 I'm sure many of you were looking to see Peter Provenos show up right now and Peter was called back so I guess we could call myself the taller Blonder version in some ways. I know that they are huge shoes to fill and so I'm very appreciative of my panel colleagues being patient and thoughtful with me as we go through the discussion of what is really important. I never hear a patient family story that I just don't have this pain in my stomach. I don't think any of us do. I think we all were drawn to health care because we care because we want to make a difference because we want something to be better and people have talked over this on this stage over the last 24 hours about the failures. Why haven't we gone further? And the one thing I loved about Carol's video is the very obvious point. Patients and families want to be a part of the solution and the solutions may not be within us. And so we've talked for a long time I think with a degree of rhetoric and insincerity in health care leadership about patients and families as partners. I look at the fact that that doesn't exist today in a meaningful way as a leadership failure. We as leaders in health care if we don't make it comfortable if we don't make it easy if we don't make it a requirement it's not going to happen. And so this leadership failure actually needs to change. And in that change I think is the path forward. The path forward of true partnership. The path forward of listening to the voice of the patient. And as as Peter said to us yesterday the path forward in love in compassion in commitment and in that alignment. We know and I use this phrase often in my day job culture eats strategy every day of the week. There is absolutely no one else responsible for culture in any health care organization or in any company besides the leadership. You establish the culture you feed the culture you nourish the culture and if you don't do that every minute of every day your culture will fail. And when the culture fails in our industry bad things happen. They happen to vulnerable precious thoughtful individuals who are someone's mother brother sister child. So we have to recognize that this is a gift that we are privileged to have. The other thing that strikes me about Carol's video and being a part of the solution is that we do have to fundamentally change some of our paradigms. You know I'm blessed to have amongst us in this audience so many people from the field of anesthesia so many surgical colleagues and you know Peter as the owner and developer of many checklists along with the tool I'm a firm believer in checklists. But fundamentally what does a checklist do besides what I'll call in very simplistic terms the recipe it's the pause. We have an urgency addiction. That urgency addiction many times is the cause of error when if we just paused if we just thought for a second because in health care we have the biggest and the brightest and the smartest people around us and it only takes that second to make us think about what we're doing. That pause is one of the most powerful things that we can do every single one of us. And we all know that that pause leads to more effective care use the checklist think about what we're doing ponder for a millisecond and we will save lives. I wanted to share a brief story of one of the positive things that happened for us in my organization that I'm super proud of with the pause and it talks about the concept of surgery. So I can remember growing up and my dad would have need for periodic surgery and people would say to him oh Glenn it's good you're going to take a nap it's going to be fine you'll feel better you'll be all rested boy did we not know what we were talking about right. Most of my professional colleagues in the audience would say yeah a minor surgery is like running a marathon a good old 5k and then you wonder why you come out the other end and it doesn't work so well well let's think about that for as long as I can remember in my own organization short of true emergencies right when did you have surgery well when the surgeon had the next block and the next slot was available let's go let's get her done as they would say and say in in that vein I think we all know too that the outcomes from an accelerated surgical path sometimes can be great and sometimes can't and so we as an organization we're having probably too many surgical complications and they were happening in elective cases and kind of semi-urgent cases so what do you do about that so we were fortunate enough to have some physician leaders who introduced us to the RAI tool which is a risk analysis index that we adopted two and a half years ago we now have 30 350 thousand data points completed by 200 surgeons where we know if a patient is frail and we've mandated that being done and we've mandated the pause guess what 21 percent of the people that we did that index in never ended up having surgery never there was a better plan four percent of them had a lesser surgery 50 plus percent of them had prehab they got stronger before we did what we needed to do and only 20 percent went on as planned the learnings from the serious events that occurred after our surgeries forced us to reflect and think about the pause and the greatest thing about that tool self-administered by a patient in less than 60 seconds doesn't take much time 60 seconds of pause so we need to harness these thoughts from all of us and think about what it takes to wire into the infrastructure of our organizations the positive feedback from our patients our families that say to us I know we can do better and I want to help you do better so with that I'd like to invite my panel members to come up and join us we're very privileged to have Carol with us who will articulate and share a little bit more about her stories Tom who you met earlier today who was the leader of our respiratory association Cliff who is sitting down beside who's our immediate past president for and chairman of