(George) Hello and thank you for joining us today.
On behalf of Joint Commission Resources,
we would like to welcome you to the CMS series.
We're glad to have you with us today.
My name is George Riccio and I'm Associate Director
in the Global Education Department at Joint Commission Resources.
We are happy to welcome back John Berry.
Mr. Berry is a registered nurse
with comprehensive clinical and regulatory experience
in non-long term healthcare settings.
His clinical background includes med/surg and telemetry care,
adult psychiatric care, clinical education, and critical care.
Mr. Berry surveyed and managed survey and certification processes for hospitals,
ambulatory surgery centers, and dialysis centers.
His duties included functioning as a team leader on surveys,
providing guidance to survey staff,
approving survey recommendations to CMS concerning certification status,
and providing support and education to health facility administration
regarding CMS regulations.
Mr. Berry also managed complaint intake and triage
for all non-long term healthcare facilities in Texas.
While working for HHS,
Mr. Berry's expertise assisted in the development and revision
of state licensing rules and regulations for healthcare facilities.
His expertise was also applied
to interpretation of active licensure regulations
and development of position statements for regulations.
And with that, John, I will now turn the presentation over to you.
(John) All right.
Well, thank you so much, George, for that introduction.
And for today's CMS webinar series,
we'll be discussing the CMS Condition of Participation
of Quality Assessment and Performance Improvement
and what those requirements are
throughout that Condition of Participation.
As you'll note on this slide here,
the CMS Condition of Participation was established over 20 years ago
in this January 24th, 2003 document found in the Federal Register.
You'll see that it is discussing the QAPI requirements
that are to be released.
And it identifies that the QAPI Condition of Participation at that time
was based off in response to the IOM report, "To Err is Human."
And within that report, I found it interesting to read
that there is a focus on the responsibility
of the hospital's governing body or the board
to establish a culture of safety and quality
and to define the importance of QAPI activities
throughout the institution.
Fast forward to today, in March 9th of 2023,
CMS released the interpretive guidelines for the QAPI Condition of Participation
And an area that is of note is that, in this interpretive guidelines,
there is still yet that focus on leadership
and the responsibility of leadership and the oversight
and development of an ongoing planning of the hospital's QAPI activities
and the importance of the governing body in that process.
The Condition of Participation for QAPI
is one of the conditions that applies to all hospitals,
regardless of whether you're a children's hospital
or a cancer hospital, long-term acute care hospital.
All hospitals must meet this Condition of Participation
in order to maintain Medicare certification.
The QAPI Condition of Participation
requires hospitals to develop, implement, and maintain
an effective, ongoing, hospital-wide, data-driven
Quality Assessment and Performance Improvement program.
And the hospital's governing body
must ensure that the program reflects the complexity
of the hospital's organization and services,
involves all hospital departments and services,
including services furnished under contract or arrangement,
and the program should focus on indicators
related to improved health outcomes
and the prevention or reduction of medical errors.
A hospital's QAPI program
that complies with the condition of participation requirements
can enhance a hospital's performance, patient safety,
and overall quality of care.
The focus of the QAPI Condition of Participation
is for a hospital to have an effective ongoing system in place
for identifying problematic events, policies, or practices,
and taking actions to remedy its identified problem areas
with follow-up to determine if those actions were effective
in improving performance and quality.
Now, let's move forward and break down the Condition of Participation for QAPI
and analyze the various requirements and standards
that fall underneath or within it, I should say.
The QAPI program should be designed
in a manner that addresses the unique needs,
priorities, clinical services, and health equity needs
of the hospital's patient population.
The QAPI program should function as a mechanism
to systematically examine the quality of care delivered
and implement specific improvement projects
on an ongoing basis for all services provided hospital-wide.
This means all hospital locations,
all services, and all departments of the hospital,
whether that be on campus or off campus.
And as I mentioned previously, this includes contracted services as well.
All those services that fall
underneath the hospital's Medicare provider or CCN number
should be included in the QAPI program.
However, the scale and degree of resources allocated
might vary across the hospital for allocation of QAPI services,
but it is expected that all services and departments participate
in continuous monitoring of quality and safety,
and take corrective actions when necessary
to ensure patient safety and improve patient quality care.
Not only should the program continuously evaluate
the improvement process and services,
it is equally as important for the program
to proactively improve patient outcomes
and prevent medical errors that are sustained over time.
