 Welcome everybody to what I know is going to be a really fascinating 45 minutes or so as we talk of not just the challenges we currently face within the patient's safety environment but also the actions that we believe are really important to consider and set that in the context of we've known for a long time what needs to be done and why is it so difficult for us to find the ways to do it? Now our conversation today is going to be with three truly global figures in the world of patient safety and in no particular order I'm just going to use the screen in front of me to introduce first of all Sir Liam Donaldson. Liam has been a figure of outstanding character in the world of patient safety over decades. I won't say how many because that will tell you how old he is but for many decades and certainly was at the earliest stages in recognizing the importance not just of appropriate methods of governance of clinical governance in healthcare but also that vital the vital role of the patient and their family in being able to talk of their experience and being able to share their experience with others so welcome Liam and I know it's going to be a great conversation that we have with you today. We're also joined by Jeremy Hunt. Jeremy Hunt as many of you know was the longest serving Secretary of State for Health for the NHS in the UK Health Service and for the UK government but also he's held Secretary of State positions in other ministries and governments and in particular in the foreign offices as foreign secretary and that may be relevant to us I think as we discuss about the importance of a global movement for improving patient safety and Jeremy has now spent many years not just in his own work as a minister and now as Secretary of the Health and Social Care Select Committee but also in learning himself of the importance of safety but also some of the elements that we need to introduce across our societies and our countries and thirdly to everyone in the audience for the Patient Safety Movement Foundation Joe Chiani who was the the founder of the Patient Safety Movement Foundation and through his his corporation Massimo and the foundation being that that that touchstone that that group who has kept the movement going who has continued to stimulate it who created the concept of reducing harm to zero and maintaining the importance of our drive to do that and that's created issues for many in fact the challenge to reduce to zero in itself is something that that people will often want to talk about so I know that we're going to have a great conversation from the three in the room and I hope I will be talking very little over the next 40 minutes or so so let's go back to the to the to as what we'd say in in the UK the batting order and Liam as the sort of the longest serving patient safety expert I think probably in the room today you've seen the challenges emerge over the last two or three decades and the actions that are put in place but now in your role as the WHA envoy and leading work on both the action plan for the next decade but also on many other different elements what what do you think are the the current challenges and and a couple of actions that you think will be important to introduce well Mike when I started on this journey I was Chief Medical Officer in the UK and we produced a report around the same time as the Institute of Medicine to her as human report and we called our report in the UK an organisation with a memory and at that time very very few people were involved in championing the need for safer care safety was seen as fire risks or hazards of tripping up on a on a loose floor tile things of that sort and when safety came in it tended to be referred to as medical error and that term became increasingly outmoded as we started to talk to the people in other fields like aviation who have achieved great improvements in safety but by concentrating not just on the individual error in isolation but on systems and the way in which systems make it easier for people to make errors and mistakes and also when those mistakes happen in a weak system the impact is much higher somebody might die or be seriously harmed so when we started it was a domain of interest of a very small number of people and then the number of enthusiasts grew and the number of passionate leaders grew and the number of researchers grew but my question always even when I'm talking to audiences today is how much do you think patient safety as a way of clinical life has penetrated the mainstream is it five percent ten percent fifty percent a hundred percent and most people put their hands up in the audience and they suggest maybe 15 20 percent of clinicians and others are practicing and following the philosophy and the concepts of patient safety so my big challenge for everybody in health systems around the world I think is how do we get better at moving from that minority of enthusiasts and champions to the majority so it's it's in an old cliche everybody's business patient safety is everybody's business thanks Liam thanks that that that will be the challenge isn't it and we often hear here um Don Boeck in particular talk about um workers getting getting it as work has to be done uh and uh the need to recognize that uh that this is as you said a way of life and not something to just be added on to um Jeremy you've you've you've borne the brunt of many challenges to to uh some of the chain changes that you wanted to bring about to improve the safety of patients uh uh in the UK system but and now you're working closely with with with Liam I know and with WHO colleagues uh to look at uh more of a global picture what's your views on the last particularly your interest over the last 10 to 15 years I think the first thing to say is that you know we shouldn't beat ourselves up and and say that we haven't made progress because I think there has been massive progress um I mean you can go back to the um hand washing campaigns that Liam did a huge amount to get going at the World Health Organization when he was Chief