 Thank you, and I do want to thank the patient safety movement and really my friend Joe Chiani, especially for your leadership and persistence It has been really inspiring to for us to work with you on so many efforts You've been a real presence in Washington and that has made a difference. So Since we sit in Washington as well our headquarters are there. We have been very happy to see Such fighters along our side as we all are really working on this incredibly important issue So one of the ways that leapfrog has been very active around patient safety Has been as part of this coalition that is developing The concept for a national patient safety board and advocating to have it put in place We've been part of that for I think it's three years it was prior to COVID actually that we started getting involved with it the The Jewish Foundation really was the the lead spark that got this moving and just truly a leader in this area And we'll we'll talk to Robert in a minute about that, but we felt very strongly at leapfrog That on behalf of our purchaser members who are employers who purchase health benefits for their employees founded leapfrog that we had to be more effective and Identifying this problem as a national priority that without that spotlight of a national priority We felt like we just can't get the traction Because every person that you talked to and so in among employers employers are usually lay people They are themselves not in the health care system They learn about these problems through their employees or through their own experiences family members And when you talk to them they'll say yeah, I haven't heard a lot of these complaints or problems or issues But they always think it's just them. They always think oh, yeah, oh my uncle. He had a terrible infection or something happened You can't believe it. It was just terrible. I'm like I can't believe it I hear this from every single person literally that I talked to has a story to tell and That's because and then we lay out the statistics which we've talked about today that are so disturbing one in four people Harmed when they are admitted to a hospital. That is an astronomical figure. That is unacceptable on any level But shocking to people even when they've experienced harm They just don't understand that this is so ubiquitous and so from the perspective of purchasers and for the public at large Who are their employees often? They really want to have the sense They need to have that Momentum behind them that this is important not just to us and our employees that this is important to the whole country That we all have to come together. They need that sense of National unity around this problem And so we got a very excited about the idea of a national patient safety board to bring that spotlight bring that sense of unity and Also to tell every individual who is consider who considers this a problem in their own life That you're not alone that we get it. This is a priority to us. What happened to you is a priority to us So that to us is the number one reason to have this no matter what it says no matter what this board does That's the number one reason just to have it third leading cause of death in the United States ought to have One spotlight one focus federally. So we make sure we're accountable for answers I Will say that just to add one piece to this that's been really interesting to us a couple of things One is technology. I think this board and the concept behind it has taken on some very interesting Questions about how we use technology for patient safety when we implemented EMRs a few years ago There was no consideration of patient safety. It was just like get them out there Let's get them used and the sort of assume that it's all going to come together for patients Which frankly it did not and now we're going back and saying oh geez We should have thought of patient safety when we did this and how it was going to help for that Well, this board needs to make sure that happens with the new advances in technology And I think there's been some very interesting conversations about how this board can be helpful Again the spotlight alone can have a huge galvanizing impact on that question And then we've also thought and believe strongly that Patients need to be at the center and so this board the structure of it Everything about it has been putting patients at the center But also giving patients a voice so they can tell their story. I mean you've heard these incredible stories today and Steve burrows you'll if you go to the movie tonight, which I strongly recommend The story in bleed out is so powerful had such an impact Those stories have impact, but also those stories tell us Give us extraordinary expertise into what the real problem is Because when you hear a patient story, you're understanding the full range of issues that occurred that created a problem for that patient You're seeing them in a unified way in a coordinated way that you don't get from just one perspective of one Provider, let's say who's in the mix they may might see it from one perspective the patient sees the whole perspective And that is why it's so critical that we put patients in the middle and we listen to the stories and we are We are motivated by those stories. That's what makes the real change happen So we're excited about that and then we're we're excited as well about the spotlight when maybe not as excited about the Transparency that's involved in this. We're we're huge advocates of transparency leapfrog Issues letter grades to every hospital in the country. We publicly report by hospital and what those are and it's you know It can be difficult to be that transparent. It's been very effective, but it's true. It's tough. But this board Doesn't need to do that this board isn't isn't trying to do letter grades on every hospital They're not trying to call out performance on every single thing. We have others that can do that including leapfrog