 If we are to achieve our goal of zero medical errors, we will need to reimagine the workings of every setting in which care is given. We will need to redesign our systems of care. We will need to create a culture of safety, a point that every speaker before me has made. And we will need to build safety into the education, the very identity of every caregiver. So Joe has charged this working group. The group is chaired by me as Dean of the Geisinger Commonwealth School of Medicine, and together with Dr. Neil Martin, who is the Chief Quality Officer for the Geisinger Clinical System. As our goal is simultaneously to integrate safety into the MD curriculum and integrate these curricular efforts into system improvement across the clinical system. And our goal of the working group is a truly pan-professional curriculum and to seek the endorsement of professional organizations and accrediting bodies. So this is an ambitious goal, but Joe is not a person who is modest in his ambitions on behalf of patients. So as the working group is working on a pan-professional curriculum, we at Geisinger are already moving to revamp our curriculum to brand new school, and our curriculum is only eight years old. We're already revamping it. And we're planning to do this in 2019 with a new curriculum in which patient safety will be a substantial thread woven across all four years of the MD program and into residency training. That effort at Geisinger is led by Dr. Margaret Shoemaker. The Patient Safety Movement Foundation working group comprises leaders from a range of health professions, a systems engineer, a psychologist, expert in team dynamics, and very importantly the patient voice. It includes among others the members of today's panel. And we are guided by the principles that we agreed upon at the outset of our work last summer. There should be a base core curriculum that is common to all health professions and then deeper content that is specific to each profession. But the curricular content is only part of what we need to create. We need to make patient safety central to the professional identity formation of all health care givers. That identity needs to include a sense of working in teams rather than as isolated individuals and to impart the skills of interprofessional team-based care. And critically important to all of this is training in an appreciation of safe communication. This slide illustrates the basic elements of our curricular approach. The domains in the center of this image, error science, system science, technology, and human factors are labeled core not because they are more important, but because they can be taught independently, they can essentially stand alone as content. The domains beyond the central core are interdependent and cannot be pursued in isolation. They include effective teamwork, safe communication, which is transcendently important, leadership training, and the ability to lead change. We want to create in our learners a sense that they own safety and that in their own systems they're not just responsible, of course they are responsible for the safety of their own individual patient, but we want them when they identify system problems which we know are responsible for the majority of errors, that they take ownership of fixing the system so we want them to understand system science and know how to lead change. All of this building towards a culture of safety to achieve patient-oriented safe care. So our curriculum will not differ substantially from other valuable curricula that have been published by the Institute for Healthcare Improvement or the World Health Organization in its content, but it will be novel in its delivery and in its goals in focusing on professional identity formation. So for example, more than focusing on didactic content, which is important, we aim to shape the professional identity of caregivers to incorporate the patient's voice, not just as examples of cases, but incorporate the patient as partner in achieving a safe culture. To make the delivery modular and adaptable with active engagement of learners in degree programs, post-doctoral residency or other training, and through the continuing professional development of fully trained practitioners. To achieve not merely information transfer through this curriculum, but moving the learner from knowledge and skills to intention and from intention to behavior, all of which will produce learners who will inform and lead change and create a culture of safety. Alicia's video gave a palpable example of an unsafe culture exemplified by the arrogance of the infectious disease specialists, indifference to the patient's own observations, and too many examples of unsafe communication. This emphasizes the importance of addressing professional identity, including humility, which is essential to teamwork, the critical value of the patient's voice, and certainly the importance of safe and effective communication. So we're fortunate today to have a panel of respected leaders and thinkers with a range of perspectives, and I will ask the panelists to come up please and join us on the podium or on the banquette, and I'll ask my colleagues to introduce themselves briefly and we'll start with someone who at this point probably needs no introduction, Alicia Cole. Thank you. You saw just a small fraction of my story, and people often ask me, what was the worst part of what you've gone through? And one night the doctor came into my room and he said, Alicia, I don't know if you're going to make it through the night. And if you make it through the night, I need you to know that in the morning, if there's a choice between taking your leg and saving your life, I'm going to take your leg. That was the longest night of my life. And that night I dedicated my life, and I said, Lord, you take my leg, you do whatever you need to do. But I promise you I will spend the rest of my life speaking out for patients and families and victims and survivors of medical harm and bringing their voice to the table. And so I'm honored to be a part of the Patient Safety Movement Foundation, and I'm honored to be a panelist here today working on this important