 Joe, thank you for your visionary leadership. You're a CEO of a publicly traded, amazingly successful company. You're founded this spectacular movement, but mostly, Joe, of what I admire is your humanism. You see, words matter. They matter deeply because they create how we feel. Those feelings generate the stories that we tell and those stories drive how we behave in the world. And Joe, I think you must be the only CEO that uses the word love, and it's real. I know it, brother, and you mean it, but these words are so, so powerful. Words, like Jamie said, where he was told, it's not your fault. Words like, I'm sorry. Sometimes silence as the most potent word that we have. The word patient safety gets a lot of attention. The word movement hasn't been dissected much, and there's a science behind creating a movement, and no doubt this is a social movement. The author, Charles Duhigg, has these three-item checklist for social movements. Clear behaviors, you can think of as a checklist. A small group with really tight social connections and then looser connections with many, many other teams. Example how social movement spread. Rosa Parks, one of the leaders of the civil rights movement, wasn't the first to refuse to give a receipt on a bus. Indeed, there were hundreds for years before her. But she had been trained by a charismatic reverend, Martin Luther King, in a simple behavior, a checklist of nonviolent protest. And when Rosa gave a receipt, she was a social gadfly in about 40 different social groups, and everyone loved her, and she connected them. And each of those social groups had really clear activities. They were tight. And so when Rosa was arrested, it ignited a revolution, because each of those did their own work to organize the protest. In this case, the boycotts, and they spread all throughout Alabama and the country. Joe, what you've created here is a social movement. Our 17 apps are those behaviors. These 35 chapters are those nodes in those 17 countries, but the magic is those small little micro-learnings that are created in the hospitals where the work gets done. And many of you have asked, why isn't this spreading? Why aren't people doing it? And I'm gonna go back to what's been a theme here, the stories. You see, we have all used stories externally, saying how do they get attention? How do they motivate change? What we haven't dissected is turning internal, and look at the stories that we tell ourselves. Stories about whether we're powerful or powerless. Stories about whether others are competitors or collaborators. You see, stories define what we do. You change the story and you change everything. Stories like JFK, I Want a Man on the Moon. So we're gonna dissect the stories that are hindering people from joining this social movement, because we know the mechanics. Those three things are immutable, but the reason it's not spreading is internal and deeper and something very human. But I'd like you to either write or reflect on the words I will, because I know Joe is a outcomes-driven CEO. This conference isn't about hearing stories. It's about action. It's about saving lives. So at the end, I hope, and through the days, we'll have time to question what's your I will statement that's going to come out of this. Now, I'd like to explore these mindsets of what are holding us back. And if I were to say, what's the greatest safety movement or the opportunity in the world, it's changing the narrative from success is healing in hospital to being healthy at home. Because we know 40% of hospital admissions should never happen in the first place. At least we could reduce that. There's good science on that. So yes, we need to manage what's going on in the hospital, but we need to explore what narratives are holding this movement back from spreading. And my friends, I'll put forth, there's three narratives that are holding us back. And I'd like to share my own journey on trying to understand and reframe those narratives. The first narrative, and it's the most fundamental, is we still accept harm as inevitable rather than preventable. We say we don't, but we've been hearing the same darn stories for 20 years. And we know hospitals can go years without infections. If we really believed it was preventable, we want to accept these stories. My own journey on this began in 2001 on a snowy night in a dark corner of our pediatric ICU where Josie King was taken off of life support and died in her mother's arms. She was burned and ready to go home though, was healing, but a catheter infection and then unrecognized sepsis sacrificed her. Her mother came to me because she was worried that this was going to happen to her other daughters and said, could you tell me this won't happen again? I wanted to give her the executive spiel of all the great stuff we're doing, but I couldn't. I looked at her and said, I can't. Our rates of infection are sky high. We don't have any science-based programs, but I will give you an answer. You see, at the time, myself and every other clinician still in this training just accepted that sometimes when you care for sick people, little girls will die. And she did. We accepted it as the cost of care. We accepted harm as inevitable. So we did some things at the time that were heretical. We declared a goal of zero infections like this. My colleagues thought I was off my rocker and perhaps I was. We made a checklist of best practices. We encouraged doctors and nurses to work together to make sure that checklist was used. We investigated every infection as a defect to change that culture and that narrative and we had accountability for those infection rates. The rates not just plummeted, but now just a year ago, we published that this program and a lot of other work was spread state by state across the country and now these catheter infections are down 85% from when to urge human to now, like a remarkable success story. And to put this into context, when this work started, central line infections, one small item of your 17 checklist killed more people than breast or prostate cancer and we just accepted