Medical Officer which was the start of much more focus on patient safety around the world uh you can look at areas where we've had specific focus in England for example on maternity safety where even though we had a very um depressing uh report published a few weeks back as to some things that happened at Shrewsbury and Telford Hospital over the last decade we've seen a 36 percent reduction in neonatal death rates a 25 percent reduction in stillbirths and you know these are very solid figures and this is very solid progress in the right direction and I would say that culturally um we we're halfway there we're not more we we now I think it's it's now quite normal in health care to talk about the dangers of a blame culture and how important it is to support support clinicians to speak openly and transparently when things go wrong the things that Liam was just talking about whereas I think you know if I think exactly 10 years ago when I became Health Secretary there were still a lot of people who felt that if there was a problem in the NHS it was dangerous to talk about it publicly because it would damage confidence in service and I don't think people say that now and I think people recognize the importance of openness and transparency so I think we have made progress I think our challenge is the pandemic has really set things back in lots of ways um you know in I'm just going to be parochial now talk about what's happening in in England but we have 6.2 million people waiting for treatment 19,000 people waiting more than a year for treatment 6000 people waiting more than two years for treatment and the risk you have with those kinds of volumes is that we go back into seeing healthcare as a numbers game and we we start thinking about statistics and not people and then the patient safety corners get cut and you start to see all the risks emerging uh that we know about only too well and so I think there's a real risk that as politicians focus on targets to get this backlog down before an election that some of the important lessons that we learned about safety and quality are unlearned so what would I say are the the three things that we need to to think about I would say that going forward globally there is a massive issue about workforce I mean the United States needs a million more nurses Germany wants 300,000 more nurses we need another 4,000 doctors just to deal with the backlog but globally the WHO say there's a shortage of 2.1 million doctors and the normal thing of just importing doctors from other countries when you need them is now stretching the bounds of what is being ethical I mean we have more than 300 NHS employees in England from Somalia and I'm sure they do a brilliant job but you have to ask yourself whether it is justifiable ethically for the UK to be importing doctors and nurses from a country like Somalia that needs them so desperately and so we have got to start tooling up our system start training more doctors training more nurses finding ways to dramatically increase because this demand with advances in technology and medicine is only going to increase and then I think the next big really radical change is technology and this is going to have a massive impact in helping the patient safety agenda and helping the transparency that underlines many of the reforms that we've all championed and I think some real thinking about how we could use the tech revolution to transform the safety of care delivered is really our next big step. Thanks Jerry so three key areas to work with and in the sitting in the chair next to you certainly in my screen we've got someone who leads a big technology revolution and has led it for a while now but you've also got some other thoughts I think Joe in terms of the other element that you mentioned about how do we incentivize the system to do what Liam said which is to have this as our way of life so that there is there is no alternative and I'm just wondering Joe what what you'll look particularly interested in your on your views about technology and how that will help us but also what about this issue about how do we incentivize systems to do better. Thank you thank you so much Mike first of all on the technology side the computers can do things some things much better than human and human can do something much better than computers one thing computers can do a really good job at is keeping track of things like trends like historical data so and with the advent of all of these cameras and sensors and biosensors tools like artificial intelligence or expert systems can be really effective in turning a one sigma clinician in detecting a problem to a six sigma clinician detecting a problem so one of the challenges though to create those tools has been a lack of cooperation by my peers the Medtech company and at some point it was me as well where we were hoarding our data the same data that we were that were being purchased pulse oximeter values radiology information the companies that made these machines wouldn't share that data with other people that could take all of that data aggregate them and make some sense about what could happen in the future based on the past the trend data is incredibly informative that human beings are hard to look at for them but it's easy for computers to look at but you need access to that data so one of the things that we tried to do with the patient safety moving foundation is to remove that barrier one of the commitments we asked for for Medtech companies was to share the data that their products were purchased for so that eventually it a new ecosystem is created for developers to create those predictive algorithms and I'm happy to say over 90 companies signed that pledge including giants like Oracle not on Surner as well as GE Phillips and of course Massimo but you know to take a big step back to talk about the second question about this aligned incentives concept that we talked a lot about at the patient safety movement foundation I want to just step back for a moment if I may to kind of tell you what I think