 Welcome to our patient safety moonshot panel. I'm extremely excited of the panel members we have today. The concept behind the patient safety moonshot was when we put our minds behind something, when we really believe we could do something, be it sending a man to the moon, being curing polio, we've achieved it. And we need to take that same mindset around preventable medical harm and say we are going to cure preventable medical harm before the end of this decade by 2030. And I'm delighted to have our panelists with us today to talk about the different areas that they're working on and things that would be necessary if we truly were able to achieve a patient safety moonshot by the end of this decade. First, I'd like to offer up to Karen to start introduce yourself. And the question I have for you, Karen, is you're doing such amazing work at the Jewish Healthcare Foundation around the creation of a national patient safety board. Could you share what's going on and what you've been doing in leading this effort to get us to that point? Well, thank you, Dave. Let me say that the patient safety movement has been a terrific partner. So I'm president and CEO of the Jewish Healthcare Foundation. And we have our own Regional Health Improvement Collaborative. We've worked for 22 years to reduce medical error. We've been spectacularly unsuccessful. So moonshot, we wouldn't send someone to the moon if we depended totally on the astronauts to get there safely and get home safely. We support them. In fact, we support every pilot with advanced analytics and with excellent technology so that a lot of the safety that they experience and they provide if you're a pilot, other passengers is autonomous. We don't do that in healthcare. And so one of our interests is what does aviation have that we don't have? They have the National Transportation Safety Board, an organization that is totally focused on bringing the frontiers of technology and analytics to safety and aviation and transportation. So we said, what if we had a national patient safety board? This idea keeps coming up. I say every decade for three decades, but I think it's time now. And the pandemic has made it even more urgent. We should have those same protections that frontier technologies and analytics give to other industries. Great, thank you. I wanna turn to Leah next. Leah, like Karen, you've been a leader in patient safety for many years, driving leapfrog and others to higher quality and safety measures. I'd like you to talk a little bit about the importance of aligned incentives, your organization as well as the Patient Safety Movement Foundation and some others have been trying to drive that concept and raise awareness about it. Could you talk about why that's important and especially the idea of reporting of certain safety measures that need to be increased? Well, thank you. Thanks Dave for having me and for being part of this excellent panel. The leapfrog group was actually founded on the principle that the healthcare market should function the way other markets do in the sense that when there's excellence that should be paid for in light of its excellence and when there isn't then there should be financial penalty for that in some form. In other words, payment should be tied to performance in some way. And that is just how every other market works but it hasn't traditionally in healthcare as we know. And I think that's created some dysfunction. At the same time, what healthcare should do is respond to the needs of patients very directly and patients can express their needs by choosing providers that do well. So the safest providers should be rewarded in the community by the interest of the community members in using those facilities. I mean, this is very, very simple fundamental framework for how you get better services in a community. And yet it's not how healthcare is traditionally functioning. It just hasn't. First of all, and foremost, people don't know who's doing the best job in safety. Traditionally, we don't know that. But thanks to Patient Safety Movement Foundation, thanks to all the stakeholders really watching this, I'm sure part of today's great celebration, so many others have come together to nearly push to have public reporting of patient safety in a way we never had it before. And it's truly made a difference. And I'm proud to say LeapFrog has been very active in that movement. And what we've achieved is a set of measures now publicly reported that tell you, at least for hospitals, where which hospitals seem to be doing the best job in preventing different kinds of events and errors and accidents that happen in hospitals. That's just really a breakthrough. We've used it to put together our hospitals to degrade the LeapFrog Hospital Safety Grade, which is an A, B, C, D, or F. We afford every hospital in the country on how safe they are for their patients. Others have used those measures for a whole variety of other purposes, but payment is a really part of that too. Now, our members are employers. Employers have a role to play in addition to what we traditionally think of as purchasers like Medicare and Medicaid. Employers are purchasing a lot of health benefits and they have a role to play in incentivizing hospitals to perform best. Now, that's not going to be the end of the equation because there's a lot more to do. And the moonshot here is for everything to be publicly reported for every setting, not just hospitals. We don't only go to hospitals, thank God. We also go to ambulatory surgery centers. We go to nursing homes. There's a whole variety of settings of healthcare and all of them should be safe. And patients are entitled to know which ones are which. And also employers and others who can really make a difference in rewarding excellence in all of those facilities. So what we wanna see is a world where there's full transparency, where we can begin to reward excellence with financial consequence. And finally, I have to say, we had to play defensive on this this year. CMS proposed this year to stop reporting a number of patient safety measures. In particular one, deaths from treatable complications from surgery, which is very important to so many of us. So many people have lost loved ones that way. And we do think that hospitals, we should know which hospital is doing a better job of preventing these deaths. So I will say again, thanks