 Well, thank you, Mike, for that introduction. And thank you, Joe, for this invitation. It certainly is our pleasure to be part of this great group here, and I hope to share with you in the next 30 minutes our journey throughout patient safety, patient safety, and quality. There is great power in the experiences that we have in health care, the experiences that those of us that work on the front lines of health care and the systems of care have, but more importantly, the experiences of the human beings that we take care of. There are everyday miracles in health care and, unfortunately, everyday tragedies. We at the American Society of Anesthesiologists, or the ASA, are on a quest, a quest to build a better health care ecosystem, to work at the pinnacle of quality and safety and unlock the power of purpose. Our purpose is to improve health and relieve pain and suffering, to be there for another human being in their most vulnerable moments. We are so excited to work with the Patient Safety Movement Foundation, and we are fully aligned with our shared vision of building a better health care system. Today, I want to relate to you real human experiences as we look at the puzzle of health care. Human experiences from the perspective of a physician, a family member of a patient, of organized medicine, or a specialty society, and most importantly, the human experiences that patients have. One of the great things about being an anesthesiologist is that we have the opportunity to form these deep relationships with other human beings with our patients in just a few moments. They must trust what was a total stranger with their lives. In one word, I would just say, wow. What an awesome responsibility we as anesthesiologists enjoy. Let me relate an experience I had several years ago that illustrates the foundation of our profession, trust. My patient was an elderly ex-FBI agent from New York, who was literally suffocating from a lung mass. He could only speak just a couple of words before he would gasp for what seemed like his last breath. So we had our necessary conversations, the things that I need to do to make sure that he is safe and receives a good anesthetic, the things that he needs to know about his anesthetic. But we spent some extra time talking about his life, his work, Mickey Mantle, and most importantly to him, his family. In the room were two doting daughters, a son-in-law and a tearful wife. The sorrow and fear in the room was palpable. They all knew what was going to happen in the next few days. But they were a family, and they were going to walk through this experience together. Although our time was short, our bond was rich and deep. As we concluded our conversation, in one of those moments that seemed to last forever, we locked eyes. He grasped at my hand, and with what seemed to be his dying breath, he said, I'm in your hands. I'm in your hands. What a powerful moment. What a sacred trust we as physicians, as healthcare providers, and those of us that work in the healthcare system enjoy. Patients trust us with their lives. Families trust us with their loved ones. In a vulnerable moment, we walk across with them, across the quality chasm. They must know that they are safe. Put a little bit differently, patient safety is the bedrock upon which quality occurs. Here you can see the quality pillars of access, timely care, effective care, efficient care, equitable care, and most importantly, patient-centered care. In my 30 plus years in anesthesiology, I've seen many patient safety initiatives. Here are four or five that I wanted just to highlight. When I first started in anesthesiology in the 80s, there was a lot of focus on medical errors and a lot of good was done. But medical or medication errors still occur far too frequently and still need a lot of work. The next wave that came along that I noticed was teamwork and communication. Again, focusing on teamwork, focusing on communication added a new dimension to patient safety, something very, very positive. Noteworthy in a report a couple of years ago was diagnostic error and how diagnostic error contributes to patient safety errors. Preventable harm. And finally, what's on the horizon is artificial intelligence, or what I like to say, augmented intelligence. Artificial intelligence is not going to replace a human being, but it's going to augment the decisions that we make. This is a powerful tool that is likely to improve quality and safety. But there are some risks and we need to make sure that as we implement augmented intelligence that it is done with the least amount of negative impact on patient safety. We at the ASA wanted to think bigger than just errors to reevaluate our vision and all the positives that we had done over the past few decades. I very much like this definition of patient safety from a recent publication from the National Academy of Sciences, Engineering and Medicine, avoiding harm to patients from the care that is intended to help them. Safety has now transformed what used to be, and I shudder a little bit of using this term, but used to be callously viewed as the cost of doing business into something that is more visceral, something that is the cost to human beings, something that has impact on human beings. This