CMS has done a great job of that But what this does again is that that spotlight because nothing else can happen Just can't get the momentum without that spotlight So the first priority for us is the spotlight and then we want to see where we can go from there And there are many flowers that need to bloom before we're gonna solve this problem So with that, let me start with with Robert Why don't you tell us you've been really yourself personally a real leader in this Brought together so many folks in Washington and then across the country tell us about Tell us about what's what are the key elements of the board and and where do you think it's going? Is it gonna happen? Yeah, so the National Patients to Safety Board was I designed around one main goal and that's to prevent harm from occurring in health care Organizations and I have to say dr. Burwick's executive order. I described it very well But just to go into some additional detail. I think of the National Patients Safety Board as a public private research and a development Team that is a waking up every morning I focused on three main functions to achieve that goal and the first function being to Aggregate all the available data across the public and our private sector our partners to be able to identify and anticipate Injuring harm in health care at the national level and not in other words having this body be a national of learning system to a prevent harm And in addition to identifying injury and harm Anticipating it is where AI comes into play. That's where a technology can be really helpful in terms of getting the right information to front-line care teams to take a preventative action the First function in terms of being able to Measure and anticipate injury and harm would also be looking at all of the Reports that patient staffs and the providers and families would be able to submit To the National Patients Safety Board to feed into their large Dataset the second function of the National Patients Safety Board is then to Understand the contextual factors the precursors and the causes of injury and harm especially in response to abnormal patterns of injury and harm and reoccurring harm events Then that leads in to the third function that in response to those causes this public private health care safety team Would also be charged with identifying and gaining consensus on what are the solutions that need to be adopted By those partners to actually a prevent that harm from occurring and by solutions We are anticipating that this team would come up with ways in terms of how can Devices technologies be standardized I'm across I'm healthcare Organization so that for example a nurse that doesn't have to learn how different Oxygen tanks and a defibrillator's work in different hospitals. There should be standards across the place and We also think it's very important to use a human factors and engineering lens which helps to understand how do those who actually use these had devices and technologies and they work setting interact with those had devices and Human factors and engineers are excellent at seeing so-called Crash buttons and those crash buttons that all are all too common in health care I need to be removed so that our providers Can focus on patient care versus? Being focused on doing a constant of workarounds to keep patients safe and These new solutions are really important especially in the context of the current workforce crisis We can't expect Hospitals that are facing 30% Vacancy rates with a frustrated burned-out staff to ask their teams to Follow more manual steps. We need a need to rethink in terms of how to reconfigure their Of work environment to enable all our providers and staff to a provide safe and optimal care every time and as Leah he alluded to Patients would be involved in this of both as a member of that public private health care safety team They will also be on the actual actual board of that public private health care safety team and a key function of the board would be to have sole authority in terms of approving the recommendations and reports that would come out of that R&D Team to mitigate any political Interference and and influences and in terms of the in terms of the Apollo let's see prospects We are currently working with a Republican and Democrat sponsor in the house to Introduce an updated version of the end a PSP bill that was introduced last year by Representative Berrigan and then we have also lined up R&D sponsors in the Senate. He would then Introduce a companion bill since they would like the house could do that upfront lift and then I'm a special thanks. I'm also to Joe Keone and the work at PCAST because they have Is opened up the policy window to even consider that an executive order is even possible and so we also have an executive order Strategy that's been Drafted as well and that strategy is very much connected to the work of a PCAST and essentially We will be mobilizing the NPSB a coalition that's now grown to over 80 organizations to put pressure on Creating an executive order to act on those recommendations from the PCAST report And yes, I'm completely agreed that let's also just a copy paste a dr. Burrock's executive order and get it to the president I'm as soon as possible. Thank you So Sue Sheridan you you've been a Articulate advocate for the patient perspective. I'm you're right. I'm sorry Activist for for patients and families and really by telling your own story So with with such courage because it takes a lot of courage actually for patients and families to repeatedly tell these stories that are so Personally Devastating and tell it over and over it's is incredible courage and sacrifice for you to do that And you've made a real difference by doing so so I salute you for that Thank you And you've also had a big big impact on this on the concept really of the the national patient safety board So tell us what what you're thinking. Sure. Yeah, and first of all Thank you, Leah