 First of all, I don't want to hear any more stories like Martha's again. I mean, it is just shocking that we keep hearing the same stories year after year. Secondly, Don, that was incredible. That speech that you've written for the president that I think you've improved, that you need to give to me was incredible. We actually were hoping President Biden could be with us today, but that ceiling limit issue kept him away, but hopefully next summit he'll be here and hopefully he'll give that speech before then, but he'll reiterate it here. He, as you know, has come to the Patient Safety Summit twice before. He assembled a bunch of us, including Mike Ramsey years ago, to tell him what's going on with medical errors, what can be done about it. Eleanor Alexander I think was with us too. And he deeply cares about this issue. And I remember when he was struggling to get his budget approved for doing things for education, I think two-year college and other things, I wrote him a letter saying, you know, if we could solve the patient safety problem, we could really take a lot of expenses out of healthcare system and it could pay for a lot of your initiatives that you should have. And he responded to that. And he said, you know what, it won't get scored that way, but that's solving patient safety is an important issue. Thanks for pointing it out. I want to do something about it. And he asked PCAST, President's Council of Advisor of Science and Technology, to come up with recommendations. And as they put it, it's actions he can take without help of Congress that he can have one group that works for him like CMS to do something to get the results he was looking for. So we assembled a team, Mike Horvitz, who is Chief Technical Officer of Microsoft, is also a member of PCAST. He and I are co-chairs of the Patient Safety Working Group. We have a couple of colleagues within the PCAST that are with us too. And we have this incredible team of people, you see some of them here, that are part of the working group from patient advocates like Sue, patient safety experts like Peter and Don to Chris Hart, who headed up the National Transportation Safety Board. And there are a few more that are not with us today, but Rachel, who worked for Francis Collins for years and while Francis was the head of the science for President Biden, he also chaired PCAST. And boy, did Rachel really move mountains? What an incredible resource. I wish every person that worked for NIH or any government agency was as good as you, as capable as you. But I got to tell you, when we were struggling to get going and getting the rest of PCAST to agree, two things helped us, the push by President Biden to get it done. But Ruth Ann's work that they did at OIG. And I want to first start off by having Ruth Ann maybe summarize what their survey showed, what they recommended, and then have the rest of the PCAST members talk about what we're doing at PCAST. By the way, I think we're really close to finally giving our report to the President. It's supposed to be done in December. Ah, but I won't go there. But we're getting close. So Ruth Ann, would you please kick us off? Well, thank you so much. Thank you so much for the invitation and for your kind words. And I wanted to extend appreciation also from my boss, Inspector General Christy Grimm, who feels so strongly about the movement and about patient safety. She was actually involved in the first study we ever did 15 years ago on the ground with us, and so you have just an enormous amount of support. And before I start on this, just to give some framing, for those of you who may not be familiar with the Office of Inspector General, so each department in the federal government has an Inspector General, it serves as an internal watchdog to mind the program dollars and ensure program effectiveness. So we have attorneys, accountants, federal agents, and then the shop I work for researchers who look at the effectiveness of these programs and try to make recommendations for improvement. HHS, Health and Human Services includes 13 operating divisions, Centers for Medicare and Medicaid Services, CDC, FDA, NIH, the Indian Health Service and so forth, and a $2.5 trillion budget. So we started our team about 15 years ago looking at patient safety in response to a congressional mandate. Congress asked us to look at how often Medicare beneficiaries were harmed, and we struggled mightily. We ended up sort of throwing the kitchen sink at it. We didn't know how to do this from a methodological perspective to actually nail down because it was hard to have a numerator and a denominator because it felt like we were in a haystack trying to find, we wanted an actual incidence rate, and so we needed to have a population and within that to identify harm. So we invaded a couple of counties, Alameda County in California and Nassau County in New York, if any of you are from there, thank you still, and spent months at all the hospitals in those counties just learning, learning, learning. And this is what we came up with over the course of a couple of years of hard work, a five-step process, and I just go through this briefly to give you an idea of our methods for those of you who are doing similar things, that we do a medical record review or this is the bread and butter of our work. We have 19, 20 studies at this point, but our main gig is to determine incidence rates through medical record review. So we hire abstractors to organize the record. Now with electronic health records, it's possible to look at something if you're not very, very familiar, not only with the system, but the way the hospital's retrofitted the system. Then we have nurses identify triggers in the record that are clues to harm, the global trigger tool method that so many of you are familiar with. We then have expert patient safety physicians of all disciplines do a thorough review of the medical record, including Dr. Stockwell, David Stockwell, who