 Good afternoon. My name is Randy Clark. I'm the president of the American Society of Anesthesiologists. It's my great pleasure to be with the Patient Safety Movement Organization. It's a great honor to be with you today and talking to some of the great leaders in the area of patient safety. Today I'm going to talk about two subjects that I am greatly interested in. Patient safety, specifically as it relates to anesthesiology, and also a little bit about aviation. I am the son of a U.S. Air Force officer who was a pilot in the Air Force. His last assignment was at the Air Force Academy in Colorado Springs, which is why I'm currently working in Denver. And while he was assigned there and I was a teenager, I obtained my pilot's license at that time and have been interested in aviation ever since. So I was very excited to be able to be asked to talk a little bit about innovation and how we can adopt innovation and aviation into medicine. This is an area that I have looked at for a number of years. It really comes down to how do we make progress in any area of human endeavor, not just in medical care. So I'm just going to give it a real simple overview. It's one of three ways. We can either adopt better organizations with better execution of existing ideas. We can have better efficiency in how we operate our groups and organizations, or we can adopt innovation. New ideas are adapting old ideas to new situations. And it's this third area that I'm going to talk about with innovation in aviation as it applies to healthcare. I looked a little bit at the history of the Patient Safety Movement Organization and it very much aligns with the Patient Safety Initiative taking place at my own hospital. We call this Target Zero and the goal is to eliminate preventable harm, which I think is in complete agreement with what your organization exists to achieve. This is highly desirable, a very laudable goal. It's also very hard to do. Eliminating all preventable harm while a very legitimate target requires some significant rethinking about how we deliver healthcare. I would like to introduce the idea of maybe a different approach to this issue, trying to achieve the same goal. And this would be what has been called in aviation, and specifically military aviation, the failsafe concept. And this is the recognition that incidents, accidents do occur. We have to adopt our systems to make the results as minimal as possible, recognizing that accidents can happen. The term failsafe was popularized by a book and an excellent movie of the same name as only Hollywood can do in the fiction book. Even in the best designed system, sometimes that leads to unhappy results. But in general, the idea of designing our systems to be failsafe is to recognize that errors can occur, but we just need to try and minimize the unanticipated effects of those errors. And so I'm going to emphasize that a little bit in my talk. This airplane is called the Cirrus aircraft. It's a technologically advanced aircraft that came onto the market in the early 2000s. Many people know this airplane because it's the airplane with the whole airframe parachute. This is the idea of failsafe in action. This aircraft in this particular picture was being transported ferried from the mainland US to Hawaii. When you do that, you need large ferry tanks of fuel because it would not ordinarily be able to fly that distance. As the pilot was approaching the Hawaiian Islands, he was not able to switch to his last tank. The aircraft ran out of fuel and he had to ditch in the ocean. So he activated the whole airframe parachute. Ditching in the ocean is difficult. It doesn't always result in a good clean outcome. But with the use of this whole airframe parachute, by the time the Coast Guard who took this picture arrived, the pilot was sitting on the wing of his airplane with his sunglasses on. So this is the idea of how we adopt our systems to be failsafe recognizing that events can occur. So it's with some trepidation that I give this talk to you because I know some of the backgrounds of the other individuals addressing you and they do incredible work in this area. I'm going to talk a little bit about that in just a moment. In terms of safety initiatives within the aviation industry, perhaps the oldest of the modern era is the aviation safety reporting system that was put in place in 1976. In this system, if there is a rule violation or some other problem that occurs during a flight that may make a pilot subject to administrative action by the Federal Aviation Administration. If this form is filed within a specific amount of time after the incident, it provides immunity from further administrative action taken by the FAA. These reports go into the details of whatever event occurred and collects as much information as possible in order to make recommendations back to the FAA on how to improve the aviation system to prevent those same kind of events from taking place in the future. This is a very active process. NASA itself processes this information to make it to take out all of the individually identifiable information before it reports it back publicly. When we adopt these systems in healthcare through patient safety organizations, they're not nearly as robust as the NASA aviation reporting system. We have trouble when we get into areas where patients experience injuries because then the tort system begins to take over. So it also creates a layer of obscurity around actual events that we may not necessarily be able to learn from if it wasn't reported through and actively analyzed in a peer review