 I just have to begin by saying, Mrs. Mills, how deeply sorry I am to hear about your experience. Very little can offer you the solace that we all would wish for you, but we have just got to learn from this, that Martha's loss is an extremely high rate of tuition for us to take lessons and make them into reality. So I can't offer you much more than that, Mrs. Mills, but I'll tell you, I'm really committed. Mike, thanks for that generous introduction. I remember that meeting, and my memory, though, is that I didn't have a choice. You simply informed me it was going to be announced. And thank you for the chance to be with you, Joe and Sarah. Your leadership and your courage in calling us to task is an enormous gift, not just to this country but to others. And I just want to thank you for the energy and the meaning you put into this work. My wife, Anne, is quite an athlete, despite a mysterious neurologic disease that hit her in 1997, which makes it hard for her to walk. But any given day, you're likely to find Anne swimming a half mile or more or hiking step by step, slowly in the mountains. Or more likely, she'll be taking a trip of 20 or 30 miles on her magical recumbent electric assist trike, which I recommend to all of you. Anne is amazing. So we were quite confused in June of 2022 when we noticed that Anne had steadily been losing stamina. Over six months, Anne's walking range had narrowed until by mid-summer Anne had trouble even walking across our living room. We assumed that this was progression of her neurologic disease, but we were wrong. The cause was that one of her heart valves, her tricuspid valve, had been destroyed by a pacemaker wire that passed through the valve and Anne was in heart failure. On August 2nd, 2022, Anne had open heart surgery at Massachusetts General Hospital to replace her tricuspid valve. She was on a heart-lung bypass machine for 96 minutes. On this Memorial Day weekend, last weekend, Anne and I rode our bicycles more than 70 miles. And if I hadn't had an e-bike of my own, I wouldn't have had any hope of keeping up with her. She was a speed demon. In fact, by seven months after her open heart surgery, Anne already had more stamina than at any other time in the past 20 years of her life, not just healed, but stronger than before. Open heart surgery, Anne says, is not for wimps. It's a grueling experience. For two weeks after her operation, Anne walked a tightrope in the intensive care unit as a team of doctors guided her, a team of dozens of people guided her through fluid balance and infection control, cardiac function, arrhythmia as nutrition, sedation, anticoagulation, ventilator management, kidney function support, skin protection, wound care, and more and more. But miraculously, all of that worked. It worked brilliantly. And it brought my wife from life-threatening congestive heart failure in just a few months to 70 miles of tough bicycling on a beautiful spring weekend. I say miraculously, but it wasn't a miracle. It was the product of human endeavor. It was not the intervention of the gods. It happened because people made it happen. It was intentional. What makes it seem miraculous is the complexity. Just how complex the system was that saved Anne's life. I said dozens of people worked on it, but I suspect it was actually hundreds of people. And yet we felt everywhere, all the time supported by a net of meaning and sense and even beauty. It seemed to us that every single one of the people that we met, doctors, nurses, physicians, assistants, pharmacists, physiatrists, nutritionists, clerks, housekeepers, every one of them, were part of a symphony of common effort. They were part of a meaningful whole that they knew they were part of and were proud to be part of. Anne's fluid balance was one example. One effect of her 96 minutes on a heart-lung machine was that she gained 30 liters of water in her body, in the tissues of her body, and she needed even more fluids to pour in to maintain her blood pressure. One doctor said, don't be worried about that. First we're going to pour the fluid in, and then we'll take it out. And Anne will begin to lose that water around day five. We were panicked, but he was not. And exactly as predicted on day five, Anne began to lose fluid, and by the fourth week, her weight was normal. We had no idea where we were on that stormy sea, but they knew, they all knew. That's what a high-functioning human system looks like, what it feels like. It has orientation, it has meaning, it has sense making, and it has form, even when chaos seems to loom. It uses known scientific principles of organization, success factors that were the factors for Anne's 70-mile bike ride last weekend. I could spend a lot of time talking to those factors, but I'll briefly list some of them that I think about. Three keys, the three most important to me are common systems, common knowledge, and unconditional teamwork. Common systems, everyone knew the best, and that's what they adhered to without equivocation. Common knowledge, what anyone knew, everyone knew, and a sense of seamlessness that was so desperately missing in Mrs. Mills' story was present every moment in Anne's. And unconditional teamwork, no one is the boss. Anne is part of a whole greater than themselves. Transparency, openness, communication, communication with us, a constant focus on what really mattered to Anne because they asked her, and they asked me. Technical skills and everyone involved, and deference to expertise, no matter where that expertise was, even in the lowest-ranking person on the team. If they knew it, they used it, roadmaps everywhere. So we could get into more detail about that someday, but my main point is this, we know how to make excellence happen intentionally. But unfortunately, as Joe reminded us and as Mrs. Mills reminded us, far too often excellence of the type that saved Anne's life does not happen. Indeed we have good evidence that fully reliable, scientifically organized, crafted, cooperative care may be more the exception than the rule. And when excellence fails, a price is paid. The price is paid annually by hundreds of thousands of victims of medical error, quality failures, and avoidable injuries. A few of those names have become very well known to us in this community. They're iconic in this field, Justin, Ms. Michalitsi, and Josie King, Mary McClintock, Cal Sheridan, Patrick Sheridan, Lewis Blackman, Betsy Lehmann, and now Martha Mills. This is not a game. Injuries from healthcare are a real, present, costly