 You know that voice of God that always challenges me but I know with all the anesthesiologists in the audience they just think it's another surgeon talking to them. I'm a recovering surgeon as probably many of you know. I can say that because as you know when you ask a surgeon to name the best three surgeons in the world they always have trouble naming the other two. So I'm thrilled to be here with my friend and colleague Joe Chiani more to say about that in just a moment. You know an idea eight years ago by a restless engineer spawned a global movement today consisting of 4,000 plus hospitals close to 5,000 hospitals in 46 countries saving over 90,000 people. An exemplary example of what we call health diplomacy uniting different countries, races, religions, ethnicities and languages worldwide to act on a single value proposition, patient safety. So Joe when you're done with this we could use you in government maybe at the UN. You know a surgeon general of the United States you have the privilege to serve the people you're the top doc. The position has changed significantly over the last decade or two but when I was there spent a lot of time around the world speaking with allies speaking with adversaries going to the World Health Organization, Pan American Health Organization, trying to align our incentives and our safety and security of our nation with that of others. And what you learn is you never show up at your meeting and start your presentation with I'm from the federal government I'm here to help you. As US surgeon general the job description was to protect, promote and advance the health safety and security of the United States. A deceivingly simple value proposition on paper and extraordinarily difficult value proposition to execute on in a complex hyperpartisan environment. But that job would be impossible to do without guys like Joe Chiani who are passionate, selfless and committed. Although he always gives all of you the credit we all know it takes leadership and Joe knows better than anybody that the synchronon of a leader is that you know you're responsible for the destiny of others. Joe was our azimuth he keeps us on course and inspires us. So Joe I want to be one of the many who cheer Caesar on thank you so much for all you do. In this session we will address pushing transparency and aligning incentives through policy makers. Sounds pretty simple. Transparency itself is a big challenge. We can't move forward with aligning incentives and working with policy makers unless we've clearly defined this. What does transparency look like? Right now to me it looks kind of opaque to tell you the truth. There's a lot we need to do to move forward on this. The elements necessary to achieve transparency are leadership from the top understanding that as a leader you are responsible for the destiny of others whether you're in a small clinic or whether you're the Surgeon General of the United States or a hospital CEO. Leadership is predicated on integrity. Full definition of integrity doing the right thing when no one else is watching. Without integrity without leadership we can never hope to have full transparency. Stories like you've just seen are heartbreaking but often they can humanize the statistics that we talk about here every day because then it becomes personal. That could be our child. So a Surgeon General I learned early on to find those people who had a story who could pull at your heartstrings. That you don't think of the statistics anymore you see the human side of this challenge. But it takes a brave selfless family to come forward and challenge a system the whole health system like Scott Morish did in telling his son Sam's story and driving necessary change in the British national health system which went viral. Which informs other health systems that it can be done with leaders like Scott and policy makers like Dr. Alden Fowler of the national health system in Britain and Larry Smith of MedStar and I've just been told that we're fortunate to have a congressman join us. I think he's on his way I'm not sure he's here yet but a brand new congressman from this district Harley Ruda without these disciplines there's nothing we can do to move this forward. It's a team approach and Joe always talks about that. That's why you have a multidisciplinary audience at every step along the way of that patient supply chain each and every one of us has responsibility for patient safety. So today we'll have that discussion with the panelists first and foremost Scott where are you Scott? We owe Scott a great deal of gratitude because he exposed the most painful part of his life and his wife to make the world a better place. Scott thank you very much. And now I'd like you to welcome our panelists up here Larry Scott, Alden come on up let's get started with our discussion is the congressman here yet oh ladies and gentlemen congressman Harley Ruda brand new congressman from the 48th district. Thank you congressman so good to have you with us. Sit down in my living room let's solve this problem. So congressman thank you for taking the time first of all I know that as a brand new congressman having many of them over the years as surgeon general you're still looking for the cafeteria and the bathrooms over there in the house so but I really appreciate your commitment to patient safety and helping us get through this because ultimately it's the policy makers who are going to help drive this when you get all the good information from us. Scott I want to start with you. I mean this was an extraordinary thing that you and your wife and your other children did to expose the pain that caused this and yet you see how much good it's brought as setting an example because you took on the health system. You made them listen and because of that the NHS started to change. Tell us a little about you know that commitment and how you decided to go forward. Well I guess I'll start by saying it didn't start out as an act of courage it was an act of self-preservation and it was driven by feeling wholly unsafe after what we had seen happen and the feeling that there was no basis for trust that our children would be safe for the future. So it wasn't anything noble it was really basic survival instinct needing to know what had