 Now, I would like to ask two of the hardest working people I know working towards zero with the least amount of ego, pettiness and selfishness to join me on the stage. I'm delighted to let you know that effective immediately Dave Mayer is our CEO. I'm also delighted to announce that Dr. Mike Ramsey is our incoming chair and will become the chairman of the Board of Patient Safety Movement Foundation at our 2020 summit. When I started this movement I could have only dreamed of having Dave and Mike become the leaders of Patient Safety Movement Foundation. Mike and Dave don't need introductions but I'll briefly tell you what they're doing today. First of all Dr. Dave Mayer who I told you was the architect or one of the architects he was very humble of the candor program is right now the president of Executive Director of MedStar Institute of Quality and Safety and Dr. Mike Ramsey who's the chairman of the Department of Antisysiology and Pain Management at Baylor University Medical Center and the president of Baylor Scott and White Research Institute. You also may know the Ramsey name from the Ramsey Sedation Scale. I've been in meetings where people have asked for his autograph. Mike and Dave would you please join me for a chat please come on up. I'm gonna ask you each to just make a few comments but then I want to ask you some questions and if any of you have any questions please send it to me I will look for them here and we'll ask them. Mike do you want to go first? Sure I just want to make one comment and that was as I walked in here this morning Joe noticed my tie was crooked and Sarah Kearney actually straightened it and as I walked away I thought how does Sarah know anything about ties? I never worry. Thank you Sarah. I think Joe we've really got to thank you when you think about it getting down to zero lives lost you think for every life that's lost there's probably a thousand patients that have avoided harm so if you start to look at how we prevented harm in the health care system it's enormous and as we look at where this organization's gone we've gone from the US 200,000 lives we're global we've got representatives here now from many countries around the world Mexico Australia Europe Taiwan Japan I mean it's phenomenal everybody's got on board and it's your drive that's got us there you've looked at this sort of ecosystem of health care which is brilliant in terms of you're not looking at a doctor or a hospital you're looking at a patient a patient's family you're looking at high-tech companies a patient patient's family you're looking at politicians media patient patients family you put all that together and suddenly you've got the energy you've got the input from everybody who's got a stake in this and that's what's made this so successful and it really has been a successful movement sure there's a lot lot more work to be done and we're gonna do it but I think you've got off to a tremendous start I know 2020s next year but look how this movement is vibrant and it's going across the globe and we're gonna have we have a lot lot more work to do so thank you Joe very much indeed thank you thank you I guess I'll have to start taking the time off I can wear a tie you know I can wear a tie and thank you thank you so much Mike it's such an honor to have worked with you for all these years and I'm just delighted that you're gonna take on the chairman role next year I can just imagine the wonderful things you're gonna do Dave well yeah you could see I've already adopted the tireless look I learned quickly I joke with my family I went into anesthesia because I just wanted to wear pajamas to work every day I want to wear a tie but very comfortable without one but first I just got a thank you for this honor and I'm totally honored and humbled to follow in your footsteps and what you've done it's a big challenge but I think we all owe Joe Chiani a big round of thank you and applause for his vision and leadership in creating this patient safety movement seven years ago it was truly something different and I'll share a little bit about that I always say I wish we had 50 Joe Chianis in the world who were doing what Joe did the health care world would be so much better with people with vision and urgency Joe did create urgency he put a bold statement out there of zero by 2020 that took a lot of guts but it created urgency as you heard me say in the video putting a man in the moon in the 1950s ten years earlier than you thought we did it was all a fake Joe we did it ten years earlier but they just was planned it was planned that way but no that was sort of the bold stake and I remember even Don Burwick many years ago another great visionary leader who put out a bold statement that we're going to save a hundred thousand lives in 18 months and that created action that created urgency I don't know about you but I've been doing this work for too long and I'm sort of tired of tying to PowerPoint it away trying to go hear somebody talk and then go back this is an organization about commitments and so I thank you for raising that urgency I know many if not all of you in the audience and I know how passionate you are about this and how committed in the work you're doing is great but as Joe said we can't lose that urgency we must maintain it and zero must be the only number I loved how you set it up there at the podium on the screen because one is still way too many so I look forward to working with all of you over the coming years and let's really make this a reality let's really continue that urgency that Joe instilled in us which makes this organization so