This should occur through continuous data collection, analysis,
and implementation of changes with ongoing monitoring of changes
to determine effectiveness of those changes and ensure sustainment
of those improvement actions.
The QAPI program should be a top-down approach,
where the hospital's governing body or board
is actively engaged in the oversight of the QAPI program.
This includes QAPI activities
for services provided under a contract and agreement,
which we will, again, further discuss later in the presentation.
When you're considering your QAPI program,
not only must you engage in these activities,
but ensure you're maintaining documentation
that accurately reflects activities of your QAPI program.
It's through these documentations that you'll be able to demonstrate to CMS
and state agency surveyors
that you are in fact in compliance with the QAPI Condition of Participation.
The documentation should reflect that your QAPI program
is based on the size and complexity of your hospital,
and that this is reflected in the overall scope of your QAPI program.
Documentation should demonstrate that the program is hospital-wide.
As I mentioned before, it should cover all departments and services,
even those provided under contract, agreement, or arrangement.
And the written contract,
written contracts should include QAPI requirements,
as well as the roles and responsibilities of the contractor
for the QAPI requirements.
There should be evidence that the QAPI program is data-driven.
And the QAPI program should be focused on quality indicators and measures
that are focused on improving health outcomes
and preventing and reducing medical errors.
Indicator measures should be selected with the intent of determining
if the services provided are effective
in delivering safe, quality care
and enable the hospital to identify opportunities for quality improvement.
Additionally, there may be considerations for cultural competence
as hospitals develop their quality measures.
When analyzed,
the quality indicator data that's been selected
and the data that's related to it
should demonstrate that the indicators produce
measurable improvements related specifically to that indicator.
When an organization chooses to use homegrown measures and indicators,
they should be based on the scope and complexity
of the individual hospital services that are provided,
and they must be developed in consideration
of the population's health equity that they serve.
And ensure that you maintain a list of the quality indicators
you are currently tracking
and that the indicators reflect the patient populations
that you serve.
While there is no specific set of measures or indicators,
there are some measures and indicators that should be included,
that include but are not limited to patient care data,
such as adverse events,
and data from Medicare quality reporting and performance programs,
such as hospital readmissions and hospital-acquired conditions.
CMS provides examples of measures
and indicator measures that may be included,
but are not limited to HCAHPS data,
maternal morbidity, sepsis,
and safe opioid practices.
Additionally, there should be tracking of adverse events
in response to those in your QAPI program.
Indicator data used to monitor
the effectiveness and safety of services and quality data.
And that indicator data should be collected and used
to identify opportunities for continuous and ongoing improvement,
as well as mechanisms for change
to improve safety and quality of care for patients.
Improvements that you're making
based on your quality indicator measures and data
should not just be one-time events, they should be ongoing.
Once you've corrected an area,
you've met the measure that you set for yourself
within that, the threshold,
you should have ongoing monitoring of that measure
to ensure that it has been sustained.
And it's up to the hospital,
the individual hospital and the governing body
to determine the thresholds for acceptable improvements
for indicator data.
Hospitals have the capacity to set their own thresholds.
However, bear in mind that CMS expects that the thresholds
should be in accordance with national standards of practice.
The new CMS interpretive guidelines specify that the governing body--
The new CMS interpretive guidelines specify that the governing body or board
is responsible for specifying
the frequency and detail of the data collection,
which may include but is not limited to what data will be collected,
what the data is intended to measure,
in what areas of the hospital the data will be collected,
and how frequently the various types of data
will be collected.
The guidelines do, however, clarify that the governing body
is not expected to have a high degree of technical expertise
in the area of quality data collection.
However, the governing body must have information
that describes the hospital's QAPI data collection program
in sufficient detail
so that the governing body is able to determine
what program data requirements to approve.
Furthermore, there must be evidence
that the governing body has had an active role
in the development and ongoing planning of the frequency
and detail of QAPI data collection.
Such evidence might be governing body meeting minutes
that includes documentation
that the governing body has reviewed and approved
the frequency and detail of the QAPI data collection program.
The QAPI program should prioritize quality
of efforts that affect health outcomes, patient safety, and quality of care.
When CMS discusses high-risk areas in the new CMS interpretive guidelines,
they define that as areas where the opportunity for error
is higher than in other areas.