has been the critical milestones in this journey of patient safety and why I think if we want to keep it going we need certain things that will hopefully will be self-governing and kind of the perpetual machine if you will so I think a key milestone was that to air is human report by IOM I think another key milestone was Dr. Peter Pronovost's checklist on CLABSI that showed if you did put the evidence-based systems in place you could get incredibly better results another incredible milestone was what Jeremy Hunt did with the ministerial summit on patient safety and of course what you guys did at NHS together the transparency movement that has already paid handsomely and of course I think President Clinton's CGI initiative taught us something that you can create a commitment-based organization you know the price of the showing up to a meeting isn't just what you paid for the meeting but a willingness to commit to doing something to help so putting all that together we created this patient safety movement foundation and I think maybe what we brought forward besides all of those lessons was a unification message that whether you're a medtech company like mine or a hospital or patient very important patient advocate or in the government we needed to work together to solve the rest of the problems which takes me back to the commitments we asked for we asked for hospitals to commit to zero we asked medtech companies to share their data and universities to begin making patient safety part of their curriculum and where we haven't yet achieved our objective are three ideas one is love bringing love to the patient not being afraid to love your patient and that you get too emotionally involved some people think it's a bad thing I think it's a great thing and then transparency which you got in the UK but we don't have in the rest of the world and aligned incentives as which is sorry a long way to come back to what you asked me to begin with the aligned incentive idea is very simple whether no country that I know of is 100 private some of them are 100 public most of them are half and half like my country here in the US so given that the government is paying for some of this care if not all of it I think we could put together something that will be self-governing and self-propelling and that is to pay hospitals even when they make mistakes if they put the processes in place to avoid that mistake that medical error and not pay them for anything when somebody gets hurt or dies when they haven't put that process in place I think something like that could have a huge impact and get us over this chasm of the choir doing the work but not everybody else in the church okay thanks Joe thank you so I'm looking to my my colleagues no one's interrupting you so so that means that they're there and then breathe that's why I'm happy what you're saying so um any any thoughts on on on the from the three of you on what each other have said um about a sense of a sense of purpose and direction in this in this field now then I'm particularly interested in so we we also sorry I'm particularly interested in the work that we're not doing uh and the settings that we're not particularly looking at so we spend a lot of time looking at our hospitals we spend a lot of time looking at within the processes within our hospitals to improve majority of our patients are not in hospital majority of our patients are carrying long-term conditions with them having multiple multiple meds on them most of them a lot of them have concurrent issues with their mental health with their physical health I'm just wondering where are we in terms of this debate about challenge for both in terms of the vulnerable groups the hard to reach groups but those that are haven't been really looked at closely in terms of the safety agenda and are we doing enough on that area Liam sorry yeah yeah Mike you asked me to react to other others comments and I'll pick up I'll pick up Joe's comments straight away because he raised something very important this question of data and I remember being asked to look around a hospital in England where they'd installed automated monitoring system so the nurses didn't have to do the observations and it two things struck me first of all the nurses loved it and they didn't have to be data literate the output was such that they could easily understand what was happening to their patients but when I said to the CEO of the company who was demonstrating I said to him you must have millions of data points here you must be able to look at these patients and predict from the data which patients were likely to deteriorate and we know very well that about a fifth of the avoidable deaths in hospital are caused by one reason or another people not spotting deterioration in an acutely ill patient whether it's sepsis or whatever causation it is they are acutely ill they're getting worse the nurses are busy they miss out observations the the charts get lost and one way or another the patient isn't rescued in the terminology that tends to be used so I just wonder why we can't um people could call it big data but why we can't get these large number of data points assembled and analyzed and and used to be able to intervene upstream to prevent people from suffering harm or death thank you and so I would naturally sorry Joe I would naturally then transfer that that debate into learning from across the last recent years in the pandemic to to those exactly those points and data points out of hospitals as well so where we can learn learn for earlier intervention both for the recovering patient but also the ones that haven't been able to get into hospital in the first place sorry Joe I cut across you well I I totally believe what Liam is saying and I and I believe hopefully if not sooner in a decade we will be there we've we've suffered from lack of connected devices and electronic medical records being just billing machines not being really electronic clinical records and I think that's all changing and I think you know companies like Massimo