different from I believe others so thank you thank you so much I like what you said about it being an honor because unfortunately you're both not getting paid anything for doing this tradition that'll continue I hope because because we can put the money into so many other usage but I want to thank you both and I want to ask you you know what what's yours what's your agenda going to be what's yours what's your plan what do you want to do I'll start with you David maybe Mike you could you could talk about hopefully shared by the two of you yeah you know Joe I've been involved with you for the full seven years and it's been an honor so many of the things you have instilled and believed in in this organization are things that I believe are critical to the success of achieving zero preventable deaths first you brought the patient of family members into the room from day one and friends of mine have heard me say this many years now I've learned more from patients and family members about how to improve quality and safety in my role as a leader in different organizations than I have from my contemporaries so I thought that was wonderful and and the stories and their involvement in panels was something that was very important to me too you talked about transparency and I'll share more in the panel this afternoon but that is key somebody in the I forgot who it was in the patient and family meeting breakfast meeting this morning said you know it's about transparency it's about learning from the events and the accountability to enforce change to improve that environment and that was so right on and so I believe as you know in the transparency model education has always been dear to my heart and I love the work that's been done around the curriculum we struggled for 20 years to try to change the environment in medical schools and nursing schools nursing schools have been I think way ahead of us and compared to medical schools with the Cusin project and other things they've done but if we don't know many and no I said many years ago at a panel when asked what was the one thing if I could say in one sentence what would change and create a better safety environment I said educate the young and regulate the old got me in a little trouble with some of the members of the audience but but I really believed in that if you want to change culture like aviation and nuclear energy did you've got to instill the competencies the knowledge and the skills in this new generation so they come equipped much better than Mike's my generation ever were trained in quality and safety so those are certain elements that I am very keen on and want to make sure that we all continue to move forward well the the candor program that you helped architect I call that health care 2.0 I love what you're doing and I hope that becomes embedded in the patient safety movement recently we were meeting with senator Maggie Hassan and she said something that I that I love she said what are we going to treat every patient's death the way we treat an airplane crash instead of a car accident and to me the candor program is exactly that it's treating every death as a plane crash that you got to learn from instead of a car accident that we just think well it happens yeah imagine you know again I'll expound on these a little more in the panel this afternoon but imagine if we left a plane sitting on a runway for four weeks and said you know what we're just too busy to get out there and understand what happened that's what we do with patients and family members we say you know what we're really busy to we got to go back to work but we got some time three weeks four weeks from now to start thinking about doing a root cause analysis I know we never showed that urgency to the patients and families many years ago and and we learned these are plane crashes in their lives and we've got to respond the same way the NTS NTSB responds and in all the elements of learning support finance whatever it is. Thank you. Thank you. Dr. Ramsey. I think we've got to make our hospitals safe and right now when a patient comes into hospital with an illness they're frightened they're nervous and they want to get to the safe place but the safe place is home it's not the hospital and we've got to change that and I think we are I think this movement started that change the hospitals are in general getting safer you know that nurse coming in that doctor coming has actually washed their hands before they touch you I was a patient in the hospital I made sure that happened and I think they were very glad to see me leave but it embedded in how serious it is and now if we get for instance a central line infection it's just as you talked about it's like a plane crash why did we get it and when you start to take I forget which number app it is now for the CLABSI but we've got ours down for the last three months to zero the only ones that we get are ones that get transferred into the hospital so we can get down to zero it's possible respiratory depression from the result of opioids we haven't had a death in nine years because we've instituted everything that's in that app number four and do we get respiratory depression still yes we do but it's early we pick it up early we get it treated patients don't have to go to the ICU they're not at risk well everybody's at risk I'll take that back but we've got measures in place that make it much much less risk and so that's an impact of this movement is the impact of what these apps can do and I really implore everybody read them and take them back to your institution take them back to your healthcare folk