the board for ISQA and our dear friend Helen from memorial care here locally so what a distinguished group to have together and it's really a privilege to be with all of you so Carol starting with you I can't imagine the loss of a child I can't but somehow you've gone forward from there and you've thought about how do you become a partner so tell us a little bit more about your belief in that next generation of patient safety and how we need to go forward Maya Angelo once said there's no greater agony than that of an untold story inside you when these events happen to us we need to be heard and oftentimes our voice is never recognized and yet we're the one constant in our loved ones in their room with them and so having the opportunity to tell what happened is important to us and that propels us and we start to share our stories but then we evolve the stories get us into this but we have so much more to contribute than just our stories we look at health care differently you know depending on our background whether we're a policeman like Jack Gentry a teacher an architect and yes to some hospitals demise even lawyers you know that come in but we we want to help because we know that you all can't do it alone yeah well that's so powerful and and I think that you know this it requires leadership to make it safe I can remember many years ago Don Burwick advocating for the co-hospital president being a patient so Helen tell me a little bit about you know your reaction and how your organization has tried to embrace some of the positive changes that have come from your learnings and and what you've done to advance those I say we're sorry yeah I think a couple things I work at a health system right around the corner more oil care we have four hospitals and a lot of ambulatory sites and like and so you know so much harm and and to focus on and some of the things this my third health system I've been able to work on improving safety and I think there's four things that well really five things that come to mind exactly what Carol said which is really involving patients and families very fast and being transparent and having those conversations early and we've made that transition and so it's you know you wish it had never happened but the fact that it did then there's a way to to work through that together the second is really having these bold goals for quality and safety and not just striving for better than or half of but really striving for zero or always depending on what it is and so I can talk a bit more about that the third is patient stories matter and so the patient can come in and tell their story and we need to passing that through the organization and making sure that it hits every meeting and that the it's sort of translated and used for good so we don't start any of our board meetings quality committee meetings medical except you know the list goes on without telling a story at the very first part of the meeting because it gets everybody in the right frame of mind they put their devices down they start listening and start focusing the fourth is really involving patients in design so we have in addition to working on a specific if something happened you know making sure you understand what that was and how we can prevent it involving patients in patient family advisory committees and lean so we have a lot of lean redesign we're doing and the very first first thing on our checklist for a lean event is kind of patient and family would they be great to be involved in this particular one because you get every single time when we do that we have great learnings about okay you want to work on that but actually what I think you should work on is this and it's so helpful and the and the last one is really resourcing this so I'm on our leadership team for our system and we we resource this we have teams and task forces and and we put financial support behind these teams to make these changes because they don't just sort of happen out of thin air and so it's that an organizational will to move it all forward yeah that's I think that's so important when you talk about the design and the incorporation into the design and you know Cliff as a as a leader of one of the most esteemed oversight organizations in the world in this space I'm sure when you think about the infrastructure that's a lot about what enables this success to happen so you know share with us your thoughts on how that infrastructure has changed through the years and what you think we need to do more to make it better for the next generation well that's a pretty big question well but you have broad shoulders I think one of the things we need to do is firstly just have a look at the societies within which we live and recognize the differences that we have to look at we recognize that things do go wrong in healthcare but how do we handle that do we handle that as oh well that was just another fall that was just another pressure injury that was just another bleed or do we think here is a person who has been impacted by what were euphemistically called an incident we need to go beyond that and think how did the incident occur and what can we do to stop it occurring again and look actually at ourselves there's a very interesting book called the road to character by David Brooks who was a New York Times journalist he talks about language towards the end of his book and he says there's been a change in language he talks about Google and Grams where they can actually tell you how many times a word has been used and there are some words which are increasing in use I can do it self me there are other words which are decreasing and this is I think something that causes us to think about your pause they are words like bravery humbleness kindness and they're disappearing from language kindness is used only half as much as it used to be just a few years ago that's sad and I think sometimes what happens in healthcare is that we get so caught up in the churn the