was on the last panel. We were fortunate to get Dr. Stockwell on our, we developed our pediatric methodology. Then the physician panels, after they go through the record, they meet and we have consensus meetings where they decide and determine the harm because we really wanted that numerator to be sharp and completely defensible for all the hundreds of events we've identified. And then fifth, we pay medical coders to reconfigure CMS's grouping pricing software to figure out what would the price of the claim had been if the harm event didn't exist, which is extremely hard with Medicare advantages, you can imagine. So those are our five steps. And so the report that got so much attention, and I think was Joe the first time that we were on your radar with this, was put out in November 2010. And it was the first national instance rate of adverse events. It was among hospitalized Medicare beneficiaries. That's what Congress asked us to do. And we were stunned by the results we found a 27% harm rate among those hospitalized Medicare patients. But what really blew our minds was the wide range of harm. There were, of course, the things that you expected to see the CAUTIs, CLABSI, and so forth, pressure ulcers. But we also had other things, IV overload, lots of excessive bleeding, some very nuanced cascade events that our doctors parsed through. This extrapolated from our sample means that about 250,000 patients were harmed every month. The records were at that point 2008, which extrapolating further means about 3 million harm events in a year from temporary harm all the way to contributing to death. 44% of those harms are physicians determined to be preventable if better care had been provided. And then they also established contributing factors. One thing that's interesting that only about a quarter of our events actually involved a sharp end medical error. So much more of it was systems oriented. And then the last figure on the slide, it may be the most useful. That is, once we identified the harm events, hundreds of them, we went back to the hospitals and asked them if they had identified the events through any means. Instead of reporting systems, infection surveillance, the pharmacy system, risk management, complaints, press gain, whatever. And only for only 14% of events had the hospitals identified the event. And so we drilled down more. We interviewed the nurses and the docs, and we found out a lot of it was, they didn't think, it was, Dr. Stucco's point about nomenclature and not having shared definitions, they didn't identify what happened as harm. It wasn't on a list, in other words. And there were lots of other reasons. We have a report talking all about that. That 86% of the harm events weren't identified by the hospital, we felt was quite significant. So then we decided to go back 10 years later with all the effort toward patient safety. And we took October 2018 records, did the same review, replicated it exactly. And we were demonstrated by what we found, 25% harm rate among those Medicare patients, same wide range of harm events, same number of patients, same preventability rate. And when we calculated cost, even though the cost to Medicare was hundreds of millions of dollars, only 5% of the events that we found were on Medicare's payment incentives list. And so the key incentive to be able to reduce harm didn't hit this wide range of events that we found. We also, if you're interested, have done a lot of other work in other settings, post-acute, first and foremost, a 33% harm rate in nursing homes. This is nationwide, 29% in IRFs, rehab hospitals, and 46% in LTACs, long-term care hospitals. Those are those just enormously long stays. So our two key takeaways, high rates of patient harm persist. And then the range of harm is so much wider. We actually list every single event in the appendix of our report than what is currently we think being captured by PSOs, by CMS, by ARC, and all the various different methods. But ending on that note though, I want to say that I share Joe and Dr. Ramsey and Dr. Berwick's optimism. We made seven recommendations to CMS and ARC. All of them are in some state of play. We are producing a toolkit where we talk about our methods and how we identified events to try to get this at this issue of shared nomenclature. So we feel a lot of progress is underway and we're in a real moment here, despite the fact that at that 10-year mark, we were just, you know, incredibly saddened by our results. So thank you, Joe. Thank you so much for the work. Thank you. For many of us who try to gather these kinds of data, we know too well how difficult it is and what a hard job it is. And then to present it with the wonderful recommendations you made, which were critical, but it was, it should have been critical and you guys should look at the report. It is incredible. You know, I want to maybe start with Rachel. You were there from the beginning when we began. What is your take on what PCAST's role here is and what do you hope we will accomplish with it? Yeah, thank you, Joe. I mean, I think I'm sort of the least knowledgeable of our panel in terms of patient safety. But my boss, Francis Collins, who co-chaired PCAST for the duration of our time at the White House, he himself had had issues at the NIH Clinical Center and he'd become sort of aware and familiar of how important patient safety was. And he really wanted this work group to get off the ground and ask me to kind of help in any way I could to sort of help things move forward. So PCAST, as you've said, their role is to make recommendations to one person and that's the president. And these recommendations have to be actionable. So you heard a little bit of a flavour of them by our president, Berwick, this morning, I think. That may have given you a sense of what might come out in the report that's not yet public. But I think from my perspective, coming in sort of fairly new, I was really shocked by the