is some curves modified from the work of Don Abidian and you can see that the graft is over time, state of health, and the trajectory of disease. The curves vary a little bit, but it makes an illustrative point in that the middle curve, the blue curve, is untreated disease. Healthcare systems, physicians, nurses, all of us that work on the front lines, when we do an intervention, we want to make sure that it is done with quality. Where miracles occur up on the red dot dashed line and that we avoid that green line where on safe care can eliminate and actually reverse and make people want to avoid the healthcare systems. Safety is inextricably linked with quality and the experience that the patient must have lives on that red line. For that to occur, we must develop systems, not silos, but systems of safety built on an organizational culture of safety and systems that are learning systems, always seeking to improve. From a specialty society's perspective, basically the ASA, we wanted to take a hard look. We did this a few years ago, but we want to take a hard look of how healthcare measured up. Not just anesthesiology, we weren't thinking of just the silo, but the overall healthcare system that we live in. What the gap might be, what the gap is between what is and what should be. So how is healthcare doing in America? A lot of different opinions out there. This is an op-ed piece written in the LA Times on December 27, 2018 by Robert Pearl. He's the previous CEO of the Permanent Mental Group. I don't intend for you to read this, but he makes the point that according to recent data from the CDC, the life expectancy fell for the third straight year in the United States and that we had the ability to save 500,000 lives by doing simple things that we already know, simple things with the technology we already have that address the top five or five of the top 10 causes of death as seen in the right hand side of this slide. Heart disease, cancer, stroke, diabetes, and flu. He goes on to note that medical errors are not even on this list, and if they were, they would be the third leading cause of death as we've heard today in the United States. So let's focus in on patient safety. Here are some important landmarks. 1999, and I'll spend a little bit of time talking about this in the next slide. The Institute of Medicine reported that perhaps as many as 98,000 people die in hospitals each year as a result of medical errors. That report was a watershed moment. The report dramatically elevated the profile of patient safety and the funding that went into developing safety science. The report made several errors that I'm sure most are aware of. First, errors are way too common. Errors are costly and most importantly, errors can be prevented. In the years since the report publication, it has been increasingly clear that safety issues are pervasive throughout healthcare and that patients are frequently injured as a result of the care they receive. And let's look at some of these landmarks. 2013, and some of these have some methodological limitations, but here you can see 2013. James estimated preventable deaths, 210,000 to 440,000. Makari in 2016, 251,000. The LeapFrog Group made an estimate of 206,000 in 2016. And I very much like your goal of zero by 2020. Some would say that zero is aspirational. Zero is where we want to be. Zero is our mission. And how much better to have fallen just a little bit short of an aspirational goal than to set an achievable, mediocre goal that we all may have achieved but with a 50% of commitment. This public health crisis deserves a 110% commitment. And if we fall just a little bit short, thus, so be it, we will have saved more lives. The November issue of health affairs was devoted to patient safety. And I bring you kind of an op-ed piece here by these authors. And what they describe in short was the period since error to human was published could be considered a bronze age. We moved into the bronze age where new policies, new tools, new strategies were developed. And we now sit on the cusp of an inflection point that could move us from the bronze age into the golden era. And that's where we need to go. This is a modification of Cotter's eight step change model. And the primary modification is to put a sense of urgency right at the core. That sense of urgency needs to be there for change to occur. Once that sense of urgency is eliminated or we become callous to that sense of urgency, change stops. Change does not happen without a 110% commitment to a struggle, a struggle in our case to develop systems of safety. That struggle involves all of us being strong advocates to maximize that quality curve I showed earlier. With step one, step one never goes away. We never leave step one, but it's to convey that sense of urgency in a manner that resonates with those who matter most. It's about closing the gap, about being at the table when decisions are made and having a compelling agenda. An agenda that is not an agenda in and of itself but is linked to decisive action that changes the what is, to what should be, what must be. So let's move on and talk a little bit about a personal experience about how it is like to be a family member. And my story here pales to what we've