and ask them could you do this could you institute this in your facility and if you can't why not if you got something better and if you got something better bring it to us so that we can look at it and see if it is better and if it is then we can change it thank you thank you where's the seven action will pay the seven objectives let's put those up on the board I want to talk about them we call them guiding principles sometimes sometimes we call them the objectives if you guys could put that on the screen what about the transparency and aligned incentives so tell me tell me your thoughts and your take on what we should do about that I loved your comment about the children's hospital out here and aligning incentives look it's done in every other industry where performance is you know based on incentives and if the incentive as it is today is to do more volume versus do higher quality that drives the measures and while we talk about moving from quantity to quality it hasn't occurred as quickly as many of us as hope so I think if you don't and if you don't hold yourself accountable there's a great line the best way to starve a pet is to tell two people to feed it you know you get to the point where no one owns it and and we found historically that unless you own it you know no one's accountable and that's where the transparency and accountability is so important the ability is changing I know we're now taking on big contracts with different organizations where we're taking the risk of taking care of those patients so if we don't do a good job it is gonna cost us and so there's a financial input now to make our hospitals better quality safer and partner with the patients to get them through this in in good shape and that's where I think we're getting to so I think that's getting the politicians and the payors involved in this as well as just health care workers and administration I'm not aware of one of the actual patient safety solutions that will actually increase costs even though they're gonna save lives to the best of my knowledge every one of them actually reduces costs too are you would you would you anyone would disagree with that I think Deming was right for many years and you improve the quality you lower the cost of what you do and I think there's great examples of that in health care even today so yeah you improve quality reduce risk you see better value how much did MedStar save some supplementing candor well we've been seeing tremendous reductions I'll save that for Larry Smith to share Larry Smith our risk officer is on a panel and I don't want to steal any of his thunder but it's been huge I'll tell you at University of Illinois when we implemented the seven pillars there was an article published just over a year and a half ago on those results talk about less claims shortened time to resolution and at University of Illinois we saved over a hundred million dollars in seven years I want to review these with you and just get your thoughts about every one of them so we're going to go one by one because I want to know if we are sharing as these goals as yours one unified the health care ecosystem hospitals health care technology companies government agencies policy makers patient advocates clinicians engineers payers everybody what what's your thoughts right well I think it's happening is just as I was saying I think now politicians have got into it I think payors which is much more important to the hospital have got into it and you're going to get paid for quality work and you're going to take on that risk and that's going to make us all better and the patients are going to do better and so I think pulling everything together there plus you know instead of having six boxes in the OR and we're looking at this monitor this monitor this month we've got them now starting to talk together so now we've got even artificial intelligence coming in saying this patients blood pressure is going to drop in 15 minutes unless you do something they're getting ahead of me but but speaking of payers we have insurance companies that are willing to give discounts to hospitals that have implemented the apps we need your help with one document see Ariana if you can help us there's a document we need that from your hospitals one of them that's not self-insured that could get these insurance companies running but yes payers wanting to incentivize wanting to pay I'll even add to that that in this state beta health which is a large you know med mail carrier for hospitals I think roughly about 250 has put incentives in so for any hospital that implements the five components of candor in the candor toolkit they get a 10% reduction in their medical malpractice costs because they know that the program will bring great benefits to both the hospital as well as to the insurance company wonderful so that's a great alignment but you know to the bullet one we should never compete on safety there are other things we could compete on across health systems across what you've done in technology of trying to line the companies we should never aviation never competes on safety have you ever seen a commercial that says we are safer than this it happened once and they shut that commercial down so they understand they'll compete on other things but they share everything about safety well I I totally believe when it comes to patient safety we have to put the competition aside and work together I think you can see the benefactor on this list is my main competitor metronic and I'm very glad that they joined Omar ishrock think is a visionary to step forward and and join in here but I do