data. So Ruth Ann's report had just come out when I started in May 2022. I would not have guessed a 25% harm rate, a sort of a citizen of the United States. I would not have... So I think really we have a lot of education to do with the public about how pervasive the risk is and the harm is. I learned a lot. I learned about the importance of governance and leadership at the federal level. I learned about the importance of patient and family engagement and leadership in everything that we do in these recommendations. I learned about aligning incentives from you and reporting and transparency, system change. We're going to be hearing from Chris and Peter how important changing the system is. It's not about individual blame. It's not about individual mistakes. It's really about the learning health system and how we make system change. So in the course of the 12 months that I was involved with all of you, I mean, I learned as a citizen, as a potential patient, as a past and future patient, I learned a lot. And it is frightening the state that we're in. And thank you to all of you for the work that you do to make this better. So thank you for having me. Thank you so much. Thank you. Well, Chris, maybe I think this group always talks about air transportation, how much it improves. That's a real wonderful honor to have you here. Well, thank you. Thanks. Tell us about your perspective from that and what's happening at PCAST today. Well, kudos to Patient Safety Movement for reaching out to another industry. Because a lot of industries say that industry does X. We don't, so why can I? I'm not going to learn anything from them. Same thing with the PCAST for reaching out to another industry. And so to me, what I bring to the table, I'll tell you what I bring to the table from why people are, why it is so safe in aviation and not elsewhere. And so to me, when I see an industry like this that's populated with proud professionals who are highly trained, competent, passionate, their credo is to do no harm, why is all this action that's taken place since the Institute of Medicine put out their report to Aaron Schumann, co-authored by President Berwick. Why is it that all these attempted changes for 20 years have not produced a significant and sustainable outcome? And I can tell you from what I'm seeing, based on my aviation perspective, it's because most of the changes that I'm seeing, people are talking about, changes at an individual level, the level of the individual caregiver, wash your hands, you know, central line input. I mean, all the things that are done at an individual level what I don't see is a systemic look and addressing some of the systemic issues that are inherent to this, because that's what everyday stuff in aviation, but apparently it's largely unheard of in this industry. So I'll just name quickly the five that I have seen, the five systemic areas that haven't been touched at all. And that's what's caused, even though people are trying their best to do the right thing, we're still not seeing significant and sustained improvement. Number one is threat and error management. So not only do you manage the error, you also manage the threat. So the error is the wrong medicine. We saw about that this morning. The threat is containers, medicines that are similarly named, similar containers, similar labels, so that they're easily confused and the wrong one is grabbed. So if you don't do something about the threat, then you're always going to have those errors. And so just going after the error, which unfortunately from what I see, it happens in a punitive way. People who make that error are punished as opposed to addressing the threat. So threat and error management is number one. Number two is the human factors principles that aren't incorporated, that are so much a part of everything that aviation does. And so I hear about electronic health records today about how the doctors complain about them a lot. You know why the doctors complain about them a lot? Because they didn't have the end users who are going to use this equipment involved in the design of the equipment. So by the time the equipment came out, it was not friendly to the end users because there had been no end user input. So to me, that's why the doctors didn't like it. And it's not only the doctors, it's the people who maintain the system. It's the people who are affected by the system. They all need to be part of the system to bring the human factors into play because this is an intensely human endeavor and if the human factors aren't considered, you're doomed to failure. So that's a given in aviation that human factors are big. The next one is the importance of collaboration. So we hear about this collaboration occurs in so many ways. It has to occur in, as I just now said, in the design of equipment and procedures. It has to occur in the care of the patient. I've had so many people tell me, yeah, I had three doctors. I was in the hospital. I had three doctors. And each one of them gave me prescriptions, but they didn't talk to each other. And guess what? The prescriptions didn't work together. So they didn't collaborate in the care. Then you need collaboration and figuring out what went wrong when something goes wrong. And you need collaboration in so many ways that it's just commonplace in aviation because it's a team endeavor. And so you have to have collaboration amongst the members of the team. And if you don't, then you're doomed to failure. So that's another one that I don't see collaboration. Avoiding potential single point failures. That's a huge one. The biggest, the worst accident in aviation history killed almost 600 people was a single point failure, where the captain thought he had a clearance to take off. The rest of the people in the cockpit knew he didn't, but they were afraid to speak up. So he tried to take off and ran into another 747 on the runway. He killed almost 600 people. To me, that concept of