happened why it happened whether it could have been prevented. I didn't assume it could be but I wanted to know if it could have been and and then with time when I realized that actually the system was responding in a way that was wholly unexpected by me and increasingly unsafe just desperate to change it and it just became a journey so it was just a lot of little steps along the way. How receptive was the system in the beginning when you challenged well there is only any learning because of a complaint. I didn't complain for 15 months I only complained in the end because I was advised to in the sense that there was no other route to progress. So any learning that came from it was only driven by an adversarial process and you know in in my view that was unjust not just for me but also for the staff on the other end of that complaint and it prolonged the trauma for all of us for a very long time and it was a barrier to learning and improvement. Well one of the things I take away from your story you always hear people say one person can make a difference. You did and your family so thank you. Larry I want to ask you you know being a leader in a large health organization like MedStar where you're an attorney and responsible for for risk management you're dealing with safety issues all the time tell me what's what how you're dealing with that especially the transparency part where it's so difficult to get people to be honest in this adversarial environment. Well I'm blessed to be an organization that from the top you mentioned in your comments that to do this work it takes leadership and when we talk about leadership in health care really talking about making sure that every organization we start with the board and get them really to buy into what we're trying to accomplish and then the administrative staff also supporting this is not a ground-up effort it's got to be a top-down initiative that really focuses on changing culture within the organization it's not just making a modest change it's changing the culture of the organization and so a couple things one is I'd say that as I started to say I'm blessed to have an organization that I joined knowing that they had that intention weren't there yet but when I interviewed for the job I asked the question are you ready to start doing some of this work that's going to change the way in which we we look at litigation you know around the entire country and for years and years our response to these events that result in harm have been driven by fear fear of litigation Scott mentions in his his video the other drivers that push people in the other direction that they keep them from wanting to do transparency remember that the folks we're talking about are like you and I I mean they're just they're individuals who come to work wanting to do a good job wanting to do the right thing and so the way we've done it at MedStar is taking that that direction from the top and then started one case at a time trying to see if we couldn't deal with those cases differently and and I and I and all of you I think at this point know about candle but I want to talk about a little bit more than just the process what it takes really is keeping in mind what Scott said which is the first thing we should think about is the patient second thing we should think about is the patient and the family and then we should talk about what can we provide by way of support so let me just mention if I can briefly the only way that this program will work is if in the first instance as we start the conversation with the family of patient our emphasis our thoughts are not about what's going to happen with litigation not what's going to happen if we get caught it's going to be what can we do to help this family and by the way help our staff deal with this and when we do that let me for those who might try this you can't do it based on an assessment an assessment that malpractice has occurred you can only do it on the basis that a harm unexpected has happened to this family or this patient and then you start the same process whether it's going to be whether it turns out to be a deviation from the standard of care or whether it's the best care on the world the harm is what we're focused on and the support for that harm is what we're focused on people have asked me if we later on find out that we didn't do anything wrong what do we do well what we do is say we really want to help you now in the transition from where we've been providing support to finding other support so we've heard some key terms trust transparency to be able to move something like this forward now I'll then from also a surgeon who was a clinician and has plenty of experience with boots on the ground taking care of patients and a leader in the national health system in Britain tell us the impact that scott's testimony has had for the national health system and improving well testament is like that I've had a huge impact it there's been this big sea change and I think there have been a number of things there are cases like scott's there are cases as we were talking about yesterday of the hospital crisis in in mid Staffordshire and so on that have really changed the way we think about these issues and it's just very striking listening to scott talking about how 15 months after he's having to pursue the route of complaint solicitation to get answers compared with the story we heard about yesterday of Jack Gentry where the surgeon went straight to him told him what had gone on and there was an attempt to redress immediately and all that learning can be harvested at that time whereas what we see in the case of Sam was that we had to wait so long to get that learning and what had happened in the meantime so things have changed we have a duty of Canada where we are and I think the duty of Canada is less about telling people they have to be open because I think people naturally want to be it's permitting people to and society isn't necessary to be open so if we have a motor vehicle accident we are told not to admit liability so it's it's in people's nature to be protective but we have to understand what stops them being transparent what holds them back from it so we have a new secretary of state for health who's been in the job only six months he's