believe that we should get our we'll get to I guess I'm getting ahead of myself okay number two identify the challenges there are killing patients and create actionable solutions we call them apps to mitigate them do we have more to go or there are more apps we need to create do we just need to take the ones we have right now and improve them no I think we're going to I think we've hit the major ones but I think we're gonna have more input from people and as more and more people get involved in this movement and they're gonna say what about this what about that couldn't we do better job here and I think as we show success with the ones we've got we'll fine tune them and then we'll we'll get more and then I think actually we'll we'll move more into the preventing harm as much as preventing death because I think that's incredibly important as well I think we still got to do a lot of work around systems and processes I never met anybody who comes to work each day in a hospital or a clinic that wants to harm somebody I mean they're devastated you talk to people who have been involved in a catastrophic event and it really wasn't you know to air as human as we say and you brought up it's I always said because I didn't put the right process and system to protect that health care provider at that time they made a decision that I probably would have made if I were in their situation based on the environment they were working in so if we don't figure out how to change those systems and processes and it's a whole redesign again we'll talk about it this afternoon but we can't continue to put band-aids on and think we're making remarkable changes we've really kind of redesign how we provide health care and you're right we are look we're looking at delirium now I think the ASA brought to our attention delirium is a serious problem and we're looking at that as hopefully the next apps that we'll create ask hospitals to implement the apps all of them what do you think about that one I think it's something we've got to do but I think they've got to listen to us and that's hard I think we've got to have advocates coming from lots of different directions that's why I think everybody here's got to help us move the needle they've got to come in and ask their hospital administration ask their physicians ask their nurses what are you doing look here's a list of apps that are out there that have been proven to save lives why are you not instituting them and and it's not that easy to get people to listen because I think there's a certain barrier that they feel like well we don't we don't make mistakes in our hospital and we've got to you know we've got to be transparent we've got to bring out when these things happen I think it's leadership you know it starts at the top and if you don't have the leadership in place to embrace I mean Peter's here today Peter Pronevost the central line bundle you know it still amazes me that some people don't follow something that is evidence-based and proven to get to zero preventable harms then only associate we've no certain things that will get us to zero in those areas you know to your point shame on us for not implementing them and driving those numbers to zero in those areas some of the other areas the culture and things are a little more tough to challenge and took aviation 20 years to change their culture but we can't wait 20 years we've been on this we have waited long I hate the word journey it's just I'm too old for journeys I want I want the urgency now it's we can't continue to to say we're on this journey and no it's why I love your urgency well and we've been on this journey for 30 years yeah and it's okay maybe 20 from the I own report but I don't know if you've read that brook the great white lie by Walt Bogdanich it's it's it's incredible same thing still happening yeah and you know and I know we're kind of jumping maybe to promote and transparency online incentives I mean is I feel like we've got the group here many there are not here today there are part of this movement but that's a fraction of the hospitals do we need ministers of health we need legislators to mandate aligned incentives and transparency I think if payers get in line and buy off on all this and we sure Patrick Conway there was on one of those videos from when he was with CMS I think that makes an enormous difference once they come in and say we want these measures of quality in place we're not going to pay you that's powerful incentive unfortunately money seems to be more powerful than losing lives but we that unfortunately is is where we are and that's a big driver but fortunately I know I know in our hospital administration they're very focused now on preventing harm and you know every week we have best care meetings every week we're looking at numbers we're looking at mortality rates we know having done the sepsis bundle that our sepsis mortality rate is way down it made a big difference and we can prove it and I think that's what we've got to start expecting from every hospital show us the numbers because data speaks yes yes and while we don't want to compete on patient safety in a negative way where we take confidential information of patient safety from another hospital and use it against them because we want to share that I think it's totally fine that patient safety is displayed prominently at the doors and websites of hospitals listing how many preventable harms they've had so that consumers can learn where they want to go but more importantly each one of us have to look in the mirror and say do we want that do we want it to go lower what do