busyness look chasing lab results whatever else to stop and think what does this mean for the person that I've just encountered and and that's not a new phenomenon in fact there's a story that's about 2000 years old about a man who was beaten up to walking down a road by a bunch of bandits and he was lying there naked bleeding probably dying the legal establishment walk past they had other things on their mind the religious organizations walk past they had other things on their mind a would-be enemy noticed him noticed him noticed the patient crossed the road touched him bound up his wounds put some clothes on him put him on his horse gave him some money sent him off to a hotel and paid the hotel bill by the way where's Larry wow good example we heard this morning what had happened the good Samaritan had recognized the vulnerability that we as patients and we who serve our patients because we both end up being vulnerable but he took the vulnerabilities themselves on himself and that's the challenge to us I think in this movement as caring professions as managers providing services for the caring professions to say I've paused I've thought there's a deeper problem here let's see what I can do about looking after this person who needs all the help they can to get back on the journey to a healthy lifestyle and I think that's the real challenge and the infrastructure things are necessary but they need to come out of an ethos of caring compassionate caring the micro moment of contact as Peter described it last night yes yes so beautifully stated and you know when you reflect on those points it also you can't help but go into what I feel is the one of the drivers of the clinician burnout lack of engagement whatever words you want to use I think it is that absence of kindness connection love emotion that is catapulting that and and making our work even harder because it's the exact opposite of where we need to go so Tom you know you lead a group of professions professionals excuse me who have have always been many times an unsung hero at the bedside and and and yet are very passionate about doing things right and how do you how do you bring that group forward and keep them not only motivated but engaged in doing the right things and hearing the voice of the patients and families in that activity I think at the local level I think as a leader in your hospital you need to treat your staff with respect and respect the conditions that they're working under in hospitals we are expected to work at a productivity level oftentimes over a hundred percent and that's jet that is not safe and I think we need to be able to empathize with our staff and and be there for them ultimately that'll protect the patients as well as an organization we want to make sure that we have a competent respiratory therapist caring for patients and we have an initiative now that we're trying to raise a level up of the therapist who bachelor's level upon graduation and the highest credential which is registered respiratory therapist we're not the respiratory therapists of the 60s anymore and we need to progress to that today yeah that's it's so true that you know and that creates that sense of pride too and feeling good about the work that they're doing so Carol as you've gone forward and have embraced your professional career how how have all of your life experiences how have you they affected you professionally and where you put your effort and energy in those change variables I think um I've had to reframe how I look at some things um in in particular I think our next journey with healthcare is switching from that safety one mindset to safety two and for those of you that don't know what that is is safety one we've always been reactive we're going there after safety two is how do we be proactive but more importantly how do we have a positive system and so an analogy I can give you yesterday Peter was talking about the runner and I happened to be a runner and when you train for a race I was always training to do it right but the fact is most of the time I was striving for something what I've changed my mindset is I was doing it right most of the time what I needed to do was when I did something wrong was how did I pick myself up like a child learn from that and improve upon it to me that is safety too what are we doing right let's celebrate what we're doing right um and let's bring that joy and meaning back into the workplace we can't walk away from learning from the things that went wrong but there's so much we can learn from what went right so part of me is as I engage more in the systems how do I how do I reframe and I think we all are at a point now we have to reframe how we look at health care the um you know the comments we've heard over the last day of you know God ain't it awful right you know that that creates such a feeling in us but it probably isn't the most motivating feeling God ain't it awful that sense of helplessness and responsibility and personal pain that comes when you feel the failure of something that you're accountable for and and sometimes I think that's been the the leadership failure like why why doesn't it motivate some people and and then you go back and you realize maybe folks really don't know what to do right which is where the science the apps even techniques like process improvement and and lean so Helen tell a little bit more about maybe some examples where you've been able to maybe convert a leader within one of the organizations you've worked with to realize like you can do something God it is awful but now what and um I'm a big student of IHI Institute for Healthcare Improvement and one of the things that we've say there is it's it's will ideas and execution um and so the first the first word is will and so you have to kind of harness that organizational collective and and sometimes it really does start at just being straight up honest about these are the number of patients that do not leave our