we're looking at precepts as algorithms by coalescing all the data not just SPO to impulse rate but temperature respiration rate and other information from the lab including going back to even the phenotype of the person and their historical data so that we can help predict those problems and I think many other companies are going to have that and I think part of the opening to do that has been this willingness to share data that we began about a decade ago that I think will pay off incredibly well in the future okay thanks Jeremy I can see you nodding but also itching to get in here thanks I just feel that you know all of us um have been passionate patient safety advocates because we feel that there's a particular horror in um medical error that means that someone dies or is harmed in a way that was completely unnecessary so what the public tend to think about with medicine is a disease for which there's no cure someone dying because they have a brain tumor and there's nothing you can do about it but what we all uncovered in our contact with medical with the medical world or in our medical careers is is this horror which the public aren't really aware of is which is the extraordinary amount of avoidable harm and death but I feel that to make sure that patient safety remains mainstream we need to think more in the way that Joe's talking about about how we can make ourselves part of the future because one of the problems is that people are looking at advances in medicine and they're saying well I understand what you're saying about avoidable harm and death but we're just going to make a few advances in terms of our ability to interpret genomes and we're going to be able to save millions of lives just like that so shouldn't we really be putting our effort into to these things and I think um particularly the prevention agenda is one that people are really thinking very very hard about and I think from a patient safety point of view we need to be really embracing prevention as the ultimate safety for patients if you if you give someone care that means that they don't get it in the first place I mean that is that is the safest care you could possibly give them and I just think that there are many many ways that that is going to happen so in technology for example I think it's quite interesting to think about how we are going to move to a world in which people's decoded genomes sit on their medical records in a form that a doctor looking at that medical record can interpret easily and then can talk to people about their genetic predispositions and so I don't want to move away from our core purpose which is to eliminate medical error and indeed I've written a book on it which all of you three gentlemen figure in and um the title of the book is zero so I've been very inspired by what uh Joe's Joe's big campaign of getting to zero by 2020 which sadly we didn't quite get to but it was a brilliant ambition and I wrote a whole chapter about saying why we should get to zero but I just feel that we need to find a way to embrace tech and the tech revolution in in our patient safety movement because I think that's what is getting a lot of attention. Okay thanks Jeremy thank you Joe open arms for that conversation. Open arms I love the title of your book I can't wait to read it Jeremy and I and I hopefully it'll inspire a lot more people going back to Liam's comment earlier that 15 to 20 of the people know about patient safety hopefully your book will get us a lot further because it will take the whole village sorry if we're using that too often to solve this problem we all have to do it. I think Jeremy's spot on I think you know of course I have an engineering degree and so you know what do they say every if you're a hammer everything's a nail but yes I think technology will play a huge role in preventing problems hopefully fixing things at home so you rarely have to go to hospitals and doctors and they're not as overwhelmed they have more time to give you the care you really need instead of wasting time with things that they don't need to do and also helping with the prediction and you know Jeremy said it right now with cancer with genetic sequencing people that can afford it get the right therapy there are 600 types of cancer not just a few and to know which one you have can really dictate the best course of action so the future does look bright but we can't just let it happen accidentally we've got to together push it there. Yeah thank you Liam you um I'm sure you're going to say something about something but I also want you to think about the reflecting on particularly with regard to your role within the WHO and some of those areas some of the systems and nations and states that maybe not as as fortunate as others how are we going to be supporting them because unless we do that then I think we're we're not going to tip the balance in terms of the global impacts. I'll say something briefly about that Mike before I do I just wanted to also comment on things that I've seen Jeremy doing and also Joe and in a modest way I hope myself as well which is to recognize the power of the granularity of the patient experience and when I went to Joe's conference in in California and watched the number of patients who'd been victims of harm who were part of his conference it had an incredible impact not just on me but everybody there and Jeremy has done so much in not I can't imagine any other health secretary in history that has met patients who've suffered harm and talked to them and understood their experience and then communicated it to others and I've watched with the WHO patients for patients safe for safety program I've watched audiences in tears seasoned doctors and nurses listening to the patient's story now you can't measure that but there's something about getting to the heart Joe talked about love and the heart is as one patient told me where you love from and I think that connection between the granularity of the patient's experience and the big strategic picture where we're trying to push major