we do about it I think that kind of a competition is a healthy competition and one that we should we should be pushing for do you want to add anything to that no I think ask health care health care technology companies to share their data this is not internal data this is data their products are purchased for this being displayed because we know that human beings have a tough time processing historical data and coming up with an answer but computers are great at it so to have a to have them share the data we think it will revolutionize the process of finding the problems and you know making sure you're acting based on all the information so what do you think about that I'm excited about Baxter joining we didn't have an infusion pump company I think that'll now hopefully steer the others to do it spur the other ones to do it because you know one of these we've always said and my competitors have shared their data so this is not self self was what I'm looking for promoting but I urge hospitals to not buy products from companies that don't share their data because I want everyone to eventually share their data so that that doesn't become a competitive issue so what's your thoughts on sharing data why I think it's critical I mean without it we're sort of operating without a hundred percent of the information you know Mike touched on the predictive analytics and and artificial intelligence I don't know you know for the physicians and nurses in the audience I don't know I never learned how to use an ophthalmoscope but I'm trying to look to see if I could see you know retinal injuries and diabetic changes why we've got computers even ophthalmologists sometimes have tough times picking it up with predictive analytics and now with artificial intelligence you could get all the answers that you need and thus make better choices for the patient versus trying to do it all so I think those types of tools that help support us we talked about sepsis I mean that's the alert bundles and nurse activated protocols we don't need a physician to call and you know try to reach for three hours to start sepsis treatment the predictive miles are showing that this patient has hit the risk factors let's just start treatment and we'll tell the doctor when they eventually call back those are the types of things that are starting to show some great success I think I think that's the area we're in now which is helpful to clinicians particularly when you're in a high activity area like an operating room or an ICU to be able to have something to pull together all the data that you're getting and make sense of it and alert you in advance of something bad happening that's a tremendous help tremendous I mean when you look what we see we are now I mean just take something a little bit different like breast cancer now there's a computer that can pick up breast cancer on a scan better than the human eye that's what we want we want computers to be better than us to give us the information so that we can intervene earlier than we would do if we're using our intellect and the areas computers can't be better many areas they can't be but in those areas they can look at what it's done in aviation I mean you talked to pilots I have studied aviation my whole career because I think there's such a wonderful learning from them but you talked to pilots today and they'll tell you they're not pilots anymore they're risk mitigation experts the planes could fly themselves we know that with drones I mean so what they're there for is to understand risk that is coming into a system that maybe the computers of the autopilot aren't capable of sensing and to make the adjustments that need and pilots used to hate autopilot when it first came out now many of them love it because it allows them to focus in on the most important things and get rid of the mundane boring stuff that they got they thought was tedious after a while so we've got to start thinking more like that I believe and it's possible please please down to Australia last year and I got a chance to get into the cockpit of a 380 and looked at all the instruments that were there and there was only one thing that moved there was this one stick sitting there by my right hand so I said so what does this stick do and he just looked at me and he said push it forward houses get bigger pull it back houses get smaller yeah well I I want to just hit the last two promote patient dignity and love so what it's all about I mean it's Carol Hamilton is taught me it's the patient first last and everything in between and I love that quote of hers and that's what it's about Berwick has been wonderful in the stories he shares about we are guests in their life they are not guests in our life and once we adopt those principles and embrace them I think we'll be a lot closer to that zero by 2020 I think the problem is so that we put work pressure on nurses physicians as well you've got so many patients to see get this patient out of this room by 10 o'clock we can get you another very sick patient in in an hour and it starts to distance you from the fact this is a human being this is somebody that you've got to love this is somebody you've got to be there to help and it's not a commodity and yet the work pressures drive us in that direction and we have to be able to pull back a little bit and this is number one the patient and patients are so much about their own health and their families know so much about them that when we don't give them that love and that dignity they can't help us they shut down they're afraid to speak up last but not least educate providers young and old