and and when I use the term activist I want to I want to Invite everybody to think about this because there's this lovely concept of positive activism where we use our energy of differences to promote and Motivate and change and so I say what I say activist I say it with you know positivity and I invite everybody else because like I said earlier Advocates talk about it activists do it and so that's why I'm gonna be you know Insistent that we're all called activists in terms of the national patient safety board I personally support it and patients for patient safety us supports the concept and we've been in it from the beginning Really trying to learn about it in and make sense of it in where how does it really impact us? And first I want to support it in terms of the threats that I gave this morning, you know number one threat There's no one in charge. Well, this gives Patient safety a federal home it signals that this is a priority in our country. We need that The second threat that it that addresses is the this assumption that the health care system Convicts itself while we that concerns the patient community because we think we should be up the table and like Robert said Two of the five board directors will be patients or family members who have experienced harm who have a track record in improving safety The other threat that it, you know It basically addresses all the threats that I said this morning now Personally in terms of you know, we had at the coalition kind of a use case that we use my son Cal That probably many of you know that Cal suffered brain damage from his newborn jaundice in 1995 Something that is completely preventable. It was because they use visual assessment Young doctors and nurses didn't know Really the dangers of jaundice because they were young There was early discharge so it was a really perfect storm when Cal fell through all the cracks We actually watched him suffer brain damage in the hospital. He he lived through that experience. He's 28 now Severe cerebral palsy hearing impaired speech impaired mobility impaired Funny he was he was gonna come with me today But he actually has some stand-up comedy that he's performing tonight. So he's not with us But but in thinking about what happened to Cal, you know, this was 1995 It took a long time to get Cal properly diagnosed and when he was diagnosed by a team of Specialists at a University United States. They said Cal was the only case of Curnicorous in the United States Curnicorous brain damage from jaundice, which was really eradicated in the developed developed countries in like the 1970s, so they had not seen a case of of Curnicorous in the United States It really happens more in developing countries Africa Eastern Mediterranean region Southeast Asia So Cal was really Anomaly and then I had the opportunity to testify at HRQ in 2000 and where I met Sir Liam and there was a front page article of Cal on USA Today and I Was inundated by phone cards from parents that day saying they had a baby Just like Cal that that baby had Curnicorous and so the moms, you know, we all got together. We connected the tots No one was collecting this data We were thinking Cal was the only baby in the United States and then then I connected with researchers who had been creating a registry for research Where they had a hundred and twenty five cases of Curnicorous in the last eight years This data was flying under the radar. It was flying under the radar It was packaged and buried in many Confidentiality clauses where people couldn't talk about it But to know that had those cases come forward and had that data been collected like by an NPSB I Think Cal would probably be okay today. Well, he is okay today He probably wouldn't be dealing with his Disabilities today and so it really made me think about our healthcare system and our data and To this day, I don't think Curnicorous gets captured anywhere and I've spoken to other patients here We just don't say we're harmed. There's data and it just kind of goes somewhere But it's not going to where it should be and so, you know, what the moms did of the children with Curnicorous is Given there was no NPSB We created our own NPSB and so what we moms did is we reached out to the health care system the very health care system That harmed our kids. We reached out to the joint commission CMS CDC HRQ ASPE the American Academy of Pediatrics Nursing organizations, I'm forgetting some names But all of those stakeholders came to a workshop that we moms hosted and so we said to this whole system This is you know the whole industry system on newborn safety. We said we've got a problem. We got a here is our data So we provided the data we handed over the hard copies of their birthing records And so they we worked together and then we collectively came up with a solution So over a period of time the joint commission is an issue sentinel event alerts leap frog. Thank you adopted that in your survey CDC announced it as emerging public health issue The AAP eventually called for a universal Billy Rubin test for all babies and that's why our babies were being harmed So we kind of created our own group to do what I think the NPSB would do So when we did this use case, you know it it really seemed that an NPSB could have caught that data early on and Elevated such a rare but harmful and an awful condition that you would have sounded the alarm Absolutely, and you did have a huge impact on that Although my child 10 years after yours was born had a near miss they almost right they did not do the test And so you educated me on the fact that this my child was not the only one here. We go again, right? Everybody thinks we're the only one Sir Liam Donaldson Like to talk with you. You have some actual experience to tell us Because you've implemented something like this in the UK. So what are we doing right? What are we doing wrong any advice and how's it going? Well, the very first Incident report I received was in 