not from a healthcare background and I met him recently he said I do not understand he's worked out already I do not understand you're in a high-risk industry where mistakes are made why you so embarrassed to talk about them because this is your normality so what are the barriers and how do we approach them we've really got to understand what the barriers are because it's not a simple thing it's multiple things it's not just litigation in the case of England it's not just the coronial system that does scare people it's this adversarial nature of it and the fear of and you and I both know that it's not easy to go to someone and say look we made the wrong call here we made a mistake and it's not usually just one thing and so what we're actually talking about is a series of potential opportunities that have been made by multiple people and we've got a corporate responsibility for talking through all of those because generally what we find when things go badly wrong is there's five or six steps where it could have been avoided right so you know some of us are old enough remember the house of god the book and movie back in the seventies yeah which that wasn't about patient safety but embedded in all of these adverse events was patient safety issues there and then we have to ur as human back in ninety nine with the then the Institute of Medicine calling it out and and when you look at that title to ur as human implies that people will make mistakes it's not perfect and so I think that as you already pointed out Larry that it's important for us to start to be able to look at the difference between neglect malfeasance and an honest error and and so I will ask the Harley from as an attorney I mean we live in this adversarial society can we get to a point where it's not good guy bad guy but we can actually look at this and make some good informed decisions that don't prevent transparency from happening because people are scared to talk well full disclosure as you're a recovering surgeon I am a recovering wagon for about 20 years and being a member of congress is much like being an attorney you're a jack of all trades master of none so I'm probably the least qualified person to be on this panel but the reality is yes we've got to address it you know we have approximately 200,000 deaths in U.S. hospitals annually and and Scott's situation is is is one story of many that happens every day in our country and and across the globe and the costs associated with that from litigation and and settlements certainly adds to the fact that we spend 18 and a half percent of our GDP on health care so we've got to get addressed and by the way that's just the death that doesn't include all the other mistakes that take place that also add a price tag to our medical care here and and spending 18 and a half percent of our GDP on health care that's twice what the European Union nation spend so we know that we have an opportunity to get cost out of the system and this is a really important one so we need transparency we also need common data that is shared across the platform so that people can fully understand how to address this problem in a more concerted effort to bring these costs down and more importantly avoid avoidable deaths right well thanks for those comments and they're very insightful especially that we're spending over three trillion dollars a year on what we call health care and actually it's sick care it's not health care that we spend the money on and it's pushing 19 percent estimated to be even more and so buried in there all of the preventable deaths and as you pointed out as well I think it's important we're here to prevent patient death obviously but the morbidity is astronomical as well the complications the harm that's done for a person who lives but they may not live as well as they used to live because of those mistakes how do we get to that point where people feel free to be able to express now we spoke about to say you guys have created that culture within MedStar that you know people are willing to say look I made an error here okay so talk to us how you built that culture that people feel free and and and transparency can thrive rather than opaqueness where people are scared well it's a great question I want a full disclosure MedStar is on I think yesterday somebody said we don't like the term journey we want to get action MedStar is on a journey this is not an overnight phenomenon we have not achieved 100 cultural change within MedStar got I've got we've got 2,500 physicians who work for MedStar we've got another couple of thousand that provide services in private practice we haven't reached all them they're not they're not there yet many of them are still suffering from the same fears and concerns that drove them to go in the in the direction of the old system to begin but we're getting better and this is one of the things I think that's really important about the cultural change and coming from the top I Aiden is absolutely right it isn't about teaching people to do the right thing it's allowing them to do the right thing and I've said many times again my job is so easy all I have to say when one of these events is reported to me and the staff asks what do we do do what you think is right and will support you let me know if you need my support but just do what is right I would say that once you start that process with an organization be careful if you don't mean it because once you start saying those things to your staff if you don't live up to those principles your staff will turn against you they'll realize that this is just hollow another another program of the month rather than a change in the way in which we do business okay so once that starts to happen it's like wildfire no I'm sorry for the reference but here in California but it's like wildfire it starts small it just keeps on building and building and building in this case I don't want to control I want it to go out of control I want it to go from our organization to the organization the country so on this issue of transparency one of the challenges that I see is that as we move forward with this concept and I'll ask you to talk about it Aiden as I look at it there's this two paths we can take an honest good physician making an error we can call