change is very important on the situation of the low-income countries I think the the key link there with avoidable harm is basically to access to care and the big goal of the WHO and and many other global health agencies is universal health coverage that doesn't mean everybody gets health care free but it means that nobody is denied care who needs it for their health and well-being or nobody is financially ruined because they fall ill and that goal of universal health coverage as Jeremy said earlier we have to embed our patient safety ideals into that bigger ideal of providing universal health coverage for for everyone but certainly lack of access to care in in the large slices of the world is the biggest cause of avoidable harm I've also got hopes that that through the WHO in its convening role will be able to accelerate the process of the global patient safety action plan which is a key formula for setting out almost a decade of work do you want to say anything about that because I think that's that's going to be a for a number of countries that don't necessarily have access to politicians and leaders such as you three it gives them a frame too within which to try and work to create that appropriate environment yeah and a lot of people were involved in that from countries around the world experts so there's a lot of buy-in but also a lot of ownership because so many people played a part in in producing it so I think what I found in working with WHO over many many years now in general the high income countries feel they can do without WHO's advice but within the middle income world and the and the low income countries they are very very grateful for guidance and help and support and in on the whole tend to value plans like this and they act as a big guide for them going forward and I think that's what will happen with this global safe patient safety action plan yeah but one thing I would like to add to what Liam said is you know the same way a lot of those low resource countries went from no telephone directly to the cell phone if we could get these low resource countries where they're going from no access to care to hopefully access to care that has patient safety in it to begin with and still and what I'm talking about is there are about what I call 30 to 40 standard operating procedures that if you put in place then human errors which were all made don't have to lead to medical errors and most hospitals around the world don't have them all some have some of them but boy wouldn't it be a great opportunity from day one as they create their healthcare systems to to a hard wire that patient safety in it yeah yeah it's fascinating you should talk about operating procedures because Joe because I was a party to a conversation yesterday with a hospital it is struggling with what we have in in the UK called never events and and one of the elements that they introduced which has reduced their number dramatically is is what we over here called loxics or local operating procedures and when Jeremy was Secretary of State he introduced a system of a national operating procedures and also those that would be adapted locally and they are starting to influence it's very interesting how some but some hospitals doing and other hospitals not doing it so it's this variability I think in implementation that is is currently not helping our patients but also significantly not helping our healthcare workers our staff who are also implicated so often without reason actually in the errors that are being made Jeremy you mentioned the issue of culture and healthcare and healthcare workers and often the system is being the issue rather than the individual have you got any more thoughts about this because you've reflected on it I would just say that you know as we sort of think about things that are changing in healthcare so whether it's genomics or technology or the aftershock of the pandemic I think it's really important that we don't forget the central goal which our campaigning has started to move things towards but which there's a lot more work to do which is that in the airline industry they managed to create extremely high safety levels by putting in place systems where mistakes were learned from quickly and they managed to stamp out largely stamp out a blame culture and we haven't done that yet in medicine but the goal would be so huge for patients if we had a culture in which we self-corrected where everywhere in any hospital anywhere in the world when there were mistakes instead of people asking which doctor or nurses to blame people said what went wrong and how can we make sure it doesn't happen again now that is a very very much harder thing to do in medicine because when people die people naturally want to look for a person who is responsible and attach blame it's just it's understandable whereas in the airline industry most of the time in those situations you're dealing with near misses so it's it's more straightforward to say we're not going to blame anyone when you haven't and as we saw and I'm sure you've all seen the film Sully but when you when you end up with near misses that are dramatic there's still an overwhelming urge to try and find someone guilty even in the airline industry but I think that is a very big goal which we should carry on aiming for because I think that would be as we move into the tech revolution the genomics revolution there are still going to be all these errors there are still going to be mistakes there'll be different types of mistakes but doctors nurses midwives are still going to get things wrong and if we could learn that lesson from the airline industry the oil industry the nuclear industry about creating a positive learning environment where people aren't penalized for speaking openly and transparently I feel that is really as much worth aiming for now as it ever was I love that and by the way something terrible has happened in the US a nurse in Tennessee who made an error has been prosecuted criminally and when when you do that the learning culture goes away it