For example, where there are complex processes,
and or where the consequences of poor quality or medical errors
are more likely to have a serious adverse impact on patients.
Examples might include emergency departments, L&D units, ICUs,
and care areas treating immunocompromised patients.
High volume areas are areas where the number of potential patients
who could be adversely affected is high due to common elements in their care.
These areas may include but are not limited to
clinical staff hand hygiene,
sanitary food preparation, and medication administration.
The problem-prone areas
are areas where the hospital's own internal QAPI data
shows a history of problems, or where nationally available research
or expert consensus has identified areas especially prone to problems.
These areas may include hospital-acquired infections,
central venous catheter use,
patient handoff communication processes between healthcare members of that team,
and systems for identifying patients, as well as medication administration.
Incidence refers to the rate or frequency
at which an event being measured occurs within a specific timeframe.
Prevalence refers to how widespread something is
at a specific point in time in a particular place or population.
And severity refers to the degree
or seriousness or significance of an event or issue at a hospital.
The QAPI program, the intent of is to take actions
aimed at performance improvement focused on these areas.
Ensure hospital leadership can provide evidence
that its improvement activities are focused on these high risk,
high volume, or problem-prone areas.
Ask yourself,
"Does your hospital have any data
either derived from your own QAPI data collection or the public
on incidence, prevalence, or severity
to support the choices that are identified in the indicators that you're selecting?"
"Does your hospital have evidence
that the activities affect health outcomes
through improving quality of care or patient safety?"
And surveyors will ask to see evidence that the hospital attracts data
for the identified indicators,
which may include but not limited to blood product,
transfusion reactions, drug reactions, errors in medication administration,
and infection control related errors and events.
CMS expects hospitals to have a system
that can track and analyze medical errors and adverse events
in an effective and meaningful manner.
Furthermore, hospitals should educate all staff,
including contracted staff,
on what is considered a medical error and an adverse event,
as well as when and how to report such events.
CMS adopted the definition of an error
from the Quality Interagency Coordination Task Force,
which is, an error is defined as the failure of a plan action
to be completed as intended
or the use of a wrong plan to achieve an aim.
Errors can include problems in practice, products, procedures, and systems.
Such medical errors might include medication administration errors,
like wrong medication, wrong patient.
It could be surgical errors, like a retained instrument,
wrong surgical site.
It could be an equipment failure, such as alarms not working properly.
Infection control errors,
such as incorrect processing of sterile instruments
not following the manufacturer's instructions for use.
There could be blood transfusion related errors, or even diagnostic errors,
such as misinterpretation of test results.
It should also be noted that
near misses should equally be considered
as much as errors themselves,
as there's a lot to be learned from near misses
in terms of potential system weaknesses
that could occur and potentially result in actual harm in the future.
As such, hospitals must track
and analyze errors that result in near misses,
and focus on their prevention and reduction.
Medical errors and adverse events should be analyzed
to determine the causes by using a systemic approach
and implementing appropriate corrective actions.
Preventative actions might include changes in policies and procedures,
repairing or replacing equipment, staff education and training.
And whenever you're considering what staff to educate and train,
it should include all necessary staff
that might be affected by the change that has occurred,
specific to the error or adverse event that has occurred.
And furthermore to that note,
ensure that there is sufficient documentation that supports--
that can demonstrate that staff receive that education and training,
and also documentation if you revised or changed any policies and procedures,
or if you repaired or replaced any equipment.
Furthermore, there should be a method to assess
whether the strategies and actions implemented
resulted in improved outcomes,
and that those improved outcomes are sustained over time.
Indicator data related to a specific area targeted for change
should be able to demonstrate that improvement
through your QAPI program.
The CMS interpretive guidelines specify
that performance improvement projects are differentiated
from performance improvement activities.
And that performance improvement projects
require significant amount of upfront planning,
include project objectives,
and have a definitive beginning and end, they're time limited,
whereas performance improvement activities
make up the continuous ongoing functions of a hospital's QAPI program,
such as ongoing tracking of medical errors and adverse events,
analysis of data,
implementation of changes with associated education and training,
continuous monitoring of quality and safety
in all hospital departments and service areas.
There are no specific types of performance improvement projects
that are required annually,
but each hospital's governing body should determine
the number and types of annual projects
based on the complexity and scope of the services
provided by the hospital.