plague. And this plague can end if we do the right thing. Now, Anne's excellent care had a leader. It was Dr. Taurus Sunt, he's chair of cardiac surgery at that hospital, Dr. Sunt's uncompromising commitment to excellence, support to his team, respect for all, and dignity. They infused our experience, common systems, common knowledge, unconditional teamwork. You could feel it everywhere, all the time, safety, excellence is not an accident. It is the consequence of intentional leadership. The same is true for a nation, our nation, the United States will not have for everyone the quality of care that it deserves without leadership at the highest levels in organizations and in the public arena. Now, I'm going to take a risk here. You'll see the risk. I'm going to overstep my authority. I'm going to suggest what that leadership would sound like from the very highest level of all in our nation from the Oval Office. I am, as you know, not the president. Don't get me wrong, I wouldn't mind being president, but as the saying goes, my path to victory is narrow. So I'm not holding my breath. So the record though, if I were there, this is what I would say from the Oval Office. My fellow Americans, I am today issuing several executive orders that can save tens of thousands of lives every year in our nation and avoid pain, needless suffering from many, many more. The topic is patient safety and health care, and I need to set the stage. Like you, I could not be prouder of or more grateful to our nation's health care workers, doctors, nurses, technicians, pharmacists, managers, aides, all of them. The list goes on and on. Their commitment, their skill showed through brilliantly in the COVID pandemic. But my friends, we did not need a pandemic to remind us what they do for every day to help us. We are truly blessed by their presence. But there's another fact. It's a disturbing fact about health care in our nation, which needs urgent attention. That fact is that health care is far too unsafe for patients. In recent months, my science advisors have taught me a great deal about our challenges in patient safety and about the high toll in injuries that medical safety problems take on our neighbors and on ourselves. By injuries, I refer to avoidable complications from medical care. Things like infections that people get when they're in hospitals, errors in diagnosis, mishaps in surgery, medication mix-ups, mishaps. We know about this toll and have known about it for at least three decades I've learned, and tens of thousands of patients each year die from such injuries. They are not dying from their diseases. They're dying from errors and avoidable complications in their care. And hundreds of thousands of others suffer pain and disability. Now I want to repeat, my fellow Americans, that we have a superb health care workforce in this country. They are not the causes of these medical injuries. They are not the cause. In fact, they do their level best every day to prevent them and to intercept errors before they do harm. The high toll of patient safety problems occurs despite their best efforts. Patient harms frustrate our nation's caregivers just as they frustrate patients and their loved ones. There is good news. A large proportion of patient safety problems can be avoided. In fact, believe it or not, they can be eliminated. That's not a theory, it's a fact. There are hospitals in this nation that have driven certain kinds of infections to zero for months at a time. There are hospitals that have virtually eliminated pneumonias that can come from ventilator machines. Or eliminate painful pressure sores that can come from prolonged time in bed. Or they have cut surgical complications in half or more. They have not done this by blaming their workers or yelling at their doctors, rather by adopting safe practices that protect both the workers and the patients from hazards. You experience the results of safe practice yourself in another industry, aviation, every single time you board an airplane. Commercial aviation was not always as safe as it is today, but today it is ultra safe. Occasional tragic aviation accidents still do happen, but they're incredibly rare. Today, you would have to fly continuously on a commercial flight for over 6,000 years to have a 50-50 chance of being injured as a passenger. Compare that with healthcare. Where recent research has shown that almost one in every four hospital patients experiences an injury from their healthcare, one in every four. Roughly speaking, that means that from the viewpoint of injury, you are more than 2 million times safer in an airplane seat than in a hospital bed. How did aviation get so safe? Well, I assure you, it was not by telling pilots not to crash. That would be stupid. Pilots are always trying as hard as they can to fly safely. No, aviation got safe, not by blaming its workers, but by developing and using everywhere standards, practices, designs, methods, tools to support safety. It used science to get safer. No pilot takes off today without using a pre-flight checklist to aid memory. No plane skips serious maintenance at frequent intervals. Every pilot reminds his or her crew to speak up without any hesitation if they think something is wrong. Pilots report every potential problem and near miss to a central national aviation database so that everyone can learn from it. Pilots don't hide their mistakes. They report their mistakes, and they feel safe in doing that. They know that teamwork really matters, and they make sure that everyone feels safe calling out a mistake if they see one. And by the way, pilots make mistakes every day, just like every other human being, including doctors. What's different about their world is that it is built to help them make fewer mistakes and that when they do error, the systems around them catch the error and prevent it from doing harm. The safety system does not blame the pilots. It enlists them in prevention. Now, we need a healthcare system. Every bit is safe is our commercial aviation system, and we can get there. And as your president, I feel that it is my duty to encourage, support, and we're needed to demand faster progress towards safer healthcare, faster than we've ever had before. We will make improving patient safety a national priority, and we will apply that everywhere in our nation, not just in a few pioneering hospitals but in the care for every single patient in our country, no matter where they are cared for. This progress cannot be achieved