it. So we have the ability to cure public health problems of that scale. And so we got curious and said, why did this social movement take off when so many others floundered? And it took off, I wanna explore on three levels. On the national level, it took off because of three simple things. Number one, we had a valid rate of measuring infections that was epidemiological sound. I'll put forth to you that infections and they're not perfect are the only harm that we have a valid measure for, sadly 20 years after we've been doing this. I don't think we have a valid measures of any other harms. Doesn't mean we don't stop the work or we're not counting, but shame on us and shame on policymakers. Two, it was publicly reported and that itself didn't do it, but the great journalism work who called out stories of hospitals whose rates are 10 times the national average to hold them to account for what they did drove most of the behavior. And three, we had science to guide us. We had evidence from which we could make a checklist. We then went into 200 hospitals. We published it recently to say, what separated zero hospitals from non-zero hospitals? Cause it wasn't just the checklist. Zero hospitals, my friends all did four simple things. Their leaders declared a goal of zero infections. If I walked into that hospital and asked the CEO what's your goal and they said, uh, you know, my ICU dot got that, guaranteed they weren't zero. Second thing they did is they created an enabling infrastructure. What that means is they provided project management, they provided training, they provided data and feedback and they provided checklist, tools to make it easy for clinicians. Three, they engaged frontline clinicians and connected them in peer learning communities. And fourth, they transparently reported results and had clear, clear accountability. If you had an infections, someone asked why. But we went deeper. We partnered with some of our anthropologists and they said something deeper happened at the individual level and we wanna find out why. So we interviewed hundreds of clinicians and what we found when we were speaking them was profound. You could see in their eyes what they believed in their hearts. They started telling a new story. When we started, they all said, these infections are inevitable and I'm just a and fill in the blank. I'm a nurse, I'm an attending, I'm a resident, I'm a tech and I'm powerless. And they got to zero when they told a new narrative. So we got curious and said, okay, well, if we could find what leads to that narrative, we have the most powerful force for change in the world. And as we looked, we realized there's quite a robust social science literature that tells us how to create new narratives. It's called believing and belonging. I have a TEDx talk, if anyone's interested in this specific thing, two pieces. The believing piece is the leaders of that organization committed to zero and believe that their people can do it so they believed in it themselves. And if you want an example of the power of belief, I'm a runner, so I like this, take the story of Roger Bannister breaking the four minute mile. For 2,000 years since the first Olympiad, leading scientists said, it is impossible to break the four minute mile. You will die trying. Well, Bannister as a medical student to go tribe broke it in 1954 and he didn't die and you may know that story. But what's often not known is the next year, this 2,000 year record, 12 more people broke it. The year after, 156 people broke it. And now high school kids are breaking it and the last New York marathon, a guy ran a four minute mile for the whole 26 marathon, unbelievable. And what changed? Not evolution, not blood doping, not new sneakers. The stories they tell. Bannister freed all of us to break that four minute impossibility and Joe, that's the legacy of this movement. The second piece that they did was they belonged to peer learning groups. It wasn't economic incentives, it was belonging to a learning community. I'll give you an example of learning communities. How many of you have seen Mary Poppins? The movie or the plays? You all probably know a very prominent feature in the play is these birds chirping when she's dropping down from the sky, when she's skipping, when she's spanting. And that's because that's what London was like in the late 1940s. Because London was filled of two types of melodious songbirds, the red robins and the blue boobies. And they thrived because they pecked through the tops of the milk containers that were left on people's stoops. They sucked the fat out and they were plump, very well nourished birds. But then the milk companies changed the containers from cardboard and steeple to aluminum and flat. And it required a few of both birds or required the birds to learn a new technique. They had to learn to tuck their beak in. And those both birds are equally smart and a few of both birds learned the new technique. But the red robins are extinct now in downtown London and the boobies thrive. And the difference is the robins were solid birds. They had their stoop or their corner. We call it our department, our specialty, our hospital, our country. And that wisdom never was shared. The blue boobies are flocking birds. They fly into V, they fly strong and proud together. And that wisdom quickly disseminated through those organizations. And we need to be much more like those blue boobies if we're gonna solve this problem. The second narrative I like to share with you is that we say healthcare is a system, but it is the furthest, furthest thing from a system. Russell Aikhoff, the great system theorist, said as a system is a set of parts interacting to achieve the goals. We have all the parts. Matter of fact, the parts are all in this room. They're not aligned around a goal and they certainly don't interact the way they need to. But there's lessons we could learn in many of your students of high reliability organizing. What these organizations that truly work as a system, they organize around the needs of those they serve. In our case, our