health professionals and training patients and families about patient safety while it's been my passion you know many in the audience know we started the telluride patient safety roundtable for medical students nursing students and resident physicians 15 years ago we had experts come together with create a curriculum and it was around transparency and open and honest communication being the key patients and families teach side by side with us at this at these camps we're now up to six a year we do four in the US we do one in Sydney Australia and one in Doha Cutter with the same curriculum and we've put over 1200 future health care leaders through the curriculum it's a week-long immersion it's supported their scholarships so that it's all free for the students and residents but it scholarships by medical malpractice companies of all people because they believe if you educate the young you will lower risk later and will make everybody better off and stuff and I love the emails I continue to get from these kids who went through seven eight years ago and how their chief nursing officers and their quality and safety officers we've got a wonderful girl from dignity here who went through our camp two years ago and she's up here gonna make a commitment so it's it's it's the heart of what I do and it's why I love education I just echo that I mean we've got the American Society of Anesthesia here we've got the European Society of Anesthesia here the Mexican College of Anesthesiologists are here I've been down there talking it's about safety and these big organizations are putting safety number one that's why the co-covening this operation today I think that that's the signal that finally safety is really in the forefront and that's where we need it to be I'm very excited the number seven that this year we're introducing the curriculum very I really believe the trick with the curricula and the challenge to the team was to make it something that everyone could implement as I know there's been others but they get put on the shelf it's hard to use them and I hope you agree that what these gentlemen and ladies have created is something that can be used I'd like to see us as an organization go to the LCME start changing we always say assessment drives the curriculum and until the board start putting questions on the national board exams and the LCME accreditations of medical schools still start asking for what the curriculum is around quality and safety otherwise we're not going to credit you as a medical school it's like trying to change culture in hospitals when you don't have effective leadership so the curriculum is great now we've just got to make sure that the regulators regulate it and bring it as a mandate into medical schools and nursing schools we have several questions from the audience I want to ask you some of them one of them was then I was gonna ask you I'm glad you're asking it and I can't tell who's asking it but I'm gonna say the first one is there gonna be a new goal tied to the mission after 2020 passes or we're gonna be bold enough to do zero by or some other goal after the 2020 passes I'll get into that a little bit I think you've started something now that initially was the United States now it's global mm-hmm and it's it's an enormous task and but you've got it you've got a vibrant organization we've got to keep that alive we've got to keep it dynamic and we've got to make the globe a safer place and we've got to make medicine and health care across the world safer and I think what you've started is just mushrooming and we've got to keep that drive going and it's gonna be a challenge absolutely but we can do it what do you think Dave I you know you said it well in regards to one is just way too much and we've got to figure out how that's aligned and how we come up with a statement that continues to create the urgency and if we got to put another stake in the ground we'll put it there but I think we've got to be it's the urgency we can't lose that and we've got to be bold I've got one question for you and I'm sure there are many it sure it's on there how are you going to remain within this organization that you've built and nurtures because we can't do it without you and I know you're gonna stay on the board but I would think many people want to know what are you gonna continue to do to help Mike and I I know the answer already but I just wanted to well I'm not leaving I'm not quitting but I really but I really felt for many reasons including the goal of patient safety with a mission it was good for it to have in new leadership this cannot be about me it never was it was about the mission and I think by the two of you coming in it reinforces that this is about the mission and I'm gonna help you like everybody else here like the two of you helped me I'm here at your disposal and I'm dedicated to this whatever goal we pick it's mine as much as it's yours so 0 by 2025 0 by 2030 you have a taker what do you guys think if should we do another bold goal like that 0 by 2030 2025 raise your hand if you think we should do it alright so what is it raise your hand if by 2025 it has become global 2030 you're 35 no I think so I got more hands at 2025 yes so we should because it does need urgency it does it can't be a journey the journey start at 30 years or we got to get to the end and you know I've said this before many companies many people here are from companies that make things like mine if we have a failure rate like this we stop the line and we don't manufacture till we figure out what's happening so you know to me elective surgeries shouldn't