process. I do think that the aviation system for reporting these events is a robust one. We probably should look at something similar in medicine across all specialties. We have something similar to this in anesthesiology that I'll talk about a little bit at the very end, but we also may need to look at ways that we can open up our whole dispute resolution process to be more open and helpful in preventing errors that occur in medicine. So I mentioned previously some of the speakers to this conference have had a long history of studying safety and aviation. Peter Pronovost is a leader in this area. This report from 2009 in health affairs recounted the information on the commercial aviation safety team. This was a landmark group of investigators looking at how we can improve aviation safety. This was the group, the CAST group, that really promoted the use of checklists and training on how to use checklists in emergency situations. I can't emphasize that latter point more strongly. The one emergency aviation situation I've been in my flying career, not having worked on my checklist for that event in the recent past really did not allow me to use the checklist to the fullest extent possible. The idea between behind crew resource management and teamwork training arose from the CAST aviation reporting. The incident reporting system was reinforced for the value that that provides, even though it predated the CAST work simulator training and standardization. Anybody involved in patient safety know that standardization is absolutely essential to our ability to drive improvements in health care. If everyone is doing their own thing, it's impossible to measure and impossible to make specific recommendations for improvement. I do want to talk about one specific aspect of the crew resource management idea. CRM came about because of a failure in crew relationships that led to an accident when the co-pilot and the engineer for the aircraft gave excessive deference to the captain of the aircraft, allowing the aircraft to run out of fuel and crashing short of the airport. The idea of being a good follower was really established by this concept. The era of the infallible leader is over, but this does increase the responsibility on other members of the team. And everybody must approach their tasks and their role with diligence, honesty and mutual trust. And the whole idea of trust I think is essential to the ideas of how leadership can truly operate effectively and meaningfully. So what are some of the new areas in patient safety that might be applicable to aviation? Well, like aviation we keep trying to apply the principles of high reliability organizations to health care. I think that's an imperfect match for health care. The consequences of decision making in health care tend to be concentrated on individuals, not large populations. We have poor standardization in health care. Typically we're getting better. We operate more like a boutique rather than an HRO such as a nuclear power plant. And while we work in a technological environment, our decisions are both personal and individual. Technology is not always employed as a protective measure. One area that I learned about in my research on this topic and in my background in aviation, when we develop new aircraft, the flight envelope is slowly expanded to new speeds, new altitudes, new configurations of the aircraft. And so the envelope is expanded slowly. But by using new mathematical techniques, we can cause perturbations in the aircraft's situation, measure the reaction of the aircraft, and then use that to mathematically expand the flight envelope. And I apologize for the term spastic pilot, but you have to realize that these were engineers that came up with this concept, not people in polite company. So this idea I think is adaptable to health care. If we have intelligence systems that measure the response to the drugs that we administer, especially early in an anesthetic, and be able to look at or predict how the patient might respond to the same drug at different doses later in the anesthetic. So I think there's some opportunity here. This particular area, my two daughters are very excited about, we need to understand why women are safer in aviation. I want to give you three examples from the British experience. They found that their female pilots were much less likely to be involved in aviation accident accidents, even accounting for the small fraction of women in the British pilot population. This has held up in the United States studying accidents from 83 to 2002, with again about 6% of the flying done by women, but they only had 4% of the non fatal accidents. They only had 2.5% of the fatal accidents, even though they're 6% of the flying population, meaning that women may be two and a half times safer than men in aviation. And in the military itself, Army studied this area from 2002 to 13, 10% of Army helicopter pilots during this interval were female, and they accounted for only 3% of the accidents during this interval. And even the presence of a woman on a flight crew also resulted in a proportionally reduced number of crashes in this area. This area has been looked at in medicine, specifically in internal medicine. I would love to be able to look at this information in my specialty, see if this holds up for female anesthesiologists compared to males. So what are some of the other areas and how do they compare between medicine and aviation? Well, as I mentioned with the Cirrus aircraft, these are technologically advanced aircraft, meaning that they have very integrated