that a teachable moment the chief of surgery chief of medicine chief of ICU brings that person in and says you know you made an error let's talk about this versus punishment if all there is is punishment you're never going to get the transparency so how have you approached that within NHS so that we can have people move more toward a transparent system where we use more teachable moments when indicated yeah and I think I think it's complex I think there are a lot of things going on and I would talk about some of the key things so for example we are introducing a medical examiner model so for death and as you say it's not just about death it's about harm but this is a starting point what will happen is all all deaths will be examined and opportunities for learning will be looked at and this will be clinicians who can then support the team and say look we're concerned or the family is concerned something went on here and support them and talk through what went on in essentially virtually real time so none of the 15 month delay I think we need to think about how we reproduce that supportive model for other harms and not just death but I think it's a it's a good starting point amongst it I think culturally getting comfortable with these things is difficult but it's that support mechanism as you say it comes from the leadership so I remember talking recently about a case where somebody an orthopedic surgeon in the States had made an error and he went to his boss his director and the guy said stuff happens suck it up and he ended his career then now we have to move on from that sort of thing where the the right people in leadership models where they understand that this has an impact both on patients and family but also on the staff and are much more supportive about it and I think that is changing over time but as you say culture change takes time it doesn't have an incident go ahead please go ahead just follow up on that so we all saw Jack Gentry yesterday and and he's obviously one of my heroes also a friend and I know a lot more about the backstory in Jack's case than most and one of the back stories was the surgeon who did the surgery is a wonderful surgeon and a great human being yes he and he was the perfect person for this to happen because he knew what to do right away into the right thing but he said to me at one point months months after thank god what happened to me as a surgeon happened at MedStar or in an organization where I could do what I wanted to do otherwise I would have had to bury this somehow and live with that for the rest of my life Jack and Justin Tortellani the physician are great friends Teresa and Jack still have a great relationship with Justin Tortellani that's what can happen when you do the right thing and you can actually help heal the caregivers in addition to healing the patients but it's all parts of the system aligned so we've we've got a very high profile recent case where a doctor was convicted of gross negligence manslaughter where the trust were very supportive the coronial system which I believe you don't have here but the coroner was the one that pushed for prosecution so unless all the parts of our system are aligned we've still got a problem well besides the alignment one of the things that I can recall having been a chief of surgery and and running a hospital in a health system um you can have physicians who want to be honest about or nurse for that let's not just say physicians it's anybody in that chain but um you have chiefs of service who are worried about their metrics the numbers that they have to report okay you have a hospital CEO who's knows they're getting rated by various oversight groups that are worried so the culture has to change throughout the organization so Scott tell me how you addressed that when you were talking to the NHS realizing that this was multifactorial from the bottom up to the top well rather than thinking in terms of how it's been addressed because I would say we're at the very beginning of the journey what's changed really is that the conversation has moved on I'm not sure for frontline staff reality has changed yet so I think the barrier to zero is the culture of fear I don't actually think I think Joe yesterday described it as a culture of apathy I would describe it as a culture of fear I don't think any of my any of the people I've met or any of my friends who work in healthcare are apathetic but I do think they're afraid of how the system will treat them and it's the fear that needs to be rooted out and I think actually when that happens you'll get closer to zero and um in in the context of that this is where policy makers and legislators really matter because they are the people that have to change the laws so that we don't punish our we learn from our but we do punish cover up we do punish bullying we do punish scapegoating and we actually get to a point where not only do you not have to wait 15th in my case 13 months 15 months for a complaints form but you don't then also have to wait for five or six years for the result of that because the feedback loop and the speed of it is really critical yeah Holly I wanted to ask just wanted to ask you something because you know you you you're hearing the fear in the system people trying to protect their brand people trying to protect themselves um obviously you're you know we're not asking you for any commitment I but I just as as an attorney and a new congressman tell us your thoughts on how we might move forward to free this burden from people who want to be honest well you know I obviously am working in the greatest bastion of dysfunctionality in the United States as we see with the government shutdown we're dealing with right now thank you for your service thank you the the question I actually want to ask you guys is that we have to overcome the culture of trying to not allow this information to be transparent so if you get the transparency there also has to be I believe an economic tipping point right if if the cost of of being non-transparent is better than the cost of being transparent then we haven't had the economic tipping point that we need to move forward so I'm really curious from your point especially because you as a company you've made the decision that it is cheaper