The number of projects should reflect the scope and complexity
of the specific hospital,
And hospitals may choose to participate in QIO,
Quality Improvement Organization projects
to fulfill their annual project requirements.
However, they are not required to do so.
The hospital's governing body, medical staff and administrative officials
are all responsible and accountable for the hospital's QAPI program.
The medical staff may delegate leadership responsibility
and accountability for the QAPI program
to the medical staff's executive committee,
if they have one.
The CMS interpretive guidelines do specify that the administrative officials,
however, includes at a minimum
the hospital's CEO, Chief Operating Officer,
and the Chief Nursing Officer or Chief Nurse Executive.
But it might also include other executives in the hospital's administration.
The responsibility for QAPI requirements includes all locations of the hospital,
including on-site and off-site locations,
inpatient and outpatient departments and services,
and with regard to all services provided directly by hospital staff,
as well as those services provided under a contract or agreement.
Hospital leaders are responsible for ensuring that the requirements
in the QAPI Condition of Participation are met.
Ensure that there is documentation
that hospital leadership,
as identified on this slide, are actively engaged
in fulfilling their QAPI responsibilities.
While executive leaders
and the governing body are not expected to be directly involved
in the day-to-day activities of the hospital's QAPI program,
they should, however, be actively engaged in the oversight and periodic review
of the hospital-wide QAPI program.
The governing body's periodic review of the QAPI program
should ensure a plan is developed
to implement and maintain the QAPI program,
approve the number and types of annual projects
based on the complexity and scope of the services
provided by the hospital,
specify the frequency and the detail of data collection,
review progress of QAPI projects,
and evaluate effectiveness of implemented improvement actions.
Performance improvement activities should be prioritized
to focus on high risk, high volume, or problem-prone areas
and areas that affect health outcomes, patient safety, and quality of care.
The governing body should be provided necessary information
regarding the hospital's QAPI data collection program,
as I mentioned before,
to ensure that they have sufficient information
to determine what program data requirements
they would like to improve.
As well, hospitals must ensure adequate documentation
is maintained to demonstrate active engagement of the governing body,
such as a QAPI program meeting minutes
and attendance rosters that demonstrate attendance
and active engagement of the governing body members
in the QAPI program.
The QAPI should be a standing agenda item
on the governing body's agenda and meeting minutes,
and there should be documentation
that indicates resources are made available to the QAPI program.
For example, budget meeting minutes,
identifying allocation of resources to areas
that aren't meeting the threshold
that's expected with the indicator measures.
QAPI should be integrated into the responsibilities
of the executive leaders and the governing body.
And those leaders should ensure clear expectations for safety and quality
are established and communicated hospital-wide,
which includes informing all staff and contractors
of their specific roles
and responsibilities for safety and quality,
such as reporting adverse events and safety risks or breaches.
A governing body that is fully engaged
in hospital-wide continuous Quality Assessment and Performance Improvement
can significantly enhance the hospital's ability to provide
high quality and safe care to its patients,
and in doing so, reduce the incidence of medical errors
and adverse events throughout the hospital.
As I mentioned on the previous slide in the discussion,
ensure that there is adequate documentation
to demonstrate that the leadership,
from the governing body to medical staff, CEO, COO, CNE, and CNO,
are actively involved in the QAPI program.
Ensure that the meeting minutes reflect the active engagement,
that there are agendas that reflect the ongoing QAPI activities.
Ensure that there is documentation of an annual QAPI program review
where the governing body can determine
what sort of QAPI program data collection will occur
and indicators and measures that will be reviewed.
And approve the number of QAPI projects annually,
and ensure the documentation reflects
that leadership are making decisions based on QAPI data.
If there is QAPI data that indicates
that a particular indicator is not meeting the measure as expected,
that there are sufficient resources
and decisions are being made to allocate resources
so that changes can be made to the action plan,
to ensure that ultimately those indicators and measures
will meet the threshold that has been established.
For the services that are furnished under a contract,
there's a specific requirement,
not only in the QAPI Condition of Participation,
but also in the governing body Condition of Participation
located at 42 CFR 42.12 (e).
And that further emphasizes
that the hospital's governing body
must ensure that contractors provide services
in a manner that allows the hospital
to comply with all applicable Conditions of Participation
and standards for the contracted services.
The hospital must be able to demonstrate how it includes services provided
under an arrangement or contract in its QAPI program.