1987 I was a young regional medical officer working in the northeast of England and local hospital manager rang me to say Patient had died in his hospital during surgery He'd been given a bladder washout as part of the procedure and the long wrong solution was given and that killed him So actually an error that could still occur today, but the Important thing about the call was this was not a call to alert me to a patient safety incident The term wasn't even used in those days it was because he was Wanted to advise me that there might be bad publicity for the NHS and Just thought I could be aware if I read something in the newspaper This was what it was about and he used a phrase that The Brits in the audience will recognize and not everybody else will He said oh well, don't worry. It'll be tomorrow Tomorrow's yesterday's fish and chip paper and basically in the old days Fish and chips was served in a bundle of newspaper and when you wanted to say well There'll be a bad story in the media, but it'll quickly disappear You said that and I said to him well a patient died. What are we going to do about it? Anyway, I tried over time over the next few years to raise Concerns with Leaders of the National Health Service and they were really it wasn't that they weren't interested. They were bemused They didn't see any connection between the different incidents that were occurring So I reached out beyond the health care system to people like James reason Charles Vincent Rona Flynn who was doing research in the oil fields in in Aberdeen and Ken smart who was the safety officer for British Airways So that when I became chief medical officer 12 years later, I was able to Have enough knowledge to set up a patient safety program in the NHS And one of the first things we did was to set up a national agency the national patient safety agency Eventually it was abolished wrongly in my view. I think because the government was trying to Reduce bureaucracy, but essentially it had a mixed-track record But the most important thing that I would say for you doing something similar setting up a national body is To determine what its positioning should be in relation to the change that's required in patient safety And I've spent a lot of time thinking about Strategic change in Population level to try and make care safer and I haven't changed over those 36 years my basic Diagnosis of the things that need to change, but they prove very very intractable. So for example Mainstreaming patient safety in the culture of the NHS It's still a bit of a silo and it's remained like that for over 30 years Nothing can really No transformative change can occur until it's mainstreamed Learning Relatively weak still we have plenty of data. We have a lot of insights, but we're not we're not picking up and learning from it Solutions the very few evidence-based solutions Having an independent voice Accountability patients and families these are big thematic issues We can deal with some of the technical things and make improvements in patient safety But until we start to become transformative to those things then We won't change at all. So I would just point out to you something that you're all very well aware of patient safety Attempts to improve patient safety are occurring in a complex adaptive system and Much though the politicians won't like this the only way to achieve change in a complex adaptive system is by a learning Approach it isn't by issuing instructions guidelines directions that will have relatively little impact So think very very carefully if you're setting up this agency this new board Don't just list the functions learning data analysis Look to see how in a complex adaptive system It can be an agent for change. What mechanisms will it use what powers will it have? How will it be accountable all of those things? And I think if you do that you've got a chance of a real breakthrough But if you ignore it and just by rote almost list the functions that need to be addressed and allocate them And leave it to get on with it. You won't achieve a great deal Thank you. That is extremely So now we have professor nash Mishkadi who has Really great experience to tell us from other industries, which is something I love about this conference Is that we do have these examples from other industries and really a significant leaders Who have who've really been there and done that who've done what we're trying to do So so what's your what's what is your wisdom and advice for us? Thank you, yeah It's a pleasure to be here when I see it my fine panelists and as an engineer I feel like a bull in a china shop People with medical background doctors and that I'm a simple very very Unsophisticated engineer my research for the last 34 40 years have been in the area of human factors and safety culture of Safety critical systems by safety critical system I mean those systems when something goes wrong It harms the people the passenger the patient or bystanders and the industries that have been working with the safety critical system Has been primarily nuclear power industry. I have been as the Honourable Chris Hart mentioned to Trimal island Chernobyl Fukushima Daini Fukushima Daichi That's a there are other creatures. They don't go there. I've been to The water drilling accidents refinery accidents and others one thing that I learned which is very related to this discussion here of National Patient Safety Board is as was mentioned earlier many times Dr. Durkin mentioned that dr. Ramsey mentioned that dr. Berwick mentioned that is the issue of learning and information sharing. I think one of the best and biggest Contribution of national transportation safety board that as you may well know Investigates accident in five modes of transportation and it's Independent federal safety investigative agency milling is independent from DOT it investigate Aviation accident maritime accident railroad accident surface accident and number five is the most