to be transparent more economically feasible to be transparent but then then to try and cover it up we didn't know that we didn't know that when we began one of the um the leaders that I had to spend some time with in the very beginning was our CFO um who was obviously a concern that I was heading us in the right financial direction and I said to him and and I said to the board I can't tell you I don't know yet we don't have enough experience with this model to know whether it is less or more economically advantageous for health care but it's the right thing and I've always felt that in doing the right thing I know I sound like a Pollyanna that you end up with good results I can now tell you although our our program is as as as robust as it is doesn't capture 100% of the events as it should and work with them through this process it captures some percentage fairly significant maybe 25 30 40 percent and over the last four years the only way I can measure whether this program is successful is looking at it in the context of what we spend for malpractice both the we're self-insured so I actually have a direct relationship to the the money that's spent and over the last four years I I try to be very careful when I give this information out because I don't want to overstate the the reality we have saved upwards of 20 million dollars a year on the funding that we put into our captive insurance company against what our actuary tells us we should be putting in based on what he projects our spending should be for the kind of program we have number of physicians we have our history Larry what's that percentage savings well it is it's about a 20 percent savings so a very substantial save we're about a hundred million dollars I would hope that you all would publish that well we are but I want to say but I want to say in that publication I can't the holy grail of risk management is being able to say we put this into intervention in place and we got this result I can't do that this is too complex it's a piece it's a part of a mosaic that includes all the work that's being done through this wonderful organization looking at sepsis prevention so that isn't the same as what I'm doing on the litigation side all those things go in to create a better safer environment that also has as a component this transparency initiative that works when there is error or when there's harm so I can't say any one of those but what I can say as I said to our CFO I don't know what's I don't know what's causing it to happen specifically but I think it's all so we can't stop any okay and we got to keep on building on Scott you had a comment yeah I was just going to say in terms of financial tipping point the reason it hasn't been recognized is because the cost isn't counted and actually the cost is staff turnover it's burnout it's suicide absolutely and it's the loss of trust between everybody that is involved in this and that harm goes on for lifetimes unless there's mediation and resolution and you know driving towards just culture is about capturing all of that that's a key point because you're covering the hard cost and that's the soft cost which the time and effort and misery that is hard to put a tangible number on and it's not just felt by me it's my wife it's my children from one of whom lost a brother the other of whom never met a brother it's our wider families but it's also every member of staff that watched him die and they all went home to their children the same night and they weren't supported because they were locked in an adversarial process and they you know some of them were actively blocked from helping tell us what had happened so what did that feel like so let me give a little historical perspective that I think there's probably many people here from Orange County and Joe and some others and so when we talk about patient safety I'm thinking back in my own career where I was a general vascular surgeon I subspecialized and trauma burns in critical care but the the basis for our trauma system here in the United States today was a report done in the 1970s by a doctor west here in Orange County who was a surgeon who reported unpreventable deaths from trauma right here in Orange County and that changed the whole landscape nationally where they saw that there was a significant amount of patients that were dying from simple things a pneumothorax a collapsed lung bleeding that wasn't stopped appropriately an airway that wasn't managed you know in the field this is when paramedicine was just starting so we forget that there have been people working before in this area although we didn't have a patient movement like we do today and we didn't have a Giochiani but there were people that recognized 40 years ago and more that we were missing things and so today it's taken us almost a half a century to have a discussion like this about transparency you know so I think we're heading in the right direction but the next thing we probably need to talk about is metrics okay so one of my colleagues at Tull Gawande talk about a checklist you know taken from pilots let's talk about checklists let's talk about metrics and to your point like is there some way we can measure this to be able to demonstrate that we are making progress who wants to start well I can start on that okay thanks it's interesting you were talking about trauma because trauma is one of the areas where by using the data and being open about it we've been able to change and show real measurable difference in the outcomes from trauma by revising our trauma system so we've gone to fewer trauma centers managing trauma now that was a difficult battle because people didn't want to give up this work but we use the data in a very open way to say we're not where we should be we admitted we could be better and that that had a real impact but patient safety is hard to measure so we talk about what's avoidable and preventable how do we decide that so in my own practice I might say you know I so I was a correct surgeon for 10 years and I kept a very tight eye on what went on and in that time I had six deaths from planned surgery and I can remember the detail pretty much of all of them and sometimes there were clear cut opportunities so a patient who died of C. diff clearly that's an