heard today. And thank you for sharing those stories. Those stories are what drives change. My story, being a neuroanesthesiologist and neuroscientist involves the brain and involves my father. Three years ago, my father had coronary artery bypass surgery at the age of 85, which is no small feat and a decision that our family struggled with. Here to for or before his surgery, he was active, climbing on the roof as an 84, 85-year-old, fixing leaks in his roof, very strong, not having surgery. He had developed a severe, suddenly basically severe coronary artery disease would have been a death sentence to us or to him. But as a family member, I also knew what the implications were of having coronary artery bypass surgery on the brain. And it was kind of like damned if you do, damned if you didn't. He had his surgery and the surgery itself went smooth. But postoperatively, he developed what I would term hypoattentive, postoperative delirium, essentially a state of acute brain failure. That finally resolved that what lingered, the residual deficit for him was cognitive deficits that have affected his memory. I was with him a week or two ago, we still had great conversation, but he's not the same that he was. It has affected him and affected his quality of life and affected our family. Preventable harm not only affects a single patient, but their family and the nucleus of the relationships that they have. So let's talk about the vulnerable brain. We are in the midst of a great tsunami in the United States, the elderly being most vulnerable to postoperative delirium. Delirium can be termed as an acute decline in cognitive function and attention and represents acute brain failure. A high-risk group are the elderly and it can occur in up to 60% of selected patient populations. There is significant morbidity and mortality associated with postoperative delirium, including myocardial infarctions, pneumonia, respiratory failure, progressive cognitive decline or accelerated cognitive decline, and it can even enmask and maybe even accelerate the onset of Alzheimer's disease. It's been estimated and reported several years ago to cost the US healthcare system $150 billion. Dollars may be well spent, but certainly if we can attack this patient safety target could be repurposed to other patient safety issues or other healthcare issues. And 40% of the cases are deemed preventable. This made this a very, very attractive patient safety target to us at the ASA. So we undertook the perioperative brain health initiative several years ago. It was our moonshot. We knew that in order to be successful it could not be a one-year blip during my presidency. It had to be sustained over time and it needed to be collaborative. Several years ago we held our first collaborative meeting and there were over 35 stakeholders in the room. Our mission with the perioperative brain health initiative is to optimize the cognitive recovery and perioperative experience for adults 65 and older to make available a three-year comprehensive plan that institutions, organizations could use to become centers of excellence, to create a campaign through which all providers have greater awareness of the importance of preoperative screening for delirium, identifying those of us, those patients that are at high risk, and appropriate protective measures to mitigate that risk and then when that risk, when that episode of delirium occurs to provide best practices for treatment. And among the stakeholders I cannot tell you how important the collaborations are, particularly collaborations with patient groups. We collaborated very closely with the AARP and I thank the head of our perioperative brain health initiative, Lee Fleischer, who you hear from in the next panel for his collaborative relationships in making this work. They have a global council on brain health, the AARP which its mission is to maintain and improve brain health. And here you can see Lee, a letter to Lee, inviting him to the international drive to illuminate delirium. Essentially another group of stakeholders trying to eliminate this disease and it's in association with the Alzheimer's Association. We at the ASA very much like the patient safety movement foundation and their actual patient safety solutions. We connect strongly with all of those solutions. Here are a few that just jumped off the page when I read them. A culture of safety, medication safety, obstetric safety, handoff communication, airway safety and most strongly it connects with the big project we're working on now, postoperative delirium. We must develop learning healthcare systems that align science and culture and embed best practices into a system of safety. And finally, let's talk about the patient. This graph here is reflective of what's possible in healthcare showing you the evolution of the treatment of acute coronary syndrome or myocardial infarction over my lifetime. 