by top-down government mandate. It can be achieved only in full cooperation with and infinite respect for our nation's clinicians and healthcare organizations. So today, I'm inviting the strongest possible partnership between government and our entire healthcare enterprise, public and private, to make our healthcare far safer than it has ever been. My aim is rapid, large, and sustainable improvements in patient safety in our nation, and so I'm taking these four initial steps. First, my administration will establish national leadership for the improvement of patient safety as a national priority, and that starts with me. Ultimately, accountability for progress will rest in my office. I will appoint a White House coordinator for patient safety reporting directly to me. I will direct the Secretary of Health and Human Services to establish and chair a government-wide patient safety coordinating group to assure the highest levels of cooperation among federal agencies and departments in support of the safety agenda. I will direct the Secretary of HHS to establish and support an ongoing public, private, national patient safety team modeled on a similar structure in aviation. That team will include, of course, clinicians and safety scientists, and also, most crucially, patients and family members with experience of injury in healthcare. We will make no move in this agenda without the direct inclusion of the voices of patients and families, and we will include people from marginalized communities that are especially affected by patient safety problems. This national patient safety team will continually identify and recommend potential solutions to the nation's patient safety challenges. Second, my administration will take steps to assure that every patient in America can benefit from progress already made in improving patient safety. The best safety practices in our healthcare system need to become the standard practices everywhere. The best results anywhere will be the results everywhere. I am directing the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality to develop and maintain a high, a list of high priority patient harms and practices to avoid those harms. And I ask the Centers for Medicare and Medicaid Services and private sector organizations to provide support and incentives, strong incentives for all hospitals throughout the nation to adopt those priorities and those procedures and to report their progress openly and publicly. Importantly, I will ask that this effort extend beyond patient safety to the safety of the entire healthcare workforce. Just as injuries to patients can be reduced or limited by using the best science, so can safety for healthcare workers be and will be dramatically improved. Now, I call on boards of trustees and senior executives of our nation's hospitals and other healthcare organizations to shoulder directly the burden and duty of vastly improving safety. Proper stewardship of healthcare organizations needs to include continual improvement of the quality of care, including first and foremost patient safety. It is as important, no, it is more important than financial stewardship. It is my job as your president to lead that quest nationally. If you are on a board, it is your job to lead it in your organization. Third, my administration will ensure that better patient safety and improved equity in our nation are linked. As for so many conditions, racial and ethnic minorities in our nation, along with other marginalized populations bear an extra share of the burden of medically induced injuries. Every element of my administration's efforts to improve patient safety in America, to transform it, will be focused on eliminating disparities. I insist that healthcare organizations and federal agencies measure safety outcomes according to race and ethnicity so we can see the disparities and consciously address them. And as I said, we will assure the presence and the voices of patients and families in everything we do. Fourth and finally, my administration will invest further in the science of patient safety so that errors and injuries that look unavoidable today become fully preventable tomorrow. And of extreme importance to me. Listen carefully. I will direct the secretaries of Veterans Affairs, Defense, and Health and Human Services to prioritize measurable, significant, and rapid patient safety improvement in the federal healthcare delivery systems of our nation that they lead. The Veterans Health Administration, the military health system, and in full cooperation with tribal governments, the Indian Health Service. I want these federal healthcare systems to become national leaders. I want them to be international leaders in showing just how safe healthcare can be. I will ask for regular and frequent reports on their progress directly to me in the Oval Office and I will expect rapid progress. My fellow Americans, we can intentionally make healthcare far, far safer in our nation than it has ever been. Maybe even someday we can approach the levels of safety in our commercial aviation system. Why shouldn't patients feel and be at least as safe in a hospital bed as they are in an airplane seat? They deserve that. And our nation's healthcare workforce, our marvelous workforce, needs to know that we, including their president, are there for them as they try, as they always have, as the physician's oath says, to first of all, do no harm. That is my oath too. I pledge that in the honored memory of names I have now learned, the people that we have done harm to. Justin Michelizzi, Josie King, Mary McClintock, Cal Sheridan, Patrick Sheridan, Lewis Blackman, and Betsy Lehmann, and thousands and thousands of others who have paid a price that future generations must not let us together make unprecedented patient safety or reality for everyone. Thank you and good evening. I wanna make one final comment. We all know, unfortunately, that no president, however caring a president is, is likely to give that speech. Unless and until, of course, I am. They have a lot in their minds. But I wanna point out that that speech in its appropriately modified form belongs in the mouth of every senior leader of healthcare in this nation. And especially members of boards of trustees, every CEO, every clinical champion, we have been far too slow for far too long and we will not ignite the pace and the results that we need until patient safety is centered in strategic vision of every single leader in the healthcare system. Thank you very much.