50% align:middle factors that prohibited reporting? Yeah, this is an excellent question. 00:17:41.820 --> 00:17:44.500 position:50% align:middle So this actually bridged both of our studies on this topic. 00:17:44.500 --> 00:17:49.855 position:50% align:middle So one of the primary questions that we really wanted to understand was what 00:17:49.855 --> 00:17:56.560 position:50% align:middle barriers exist at the facility level in relation to external reporting frequency. 00:17:56.560 --> 00:18:02.486 position:50% align:middle So we did ask if there were any concerns regarding legal ramifications that had been 00:18:02.486 --> 00:18:08.600 position:50% align:middle communicated to them and/or just kind of writ large facility or cultural barriers. 00:18:08.600 --> 00:18:12.710 position:50% align:middle And that was one of the more common responses that was provided. 00:18:12.710 --> 00:18:16.709 position:50% align:middle So there are certain, I like to kind of think about them as almost tiers 00:18:16.709 --> 00:18:22.593 position:50% align:middle of obstacles, there are some where it's just kind of the pure logistics of understanding, 00:18:22.593 --> 00:18:29.995 position:50% align:middle you know, what's reportable, how to report it, you know, where the materials or references 00:18:29.995 --> 00:18:33.950 position:50% align:middle are available to kind of help facilitate that reporting process. 00:18:33.950 --> 00:18:37.452 position:50% align:middle I think of those as kind of lower hanging fruit, things that can be addressed a little 00:18:37.452 --> 00:18:43.789 position:50% align:middle bit more easily but then there are the cultural and the kind of, like, legal barriers 00:18:43.789 --> 00:18:48.716 position:50% align:middle or the perceived legal barriers associated with adverse event reporting that I think 00:18:48.716 --> 00:18:53.864 position:50% align:middle are a bit tougher of a nut to crack. And so I think that that's where something like the 00:18:53.864 --> 00:18:58.936 position:50% align:middle AEDP tool really does become useful since it is an objective, evidence-based tool that 00:18:58.936 --> 00:19:04.618 position:50% align:middle can kind of standardize the reporting process across facilities. And then I had 00:19:04.618 --> 00:19:09.240 position:50% align:middle another question, how do reporting requirements differ in Canada versus 00:19:09.240 --> 00:19:15.220 position:50% align:middle the U.S.? So that's an excellent question. That's a little bit above my paygrade, I will say. 00:19:15.220 --> 00:19:21.266 position:50% align:middle So one of the interesting aspects of this research is because we were essentially 00:19:21.266 --> 00:19:26.423 position:50% align:middle navigating the reporting process with so many individuals across so many different 00:19:26.423 --> 00:19:33.049 position:50% align:middle organizations. There was a lot of variability in the tools and the materials, the resources 00:19:33.049 --> 00:19:38.324 position:50% align:middle that people referenced. Some individuals across both studies actually indicated that 00:19:38.324 --> 00:19:42.900 position:50% align:middle there was more or less a moratorium on external reporting at their facility. 00:19:42.900 --> 00:19:48.620 position:50% align:middle So there's a great deal of variability, not just at the kind of like the country level 00:19:48.620 --> 00:19:53.950 position:50% align:middle or the state level or the province level but also, even at the institution level. 00:19:53.950 --> 00:19:58.220 position:50% align:middle So when we were conducting this study, we tried our best to understand kind of the 00:19:58.220 --> 00:20:02.290 position:50% align:middle baseline parameters, like what was the context in which these actors were 00:20:02.290 --> 00:20:04.850 position:50% align:middle functioning in their day-to-day profession. 00:20:04.850 --> 00:20:09.840 position:50% align:middle And then with that information and criteria kind of about the profile of the institution 00:20:09.840 --> 00:20:15.484 position:50% align:middle and the individual responsible or tasked with making the report, we tried to control 00:20:15.484 --> 00:20:19.068 position:50% align:middle for those in the model or we tried to kind of control for them in the method that we 00:20:19.068 --> 00:20:26.062 position:50% align:middle employed in the pre-post design. So there are assuredly differences in terms of the 00:20:26.062 --> 00:20:31.968 position:50% align:middle reporting requirements between the two countries but I'm not probably the best 00:20:31.968 --> 00:20:33.815 position:50% align:middle person to ask on that topic. 00:20:39.540 --> 00:20:42.970 position:50% align:middle So I think that's it for the questions so far. 00:20:42.970 --> 00:20:47.542 position:50% align:middle Please feel free as, you know, we're going forward, please feel free to submit any 00:20:47.542 --> 00:20:48.850 position:50% align:middle additional questions that you might have. 00:20:48.850 --> 00:20:50.893 position:50% align:middle Those are excellent questions to kick things off.