patients. We don't really do that. I'll give an example. I was working with a clinic that treats sickle cell patients because I was looking at what we're causing hospital readmissions. Remember, we don't get them in the first place. And by far the number one cause, five times more than anything else was patients with sickle cell. When I dug into it, I found, well, the clinic had patients, but if someone was on narcotics, they kicked them out of the clinic because it didn't fit their efficiency of their clinic. Well, if any of you have know about sickle cell, there's a lot of pain. There are most are many are on narcotics and you couldn't think of a more destructive way to manage than to kick people out of your clinic. But they weren't working as a system. They weren't organizing around patients needs. Second characteristic of these systems is everybody's job is to improve value. Everybody's, not just the doctors, not just the nurse, everybody's. I learned this when I visited an aircraft carrier to study this. And I was standing talking to the admiral and there was a gentleman sweeping the deck next to me. And as you made know, on the power hierarchy, that gentleman is way below the admiral, way, way below. Maybe as a high school education, but on the safety hierarchy, they're equal because if there's a debris on that deck or a hammer plane comes down, they all blow up. It's no difference than the power hierarchy between the environmental service worker who cleans the hospital and the CEO. Low education, big power gradient, but safety equal because we get C. diff or MRSA if we don't clean it. Well, I asked that gentleman what job he does. And I was blown away. He stood up tall and proud, look me in the eye and said, sir, I help planes take off and land safely to serve the mission of the United States. Said, whoa, it's a guy connected to his purpose. I left there and walked into a hospital and asked an EVS worker, what job do you do? And what answer did I get? Not standing up tall and proud, sheeplessly looking away, almost shameful, saying I clean the rooms. They didn't say, no, you're not an EVS worker, you're an infection preventionist, right? Or an infection prevention specialist. I asked the person in a call center, what job do you do? I answer the phones. Said, no, no, you're a healer. You connect people to needed care that prevents cancers and prevents harm. And we haven't managed healthcare as a system. Third thing these organizations do is they hardwire the upstream and downstream connections so that makes sure the system, those parts actually do interconnect. We have a huge problem with readmissions. Nationally, it's about 6% of patients leave the hospital with an appointment scheduled. Like, what do you think is gonna happen, right? Or we send people who come to the emergency room and we send them out without any appointment for followup, just hopefully they're gonna get there because our mindset isn't, is a system, I'm just a part. And finally, they create management systems for accountability. I look at this brilliant work of 17 checklist and apps. But what I haven't seen yet is a management system where we're not playing whack-a-mole at every one, but there's a board level of zero harm, there's work teams in every one of these and others, there's transparent reporting and accountability, and it's all integrated in a disciplined management system towards zero harm. Third, narrative. And it's a new one for this group and some may say, what the heck are you talking about this? Is that improving value is everybody's responsibility. And by value, just so we're clear, it's quality plus patient experience over the annual total cost of care. Why value and why is this important for our journey? Well, right now, though health care does miracles every day and there's no doubt that we do, the vast majority of the time. Medical error we say is the third leading cause of death. The reality is we don't know how many people died needlessly shame on us, because we don't have good measurement systems. The estimates in the US vary 20 fold. But that said, it's enormous. And if you add misdiagnosis, if you add failure to give evidence-based therapy, if you give failure to control blood pressure or treat diabetes, it is by far the leading cause of death. Medicine today has one third of patients leaving their health care interactions saying I wasn't respected. I wasn't listened to. I don't know what to do when I leave. Or cancer patients waiting weeks to get a report back. And my friends, when you have cancer or you're worried about your health, time is suffering. That's harm. A third of every dollar we spend in the US, a trillion dollars collectively goes for therapies that don't get patients well or is wasted on these things. At an individual level, that's $10,000 per household. That's equal to the median net worth of the people in urban LA or Cleveland or Baltimore. So not getting this right isn't just health care. It's the future of the American dream. Because if you look at states like Massachusetts that expanded access, and I believe we need to expand access, their health care budget went up, but it came at the expense of every other social good. Parks and recreation, STEM, preschool, education, care for the elderly. So we have to balance and get this waste out of the system. And right now, every payer of health care, the federal government, state government, employers, and us as individuals, our health care expenses are going up more than our revenue. And hospitals' expenses now are at 7%, their revenues are 4% going up, and their margins are the lowest they've ever been. 1.5% and 25% of them have negative margins. And guess what budgets are getting cut from this? All the things that drive safety. Nurse staffing ratios, your infection prevention staff, your safety staff. So we have to start thinking about how do we start telling a new narrative that value is my responsibility. That these keeping people healthy at home is part of what we all need to begin to do. Well, as you know, I'm a bit of a checklist fanatic