potential single point failure is huge in aviation. Not only, I mean, that's one example, but to make sure the wing doesn't fall off. So that's why you have several spars so that if one spar cracks, then there are other spars to carry the load. So single point failures are a no-no in aviation, but I see lots and lots of opportunities for single point failures in healthcare that aren't addressed. Learning from errors and near misses in aviation, as you've heard this several times already today, people share that information about errors and near misses because usually what errors and near misses indicate is not bad people, but bad processes and bad equipment and good people who are trying to make the thing work anyway despite the bad processes and bad equipment. But I don't see that learning from, I see it hiding whenever there's an error and a near miss, it's swept under the rug and every time you do that you lose yet another opportunity to make the system safer by learning about the problems in the system. So those are the five key strategic as opposed to individual safety issues at a much bigger, big picture strategic level that I don't see being addressed in healthcare. And that's the contribution I bring to the P-CAST is bringing that perspective to it because I think there's such a huge opportunity to take advantage of that. And to me that's why we're not seeing progress because we're aiming at the wrong target. The target we're aiming at is individual safety, but we need to look at not only the individual safety, that's always gonna be necessary, but that's not sufficient. We need to look at individual safety and systemic safety and we're not, I don't see the look at systemic safety. So that's what I bring to this. And again, kudos to you and to the P-CAST for reaching out to another industry. They did it in the patient safety movement. You did it also with Najmashgadi, brought his perspective where he's a nuclear power engineer, knows how that works and doesn't work. And so again, kudos to you guys for reaching out not once but twice to look to other industries to see what you can learn. Thank you, Chris. Thank you. And your perspectives are within our report, as you know. So we very much appreciate it. Now, Peter, I think there is, I can count with less than one hand, a number of people that are synonymous with patient safety as you. But you've done something, I think, that we use to model everything else we did at Patient Safety Movement Foundation. You took CLABSI, I think pages of what to do, how to avoid it, turn it into four or five key elements. And you've implemented it. You got it implemented at a state level. And you showed that it could work. Putting evidence-based practice could work. So we're just so appreciative of what you've done showing the way. It's great to have you on P-CAST. What's your perspective on how we're doing on our report? What we're recommending? And anything else you want to share with? Yeah, Joe, thanks. And it's been such an honor to serve on P-CAST. Let me just open up from Ms. Mills' story, or what you were just saying, Chris, about. I have come to believe deeply that the secret for safe care is love. It's this energy that connects and uplifts people. And it's in all of us. And so many of our problems is because we disrespect or discount someone's idea or voice or agency that we don't collaborate because of my ego or I think they're unworthy. And that, I'm delighted to say I think that feeling is embedded in these reports, because it's the only way we're going to make progress. But when I look at, as a student of safety, if you look at, you know, all the high-risk industries, first it's really important to call out what an outlier health care is, both in the absolute magnitude of harm and the absolute failure to make progress. I mean, and that doesn't say we have like, you know, some hospital does something, but as a country, we're really glaring and what every one of those other industries have done are five simple things. They, one, have an unwavering commitment to zero harm. It permeates the whole industry. I mean, as you know far better than I, nobody tolerates airline crashes, but we kind of accept, hey, sometimes little girls are going to die when they get health care. All right, number two is we have clear federal level leadership and accountability and, you know, aviation, for example, transportation secretary, big plane crash, accountability very clear. I don't think there's any safety in any HHS leaders job description. I'm fairly certain of it. It's not even on the strategy of many of the agencies and yet it's an enormous harm. Third is they have clear, transparent and real time measurement of harms and threats to harms, as Chris said, that are analyzed, learned from and designed out of the system. I mean, thank God, Ruth, and you do your reports, but it's equally appalling that we waited a decade to know how big a problem is and we don't have reports at a hospital level despite the magnitude of the problem and that's like an incredible moral failure that how big the problem is, I can't go look up in any hospital and see how much it's going. We could, we just decided not to. The third thing every safe industry does is multi-sector and multi-stakeholder sector-wide learning and improvement, right? We do spinning up local PDSA cycles for things that need system-wide, sector-wide solutions and we've done preciously few. And the last, and I think it's the devil, the elephant in the room for this group, is the operators, the private sector in each of those industries have really good management and learning systems, right? You would never hear of an airline industry saying there's a new checklist and a pilot just says, I don't want to do it and it's okay, right? That, I mean, it's absurd, like we, and we don't have that yet in healthcare. The hopeful piece is, Joe, as you said, when I was thinking about is this possible and reflected