stops people from wanting to report problems and learn from problems and I believe as I've looked into that problem at that hospital there was a system failure that unfortunately her human error ended up becoming a medical error but to criminalize people is a terrible terrible thing and we got to we got to do something about that yeah Liam thoughts on candor then nice easy question for you how can we have true candor and at the same time protect our protect individuals like the nurse in Tennessee well I think it links back to what Jeremy was saying about the blame culture you can't have candor if the result of surfacing something is likely to lead to you being disciplined or punished or or have a stain on your career so that you don't progress your career anymore but we have to do more simply than admit the error and apologize I think you have to then work with patients and families to show them that we are learning and we need them to help us and there will always be bitterness and anger and grief at the beginning but what I've found is that many families who've lost a loved one due to have some sort of harm avoidable harm if they're given time and listen to and respected they will often want to help and I remember vividly one occasion talking to a mother who'd lost a child and the hospital had had fallen over themselves trying to express apologies and remorse and in the end they came up she told me with a big idea they were going to plant a tree in the hospital garden and she said to them I don't want you to plant a tree I don't want you to put a plaque up on the wall in memory of my son I want you to commit to learning so that this never happens to anyone else and that's what most patients do so I think we we don't just we're not just open about what happened we don't just apologize but we say to them if you if you're able to help if you're willing to help will you help us to turn this round and produce a sustainable permanent elimination of this form of harm thank you Liam thank you that was a great opportunity from that that family and that mother um we're coming to the end of our our period of time so but I just want to give you all a chance to reflect um on a couple of things but one Jeremy you mentioned that uh despite our um uh the efforts that have been made that and are concerned that more needs to be done a lot has been done um so we should be quite positive about some of the influences and the changes that have taken place um for us by in every setting uh and certainly in terms of the global impact on on safety with and I'm just wondering whether each of you could think about what you think it would be uh your positive message uh about uh our safety agenda and our positive message about our future with regard to how we take this ongoing uh commitment forward shall I start well you're the practice politician Jeremy so I'm sure you've got you can do this I want to go steal my points um so um I just I think the first thing to say is that and I'd be very interested to know if Liam agrees with me on this as a clinician but I do believe that healthcare is getting safer I think that you know if you look at the direction of travel compared to you know 20 years ago I think that overall despite all the pressures we have and even coping with a pandemic I think healthcare is actually getting safer we sometimes two steps forward one steps back but I think it's getting safer and I think that we should always remember that culture change is sometimes painfully slow but it's worth aiming for because in the end the only permanent change is culture change and that's the only change that is ever really embedded and I think that culture change is beginning to happen um so I I am personally um optimistic I think that there's been a lot of progress that's been made I think there are lots of challenges um I just want to give a plug for um my own um uh charity in the UK patient safety watch because what we're doing is something very simple with Aridazi and his team at Imperial and and Joe's giving us some support in in doing this but we're doing something very simple we've commissioned Imperial to do two things um and they are going to do this every other year so one year they are just going to publish what they estimate is the total number of avoidable deaths in the NHS in England and where they stand and where the most effort should be made in order to reduce avoidable deaths so we will have in one place an authoritative study that quantifies the level of avoidable death and I think that will be a very important addition to the debate because it will be something with impeccable academic credentials that allows us to get our head around the size of the problem and whether it's getting better or worse and then in the other year so that they'll do one year in the other year they're going to publish a global patient safety ranking which ranks all the countries of the world by the safety of their healthcare system and that will get us all discussing which of the countries we need to learn from is there some innovation in Sweden or Japan or Switzerland that we could be learning from and and I think that will also create helpful debates so I think all these things I hope will make a contribution but I think this is a time for renewing our efforts and renewing our ambition thanks Jeremy thank you um and no doubt we'll see some fantastic results from from patient safety watch uh Liam well in one of my new roles as chairman of a new health body in the northeast of England um I'm going to see whether all of my rhetoric over the years can be put into practice and um one of the things I just want to leave you with one thought I think I've we've all read and talked and spoken and listened about all aspects of patient safety over the years and but there'll be a few things that stick in our minds and one of mine is the the book by um Carl Weik and Kathleen Sutcliffe called Managing the Unexpected it's about high reliability organizations and they they um out they list the criteria of high reliability