institutional issue that we should have avoided but sometimes it's not clear cut so it's really difficult sometimes to define it so if I did an operation if I did surgery after I'd been up at night doing on call and maybe I lost a little more blood than I would have done and they got transfused then they had a cardiac event three days later was that preventable as a death or wasn't it so I think it is really difficult to define and where we're working we've got a new strategy for patient safety being developed now is to say let's measure what we can and demonstrate impact there knowing that if we tried to measure patient safety and harm across the whole system we've got to do 20,000 note reviews with global trigger tools invest that huge amount of resource that could be used for action on patient safety so we have enough data we have a reporting system that gives us two million incident reports a year and three quarters of that out of interest is actually no harm data so we've got to get better at reading that and understanding where we can have the greatest impact and measure the metrics of that so if we're doing work on healthcare associated infections it is easier to measure levels of that than it is global harm so I think we're focusing the metrics where they can have most impact one issue of course is you know the variability in care people do different things and they think it's right you know every physician feels they were trained the best they could and so the variability is something that challenges us as we relate to this because it's hard to define best practices okay because everybody thinks they're doing a best practice yet we have the opportunity now through technology through aggregating data through machine learning predictive analytics that we can get better as this as we go on but we have to put the data into the system and we've got better at that so we've got national reporting of data and you were a vascular surgeon that was one of the first to go so this started with cardiac surgery and of course everyone thought the world would end this data would be out there they'd be picked upon the world would end actually what happened was a few people realized that they shouldn't be doing what they were doing and stopped but the world carried on turning regardless and what we saw was people understanding where they sit and wanting nobody wants to be as somebody was saying yesterday nobody wants to be at the bottom of the pack so it's understanding that they could be better and change and that drove changes to the way we do the vascular surgery and how we centralize it etc etc so we have started to use that in my own practice we had data out there my data was on the system of course it's sometimes difficult to interpret when you're talking about small numbers of something you get into the statistics of it and we get quite defensive of that and you know we're sitting here talking about being transparent just before I left we had a freedom of information request about deaths from medication errors and I found myself trying to explain it away so a paper wants to publish that we have deaths from medication errors and I'm there saying well of course it's really difficult to know whether it caused the death and I think well hold on in my physicianly attempt to manage this data am I actually being other than transparent because we know there's an issue here so why don't we just say yes we know there's an issue with deaths from medication errors and not overcompensate it so the as I see the checklist has been a valuable adjunct that pilots have used for years a tool you know bought it in wrote the book about it but to me that's a macro approach is the at tube in the right place did you amputate the right extremity those kind of things how do we get down to a micro level where we have automation in the system the technology can help us as well to be able to take the variability out of that and the hunts make it safer for our patients one of the things that has come out of our effort on candor transparency is that it does allow us to do a really in-depth analysis I think David Mayer mentioned yesterday we don't call it root cause we call it an event review and try to get to understand as best we can what took place and that's allowed us to involve human factors engineers allowed us to involve other professionals that can actually help us make the difference in how we continue to provide care so you you start moving as we've been talking about from a litigation and fear environment to a learning environment that produces change and so this is all so and I also agree and as you're talking we can't be tripped up by trying to be too precise we know we've got a massive problem I think the data we're looking at is directional and not specific and so I think if we can just focus our attention on what those directional data tell us and keep going in that direction we'd better off yeah so what I'd like to do now is we have a lot of questions from our audience they want to talk to all of you so let me go through some of these and and we'll pass them on here is one if we believe that providers want to do the right thing how much do you think provider burnout well-being and the other burdens of the profession EHR documentation for example lead to a lack of willingness to be transparent anybody want to grab that start Larry sure I mean I'll start there's no question that they're interconnected what we've just begun at MedStar looking again at our peer review process because the peer review process is seen seen in our organization as I think it is the most as a punitive process rather than a constructive process and but we've tied that together by saying our effort should be looking at the whole clinician whether it's a nurse physician or any other clinician so we look at their expertise and their and their knowledge and their skill and ability but we also want to look at how they're doing in terms of their own wellness how are they psychologically physically and we also want to look at their citizenship how do they how do they perform in our culture do they accept the norms we have so I think if we focus on that I think we'll help folks do better I think the premise here that providers want to do I think they do want