institution alive these are the number of infections not rates numbers um and here's where we really sit and by what type and in what unit here's the number of you know you just keep going down the list and making sure that every leader in the organization is well aware they can talk about their financial metrics from the last month but if you ask most leaders what's our mortality rate around here they won't be able to tell you so part of it is just that initial education of getting everybody onto the same place we actually convene a leadership summit we have it every year we pulled our board members our physician leaders our executives into a room and laid all those numbers out in front of them that was 2006 and we through that process actually arrived at these things initially with that they were the goals and they said well what are this that's what their goals and they're really bold they said okay the bold goals anyway so we have these bold goals and we work on them every year and we are really taking each we have about 11 of them now striving every single one to push the boundary we look outside our organization but mostly we're comparing ourselves to ourselves and we're striving for zero I mean who cares if somebody else is at one if we're at point five we should get to zero and so one of the things that we found the most helpful to really get this to done we're in a hospital system where we don't employ physicians or healthcare so 90% of our physicians are not employed so we have something called a physician society and a series of best practice teams and they've been amazing Dr. LaGruz here in the audience and he helps start one of our women's health best practice teams they're clinicians so not just physicians pharmacists nurses respiratory therapists dietitians and we come together and we learn we take what's working well and we figure out how to spread it to kind of go to what Carol mentioned because and sometimes it's evidence-based sometimes it's just practice-based evidence there's a difference and we take that and then we harness it I'll give you a good example we when I got there in 2006 I had come from St. Joe's actually and we had already done rapid response teams I got to Memorial care and they had never heard of one how is this possible anyway so we we got everybody together and said you know how can we pull this off how can we not wait for the patient to get in trouble how can we get there earlier and there was a lot of discussion like oh well you know what's the evidence around this I'm like okay how much evidence do you need to say if you get there earlier it's going to help you know it just sort of makes sense so we actually ended up working with respiratory therapists and a few really passionate folks and then nurses from the ICU got some physician champions and we put it in place we've actually reduced our in-house mortality by from about 108 percent of expected to 90 percent that's 230 patients a year who are not dying who would have just based on the statistics and so those kinds of things and then when you share that data back with the team so the next leadership summit when we say well this is what this is what you did this is what we did then people get that will to take the next idea and execute on it so part of it's creating this organizational muscle if you will to do the work do the deep improvement work and move it out and through teams that's so true Tom someone sent a comment to you already that said respiratory therapists are the front line of our hospital and you are the ones doing the rescuing and they wanted to thank you and your profession for all they do thank you so um in that vein in within your association I'm sure when you first embrace the concept of striving toward zero you had a lot of folks that were like huh what are you kidding me how does a how does how did you work to overcome that and and did you partner with patients and families in some way to to accomplish that actually my first time here I got to meet Ed Salazar who is a respiratory therapist and his son died because he had an occluded in a tracheal tube and I think it was in his unit in the hospital so that impacted me more than anything the fact of the matter is that our family and our patients can get hurt and they can die so that was one of the things that we got us really started with this we then started a patient safety committee and today it's a it's like a round table type of a thing where we have over a hundred members where we share ideas and concepts of ways that we can help bring down preventable deaths in our congresses yard or our convention we had a closing ceremony where we brought Ed Salazar back and he talked about his story we also talked with another respiratory therapist from Utah who was part of a situation where there was a patient that went home he had had a tonsillectomy I believe and was on opioids but he only took a half of the dose but he died in asleep and he wasn't monitored and they wanted to do something positive about that so they worked with the physicians the administration and the state senate and they were able to get a bill passed a resolution where they can start moving towards hopefully addressing this on a statewide level hopefully we can do this on a national level too yeah those are the you know one of the great things about this this movement and summit is the collaboration with our policy makers it is so powerful when we can see things happen at that level and we've talked about transparency and I know one of the comments from the audience that came in too is you know how do we prevent what you dealt with from happening you know how long right down to the day you remember when someone was honest with you and isn't that disappointing and isn't that embarrassing and all the emotions that we all have associated with that and you know I live in Pennsylvania where we have a patient safety authority that's been in place for quite a while and you know we