illusive one pipeline and They issue reports independent report and then they have something which is called the most wanted list That they put the lessons from this accident investigation in a cumulative way and they carry that every year This is one of the best way of information sharing. I have been on both sides of that I use some of NTSP reports like the Vamata Accident at Fort Totten In my courses at USC and there is a similar agency called Chemical safety and hazard investigation board. That's again another independent federal Safety investigation agency that they investigate accidents and the issue report interdisciplinary investigation of refinery petrochemical accident for with CSP I work as their Advisor or they call that experts in human factors and safety culture by the way, it was a music to my ear Robert to see national patient safety board that you explicitly mentioned human factors several times kudos to you and kudos to honorable Chris Hart also for mentioning that Human factors I think is one of the most important contributing factors to many accidents as I have looked at this issue of the Design induced error if we want to stop error. We need to look at this design stage and There is another independent safety agency which is called defense nuclear facility safety board that they are Independent from Department of Energy, but they have jurisdiction over the nuclear weapon laboratory these three independent Federal agency I think they have been role models for us They issue report they try to as Mr. Hart mentioned to help us to learn from error and near misses To disseminate data and help the industry learn for example I work with US chemical safety board at the accident investigation of the BP refinery and explosion of 2005 in Texas City That report which is considered to be a similar report has been used by other Refineries in order to learn lesson I've been told that by my students that they work at the Exxon refinery that they use that report I've been told that by another recently that work at Another refinery in in the state of Washington. I think this is the beauty of this National patient safety board is To disseminate information. I am sitting on the board of the Joint Commission and I've been pushing our Colleagues on the board of and at the Joint Commission also to join this movement I have been pushing for you and then unpaid promoter of you getting the human factors and ergonomic society To support you. I think this is a must-need have now. I have to tell you something dr. Domberwick your talk this morning Changed the last part of my comments because of your talk and because of mr. Joe Kiani stock I went up and I picked up this piece that I had in my briefcase This is a New York Times letter to editor section from 1990 33 years ago January 1990 there is a very nice letter by a very distinguished gentleman who was US senator from Deliver Joseph Biden Pushing for creating an independent nuclear safety board Then senator Biden did not believe that a regulatory agency Which is the US nuclear regulatory commission can do a good job on doing? Accident an incident investigation of nuclear power industry. That's why he wrote this letter to the editor of New York Times on December 12 1989 It got published two weeks later Senator Biden at that time was pushing for creation of indeterminate safety board. He came up with a Legislation a bill which is based on my memory. He introduced that bill in 1986 1987 1988 and Then because he didn't pass he reintroduced that in 1989 1991 1994 and what finally gave up This poor soul yours truly had a letter to editor in the same issue, which is published side by side This is my claim to fame. We basically said the same thing. We need this independent nuclear safety board in that case Dr. Berwick, Mr. Keane You have an advocate here from 34 years ago in the White House. He doesn't relent He will push for it and the only thing that we need to do is to get him reelected to finish off the job I appreciate that comment, but I have to say patient safety is a Nonpartisan issue this is one And I'm unregistered water Not committed why I'm registered, but I'm not partisan. Yeah Sorry, okay Our final panelist I want to hear from is Abby Tophic You have very interesting perspective in addition to a tragic story in your own life that you can may choose to speak about but And and your courage just like Sue's courage in really speaking and stepping forward to tell that story in addition You're a provider and that has that experience is a new lens for you in your own work as a provider I think you have some very interesting insights for us as we think about this board on how How we might bring the health care system to see their patients through this new lens as well. So Tell us. What do you think Abby? Thank you? I would like to first Express my gratitude to Joe and Sarah and the patient safety movement foundation for giving me the privilege to be here When I chose to be part of this movement Was mostly because I just didn't want my brother's loss to just be that just a loss or a loss statistic I wanted to be a stepping stone towards creating a change and preventing others from going through the same pain and I Truly believe that errors should be looked at as an opportunity to create change But a change that it's a constructive change that is Implemented and enforced by an entity that believes in the truth in the transparency and the accountability and teamwork otherwise, we're just all individuals or entities or victims and organizations that are isolated and scattered and Just cries in a chaos and we're only going to be facing a history of repeat and repeat of history I think Sue so brilliantly explained of the importance of having such an entity in the last panel and today but as a healthcare provider, I also truly believe that Empowering patients is so important in this movement Because I believe that patient safety is a partnership It's a