to do it but have we created an environment that frees them to do it I mean as a chief I remember looking at all of the morbidity and mortality reports and what we remember in the old days what we would do is blind it it would be surgeon A surgeon B but everybody in the room knew who surgeon A was and surgeon B and C because you knew the cases they were doing and of course when you had those discussions you don't understand my patient was sicker than the rest and you have all of the excuses because you're trying to protect your your silo and make your chief look good and make your hospital look good because there's reporting there we're not there yet but I think we're making significant progress let me move on to the next one Harley this one is for you secretary of health in UK required all of NHS hospitals to be transparent and publish regularly their preventable harms are we ready to do that in US hospitals yes we are if we can get Congress and the Senate and the president to agree that's always going to be the challenge and this kind of goes back to part of the conversation about when you were talking about at the micro level first of all we've got to have standardized data protocol that we're able to accumulate at that level and and and then use that data to be to provide the appropriate analysis but I do think one of the challenges that we're going to have and I'd like to hear your guys input on this is that you know this as much as patients in the public want medicine to be scientific it's not there's a lot of art and and human interaction and involvement and error so I wonder how we get consistency in transparent data when you have so much human interaction and in the artistry of medicine involved right well give us your experience and then let's got comment it's not straightforward I mean if you start with the premise you want people to be open that's great but actually there's a lot of complexity along the way with that and what we find at the moment is that very strong organizations are very open what we see is that if you look at our CQC our inspectorate ratings the outstanding trusts staff report that they feel able to speak out etc etc what we often now find is that if you look at really strongly performing trusts across the system they report for example never events at a higher rate than other organizations which seems surprising and the risk is that while you're going through this process of encouraging openness the ones who are willing and step forward start to look out of kilter they start to look like the worst so you've got to be able to manage that and we live in a world and I'm sure it's the same here where we are very heavily scrutinized and that's appropriate and we had a session on journalism yes people are looking at this and we've just got to be careful that there isn't a punishment for inadvertently for being honest and open reporting and we have disparate parts of the system and we're trying to align that better and some parts will say well we want to go in and manage this because that's the expectation of us so we want to respond to this in a way that may discourage the reporting so you've just got to be careful how you but that tone is set from the top yeah it's ownership from the top and it's what I'm making sure and one of my roles is to stop people leaping in I have organizations who are open they say we've got an issue with their events we want support one of the things I sometimes have to do to be honest is go to other parts of the system and say back off let us support this it's that teachable moment versus the punishable moment and it's the leader that has to make that decision with the appropriate data as you said with the appropriate policies in place that there's a departure so when you start to see a trend as opposed to one thing so I think Holly we're moving in that direction but we need better data better systems in place to look at those variable practice patterns which often lead to these problems Scott you have a comment just to sort of counter the proposition the practicing of medicine and the delivery of health care may have an element of art but actually the process of understanding stuff when it's gone wrong that could be scientific there's no need for there to be art in that actually you need skills yes conversation interpretation expertise objectivity a whole load of things we don't have people with those skills we don't train them we have media teams we have litigation teams but we do not have safety investigators right we don't have media I think what you're talking about you know what we would call that in the science world with the health literacy how do we take very complex science the most complex science the world has ever known translate it in a culturally competent health literate manner deliver it to that end user we call a patient who may have a high school education okay and now they understand it and the expectations can be set right now there's a big gap you're absolutely right okay so our expectation has been people can just do this without any support training this isn't what they were trained to do and we have to do that and part of what we're doing is more training around investigation and response and resolution and that's where we need transparency is honesty about the fact that that has not been normal that isn't the reality that people work in it's what we want and it's that's actually the goal like it very quickly if you're going to do this kind of work as an organization you have to put resources into the program you can't expect it's just going to happen without resources and and train people who know how to deal with these issues is extremely important yeah is another great question with transparency are you saying there should never be complaints to health departments for hospitals or medical boards for doctors do you think teachable moments can replace medical board complaints with a doctor who has multiple victims I know that the word would be victims but no you should always have a right to complain the system should always expect that there's a right to complain but it doesn't mean that you should rely upon complaints for safety it doesn't replace the system that we have the system we have already to monitor physician