1955, President Eisenhower had a moderate heart attack. He was rushed to the hospital, placed in an oxygen tent and given what was termed tender loving care, the standard of care in 1955. He conned the less than the hospital for six weeks and left the hospital at that time. Mortality at that time was over 40%. If you had acute coronary syndrome, the mortality has been steadily decreasing due to some of these interventions. First in the 1970s, a coronary artery bypass surgery came on the event and oftentimes was a solution to acute coronary syndrome. Angioplasty and stents became very common application in the 1990s. And then in the 2000s, a quality improvement initiative nationwide to reduce the door to balloon time was instituted, essentially decreasing the mortality to less than 10%. And I've never shared this in public, but in 2013, six years ago, I was in that bin, in the 2000s bin, in the QI bin. If I were living in the 1950s, I would not be talking here to you today. Just real quickly, my story, my wife and I have a regular date on Saturday morning at Hot Power Yoga. It may have been one of the risk factors for coronary artery disease, but it was about two to three miles from our home. And I had sailed through that class, was starting to drive home, and I kind of felt a little bit of chest tightness. Being in full-blown denial, I said, well, I must have asthma. I must be reacting to something in the car. So I rolled the window down, didn't improve things, had my wife take my pulse, thinking maybe I was an AFib, it was regular. So then it kind of downed on me, well, maybe I'm having a heart attack. So again, the drive home was about two or three miles, and so I said, well, I'm gonna stop into a parking lot, let you drive, and I didn't tell her this, but just thinking, you know, I might have a latent heart arrhythmia and crash the car. So we stopped in a parking lot, I went down to the back seat and laid down and told her to drive home. A great decision to let her drive, a poor decision to direct her or ask her to drive home. About 30 seconds later, I kind of realized, you know, maybe not such a good idea to drive home. Fortunately, just across the street was a hospital, hospital I'd never been to, but I told her, well, drive to the hospital, let's see what's going on. So she drive to the emergency room and I told her to drive up right at the doors, which immediately summoned a guard that said, you can't park here, no, no, go away. I told her, well, tell them your husband's in the back seat having chest pain and shortness of breath. Those words triggered a response, and within seconds, probably eight or 10 people came out. They came out first with a wheelchair, looked at me in the back seat and went back and got a gurney. They put me on the gurney, took me into the emergency room, and I was attacked by a wonderful team of technicians, nurses, and doctors. IVs went in, EKG stickers went in, crushed aspirin went in, et cetera, and I was having the real deal, an ST segment elevation. Now as an aside, one of the greatest threats to patient safety is when you have a doctor as a patient. So I was sitting there interacting with them in my, you know, column cerebral way, and I said, well, what about giving me some nitroglycerin? So they checked my blood pressure, gave me some nitroglycerin, and ST segment decreased to ST segment depression, which was indicative of a reperfusion. And that triggered another series of events where I was rushed to the cath lab. The interventional cardiologist was called in, and the interventional cardiologist essentially put, did an angioplasty and stent. On my left anterior descending artery, which was totally occluded, the so-called widow maker. So I went back, they took care of that culprit lesion. A couple days later, they come back and took care of another couple of lesions, and I was discharged the next day. Instead of spending six weeks convalescing in the hospital, I went to the gym that afternoon. Did my regular workout and was on a treadmill. And I stand today as a testament of the miracles that can occur in healthcare. I would not be here, but for the innovations that have occurred over the past few decades, and the wonderful team that took care of me, without any, at least apparently to me, adverse events. I leave you with the words of Mark Cuban. I don't oftentimes quote him, but I did find this quote very apropos for today. It doesn't matter if the glass is half empty or a half full. All that matters is that you, we are the ones pouring the water. We are the ones, and I know I'm speaking to the require here, but we are the ones that are responsible for fixing this problem, responsible with all the stakeholders in healthcare. And that includes everybody. Our work has just begun. And it's been so gratifying to be here today and hear that silence, the patient care stories are not an option. The stakeholders of healthcare, we cannot sit on the sidelines any longer with what is the third leading cause of death in the United States. It must be treated as the third leading cause of death in the United States. And we must engage or essentially continue to enable the harm. I thank you for your time and attention. And again, we enter the golden era of patient safety in a very collaborative fashion. And I invite your commentary either by telephone or by my email addresses up here as to how we can continue to work together the American Society of Anesthesiologists being 110% committed to reach a goal of zero by 2020. Thank you, the Patient Safety Movement Foundation for all the work you are doing.