 Good morning! Yanaka, good morning! So good to see you, so good to see you all. I know the title of my presentation is State of the Movement. I'll give you the punchline. It's great. And I'm gonna share with you some stories. I want to come back to that. But you know, the punchline is because of really people like you that don't just mean well, but do well, work hard, I'm grateful to Mike Durkin, Mike Ramsey and Sonna's for taking us back to our roots where we asked the hard questions, we pushed people to do the right things because it's not easy. It's easier just to have a kumbaya, just networking. No, we when I asked people when we started what made us different, they said you bring a sense of urgency, we're action oriented. And that's what we got to be. And we borrowed from the Clinton Global Initiative to make this a commitment based meeting where people don't get to come unless they make commitments to zero. However way they can do it. If they're a hospital to implement evidence based practices. If you're a technology company to make a commitment to share your data so that one day we have tools like AI that can be used to predict problems before it's too late. But I got to tell you, I want to first start with thank yous. I am so grateful for the work that you all have done and you continue to do. I'm grateful to have Don Burwick, who pretty much started this. And it was until about 2011 where I saw some data that came from OIG, which were blessed to have truth tellers like Ruth Van Durel, who's going to be with us today, who is not afraid of telling the truth, that told us we're not doing enough and patient safety isn't just the responsibilities of Don Burwick's and Peter Pronovost of the world, but it's all of ours. You know, I think they said when the world becomes so bad, like unfortunately it seems to have just telling the truth is an act of heroism. And that's indeed what OIG did recently. We'll talk about it where they reported that one in four patients are getting harmed in our hospitals. Back to my thank yous. I want to thank also my wife, who got more involved and has given so much to patient safety. And I appreciate it. Thank you. I want to thank President Clinton, which we'll see tomorrow. Without it, we wouldn't have been able to convene these meetings and really get it going. He's come every year, even when we did it virtually. He showed up and it's going to be here with us. You know, and I want to thank Jeremy Hunt for starting the Ministerial Summit on patient safety and have a President Alan Broussé in Switzerland for the first time, a world leader, a president, convene a meeting just on patient safety. President Biden for charging his Council of Advisors of Science and Technology to give him actionable plans to improve patient safety. For our board, for all of the volunteers, for the patient advocates that are really our North Star, they remind us what we've got to do and how bad the problems are and how we've got to fix it. You know, Mike Ramsey always says, we're all going to be patients one day. And he couldn't be more right. In fact, President Clinton, who helped a year before me, needed the health care system to save his life. And UCI did. A year later, I needed the health care system to save my life. And UCI was there again. It did. I mean, how lucky am I to live in Orange County where I've got a hospital, a teaching hospital that committed to zero, implemented all the evidence-based practices. And a children's hospital where I can take my kids, children's hospital of Orange County, where they made the same commitment. And I've achieved incredible results. We're going to hear from Kim Kripe later and people at UCI are buying to tell us what they've done. But I got to tell you, I want to share with you my story, because I think it's important to, it's the first time I've had the vantage of a patient. I've always been on the other side of this. And I, it was about 10 o'clock, I guess at night, where it's the last thing I remember until I woke up in the ICU bed after my surgery the day later that my son found me unresponsive. And I had, unfortunately, aneurysm. I had subarachnoid hemorrhage and he called 911. He waited for them outside to make sure they get in the right place, 13 years old. And he made sure I got going. But they took me, unfortunately, to a hospital that wasn't UCI, that wasn't some of the incredible hospitals around. They took me to a hospital that treated my family, kids in the middle of the night, like, I don't know, maybe people that are breaking in to the hospital, they wouldn't let them sit in the emergency room lobby. But let's, I might be a little bit, let me go back to UCI. Thanks for incredible effort by a lot of people at middle of the night, our chief operating officer, our lawyers, Dr. Bill Wilson, our CMO. But they all came to try to transfer me to UCI. It was a stroke center there that could help me. Fortunately, they ultimately did. And the doctor, they did an incredible procedure on me, you know, put the coils in and didn't have to open up my head. And I spent three weeks in an ER ICU. And I didn't want to take opioids because I learned from these meetings that one out of five people that take opioids get addicted to opioids. The pain in my head got so bad. Really, the only thing I could imagine was legality and just cutting my neck off so I could get rid of that pain. Finally, I said, give me, give me opioids. But by then I was in this crazy vicious circle that they couldn't get the pain away. They weren't working. So one of the ICU doctors, a new doctor in Florida who had this, I guess, experimental procedure where they shoved these probes up my nose, took it right to my brain and then injected the painkillers in and that worked. Oh, my God, I felt so good. I was ready to wear the T-shirt that says opioids rule. Yeah, yeah, it was, you know, these things are needed sometimes. But unfortunately, very quickly, I became addicted to it. I became resistant to it. I went from saying no to opioids, wanting it now every five hours, every four hours. I became very irritable, as my wife told me later. My team came in, put bridge on me and I quickly calmed down. I was able to get back to every six hours, went from 15 milligram dose to 10 to five to nothing. But while I was there, I'll tell you, the care I got from UCR-Line was incredible. It