to the partnership with the Patient Safety Movement Foundation and so many others like all of you in this room and here on this panel, we were able to get that restored, which is actually not a common occurrence that you were able to restore a measure like that. But again, we're just playing defense. We need a moonshot and that's where you look to leadership like yours, Dave, to get there. No, thanks, Leah. I mean, your points just like Karen are so important. I think of, you know, primary hip and knee replacements when those measures were when we're put in place to track infections in hospitals, it was many years ago and today the majority of those cases are being done outside the hospital, hip and knee replacements moved to ambulatory surgery centers and the public as well as others have no clue on infection rates going on with those cases. So it's an important area. So we've heard about the importance of the creation of a National Patient Safety Board. We've talked about the importance of aligning incentives to outcomes, not to pay for quantity and volume of procedures. The third part is I'm gonna turn to my really good friend, Dr. Davila, who's been leading safety initiatives across the country of Mexico for many years and true leader. Javier, can you talk a little bit about the third area? Why transparency, be it outcomes or be it preventable medical harm events needs to increase. We need to embrace transparency and maybe even share an example if you have one of why transparency has made your country or others safer. Thank you very much, Dave. And thank you so much for the invitation on Patient Safety Movement Foundation. I'm a part of all of you. And as you remember, I'm a part of the board of directors and it's a pleasure and honor for me. And yes, this is a very important issue. I think healthcare transparency as the Institute of Medicine States is making available to the public in a reliable and understandable manner. Information on the healthcare system's quality, efficiency and patient experience, among others, being able to share data to achieve better outcomes, quality and cost of care, for example, generating trust and a better connection with the society. Transparency can also improve quality, safety and efficiency throughout the healthcare system making healthcare practitioners more accountable, which can lead to better patient outcomes. Also the importance of having the ability of a clinical benchmarks that allows us to identify where we are and the aspect that we can improve and learn from other organizations. In this particular case, a healthcare culture where quality metrics have been historically treated like closely guarded secrets can be a significant challenge to transparency. Changing this attitude means changing perceptions and workplace politics can come into play. You mentioned examples in Mexico and I can give you one. The model of patient safety we named Consejo de Saluridad General. It's a healthcare council in Mexico that it's a very important structure of the Mexican government and they are giving guidance based on best practices. So organizations can improve the healthcare attention and reduce the risk for their patients. This model has been applied by public and private hospitals across the country and they have the responsibility to give the guidance and rules for the hospital's accreditation. They have the regulations for public and private hospitals. So this is very important for us to include this issue to transform the culture of transparency and all the hospitals and the academies. You know that I am a part of the Executive Committee of the Mexican Academy of Surgery and we are following these guidance and regulations from the Consejo, the healthcare council of the government of Mexico. These are just some examples. Oh, that's great. Thank you so much for sharing that and the importance of transparency. We've just got a couple of minutes left and I wanna just really quick ask you all the same question. Karen, what can our audience do to help you in your work? Go to our website npsb.org and you can do a number of things. You can join the coalition. We have over 50 organizations. I'm representing all the stakeholders in healthcare. You can tune in to our podcast called Up Next in Healthcare Safety or you can just sign on and tell us your own story. We would love to hear your story of your encounters with the health system and some of the challenges you faced. Great, thanks. Leah, what could the audience do to help you and leave fraud, move things like aligned incentives and mandatory reporting forward? Well, first you can also, you can go to Karen's website. We're big supporters of the board of patient safety and you can go to Dave's website. We're big supporters as well of the Patient Safety Movement Foundation. So we're all part of the same family. And of course, you can go to our website which is hospitalsafetygrade.org or leapfroggroup.org, sign on to our campaigns. We've got a number of campaigns going to advance payment reform and public reporting. That is our core mission. Great, thanks and finish this off, Dr. Davila. What could the audience do to help you and your initiatives in Mexico and across the world? Well, I think first of all, it's to be a part of transforming the culture of safety which it means is the example of this pandemic COVID-19 had occurred. So when I asked to my colleagues and physicians, are you still following our apps, actionable patient safety solutions? And some of them answered, well, Javier, this is an emergency situation. Let's talk about the apps later. And I said, no, it's the same situation. So because we are in the same situation that in the past, the first goal is to prevent harm and to have saved our patients. So it's a very important moment to recapture the healthcare system complete in Mexico with two milestones, political and academic support. Because if the authorities and physicians and nurses and the multidisciplinary team is not involved, it's gonna be very difficult to keep saving lives and for our patients and for our colleagues. So this is very important moment for that. Oh, thank you. And I know we're out of time. I was ploughed to talk to all of you for another hour or two. You're doing great work. Thank you so much. And we'll stop here and move to the next panel session. Thank you very much panelists. You've been great.