subject of curriculum. Thank you. Good morning or good afternoon now. My name is Mike Durkin, and for the last five or so years, I've been privileged to be able to lead the patient safety system in the UK or in England as the National Director of Patient Safety. The UK, as you've heard, is a universal health coverage system. We have 500 hospitals. We have 8,000 general practices. We employ 1.4 million people. But we concentrate on hospitals. We concentrate on hospitals. We forget about the home. We often forget about our 600,000 people who are captive in care homes in their social settings. We often forget about those who are captives in prisons. Those are in asylum-seeking detention centres. There are many other parts of our system here and our systems around the world where we also need to start to look to help and support their safe care for their journey themselves. So thank you. We're talking later. So that's enough for me now. Thank you. Good afternoon. My name is Phillip Greiner. I am the Director of the School of Nursing at San Diego State University in California. Good day. My name is Annegret Hanawa. I'm a Professor of Health Communication and I direct a Centre for Health Care Quality and Patient Safety at the University of Lugano. My work focuses on safe interpersonal communication as a pathway to safer care and have developed a model that can help us save patients' lives and also make health care institutions more resilient to failure. Good afternoon. Excuse me, Ron Jordan. I'm the Dean of Chapman University School of Pharmacy in Irvine, California, Orange County, California, the home of the patient safety movement. My faculty and I have been engaged with the patient safety movement for about five years and I'm also a former President of the American Pharmacists Association and have been working on patient safety and safer use of medications for my whole 40-year career. Thank you. So we're now going to promote a discussion among these distinguished colleagues of mine which will leave time at the end for your questions. So we encourage any of you who have questions about our curriculum to submit them on the app and we'll be able to pose, I'm sure not all of them, but at least some of them at the end of this discussion. So I'd like to begin by asking Anna Gret about safe communication because studies have shown and you've contributed to this body of work that 80% of serious adverse events are caused by communication failure and the three-quarters of patients in such events die. So I'd like you to talk a little bit about what is unsafe communication, how does it happen, and what can we do about it? Thanks, Steve. So I've asked myself that question for the past few years and I've analyzed hundreds of cases now gone through patient safety events line by line to find out from a communication science perspective what is going wrong, what is contributing or causing to that harm. So what I've found is there's five things that keep going wrong all the time, persistently through all kinds of patient safety events triggering that harm. So what we need to be doing is looking at those five things and correcting them. So what I've done is identified them into five different competencies, core competencies that we need to be implementing to addressing those causes of patient harm. So what are they called? We summarize them in such a we need to be more sufficient in our information exchange. That's what the S stands for. Accuracy is the second part. We need to be facilitating our communication with each other to ensure that we're talking about accurate content, that our understanding is accurate. We need to be more clear. We all know the unclear handwriting. We all know there's many facets to that. We need to be contextualized in our communication. That's where timeliness comes in. That's where interprofessional barriers come in. And we need to be recognizing the needs and expectations of our counterpart, not just as a patient centeredness tool, not just as a patient satisfaction tool, but as a safety instrument. So those are the five core processes that keep going wrong, that keep preventing people from finding a shared understanding and that keep triggering preventable patient harm. So what's different about that approach? We've done a lot to improve communication. We have team steps with IAPAS and SBAR. We have CUS, we have CANDOR, we have spikes. We have all these tools we've implemented, and still the issue persists. So what we found in these case analyses is that it seems to be that fundamental understanding of what constitutes those safe processes that seems to be missing. To give an example, we all have different labels. Everybody plays this game. In Germany, we call it the Stille Post. We, you guys, call it the Chinese whisper game, the telephone game, whatever you want to call it. We all know, we knew it as children, that if we, if I would tell Alicia something into her ear and we would be whispering that, Steve would be having a different response to that. It wouldn't be the same anymore. So we assume we can pass information through people. Why do we have a handoff problem? Another example, we assume that communication can be conveyed through information. But we know that only 7% of the meaning we get from messages comes out of words. 