on the journey that most of you participated in CLABSI, all five of those things were done. Josie King created a burning platform of zero CLABSI, right? And people thought we were nuts, but it triggered it. When we started CLABSI, there was no clear federal ownership of it and indeed we measured them five different ways and each gave a different inference of how big the problem is and whether it's getting better or worse. So the market was confused, but we got CDC to say you will be the measure and the agencies will collaborate to get this problem solved. We did sector-wide innovations and it's a simple system engineering approach, but when we started this, central line kits had a soap called Betadine, but a soap that was 50% more effective, chlorhexidine, wasn't in the kit. So when I'm a critical cure doc, I'd have to run down the hall to get it. I mean, the stupid design of a system, so it didn't happen and we simply, but we had every, most of the states involved in this. So we called the five manufacturers and said we want you to swap out this soap, put the better one in there, cost a few pennies more and we guarantee you all these hospitals will buy it. We spoke to their purchasing agreements because it's a better solution and at least for this, we had good management. When we developed for this toolkit, CEOs declare a goal of zero harm to review infections to create shared accountability where they support people if it's not. And so I think if we, which we are keeping those five things top of mind, but then importantly, the private sector has to say we need to tighten up our learning and accountability systems because we've talked about them, but they're not, they haven't been that advanced and the session this afternoon will be to share a prototype of a model that I think is hitting some good results that could be matured. So thank you. Thank you, Peter. Thanks for, I think your presence on the working group has been phenomenal in helping us not be afraid to take bold steps. So thank you. Thank you so much. Sue, last but not least, the voice of the patients, someone who unfortunately suffered a lot due to the errors that happened too often. You being on our PCAST working group have been the North Star to make sure we don't forget what we are here to do. Please tell us about your interactions, what's important to you and how you see this going. Well, first of all, thank you for the opportunity to be on PCAST and on this panel. You know, I kind of see PCAST, you know, I've been a participant, but I've also been observing for the past year. And I kind of see the PCAST being it may be part of my role was this, but I see humanity meeting up with science. And I think that's what has been this really dynamic of our conversations. And when I would see you guys getting off track, you know, it's like, whoa, whoa, whoa, this is about patients and families who have experienced harm. So I think it's been a really, you know, lovely dynamic throughout the year. And something that I want to reinforce that Ruth Ann said and Mike said and you've said about optimism and excited about patient safety right now, despite the fact that my family experienced really significant harms. You know, there's a saying that says always believe that something wonderful is just about to happen. So that's how I wake up and that's how I think about this. Let's just think that something wonderful is just about to happen because I feel like we have the opportunity. So what brought me into PCAST not just being so shared and with family members who have harmed, but I'm also part of a group, Patients for Patient Safety US. It is a chapter under the WHO and our mission is to implement the Global Patient Safety Action Plan that you'll hear about later. It's very strong in patient family engagement and so patients for patient safety US formed two years ago, two years ago tomorrow. And up in the mountains in Idaho, you know, thinking, gathering, dancing, drinking, cooking, envisioning a safer healthcare system. And while we are all together and over the years we've identified I'm following your thread of five. So, you know, we as patients all of us who experienced significant harm in healthcare, we identified what we call our five threats. And as we sat around thinking about our experience and we're very seasoned patient activists. We've changed our title from advocate to activist because advocates talk about things and we act on things. And so that's our new title. And so as we we really looked at the five threats that we thought were in our opinion the most important areas in patient safety. The first threat that we've observed is there is no one in charge of patient safety. You know, we all experienced harm. We all want to be part of change. We wanted to tell somebody, we want somebody to take action. We wanted one place that was committed to reducing harm and in the United States no one is in charge. At the federal level or at the organizational level it's not at the C-suite, it's not at the board, so that's threat number one. No one is in charge. Threat number two, there is an assumption in the healthcare system that the healthcare system can fix itself without those of us who have experienced the most harm. And I think this is I think we have enough evidence over the past 30 years that the healthcare system hasn't fixed itself. And so this is the call to engage those of us who experience harm. We have that wisdom. We have that knowledge. We are the constant in patient safety and we're not collecting that. And because the fact that we're not including patients, families, communities especially marginalized communities we have ended up with inequities in safety. Imagine what it would be like if we had disability groups, racial ethnic groups, and other groups marginalized groups sitting around the table helping design the healthcare system to benefit them. I mean that would be remarkable. The third threat is truth