 Hello, I'm Joe Chiani, founder of the Patient Safety Movement Foundation and also chairman, founder and CEO of Massimo. I have long believed that we should all do whatever we can do to make things better. Some of us can do more, some of us who can less, but I think if we all bid things to make this world better, we'll 20, 30, 40, 50 years from now find the world much better, much kinder, much just, much safer. I call that micro-fixing and I try to do it all my life and Patient Safety Movement Foundation is an example of that. I had seen the report to Eris Human back in 1999 where medical errors were killing maybe 50 to 100,000 people according to that report. I was shocked by that and watched many, many incredibly gifted doctors step in to try to improve that. And I thought at the time it's being handled, it's being fixed. It wasn't until 2011 where I saw the report from Medicare that showed about 200,000 Medicare patients were killed to medical errors or seriously harmed. And I was shocked by that and I decided at that time to try to do something about it. I had discussions with Dr. Pronovost who many of you know is one of the leaders in Patient Safety and had done some incredible work reducing CLABSI by bringing the essence of what needs to be done instead of pages and pages of what needs to be done to reduce CLABSI. And he encouraged me to hold the first summit on Patient Safety and see what happens. At the same time I've been traveling with President Clinton to Africa to see the work he had done. I told him that I'm thinking of doing this and I told him what the problem is the next day he said to me, you know that's more people than we've lost in the Vietnam War and Korean War combined. And if you do something about it I'm going to help. I'll do whatever I can to help you. And he stayed true to that from the first summit to the last summit we held before COVID he came to every one of those summits and helped convene the incredible people that came to our summits. But from the very first day back in 2013, January in 2013 when we held our first summit we decided to do things differently. We decided to one make it a commitment based organization meaning you get to come one time to our summit without making a commitment. But the second time you can't come unless you made a commitment and that commitment is to help get us to zero preventable deaths. We made a bold goal of zero by 2020 which we did not achieve but we achieved a lot of wonderful things. We helped unsilow our healthcare ecosystem. We brought doctors and nurses and hospital executives together with patient advocates who had lost a loved one with med tech companies who were part of this industry making products to help patients to regulators and to the different government bodies from CDC to HHS. And we were able to get not just the United States to make patient safety a key agenda but the world. More than 50 countries joined in. The work we did has helped create an unbelievable momentum for patient safety. From the wonderful work that Secretary Jeremy Hunt at the time head of health and human services in UK did to bring transparency to the NHS system to help create the ministerial summit on patient safety to the work WHO is now doing in creating a 10-year goal for patient safety. We had a lot to do with that. We brought momentum. We gave visibility to something that was only really known in the medical mostly hospital realm and we got over 5000 hospitals to commit to zero. Some of them unfortunately a minority of them implemented all of the evidence based practices that are known to deal with patient safety problems. Their work by the end of 2019 had saved over 250,000 lives. And we were able to get almost 100 medical technology companies to make a pledge to share their data. Why is that important? Well, you can't do predictive algorithms to detect when a patient is going to get into trouble. You can't do decision support unless all products, all technologies that touch the patient share their data electronically, the data that their products are purchased for electronically so that you can create those algorithms and hopefully save lives, help clinicians know things before it's too late. And we did a galleon effort to educate Congress, White House on the need to do something more than affordable care act. While the ACA went far in identifying never events and creating incentives and disincentives to avoid them, it wasn't good enough because it didn't go after everything that killed people. It went after things that cost the most cost, secondary cost to the system. So we went to Democrats, Republicans, we went to both sides of the aisle and talked about what needs to get done. Transparency, our financial system has transparency, something less important, money. So if you're a public company like the one I run or you're making search engines like Google or make ice cream like Ben and Jerry's, all of us every quarter have to report our revenue, our earnings, our risks so that investors can make an informed decision. Well, we don't have that in hospitals. Even though hospitals, half of their revenue, if not more comes from the public, they being Medicare or Medicaid in our country, you don't see quarterly statements from hospitals reporting their outcomes nor their medical errors. We also taught, learned a lot from some of the hospitals that implemented these evidence-based practices. And with that, we went and recommended aligned incentives. What is aligned incentives? It's to align the incentives of the hospitals and staff with patient safety. If you were to take your car for a tune-up, and the next day you went to go pick it up and they said, sorry, your car caught on fire, they don't charge you for the tune-up and they most likely will actually replace your car. But if you go in for a hip surgery or a recent case that Dr. Ramsey told me about and or if someone went to donate a kidney and if they kill you, they still, the hospital still gets paid for the primary procedure. And with all the tort reform, some of them justify there's hardly any recovery for the family. So aligned incentives is a very simple idea. If you just put the processes in place and someone still gets harmed and because you had the processes in place, you will get paid for everything. For the primary care, any secondary care. But if you didn't even try, if you didn't even put these evidence-based practices in place, then you get nothing. And to err is human. But to not put the processes in place that could avoid human error from becoming fatal is inhumane. And we know very well that these evidence-based practices work. I sit on the board of Children's Hospital for Orange County. I also chair the quality committee. And when I first was going to join, I said to them, look, we're going to have to be the safest hospital in the world. If you can bring me on, I'm going to be, I'm going to be a pest until we get there. And to Kimberley cried to credit, she said, well, that's why I'm asking you to join the board. And I remember joining the first quality committee meeting, and they were going through the list of never events. And as long as they were below the average for other Children's Hospital, they felt they were doing the