93% of the meaning we get from messages comes out of the nonverbal communication. So imagine how much potential we have to improve the application of team steps, of iPass, of if we would just build the fundament for safer sense making underneath those. So that's a different approach. It's not rocket science. You can count them off in one hand. It's easy simple to implement. And what I think is we have a potential of improving 80% of patient harm. But I also believe that's where safety culture starts. We keep talking about safety culture as something that comes from the roots out. So what does safety culture mean? Safety culture means that asking questions is no longer a may, but a must. Safety culture means that silence is a compliance problem. Safety culture means that whistleblowing is expected from colleagues and not punished with evil looks. Safety culture means that we naturally include patients and family members and care companions in assistance for safer patient care. Safety culture means that we no longer assume that communication has taken place. And if it has taken place, we no longer assume it has led to a shared understanding. And safety culture means we do not wait until tomorrow. When 80,000 more patients have died because we don't have to wait until 2020. We don't have to wait until tomorrow. We can start now. While we're sitting here in science, we're developing the curriculum, the educational contents, to make a difference. We're developing the testing to assess safe communication and prove it in institutions now. We're developing tools for patients and care companions to participate in safer sensemaking with our practitioners. So we're ready to start, because in the end, healthcare, at its essence, no matter how much advanced it becomes, will always remain an encounter, an interpersonal encounter. And it's at that encounter where the nurse and physician and patient meets, that encounter will decide if patient safety or harm will occur. So it's our task to make that encounter as resilient as we can. So that's tremendously important. And what you have been talking about is communication as creating the right culture. And so I'd like to pose a question to Mike, building off of that. We saw in Alicia's video too many examples of physicians who failed in their ethical responsibility as reflecting an unsafe culture. And yet we know that learners, more than the didactics we deliver to them, will often, in terms of their behavior, model the behavior of the culture in which they're trained. And so how do we go about building that sense of ethical responsibility and changing the culture? Yeah, thank you, Steve. Nice easy question to consider and ponder. And there are many people in the room who I'm sure want to contribute to this. For me, I break it down into some simple elements. And that the core of the elements is to move our conversation around professional identity formation in whatever profession, healthcare profession we are, into a shared ethical dimension of our identity. And to remind ourselves of our ethical responsibilities, not as a healthcare giver, but as a human being. And first and foremost, and I suspect that in our current curricula, in our current teaching methods, whether that's an undergraduate, postgraduate learning on the job, we've forgotten some of those basic ethical dimensions. So it's absolutely essential for me to see that as a core element of any curriculum that we develop. So what are those elements? Now we've talked about leadership and the ability to lead, but also to be led. But I think within that we've concentrated on the political leader, we've concentrated on the professional leader, the manager leader, the patient is a leader. The patient is on their own journey. They're leading the way. We're just supporters of them as they go through their change. Many of our patients now in the latter decades of life will have three or four different, maybe up to 10 different coexisting medical conditions. They will have multiple impacts from many of us as privileged to be able to offer them care. We need to see the patient as a viable leader in their own journey and respect that position that the patient holds. Deming and Donabadian, two wonderful architects of improvement and of systems generation and improvement, both brought us together in slightly different ways. They are the concept of process and outcome will improve. If we get those two things right, that will improve our clinical outcomes. And in any business system or any manufacturing system, getting the system and processes right. But they also recognized, particularly Donabadian, that it was the ethical dimensions of the people who work within that system that are ultimately the driver of whether that system is a success. So what are some of those key elements of ethical elements within that? First and foremost, I group together a system of principles that the operates around trust, honesty, respect, and compassion. Those elements are core to how we behave towards each other within a successful system. They're core and need to be supported and generated in any curricular changes. But they are actually essential as we work within a team, an interprofessional team, with no hierarchy except that the patient is at the center of that team. How can we help demonstrate that those are really in play? Now we've learned in England in a scrutinized media system how important transparency is in terms of sharing information but also in terms of helping, using it to drive improvement. So transparency is key for this. But equally key for transparency is the data sharing element of transparency. We all have and own lots of data from our clinical workplaces. But that data is the patient's data. We need our patients to be able to own their data and use their data and we absolutely have to support them using that data. Whether that's at the manufacturer and developer and innovator level or whether it's at the practice level in our operating room, in our general practice setting on the ward or in the home. Absolutely vital that we do that. Without true transparency of data sharing, how can we be candid? So candor is the second element, key element of sustainable change. To be truly candid, we all need to have the same information at the same time and no one should own it more than the patient in that respect. So when things go wrong, we absolutely have to be candid about that but in the knowledge that all people have the same level of information around it. Third element for me on this is courage. Alicia showed huge courage in her ability to see through the journey that she was on but she had to also do it in a confrontational way at some element where she disagreed and I had to have a conversation like we should not be having to do that. We should not be creating an environment where patients do feel that they have to confront and challenge. That should be the day of regard of the clinical professionals who are looking after our patients. The last thing for me on this, I think