partnership between all of us who provide the care and all of us who will receive the care one way or another either currently or in the future and I've seen it time and again in my patients who are so lost because they don't know anything About what safety is all about we all go to school and get educated about how to become successful But we never go to a school or there's no entity teaching us how to be educated and how to be safe and it's devastating when I hear my patients who are Only realizing what they didn't know after they became victims And I think such an entity can also play a very important role in Empowering everyone in the community about how to be a safe patient how to make the right decisions how to pick which Hospital they want to have a procedure with based upon whether or not these are safe hospitals They these are accountable hospitals people Who are patients are you know only talk about? The issues that happen to them were mistakes only after the fact and I think it's very important to create Proactive people proactive patients who believe in prevention as well Thank you So we only have three minutes left, but I have very much been grateful for the wisdom from this panel This has been extraordinary So I'm going to ask one question now for all of you to think about and answer which is We are talking about the National Patient Safety Board, but we want to build a sailboat What's the wind what is going to move it? How is it? What's going to give it momentum going forward? Because I think it's very important to recognize with patient safety Oh, we know a lot about how to how to fix the problem. We just don't do it enough What what galvanizes change what makes that difference? And I'm gonna I'll start with an answer to give you a chance to think about it, which is for me it is It's that spotlight and go back to that It's really shining a light on the issue on a national level and the spotlight is galvanizing It changes the way we think about the importance of our own work on a day-to-day basis as providers Or as patients as in whatever role we play in the health care system, and we all have a role every one of us It reminds us that that there's a there's a mission behind it. There's a reason and and it's important So that's my feeling about that's the wind that's going to make this sailboat across the ocean Can I start? Yes, you may sir Liam one of my other Pro bono roles with who is I chair the polio eradication board I would say the way we would galvanize Patient safety is to show That we can eradicate something big If we could show that we could eradicate sepsis not just lower its incident, but completely eradicate it We'd galvanize such Unified commitment that I think it would show that it's worth making a commitment to patient safety in many other areas as well Thank you. We need wins. That's a that's a great one Sue Okay, you know what my answer is but um I think and and Liam I'm going to quote the the global patient safety action plan that says Perhaps the most powerful tool in patient safety is patient family engagement and I want to add to that I want to add that, you know, we've kind of talked about The force and the wind in the in the sails of our health care system Really the power of the patients and families civil society patient groups disease based groups population based groups That really have no aggregate voice right now And that's what patients for patient safety us is trying to do and that you know This really needs because we are the ones that experience the bad outcomes And we need to get together and find the avenues and work with our government And and fortunately our government is opening doors to patients and patient groups now To really move this to push the to be the force to push this into reality That's a great answer Abby involve the patients involve the future victims involve basically everyone, you know We'll I mean dr. Ramsey constantly reminds us that we're all going to be patients one day. So That means everybody. It means the society. It means remembering that You know without the society you can't really you know participation of the society you can't really create any change Robert and I think One advocacy there's a power in the numbers You can get involved and join the coalition by going to ww.npsp.org And we also have a platform to write a letter to your Representative to ask them to reintroduce the n PSP bill And also as soon as you see the p-cast the patient safety recommendations likely in august A rake to the president tell your story as a provider researcher patient and say you want the president to Do an executive order to accept to accept the p-cast a patient safety recommendations. So then secondly The i'm health care industry. I'm of course has influence as well And I think that there's a chance that they will get involved in this advocacy as well because of the workforce crisis They need new solutions to Design a work environment to allow all A page to allow all staff and providers to achieve safe optimal care. And I think That is helping to elevate the urgency around a patient safety Absolutely I think the stars are lined up for patient safety President by them being in the vitas With his advocacy Activism and interest in patient safety. Mr. Joe Keane being in p-cast and p-cast having Dr. Prono was seen that they are advocating for patient safety And also I see the joint commission under the leadership of the Dr. John Perlin. They are very interested in that ihi. Thanks to the creation of uh, Dr. Bear Victor interested. I think the stars are lined up and people the patients People like me who are a researcher. We are fed up Of seeing all of these preventable medical errors I think we have a very special unique windoff opportunity Between now and next four years being honest with you I think if mr. Biden doesn't do that no other president will have the guts to do that Well, that is a powerful way to conclude our panel, but