be happening until the hospital have put together all the apps at minimum I'm not saying the apps are going to be the cure for all but it's the minimum thing we can do safety measures have got to be hardwired into every hospital absolutely I got another one Richard Branson office says take care of your employees and they will take care of your customers how can we better care for our providers to improve patient outcomes right on I mean that's a perfect statement like I said so many times we put people Mike talked about the pressures of running faster jumping higher and doing more and stress that's called look we've got everybody in this audience knows it I mean 400 physicians in the US commit suicide every year it's two medical schools that basically are wiped out from the stress and the burnout nurses suicide rates are higher than the general population Lucian Leap many years ago said we've got to bring joint meaning back into the workplace so how do you celebrate people with good catch programs how do you put in care for the caregiver programs and support most of the care for the caregiver programs for those that you know this already if you have them they're not responding all the time to just patients who have been harmed unintentionally but preventably they're responding to their colleagues and their partners who maybe work with a patient for seven eight days and got to know the family and forever the illness lost that patient that's stressful that takes a lot out of you I don't know how many saw the the photo that went viral about two years ago of an ER physician who walked out of a trauma unit after trying to save a 17-year-old who was in a motor cycle accident the paramedic stayed around they worked on the boy for 90 minutes and they lost it in this ED doc just walks across the street kneels down and starts crying and then has to get back up five minutes later and go back in and deal with another trauma event I mean the stress we put our caregivers on so we've got to bring joint meeting we've got to be respect and we've really got to support the teams because if you don't take care of associate safety again I don't know if people realize but being a caregiver is the most dangerous job you could have more than a construction worker with needle sticks falls Larry Smith leads our associate safety program it does an amazing job but we're seeing those numbers come down because we're focused not only on patient safety but associate safety like I think there's no doubt we have to be accountable and I think everybody understands that in the health care profession but when you make a mistake why did the mistake happen and and I'm preaching to the choir here but we have to look at what was the process because it's incredibly stressful did somebody make the mistake because they were just lazy possible and that's the accountability part but we have to look at the process and say why did that mistake happen was that was the drug lately not correct was was there some process that we could change to make things safer and stop that mistake happening that's what the airline industry did you know a pilot can come back and report a near miss and provided he reports and he did things correctly they'll look into it and try and make a correction and we have to make health care safer from that perspective that we all have tools that are really very dangerous and we're working under time constraints that make it even more dangerous and we have to use processes to try and prevent that happening and make make the workplace safer for the provider last question to you too then I'll ask you for your closing remarks I know we're running a bit late but we plan for this potentially we gave you bigger breaks than ever before so last question Joe mentioned his frustration towards people with apathy towards planning for zero how do you think we can help or force clinicians and hospitals move away from apathy and towards action don't pay for apathy don't pay for apathy I like that regulate the old I'm a big believer in pay for performance I think you know I've got enough gray hair through my years to see that when those measures were started to you know began to put in place whether it was skip measures or core measures or whatever they started changing people's culture back at University of Illinois I couldn't get our ORs to get above 45 50 percent of antibiotics skip compliance within the first hour of the city you know all the things that we knew were evidence-based and the moment CMS made it a pay for performance measure within six months we were up to 98% and all the sudden people took notice because they said oh we're gonna get penalized if I take the scalpel too quickly so you know I really believe there's got to be a balance of education driving evidence-based practice but the apathy only goes away when there's some incentive tied to that either good or not good I think you're right any closing remarks for the moment I know you'll be back here again with us today and tomorrow no just thank you for all you've done and creating this amazing global experience to listen to the people that are here and coming from all over the world I mean ten people from Taiwan that's a credit to you Joe and your credibility and your passion around this so thank you thank you so much let's just say we want the support of everybody in this room please you've got to help us we're gonna move the needle together and let's get more people involved let's get more hospitals involved and let's make this a safer place thank you thank you thank you so much thank you for taking this responsibility