which is probably the most difficult but others in the room who've heard me say this before is I think is essential. So when Donabadian was talking about the ethical dimensions of the individuals that are really the key to driving a successful system, Joe mentioned it earlier in his opening remarks. Donabadian and I also think the same way. The key essential ethical dimension that we all need to have in our daily work is love. That's not the soft, fluffy love. It's the commanding love. It's the love that generates respect and honesty between ourselves. We use it often in our family life. We should need to use it more in our professional life. So a love for our team, a love for our patient, a love for the organization within which we work and hope to develop to become better. And in this context, I love for each other. So thank you very much, thank you. Thank you very much, Mike. That was very powerful. Alicia, do you wanna add to that? Can I piggyback on something there? As a patient, I want you to love your job. I want you to wake up with a passion every day. You don't have to love me. I want you to love what you do, but you will respect me. That's what I want from you. I want respect. I want you to see me as a customer. I want you to see me as a partner. And I think when we talk about curriculums, I'll give you an example. In one of my past lives, I used to be a senior litigation paralegal. Now, in the legal field, when first year attorneys come into a law firm, they know nothing, and that's okay. They fully admit, I know the law, man, I know cases, I know history, but I couldn't do a pleading to save my life. I don't know how to do the practical day to day. I don't know what to do at the courthouse. And so you're taught, coming out of law school, that you partner with the senior paralegal, and you become one with that person. It's like Batman and Robin. That's your team. And even as you go on through your practice through the years, there are attorneys who will not go to court without their paralegal by their side. We don't have that in medical school. Doctors and nurses don't have that same kind of respect for one another and admiration for what each other's job descriptions are. And I think we need to incorporate that kind of respect into our medical school curriculum, because honestly, if you can't even treat the nurse with respect, you're a second year doctor, and there's a nurse with 35 years under her belt, and she says, well, you know, doctor, I'd like to make a recommendation or would you like me to call for a consultation? And he says, no, he doesn't respect me either. There's no way he really can. That's just marketing talk on the brochure. If you can't respect your co-worker, you definitely don't respect me as a patient laying in that bed. So it starts within the team, the healthcare team, and then it spreads to the patient. That's absolutely fundamental to culture. Thank you. And this was not planned, but it's a perfect segue to the next question I'd like to ask, which is about interprofessional team-based care and making that truly team-based and not hierarchical. So we have Ron representing pharmacy and Phil representing nursing. How do we build that sort of a culture across teams and have them working together functionally on behalf of the patient? Do you want to start? Okay. I would move that our interprofessional teams need to be educated together. We need to begin the process very early on. Learning how to communicate effectively, not just with each other, but with the people that we're taking care of. I come at this more from a public health perspective, working with people in their homes. And one of the biggest issues that we face is what I'll call a power distribution. When you walk into a patient's home, it's very clear that the patient is in charge. You're a guest in their environment. When you walk into a hospital, the whole power structure shifts. And now you have the healthcare providers who often feel they're in charge, not the patient. We walk into patients' rooms unannounced. We assume we can go ahead and do things to patients without asking their permission. It's a culture that develops around the provider and the patient's accessibility to the provider rather than around the patient. So I think that it begins with how we educate our provider groups no matter who they are. And it goes from the top of the line to the bottom of the line in care. It's everybody who touches the patient from the nutrition worker, the housekeeper, the hallway up through the rest of the provider group. So the challenge in education is creating these capabilities to get people to learn together. There's so much complication with busy curriculums, lots of requirements from accreditation agencies. In pharmacy, the accreditation agency has made a major commitment to ensure that interprofessional education that includes prescribers and nurses and other parts of the healthcare team are engaged early in the process. And every school in the country is working toward that. But it's a difficult, difficult challenge. The other parts of it, I think, is one of the areas in interprofessional education is to get each member of the team to recognize the value of the other person and where their expert and where they should lead in making decisions on a moment-by-moment basis because knowing when you should assert your knowledge and when you see something that's not headed in the right direction no matter who you are on the team is the most critical challenge. One of the things in pharmacy we're trying to do is to get pharmacists to assert the knowledge they have about medication use. Medications are the most frequently encountered form of medical therapy. They're also the most frequently counted place for errors in healthcare, unfortunately. And we're trying to get pharmacists to own those errors and to recognize that they have to take responsibility in every situation to assert their knowledge to prevent those errors from happening. I love the who's, who, World Health Organization's efforts to change medication errors around the world, cut them in half in five years, and what they wanna do with no ask check, be