organizations and there's one of those criteria that I really love and it chimes with what Jeremy said about aviation the thing about aviation is they now have so few accidents that they've so I said well what how are we going to learn there's no accidents to learn from and basically um this criterion of um Weik and Sutcliffe um answers that question they say a high reliability organization should make a strong response to a weak signal of failure and to me that's a gold standard as I visit all the hospitals in in my region in this new role I'm going to ask them show me an example of where a weak signal that there may be a risk somewhere in the system you've pounced on it and dealt with it and put in place the action necessary because to me that's the test how far upstream are you anticipating and preventing great thanks Liam and I the reason I was turning round was because I was looking for the book uh which I happen to have I don't think you can see it on there hey Jeremy where's your book what about but it is it but no for everyone who's listening print yeah I'm afraid okay but Kathleen Sutcliffe's book is very it's a very good and car lights very good so thank you Liam but also good luck in the good luck in the north as they say over the next next period Joe what positive messages have you got for us in terms of our our sense of our purpose direction and I really do embrace what you've talked about love and I know that a great hero of mine of Ada Stonobadian always talked about that as being a key a key part of of any system made up of individuals and individual processes that it was the it was the ethical values of the individuals that were held within that system that really made the difference and and he purported love was being absolutely key to that so what are your positive messages for us well I I definitely have one but before I go there I love what Liam said it's that jumping really excessively to a small signal is key if that's part of an amazing culture and I see at a hospital I'm involved with and they're amazing and of course with what I really think Jeremy the reason you can do what you're doing in England is because of that transparency law that you created so kudos to you I hope many more countries will follow it because once the data is there you can learn from it and nobody wants to be last so it creates a nice competition for the for the right things one thing that I know Mike you're aware of many of us here are aware of WHO is has been working on a paper that unfortunately reports that patient safety got hurt a lot during COVID pretty much everything doubled or even got worse on all fronts of patient safety and I and maybe it's because of my own bias but I think what probably was the biggest difference between before COVID and after and during COVID was the lack of families being allowed in to be advocates for their loved ones and you know until we all learn to love strangers there is somebody who loves that stranger it's their family and that person also can be an extra help for the lack of nursing and doctor shortages without the skills but you know it wasn't a play-doh who said the best doctor is one who gets sick a lot well families know their loved ones and I think we can do a lot better learning from that lack of family and embracing them in our hospitals to be advocates for their loved one but I'll leave you with a great great hopeful result so Liam I hope the challenge is on that you get the same result I did in a smaller place children's hospital of Orange County I joined the quality committee several years ago and I'm on a member of board directors and shock implemented every standard operating procedure we know of we call them apps by the way they're on the patient safety movement foundation website and they also before they implemented them they decided to tie the bonus of the faculty a third of it to zero if we achieve zero at the end of the year you get a third of your bonus you don't you don't once they did that the hospital already had a wonderful culture but they went through all the apps the procedures mark green the parts they were doing yellow and red what they weren't doing with a mitigation plan to get on the green and in the first year they didn't get to zero and to their credit they didn't say this is ridiculous let's get rid of it the faculty said let's double down let's increase the bonus factor to it and I'm happy to report over five years now they've been at zero so we know that you could get to zero and get really close to it if you put these standard operating procedures or evidence-based practices or we call them actual patient safety solutions at our foundation you can get there so that's I think maybe the message of hope that just put them in place and measure before and after and see what happens great that's a fantastic story and a great example for us Joe to move on from our time is up it's amazing how quickly 45 or even 50 minutes goes when you're listening and I was always taught to take every opportunity you can to learn something every day so listening to you three I've learned a lot today and so thank you for that it's also been very entertaining so thank you for that and I hope that all of you are at the summit who are listening to our conversation will take away some the messages that we've discussed but also that it gives you confidence that you're doing the right thing and that there are lots of opportunities for help from different avenues and different individuals so may I thank Liam, Jeremy, Joe and also I have to say in the background Isabel who's managing the recording for this interview or fireside chat thank you all very much for giving up your time and thank you for your ongoing and continued commitment to help improve the safety of all our patients and our healthcare workers so thank you all very much and I hope you have a very good and pleasant rest of the day whichever time zone you're in thank you very much thank you so much Mike thanks to see you all bye everybody look forward to seeing you all again soon