are required to disclose even if it's in a perfunctory letter right but I'm curious Cliff you know as you think about those variables what are some of the things that you've seen help accelerate that transparency or our levers maybe that would advance advance that thinking if I can just take you back to a previous role I had as the CEO of the Clinical Excellence Commission in New South Wales responsible for safety and quality across 254 hospitals to on two million plus admissions per year a population of seven point four million people we didn't know what to do the minister asked me to take on the role I had a board chair Bruce Barraclough who was a previous president of Isquia and a great leader that was my board chair and myself we had no other board members we had 12 staff nine of whom were admin staff and we said what do we do we thought well the first thing we should do is actually ask people and we had two communities to ask we had our staff and we had our patients and so we started asking what's going wrong and they told us and we we provided an anonymous online program for reporting anybody could get online if they had a staff membership the patients had to go through a complaint process which again was probably slow on the uptake from our point of view but we started to get some answers not only about what went wrong but what we should do and and to our horror we found that the biggest problem that we're seeing in our hospitals were people on a general ward they got through the ITU they got through the theater they got through ed they're on a ward and and they lay there calmly quietly needlessly dying because we didn't recognize the triggers that we should have recognized so we asked why and and Tom Williams didn't this that the number one reason why was no one was measuring the respiratory rate in these patients and yet we knew that there were two groups who knew how important respiratory rate was it was the staff themselves the reason they weren't measuring because it took too long we'll stand there for a minute counting the breath rate right but the other one was the family members mum would come in and say there's something wrong with Tommy he's breathing too fast or somebody would walk in and say my dear old art is really struggling to breathe they knew we didn't well we close mind we weren't being mindful so we introduced a whole new program just to divert from healthcare for a moment we went to the surf lifesaving movement okay and we said how come since 1937 to 2004 I think it was there had not been the single death of a swimmer between the flags on a New South Wales beach up and down the coast not a single death they said that's very simple doc we watch so I'm sorry we watch because if we wait for the swimmer to wave their their hand it's too late and the penny dropped so we built a whole system when we asked the surf lifesaving people if we could use their logos and they said yes and we called it between the flags we redesigned our charts so that anybody could see when our patients parameters were outside acceptable levels including the respiratory rate you know for the next four years we saved 1500 lives by a simple thing as reconfiguring a chart not just the chart itself but on the obverse of the chart well what to do in your facility so it varied depending on whether in the tertiary facility or a little tiny county hospital a little tiny county hospital if someone was outside the norm and needed transfer you call the paramedics to come across and help manage the patient until the helicopter arrived exactly it was such a simple thing but we asked the people who were involved listened to them and asked them how we should change the system and they did yeah that's a powerful story of so many good points and it one just asking i've never asked a healthcare worker or a colleague or a patient or family what they thought and that they wouldn't tell me they always are willing to share we are not willing to listen and i think that's part of of of our failure and the fact that you also chose to reach into another industry that did it better than you better than us and we're humble enough and thoughtful enough to say teach me teach me what i don't get how can you do this when i can't so kudos to to your leadership in that and emulating those values of humility and listening and learning tom you had a comment i can yeah you mentioned about respiratory rates and that type of thing when i was a director at a hospital a 500-bed hospital my medical director would come to me and say tom your patients they keep coming back to the icu what's going on as if we it was our fault maybe it was i'm not sure but what we did was we put together a way that we can determine the patient are they ready to leave the icu and we did it with the physicians and the nurses and all who are related to the care of that patient and then we scored that patient at their risk level and then based upon that if they were ready to go they'd have protocols that the therapist would follow as they take care of them on the floors but i think oftentimes they leave the icu and they're forgot about and they can bounce back quite easily they need to be assured that they're ready to go and they do yeah so can i just please i've been fortunate enough to learn so much from cliff and cliff who's taught dav and cliff often talks about mindfulness and i just want to share how you know we in health care can help other organizations as well so um it was a year ago and i was on a cruise and you have to take the little tender ships from the cruise ship to the different places on the way back the waves were really bad and they were struggling to get us off the tender onto the ship and i had my young son and it started getting so bad that you could feel the angst on the tender and it was hitting against the ship hitting and hitting and my back was there and so next thing you know the assistant captain there's a bunch of people trying to get us