sure that patients understand their medication, be sure that the communication about what should be used has been clear and safe. Lots of things like that, and we need to be sure as we train interprofessionally that we have that kind of clear safe communication underlying everything we do and that we have the respect for every member of the healthcare team and beyond the professionals on the healthcare team, the others that are in that institution who might spot something that's going wrong and need to also be respected, be it a family member, someone cleaning the room, there's lots of things that people can see. Mikey, do you wanna comment? Yeah, so I think, so far we've been concentrating on the, if you like, the load of change that needs to take place by the individual. But I think the other dimension that we need to throw in here is the role of the organization within which the individual is working, whether that's in an industrial setting, whether it's a hospital setting, whatever the care setting is, the organization that's supporting patients and employing individuals in different ways. And I think often the organizational ethical value isn't necessarily aligned with the ethical values of the individuals who are working in that organization. So to paraphrase, I think it was Liam who coined this phrase a long time ago. In our work, looking at the organizations around this country and in my help and support, looking at organizations in other parts of the world, I've paraphrased his phrase and to think we have islands of huge endeavor to change and improve, but around us we're in a sea of complacency about what the basic elements are and what the improvement journey should be. And this is the complacency of our system. And that's where I go back to the organizational responsibility and accountability to help set the climate. And that's where the managerial leadership, the senior leadership, board leadership is so vital, as well as the team leadership and the leadership with the patient. Absolutely. So, Alicia, I'd like to ask you, our goal is to make the patient not merely an example of how things go wrong, case studies, but actually a partner in how we train professionals. How do we go about doing that? Well, I think, first of all, when you include patients, there's an urgency that's added to the situation. And that's the first thing that I wanna say. This is an urgent matter. Medical errors are responsible for so many deaths. And might I say, we hear about the number of deaths, but we don't hear about the people like myself who end up suffering the rest of their lives or with prosthetics or other things that they have to deal with from now on. So I say, we start bringing those patients in. When in medical school, some medical schools have simulations. They have actors who come in and they've learned a script about a condition and they interact with the doctors, I mean, with the medical students. There are so many patients around the country with real, real stories and real situations start bringing some of those patients in and sit and have a conversation with them and start learning from the horse's mouth how to improve care, how to, I mean, there are certain things about a condition that a script can't tell you. There are certain ways you feel, different types of pain that you will have as a patient that's not on that piece of paper. So it's important that we start bringing in the patient voice and not just talking about patients or talking at patients, but speaking with patients. I love that, Alicia. And I think that it's one of the things that we have to do with this curriculum. We have to kind of follow the model that the patient safety movement uses here to bring the patient and their story forward as we're teaching individuals. Whether we can get enough patients in every school, health profession school in the country is unclear, but we could use compelling videos to get started every day when we're gonna talk safety, which should be almost every day that we're teaching anything in the curriculum and use those videos and use that engaging technology to get students to understand the responsibilities that they have and how and where things go wrong. And I'd like to add also that for those medical schools and programs that do have patient safety classes already, we believe that patient safety should not be an elective. It should be part of the core curriculum requirement because too many times, I know I went back to school in between all of my doctor's appointments. I went back to UCLA and I got a postgraduate certificate in healthcare management and leadership. Now, they had a masters of hospital administration and I could have taken that, but all of the patient safety classes and the patient advocacy and all the meat and potatoes of what I wanted was in the certificate program and not actually in the master's program. And I think there should not ever be a hospital administration master's program that doesn't require patient safety, infection prevention 101. Those things should be in the core foundation of every single healthcare provider in the world. May I add? Thank you. If I may extend on that, we're absolutely agree, but we also need to instill it into continuing medical education, not just in basic medical and nursing education because we want to accomplish this in two years, Joe. So let's do it now. Absolutely, and that brings up a fundamental principle of the curricular effort, which is that we're not just aiming at health profession learners at their earliest stages, but also through their postgraduate training and throughout their continuing professional development. So we've had some very good questions from the audience and I'd like to pose them to you. You don't know what they're going to be so this could be exciting. I like this one very much. Communication, leadership, team, all relate back to CRM, concepts, crisis of resource management. These are complex learned behaviors. What is the role of simulation in the curriculum? You've mentioned it already, Alicia. Aviation, the nuclear industry already used it, but healthcare resists it. Now certainly in undergraduate