This may be done by providing evidence of the evaluation
of the contracted services,
and when appropriate, conducting performance improvement activities
or projects related to services under arrangement or contract.
There must be clear expectations for safety
set and communicated
for those providing services under contracts or agreements,
and this should be documented in the contracts themselves.
Surveyors will expect, whenever they're on site, that all staff,
that includes those directly employed and those staff working under contracts,
agreements or arrangements,
are able to articulate their roles and responsibilities
in supporting the hospital's expectations for safety,
such as what safety risks or breaches they are expected to report
and how they would be expected to report them.
They should be educated on your event reporting system.
Hospitals are allowed to communicate these safety expectations
in various ways through education and training,
the use of posters or staff newsletters,
but ensure that all staff, including those contractors,
are aware of their expectations for safety throughout the hospital.
And furthermore, hospitals must be able to demonstrate
how they include services provided under contract or agreement
in its QAPI program.
Evidence of this inclusion would include
but not be limited to a periodic assessment
of the contracted services,
what resources the contractor has allocated to QAPI activities,
how the contractor actively participates in QAPI activities,
for example, providing the governing body
with periodic quality or data reports, attending QAPI planning meetings,
and when appropriate, conducting performance improvement projects.
For example, what you might often see in hospitals a lot
is certain service areas being contracted out.
This could be a radiology group, it could be a dialysis group,
or an emergency department group,
whatever the case may be,
the contract for that group should include expectations
for safety and quality,
and there should be involvement in the QAPI program.
And furthermore,
if the contractor is not meeting the expectations identified,
not achieving the thresholds of the measures and indicators
that have been identified,
then the contractor should be actively engaged in improving that area
so that they can achieve the threshold
that has been established for the hospital.
The resources dedicated to QAPI program
should be commiserate with the overall scope and complexity
of the services provided by the hospital.
This means that leadership and the governing body
should provide sufficient numbers of staff,
time for the staff
to perform their functions in the QAPI program,
information systems and methods of obtaining data,
as well as education and training
to support all elements of the QAPI programs, activities and projects.
Furthermore, there shouldn't just be staff functioning in the QAPI program.
The staff should be qualified with experience and training
to carry out their specific functions of the QAPI program
that they are assigned to.
While the leadership of a hospital may choose to use
qualified and experienced contractors
for the day-to-day technical aspects of the QAPI program,
the hospital's governing body, again,
retains the ultimate responsibility
for the ongoing management of the QAPI program.
And this is the case regardless of whether or not
that function has been contracted out to a third party.
The CMS interpretive guidelines say
that hospitals should be able to demonstrate inclusion
of the QAPI program in its budget process,
and identify in detail the resources it dedicates to the QAPI program.
This includes the resources that a contracted service is allocated
to support QAPI functions.
Additionally, the hospital must be able to provide evidence of the number of staff
that is allocated to focus on the management
and oversight of the day-to-day QAPI program functions.
The newer requirement underneath the Condition of Participation,
which is an optional requirement,
is that if a hospital has--
a multi-hospital system,
with multiple separately certified hospitals
that share a system governing body,
the governing body may choose
to opt to have a unified and integrated QAPI program.
If the system governing body
elects to have a unified and integrated QAPI program,
the QAPI program must consider each hospital's unique circumstances
and any significant differences between the hospitals.
If one hospital provides L&D services in the system
and another separately certified hospital does not provide L&D services,
then the hospital that provides L&D services--
then the hospital that provides L&D services
would be expected to have indicators and measures
related to that service area,
whereas the hospital that does not, would not be required to have indicators
for that particular area.
As well as the significant differences in the patient populations,
and any differences between health equity needs
that might exist
should be taken into consideration
when developing a unified and integrated QAPI program.
The policies and procedures should be established,
and there should be mechanisms in place
to ensure that the needs and concerns of the separately certified hospitals
are given due consideration,
and that the QAPI program ensures
that the issues that are localized to a particular hospital
are considered and addressed appropriately.
Thinking back to a couple of slides that we discussed earlier,
there should be adequate resources allocated.
There should be, if one of the hospitals in the systems
is not meeting a particular indicator and measures,
then there should be adequate resources allocated to that particular hospital
to ensure that they can meet that specific indicator or measure
that they're trying to obtain.