telling is optional in healthcare in the United States. We've all experienced, especially when harm occurs there is no requirement that patients and families are told that they've been harmed by the healthcare system. There are requirements that that information has to be reported to state and federal authorities. That doesn't happen. And so we see this truth telling has like persisted the lack of truth telling has persisted throughout the years that is indefensible. We need to change that. The fourth threat is we don't have the right data to even know the magnitude of harm. And we don't have the right data to really fix patient safety. And so we recognize that a lot of our data after harm disappeared. It went behind protected walls in either confidentiality clauses. We know that today it gets behind protected walls and PSOs. And frankly a lot of our data simply never gets collected. It lands nowhere. So we need to improve the data. And the last threat that we see is the lack of implementation and the failure to adhere to evidence based practices. So many of us and our family members have been harmed where there is an evidence based practice sitting on the shelf. And so those are the threats that we've identified. Now I want to share well, I was going to share some expectations, but instead I want to throw my hat in the ring to be president. A little healthy competition. But if I were to be president Sheridan and if I were announcing the results or the report. You started something here, Dr. Burwick. Yeah, exactly. No, I would say my fellow citizens, mothers, the dads, the sons, the daughters. I'm sorry our health care system has harmed you, but I am here to assure you that someone is going to be in charge of patient safety. In my government, in my agencies in every hospital that gets reimbursed by CMS. I would assure them that there will be medical collaboration with patients and families and communities and marginalized communities to sit with my agencies and redesign our health care system to better serve you. I would also say I promise you that going forward when there's harm to you or your family members, you will be told without zero tolerance to covering up. You will be told you will receive long-term emotional support. You will be assured that the hospital report this to accreditors, to our authorities and that you will never have to be silenced and sign a confidentiality clause for learning purposes. I would assure the patients and families and other communities that there will be regulatory reporting that we're going to use better, more advanced trigger tools and that my government wants to learn from patients and families and their experience. We talk about administrative data. We talk about data that gets reported to incident reporting systems. Why aren't we learning from the patient community? Think about all of that information that we're not capturing through surveys and reporting systems. I am committed to learn from patients on how to improve our patient safety. I promise to patients and family members that they will have access to all of their data and without filtering and without delay and that I will ensure that the Cures Act in the United States is enforced. And I will ensure that standardization of evidence-based practices with incentives and if it's willfully negligence, there will be penalties. Now, my background I'm no longer President Sheridan, now I'm Sue Sheridan but my background before my son's harm and my husband's death was international trade finance banking and so I worked in an industry that was highly regulated and I expected that in the healthcare system. I learned that that's not the case and so I think we need to really consider our oversight agencies to give them the power in the tools to look at what other federal agencies are doing with incentives and penalties. So, thank you. Thank you so much Sue. I see we have competing President's speeches now. I just want to know who's the Democrat in the Republican. Well, fortunately our president is bipartisan so we'll you know, we've never been in a better place. We have a president who is really nation's patient advocate. We've seen what is done with cancer, we've seen how much interest is shown in the patient's safety. Our goal was to be done with this report in December then April, May, so I'm almost embarrassed to say but our new goal is to be done by President Biden and we will hopefully give this report to President Biden and hopefully he will give one of your speeches and more importantly get it done. We're going to meet someone today from England that for the first time UK now has a patient's safety ZAR Commissioner, I don't know what to call it Commissioner, I think it's the right word. So it can happen and they're a bit ahead of us, thank God we look after and we'll get there and I want to end with this, unfortunately we're out of time, we're going to go to lunch now but what Peter said about love and what Yannicka said about love you know I think you were in the lobby of hospitals like I was because my sister was in the hospital a lot and I don't know you and I were born the same day, I think we all shared a lot of commonality that we care for other people and love is what is bringing us together and love is what is going to help us get through this it is discouraging to see your survey results but like you said it's just around the corner, we feel it Presidents, hopefully President Biden will help I want to thank you all, the hard work you've done on this report that hopefully is actionable I hope will make a huge difference because you both said it leaving it up to hospital hasn't been enough, it hasn't worked we need to do what the Air National Air National Transportation Safety Board has done for healthcare we're all tired of speaking to the choir we got to get this everywhere so thank you very much, I'm sorry we don't have time for more questions but thank you thank you for your work