off we had hit that water started leaking in and i can see the fear on my son's face and so i literally turned so that he wouldn't see when we were going to hit the ship we hit the ship one too many times and the fiberglass broke and i took the brunt of it so i'm in a tank top and i have blood all up and down my back and we get everyone off i get off i go i have glass picked out but the part of the story that was interesting is i'm sitting in my room and i'm thinking well eventually they're going to call me because they're going to want to talk about what happened and having already been down this road with my daughter i waited and i waited and i thought i'm not going to wait again and i called them i said do you have a safety champion on the ship and they're like we do we have a safety officer and i said i'd like to meet with the safety officer and the captain of the ship i was the one that was injured and you need to learn what you could do better and so what happened that the captain couldn't come but the second in charge who was actually there and saw it and the safety officer came and i had a debriefing with them to say you weren't inside the tender you did not see what was happening and here's what could have been done better and my point is had i not learned what i've learned from healthcare and what had gone on i would not have been mindful to take the next step because i thought of what you and david said if i just did nothing it's stasis but i put something into action and for once it was healthcare giving back to another industry that's incredible and and to be able to channel you know your your grief and loss so positively it's just amazing just amazing i couldn't be more proud to sit beside you and hear those stories and thank you for that effort and that energy and and and above all caring enough because it does come down to that you know one of the one of the things that strikes me is that we keep going back to this concept of leadership right it really does start from the top and and the importance of how it sets our culture it establishes the framework it does everything and so many times i do believe that this work people believe can be delegated um you know watching hospital presidents when you ask them about well who's really responsible for this and they'll say oh it's my cno or it's my vice president of respiratory or it's my chief medical officer um curious to hear some thoughts maybe from you helen too about how in the organizations you've been were you just fortunate enough to get the right ceo or how do you help those folks accept that responsibility because i want to come back to you carol about the fact that the organization you were dealing with didn't obviously initially accept that responsibility now i'm um it's interesting to reflect back i left an organization because i didn't agree with the leadership so you do have power to leave and go someplace else if they won't listen um but the last two organizations i've been in have been terrific um and i think part of it is um it's the leader who can set the tone so we put quality and value at the very front of our strategic plan and we have our bold goals every year and they are endorsed all the way through the organization um and then it's that leader that also says i need a little help around here to get it figured out um so um but Barry Arbuckle who leads Memorial Care he is on our quality committee he comes to all of our quality you know um reviews he he sits and goes on rounds um he's he's just you know ever present but he also knows that he needs a family around him and and our senior team really is a family it's very clinically um focused as well we have a lot of clinicians on the team and so we do daily safety huddles across Memorial Care where we're coming together the ceo is there but so is the rest of the team and then if something's coming so we'll all take that and you take that and so it's kind of this ready huddle break model but um i think it does go back to the leader creates the tone uh and without Barry's support we would not have tied for example yesterday we talked about um we have part of our incentive program is tied to reducing harm and getting to our goal um and that is something that Barry supported so there is that sort of creating the construct um that is just i mean so important yeah that's uh well that's great and i think some uh the the comments of the huddle and that kind of in your in your kind of face every day this is your job this is the responsibility probably has has has leveraged that um because you're right i can't remember which panelists said you know but i think it was you Helen do people know their mortality rates as well as they know what their cash flow was last month and you know i i talk a lot about the quality and safety as a business platform as opposed to a business platform and i still think that many organizations are evolving and figuring out that quality and safety is the business platform for healthcare and using that as a lens helps you to change it um but one of the questions that came in from the audience um Carol was they were curious about did the hospital initially view the sea diff as a preventable event or did they just kind of say hey well it happens um and what really triggered them to finally step up and accept responsibility for your for your daughter's infection so um they cultured my daughter for sea diff and rotavirus and it had to get sent off to the cdc because they had a couple kids that had passed away and they thought that there was a virulent strain on the oncology floor i did not know this until afterwards and for alisha and others that fight these infection battles you know we were talking how important would it be as a patient walking in to know what is the infection rate what are we walking into that we get a choice to say oh don't want to come here that's not going to look so good for us so um you know when we finally found that out that was just