nurse allied health professional performance this is an adjunct yeah I've been doing this work for a long time most of my life and what trips us up are the small percentage of clinicians who are not competent to provide the services they're providing and we are as an industry woefully inadequate in trying to find ways in which we can identify them and either correct their behavior or or their skills or quite frankly get them out of the business and we've got to start doing that these folks can't destroy the effort of so many good people who are trying to do the right thing harley harley that's a good one harley I have a question here directed for you but um I'm looking through a a HIPAA lens it's about a personal issue is it all right that I sure bring it up so it's a Harley rota I understand that you almost died from C. diff after back surgery three summers ago tell us how that will shape your thoughts and plans after all you've learned here well it might be a little overstated but yes I did have a I had back surgery effusion and uh shortly after that feeling really horrible a few days later and not wanting to go back to hospital I was my whole family forced me back to the hospital and what's interesting when you go into the emergency room you can quickly find out how bad of shape you are in in how they process you and uh and I've been to the ER many times either personally or with four kids and we I was quickly moved back and the hazmat suits came out and uh and they started treating me so it was uh it was an interesting to go through it it was and it was also humbling and and horrible to see the other people on that for what they were going through and I know that the death rate for those that are 65 and older is fairly high and and to hear patients being told that you know part of their testings were going to be taken out and or or worse outcomes you know made me realize just how difficult that situation is and how preventable it is by making sure that we have sanitary facilities so yeah it was it was certainly um something that that has pushed me forward to help try and address the issues that we see in hospitals that Scott and so many others have experienced first hand jump up okay we'll go to next we'll go to another one then most of the questions that are here that are very similar are like how do we alter the blame culture of our in our society you know the adversarial system that you that you're going to get sued no matter what can I can I please so some of you had a chance I hope most of you had a chance to see John Chakour yesterday in a panel John is a defense is a plaintiff lawyer who sues me more often than I'd like to to report and somehow we've created an unholy alliance John and I and I went to him let me just say I guess sort of boldly or generally we can't do the work we're talking about by just talking to ourselves within healthcare we need patience and we're doing a much better job now of bringing patients and the families that they represent to the table we need representatives of our government to think this through with us we also need the plaintiff bar this is a multi-billion dollar industry this is not going to change because we tell it to change so I brought John in house to MedStar and we've indoctrinated him into our way of thinking and quite often John will call me when he's got something he thinks might as he say fits the candor model and will evaluate it and if it looks like something that should be resolved we'll work with him to quickly do that so I think one of the things we need to do is start working with those on the other side to learn how to do it better well unfortunately this could go on for hours we only have a couple of minutes left so I would like each of the panelists to just give a short closing comments on you know some takeaway messages for our audience and start down at the end with Dr. Fowler oh you give me the difficult bit I had to start I think it's really difficult to come up with one key point at this point but this stuff is these are wicked problems and they're going to take time and they're complex and we've got to go at it a bit at a time but because it's difficult doesn't mean we don't go there we just have to keep going at it and it's going to be hard stuff we've got to stop this attitude of telling people not to be human because they're going to continue being human and we do that a lot and we say we'll write you guidelines we'll tell you not to do stuff and we're surprised constantly that stuff happens we name things never events and don't understand why people still keep having them so there's a lot about as you say with patient safety designing out supportive stuff using the technology we had a session talking about that to get on top of some of these thank you sir Scott and the objective I would like to see for healthcare all around the world is that the whole system in every country is focused on a just culture which treats everybody with respect and kindness and fairness and as if it was their child you know you treat everybody in that sense in some sense in the way you love you've got to create psychological safety so that everybody feels safe whether they're delivering care or receiving care and then we will be able to get towards the goals that everybody aspires to Holly thank you Scott I'd just like to thank the rest of the panel and all of you because of the initiative that you are driving here is so important to all of us all of our families and also thank you Joe for your leadership and in directing this it's a I figure any guy who can graduate from high school at age 15 and have a college degree and a master's by age 22 is the perfect guy to be leading this initiative thank you I'll actually stand on Scott's comments I think if we can look at this as treating our family whenever we're dealing with these issues and what we want to have happen to them I think we would be in a much better place very quickly and last but not least I would say that I've learned a lot today and as I look at this as a big picture as if I was a certain general still looking at this it's about changing a global culture that embraces transparency so that we can get to where we want to be to have absolute patient safety thank you all please thank our panel