digital monitors in the cockpit. We are developing these kinds of systems in the operating room. We expect even future improvements to be significant. Autopilots are almost essential to flying. They make flying easier and safer. And there are some techniques looking at what is essentially closed loop anesthesia that would serve as an autopilot in the operating room. That's a research area at the present time. And there are some discussions among commercial vendors of other areas where this might apply as well. And then finally, the area of artificial intelligence is absolutely under huge amount of investigation in medicine and specifically in anesthesiology. We're starting to see some of the early fruits of this labor by decision support tools where the equipment will look at the situation in an operating room and make recommendations for next steps in the conduct of the anesthetic based on machine learning of previous cases in large numbers. I do want to mention briefly some of those things that don't translate between aviation and medicine particularly well or maybe just not yet. For pilots, medical certificates are required for airline pilots at a very high interval. We don't do anything similar to that in medicine. We do have random drug testing and aviation that's not typically used in medicine. We have very frequent simulator testing for pilots in the airlines or flying for corporate flight departments. Check airmen will sit in the cockpit observing the pilots in real action and make recommendations for improved performance while some of the lean concepts of having people walk through the operating rooms. We don't really have much comparable to check airmen for our delivery of anesthesia care. Everybody knows about cockpit voice recorders and data recorders. Those are used to analyze what may have gone wrong in an aircraft accident and find root causes. There are attempts to incorporate this into operating rooms. There is a growing field of literature on this particular area, but it's still primarily of research interest and fairly new. We have not seen widespread adoption of this approach, which is ubiquitous in commercial aviation. I'm going to close just briefly by mentioning how ASA itself addresses innovation. We have a committee on this subject. It used to be called the committee on future models of anesthesia practice. This assignment was expanded somewhat to include all realms of innovation. The committee continues to look at practice models. It also looks at an expanded role for the anesthesiologist through the entire period operative period. This is the committee where those with expertise in artificial intelligence and machine learning bring that expertise to make recommendations to the anesthesiology community. We have a committee on equipment and facilities that looks at the technological aspects of our equipment. And we actually have a fairly large free standing anesthesia quality institute since 2008. It houses three different registries. Two of those are listed here. Our anesthesia incident reporting system is a national system that is somewhat analogous to the aviation safety reporting system that I mentioned earlier. And there is a wealth of information that is collected on these events. The difference between airs and the aviation industry is that these tend to be individual reports of events that are then collated into lessons learned across different aspects of care. We are currently investigating whether to hold an innovation summit or establish an innovation center. The center idea would be that if members bring to ASA some new concept that bears some investigation and may require some start-up funding, ASA may provide that. This would be analogous, we hope, to the extremely successful DARPA agency that advises the federal government. That work is still extremely preliminary. And then I would just like to briefly mention the ASA's quality and patient safety meeting. Last year we had over 300 attendees in the virtual event. This will be held this July. And if you're interested in this patient safety area specific to anesthesiology, please try and attend. So thank you very much. It's a great pleasure to be with you. And I'm very hopeful that I'll be able to meet with many of you in person in the near future. Again, thank you. Good afternoon. I am Edwin Lofton, Senior Vice President of Integrated and Acute Care and Chief Nursing Officer at Perish Medical Center in Titusville, Florida on the space coast. Perish Medical Center has had the honor of working with the Patient Safety Movement Foundation for several years now. In fact, we were one of the first hospitals to deploy every one of the actual patient safety solutions from the Patient Safety Movement Foundation. And they've made a difference in improving safety and reaching towards our goal of zero harm. Perish is also very humbled at this point in time to be recognized by the Patient Safety Movement Foundation as a high reliability organization. Being recognized that is not the end of a journey, but the journey itself. Perish has used our mission, healing experiences for everyone all the time as our guiding force to make sure that we continuously look for improvements in patient safety, patient outcomes, and the wellness of our community. Perish Medical Center has been committed to using objective scientific measures of performance improvement such as Lean Six Sigma to guide us in our processes of improving patient care and outcomes. Again, thank you Patient Safety Movement Foundation for this recognition. We commit to continuing the journey.