you know one of many things that we don't know the chicken or the egg what came first what's interesting is i actually sit on the board of quality um at this organization now and it took us a long time to get to where we could trust each other again and someone from the outside a gentleman by the name of michael Leonard that many of you may know who you know is a big in the safety field he came in sort of had to broker a conversation and what was interesting when i finally sat down at the table with everyone is they started to tell me everything in my daughter's record and i put up my hand and i told them to stop i said i can probably tell you the page and the line because i've read that thing and michael leaned over and he said have you ever asked carol what happened and it was the first time that anyone had ever heard what i saw and what happened and sadly all i think of is all those years of last learning and that's why to ask i think your comment cliffs so much ask us just ask us and we'll tell you because there's so many valuable insights we can give because you all as clinicians come through the revolving door you get 10 minutes we're a constant we see 24 seven nobody knows our family better than us right so we're down to the last few minutes i hell and i don't know if you'd want to share any final thoughts here just um i was talking to Tammy earlier and um not to go too far into it but my father died of a medical error and the one thing i always um i've been struck by is that when i called the hospital and said guess what i did what you did i was like i'm just going to jump in there and of course i was probably their worst nightmare they're like oh um but they actually took the time to sit down with us they was immediate was within a week 15 people in a room with a surgeon and anesthesiologist and everything and um to this day my mother says that while she of course wishes it had never happened um the fact that they took the time and she really understood it and they took the time to honor it and to find out so i mean just this idea of fast communication and really explaining things and even if you don't have all the answers so i've always been struck by that and for us at moral care i just as soon as we just changed that you know risk was over here in patient in performance improvements over here like we need to be together and we have to do this right so i would just encourage everybody to really take that to heart wonderful wonderful comment um one of the ways that i found empathy is to be a patient myself and last last summer uh i had a sore throat i went to an urgent care center and they said you're fine just take these antibiotic go home by the end of the day i couldn't even talk i couldn't even breathe i turned my neck and i occluded turned out i had epiglottitis rare for anybody anymore but especially an adult um thankfully i was taking well care of i was intubated i was on a ventilator but i got to see what it's like on the other side of the tube and again me a new appreciation that i never had before i never want to have again but uh i i think that again be an empathetic and caring and loving our patients is really what it's all about we're thankful that thankful you're well cliff i think we need to understand we all have a part to play we have a target of zero but there are many examples and we've been hearing the last two days we're in part of a hospital or in one ward in one program we actually have saved lives for that patient that was zero harm and let's build on the steps and use all our connections at iskwa we try and uh train young people with webinars and seminars and the life but we also reach out by way of accreditation to the board and the management that govern organizations we actually accredited accrediting organizations to make sure that accreditation is a useful tool so we look at standards we look at management we look at board governance and so on and we we go back to the board and say you are as much part of the front line as is the nurse or the doctor or the respiratory therapist and we need to work together because we all have the same ultimate client it's not the surgeon it's not the physician it's not a nurse it's the patient and their family that's so true carol we'll we'll finish with you so cliff i will just add on to that i've heard many themes at this conference transparency many times systems trust learning but there's one word that hasn't come up as much and it's the one thing it's the thread through all of them it's communication and the thing is it takes so many stakeholders it takes the device companies it takes the pharmaceutical industry it takes systems regulatory hospitals healthcare clinicians patients it takes all of us to make the system safe safe and when you play the game of chess and you put the pieces away the king and the pond and all the in between pieces in between they all go in the same box well i can't thank you all enough it's been a privilege to be a part of this panel and i hope we've been generous energized all of you to make sure you're thinking about are you really listening are you really talking to what your patients and families are experiencing i have this provocative thought that i've been carrying for a while which is you know we do here in the united states patient satisfaction surveys we ask everybody you know was your room clean did we communicate well did we tell you about your medications and as we sit here we really don't know the breadth and the depth of the problem we're trying to solve but we know that it's about a mindset and we know that it's about believing and believing in in zero what if we asked patients how many times they'd been harmed while they were in a hospital what a very different lens on the problem versus what we have today and so i thank you all joe you're incredible you're an amazing individual it's a privilege to be a part of your organization and we would not be here without you so thank you