And furthermore, you want to ensure that you have documentation
in your meeting minutes and QAPI activities
that demonstrates that these unique circumstances
and differences and needs are being considered and addressed
for each of the separately certified hospitals
within the hospital system.
Let's go over some examples of some QAPI deficiencies
that organizations might face.
Before we get into that, I wanted to point out
that these are the top conditions of participation cited in 2022.
You can see that the first is patient rights,
followed by nursing services,
but you'll see that Quality Assessment and Performance Improvement
is the third most frequently cited Condition of Participation in 2022.
Furthermore, whenever you look at 2023 data,
again, you see the exact same thing,
Quality Assessment and Performance Improvement
is the third most frequently cited Condition of Participation.
In the first example,
the hospital failed to implement an adequate preventive action
for an adverse patient event,
where a patient required CPR
and emergent medical care after wrong medication was administered.
A CRNA administered an IV medication to a patient.
The patient immediately stopped breathing, it was grabbing the OR nurse's arm,
but not able to communicate verbally.
Subsequently, they had to call a code,
and the patient was then given CPR and ACLS.
The surveyors interviewed the Chief of Anesthesia
and said that the CRNA on the day of the incident--
that they interviewed the CRNA on the day of the incident,
and the CRNA thought that they administered a sedative,
not a paralytic.
And the sharps container was evaluated and reviewed.
And it was identified that a paralytic was found
in the sharps container.
The Chief of Anesthesia said that there was a corrective action
held with an anesthesia meeting and review of the policy point of care,
medication administration of anesthesia staff.
And the Chief of Anesthesia said
that he sent an email to the anesthesia staff
who did not attend.
However, while the Chief of Anesthesia in this specific incident
handled that or addressed this issue directly with his anesthesia staff,
the incident was not analyzed by the hospital-wide QAPI program.
It was not evaluated through root cause analysis,
and there were no corrective measures
that were implemented systemically across the entire hospital
that could potentially help prevent failures of this nature
in other departments of the hospital.
In the second example,
the hospital failed to identify causative factors
surrounding patient safety events and implement preventative actions.
In this circumstance,
there were multiple patient falls,
specifically related to a specific type of a specialty bed.
The incidences were reported.
However, they were not analyzed at the time that they were reported.
There was a trend in these beds resulting in patient falls,
and the QAPI program did not analyze that data
and did not identify potential causes
and, subsequently, did not implement any preventative measures
for three of those adverse events that had occurred.
In the first occurrence–
first example, ensure that...
...adverse events and errors, when they occur,
that they are evaluated through the hospital-wide QAPI program,
and that, if necessary and if identified,
that there are systemic hospital-wide changes
in performance improvement actions.
The second occurrence ensure that,
that there is a thorough analysis of patient safety events
to ensure that--
to evaluate and determine whether or not there can be measures implemented
to ensure a future patient's safety.
In this example, a patient had multiple consecutive missed blood glucose checks;
their blood glucose was later found to be at 37,
the patient decompensated and eventually died.
The patient safety committee reviewed the case
and determined that no preventable patient safety concerns were identified
and no further action was necessary.
However, when the surveyors were on site,
they reviewed further and identified that there had been a number of patients
who had had missed consecutive blood glucose checks
across a number of different days on a variety of different shifts.
And the QAPI program failed to analyze that data
and, subsequently, implement any corrective actions
and improvements in care to ensure future safe care.
Overall, here's some compliance strategies for QAPI.
Remember that QAPI is always a top-down process.
We want to ensure that you measure
and track adverse patient events,
analyze their causes,
and implement preventative actions and mechanisms
that include feedback and learning hospital-wide,
and prevent problems from reoccurring.
And equally as important in the QAPI program
is identifying areas where there may be potential problems
to prevent them from even actually becoming problems.
Ensure there are clear expectations for safety
that are established by the governing body,
and that this is communicated to staff.
As I mentioned, this is both staff that are employed directly
as well as those staff that work under contract.
And in addition to incident and event reporting mechanism
for adverse events, close calls, medical errors and unsafe conditions,
there should be tools and activities
that identify those potential hazards
and adverse events proactively.
As I mentioned, QAPI is just as much about being proactive
as it is about being reactive.
And whenever you're evaluating adverse events or near misses
or whatever the case may be, consider why did this occur,
what are the causes and contributing factors,
and what might go wrong and how to prevent that.
And with that, thank you very much for your time.
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