right thing. And they were. But I said to them, well, why isn't the goal zero? And why are we not looking at everything, everything that could harm someone? And they agreed. They agreed. They began working on it. And at one of the follow-on meetings, they decided that they were going to tie zero preventable deaths in their hospital to the faculty's bonus. I'll tell you, I was amazed by that. And what happened next amazed me further. At the next board meeting, they had gone through every one of the evidence-based practices that we had posted on our website. As you know, we call them apps or actionable patient safety solutions. And they had Mark Green, every one of the major items in the checklist that they were doing, and either yellow or red, the parts they were not doing. And then in the next page, mitigation plan, how to turn those yellows and reds to green. That's the moment. I believe that Children's Hospital of Orange County went from hoping for zero to planning for zero. And that year, we unfortunately still had one preventable death. And again, to my surprise, this is a set of the staff saying this is not attainable. They doubled down their bonus portion on that zero factor. And I'm here to tell you, it's been over five years. Chalk is at zero preventable deaths. So I know implementing these processes work. I've seen it firsthand. And I've seen other hospitals like Parish, like UC Irvine, like several hospitals in Mexico and of systems like UPMC implement them, and they're getting incredible results. That's why this aligned incentives, I think is such an easy way to advance patient safety by aligning the income of the hospital with patient safety. Just implement the processes, not even at this point, look for results. They will get the results. And if we don't get to zero, we'll get near zero. There are other things I think we did uniquely. We worked hard to create curriculum for patient safety so that patient safety can be hardwired in healthcare. Right now, it's something clinicians learn after they start working at a hospital. Well, nursing school, pharmacy schools, medical schools, and so forth, they need to teach patient safety. They need to teach culture of safety. They need to teach root cause analysis and zero defects concepts during the training of these students so that when they come out, they come out ready to not just do what we've been doing, but take it to the next level. And many great institutions, from my old alma mater, SDSU, to incredible institution like Geisinger and Pennsylvania and Chapman University's Pharmacy School, many came together and created these curriculums. So while we didn't get to zero by 2020, I feel like we accomplished a lot. We created the action of patient safety solutions. We brought patient safety to the public's eye. And now more people are helping pull this weight. And I think importantly, we, as a commitment-based organization, we showed that, you know what, it's easy to get together, but then you go home and you forget everything. But if you make a commitment, if you say I'm going to commit to zero and I'm going to implement these processes and I'm going to measure now versus before, that's the only way to get there. You know, they say what is measured improves. What's measured publicly, undoubtedly improves faster. We as human beings probably make between five to seven errors a day. Those human errors do not have to become medical errors. With the proper processes, we can avoid these errors. With the proper data sharing by my colleagues, we can help clinicians find problems before most people can realize it. And computers are great at keeping track of everything. Something humans are not as good to do. They can keep track of trends. I can tell you when something is about to happen. So here we are in 2022. We've had to deal with the pandemic. COVID, unfortunately, took many lives. COVID, unfortunately, proved what many of us knew that without patient advocates, without families of patients in the hospitals watching over their families, more people will die. There's a report coming out from WHO that shows, unfortunately, how much more we lost people due to medical errors during the pandemic. I think that is regrettable. But talking about before and after view of things, we know better now more than ever that one clinician approach to patient care isn't enough. You need multiple stakeholders, multiple clinicians in a hospital as a team approach with the patient's families. So we need to dignify the families of the patients and themselves so they can speak up. Plato used to say the best person to be a doctor is someone who gets sick a lot. Well, that's true to that. These people that are sick, they know what's going on with them. Their families know. And they can tell us things that we will not learn in the span of a few days while we're interacting with them. So I'm delighted that Dr. Mike Ramsey has become the CEO of Patient Safety Movement Foundation. I am delighted that Mike Durkin has become the chair. These people are selfless, mission oriented and are quietly bringing patient safety back, taking it to a new level. Dr. Ramsey is dedicating his full attention to this, which is a dream come true. I think it was either the second or third summit where I told Dr. Ramsey either by 2020, I want to end this foundation hoping that that will give urgency to end medical errors. Or if it continues, I need your help to run it. And so it gives me such pleasure to have this wonderful human being with incredible insight as a clinician and a patient to now be leading the Patient Safety Movement Foundation. We have to be relentless in our pursuit of zero. I'm happy that despite us not achieving zero by 2020, we have now put a stake on the ground for zero by 2030. And we have to never mistake activity for progress. We've got to do the hard part of asking hospitals to make commitment. We have to ask our colleagues, whether in hospitals or companies like mine, to make commitments. It's these commitments that will make a difference. So I ask you all to please once again, I know many of you were rightfully do for a rest a break after dealing with the pandemic. But I ask you to please roll up your sleeve and get to work. Make your commitment to zero, starting with culture of safety from your board down to the janitorial service of your hospitals. Look at the apps that we've created. Implement them. You will save life just like we did at Chalk, just like it's been done at many, many other hospitals. And I wish that in 2030, if we're not at zero, we're very close to it. Because as I've always said, if it's not zero, it means one of us, one of our loved ones, one of us is the next victim of human error that does not have to occur to turn into a Medicare. So thank you all for joining us. Please, right now, improve your commitment. If you already made one or two commitments to implement a few patient safety processes, commit to all of them that are on our website, and measure what you're doing. See if you see a difference. And if there's anything we can do to help you, we're here for you. So let's do this. Thank you so much. Thank you for allowing me to speak to you. It's a pleasure to have you all with us again. Thank you.