and so I made a checklist for optimizing value. And when I started doing this, what I was astounded of is that when you add the waste of every defect on this checklist and the harm to patients, it is mind-blowing. It is far larger than we ever dreamed of, but what we've played is whack-a-mole trying to tackle each one of these individual things. So let's look at this value checklist and say, there's defects and harm and we fail to help people stay well. Right now, most large employers, 15% of their employees get an annual wellness exam. We know that leads to less harm, better outcomes. Maybe half or fewer get their cancer screenings that they're supposed to or get the immunizations they're supposed to. And well, up to 70 to 80% of us don't have healthy habits. We don't eat well, we don't exercise enough, we don't reduce stress, we don't connect with our colleagues. How well do we help people get well? For every disease, every chronic disease, there's defects at every pathway. Let's take diabetes, for example. 40% of diabetics are undiagnosed. About half get the right therapy. A third have their blood pressure, their LDL, and their A1C controlled. And they have outrageous degrees of healthcare utilization. Indeed, about 40% of their admissions wouldn't need to be there if we manage these things. But whose job is it? Not mine. And then finally, how well are we managing an acute condition? The defects are, is care coordinated with primary care? Because that's good care that keeps people out of the hospital. The reality is, to date, we don't connect those wires. Is what we're recommending appropriate? And almost every procedure that's been looked at, 30% of them aren't needed. 30%. And if you go to Cancer Centers of Excellence, you see the same thing, 25 to 30% of the cancer diagnosis is change or the treatment change. Is the site of service optimal? About 40% of what we do in a high expense healthcare setting like a hospital could be done in an alternative setting, but we don't do that. And increasingly, in the home, we can now give close to ICU level care in the home. It's much more patient centered, it's safer, it's much lower expense, but we're not driving that. And within that site of service, are we directing care to a high value provider? Because the reality is, amongst our provider tribe, there's four to eight fold variation, depending on which cardiologist you go to, which hospital you go to for care, but all that stuff is largely invisible. In my new role at UH, I have responsibility for the ACO and for value in the delivery system, and importantly for the employee health plan. And we're trying to change that new narrative across a whole large system. And clinicians are resonating it because they get this concept of defects and checklist. And for my providers at hospitals or the health systems, I would encourage you to use your employee plan as the learning lab for optimizing value. We talked about unaligned financial incentives. Health systems with a self-insured employee plan are the only natural experiment where every incentive's aligned. You're at full risk for the cost of those people. In this case, they're only in network care as within this health system. We control the wellness and the ACO plans, and we control the incentives we give to the physicians to give good care. So why aren't we using those to see if we could really eliminate the defects that we have in our health systems? So I'm asking us to broaden our narrative, not that our journey's anywhere near done, but to start thinking more broadly in this concept of value and could we commit to eliminate these defects in value? Because the economics of hospital financing are not looking so pretty. And I feared we're gonna see safety budgets cut unless we're really driving the value that's gonna fund some of these needed infrastructures to keep us moving forward. Now, this big change that we're talking about is scary. And we talked about the narratives that we tell, not externally, not the stories to get intention, but us owning it. What stories are we telling ourselves? And after spending 25 or nearly 30 years studying safety and quality, I've learned that the secret of quality is that word that this meeting was opened up with. And that's love. But by love, I don't mean a 50-year marriage. Oh, for sure, there is love and loving moments in that marriage. By love, I mean what the psychologist Barbara Freerickson talks about in her book, Love 2.0. It's a fascinating book where she studies the biology of love and looks at what makes oxytocin spike, because oxytocin is the cuddle hormone that goes up when you hug or when you nurse. And what she found is that love is micro moments of connection between two or more people, micro moments. I feel warm towards you, you feel warm towards me, and we create energy. So love is listening to a colleague who just made an error. Love is putting a hand on a worried patient. Love is respectfully smiling in that homeless person asking you for money. Love is saying to that EVS worker, thank you for preventing infections. You see, my friends, this big journey that we're embarking on, and it is a big journey, is made up of thousands of small steps. And every one of those is only made possible and facilitated by micro moments. And we could choose to go make micro moments right now. So I challenge you to say, what is your I will statement? Because we've been telling the same stories of harm for far too long, and I'm tired of hearing more clumsy stories, right? And we hear them over and over again, they should be zero. And the question isn't to judge our colleagues, it's to understand why haven't they told that new narrative and how do we begin to create those new narratives by believing they can get to zero and creating communities like this where they belong to groups that they learn from each other. You see that question that Sorrell King asked me and haunts me every day, is Josie less likely to die? I think she and every other patient in this room is asking each of us and we deserve to give them an answer. So thank you.