was protocolized because I know a little bit about things. I could see when they were putting a central line in how they would drape me and the stuff they were wearing, the things they were doing to make sure I don't get an infection. I don't get CLABSI, Dr. Protovost. The way they gave me my medicine, the way they doubled and triple checked. And yet there was love there. I felt like I was in a spider's web. Whereas as soon as I moved, someone would walk in. It was everything okay. What do you need? It was amazing techniques during my surgery. Incredible protocolized care and loving care that got me through it. And my wife was there 24 hours a day for three weeks and trying to reduce opioids. I used music to calm me down. She read me poetry. And I got to tell you, there was one poem she read me because she knows what I like. She read me the poetry from Rush, Farewell to Kings, the first song. You guys should go read the lyrics. And as she was reading it, tears were just rushing down my eyes. Because that song, basically it's about not doing the right thing, trying to take the easy path. And then you find yourself one day in your deathbed that you say, I didn't do enough when I could. I didn't sacrifice enough. I didn't try hard enough to fix this. Unfortunately seemingly needing fixed planet we live in. You know, we got a lot, a lot of problems. And I adhere to what I call micro fixing, which is fixing the things we think we can fix. So there are things, unfortunately, are too big for us. Not that we shouldn't try those either. We should voice our concerns because even telling the truth is heroic and could reduce the suffering of not just people, but all the living organisms in our planet. But yeah, but you don't want to find yourself in that deathbed thinking you haven't done enough. I'll tell you, if I had died, I would have died a happy man because there was this dream I was having. It was a beautiful dream of the life I wanted to have. But I felt bad for my children. I could see the pain in their eyes. I really just wanted to live long enough where they have their own children so they don't miss the pain of losing their parents. And then I just wanted to have another chance to speak the truth, to do what I could do to make this place better. So the next time I'm in that bed and I really am dying when my wife reads me that poem, tears won't flow. Read that song. It's a really good poem. You would think a rock band can't write poetry. Some can. So, you know, we haven't been together for a few years. This is our 10th anniversary. I remember the 2020th anniversary. I was gonna get up and say we didn't do what we set out to do. We didn't achieve zero. But we accomplished a lot. I was gonna say, you know, we brought 40 countries together. We brought 5,000 hospitals together. We created evidence-based practices that are freely available to anyone who wants to use it, translated in Spanish and German. And we even made a curriculum for universities, nursing, pharmacies, hospitals to put hard-wired patients' safety to healthcare. And the work that these hospitals did probably saved over 250,000 lives. But 100 companies made a pledge to share their data. So now tools like AI can hopefully do things for clinicians. Let them know what's going on before it's too late. We're not stuck to the tyranny of the now, but historical data that can hopefully mean something to AI systems that can pay attention. And I gotta say, I was excited to come to you and have that meeting and apologize for not reaching zero. But then COVID occurred. And I think we were the first meeting that decided to cancel the meeting. And it was kind of scary, are we doing the right thing? But going back to our guiding principles, do no harm. How could we gather the best people in the world that are trying to help other people and potentially endanger them with COVID? So we canceled. And, you know, during COVID, we realized how badly we need these systems in place. Because in the moment of crisis, they weren't there to help our people. And unfortunately, we saw some of the people that we relied upon for being there for patients run the other way. But thank God we saw many, many more run towards the crisis. And, you know, we're here, we're back. I'm so happy about where we're going. I'm excited about the future. Why? WHO has made patient safety one of their top priorities. What a goal to dramatically reduce harm by 2030. Ministeral summit on patient safety, we discussed. Thanks to Jeremy, what he began, and where it's going. President Biden asking his council to give him things he can do. And by the way, he's pushing for it. It isn't the other way around. Thank God. So what are we going to do? If I could leave you with just a few ideas of how we could really, really get there. Learn from the hospitals and in the last decade did implement evidence practices. See how well they've done. We're going to have a few of them up here this week, or just next couple of days. Look, to err is human. But to not put processes we know works to save people's lives. From human error is inhumane. And since not everybody is going to do the right thing, we got to push our governments to align the incentives so that they will. So that they will see the benefit to them for doing the right thing. It's really just those simple things. Transparency helps, too. I really believe in that. I think they say sunlight is a disinfectant. Well, transparency is the greatest disinfectant. And we can learn from each other. And I think we never relied on governments to help. We started this thing as a grassroots movement, one hospital at a time. And we have to continue to do that. But the 10-year lesson that I've learned is we also could use their help. And we've got to lobby them hard. Because there are so many forces, I don't know why, but so many forces that push back. And, you know, when one out of four patients are harmed, who the hell cares about unintended consequences? It's a catastrophe. It's a disaster. So it's not like we have a system that's working 99.999% why mess with it. No. We have a system that fails us 25% of the time. So thank you. I'm preaching to the choir, I know. And I want to thank you all for coming. And I hope the next 10 years, 2030, we will not have to apologize for not getting what we wanted to get done. Thank you. Thank you so much.