medical education in the United States, it's now become standard. There are simulation centers at every medical school, but the question here is how do we apply simulation to safety? I think that for most of us here, when we were initially educated in our field, the assumption was that we could, through hours of clinical practice, gain everything that we needed to know. And we now recognize that that A is impossible and B, we don't want our students to actually experience situations like a patient fall. We wanna be able to provide the opportunity to look at what might happen if a patient falls through a simulation. We might wanna see what happens to a patient who has an infection that becomes septic through a simulation. So I think our limitation thus far has been that we have used human patient simulators and standardized patients, but we have the opportunity through augmented reality, virtual reality, 360 video, and the new technologies that are coming out to provide consistent opportunities for students to learn about those never events, about those things that we want them prepared to handle but hope they never have to see by using these new technologies. So I think there's a brave new world coming for us to incorporate into our healthcare education. Yes, they allow us to break down the episode, each individual example, into its elements and make the points. Right, Mike. So I think in the UK, and the many in the room who've been party to this, we've been at the forefront, certainly in some of the clinical disciplines of simulation. We've tended to use it at the undergraduate level and at the postgraduate early years training time. What I think many countries are struggling with is to use this as part of a CME approach and as part of as well as doing a 360 on how people perceive your performance, as well as your appraisal, have time in a simulation system. And I think that's where we need to be. It scared the airline industry when they started it, but now it's a very regular thing. We all have many friends in the airline industry who look forward to their simulator experience. So I think the issue for us is how we start to get that as part of the day reger of our CME, not just for training. It makes sense after you invest in an institution in building a simulation center, a sophisticated institutional simulated center to actually bring in people from outside of the eight hours that you teach students every day to make better use of it. So when I built these centers before, we are engaging the outside world, the ambulance drivers, the physicians and other people that wanna come in. And that's basically making better use of the investments we make in institutional education technology. So here's a question that I bet many people in the audience will appreciate, which is a request for Anagrette to repeat the elements of Sacha. Great, well, I only had five minutes. Thank you for giving me the chance. Okay, so these are five interpersonal sense-making processes, processes that we all do in our marriages with children communication and with our friends to establish a shared understanding of our intents, of our thoughts, of our emotions. So it's Sacha, S-A-C-C-I-A. S stands for sufficiency that relates to the informational content, the quantity of information that we convey. Oftentimes, we don't access the patient records or we don't read them thoroughly enough. We don't extract information enough. We don't use our communication enough to really get that content coverage that we need to attain, right? So that S stands for, to what extent are you able to get 100% of the information that you're able to get out of that patient, out of that nurse, or out of another colleague? The A stands for accuracy. Joe, I think you said, I don't know who said that earlier, more eyes see more mistakes, right? It was Jeremy, actually, Jeremy. Right, so four eyes see more than two. Why don't we utilize our communication with each other enough to actually validate the accuracy of the content that's being conveyed? Many errors happen out of that and severe errors. The C, the first C stands for clarity. We have uncertainties, but we think we've managed them, right? So why don't we use our communication to clarify uncertainty, to make sure that we do establish a shared understanding? Also with pharmacy, many cases where pharmacy physician communication, you know, I'm assuming that's what the physician meant, so I'm just gonna fill the prescription. I don't ask. Clicking that window in the electronic health record we had an incident where a new assistant physician resident clicked the window close because she didn't know what it meant, right? The second C is context. We don't communicate timely enough. We don't communicate to the right point in time. Sometimes we give discharge instructions before the surgery has started, or we give them while the physician is still, you're kind of post anesthesia and not able to cognitively process that information. Interprofessional hierarchies. Sometimes we don't dare to ask just because that barrier is there. Patience is the same thing. But also for the resident who has that, he's new at this clinic and he has that added informational need today. We're not adapting to that context when we communicate. And then the last one is the IA, interpersonal adaptation. And I think what's really important there is to move away from patient-centeredness as something that's apart from patient safety because that patient who was getting the wrong leg prepared for surgery, if we wouldn't have bracketed out that patient from that conversation, she would have said something. So that's adapting ATOC to spontaneously expressed needs and expectations of that counterpart. Those are the five core competencies that we must improve because they keep causing harm, they keep preventing us from finding that shared understanding. And the nice thing is that model allows us to label communication errors, identify them, label them. But more so, they're grounded in core principles of communication science, things like the Chinese whisper game, the telephone game. And there's eight of those things that are misassumptions, very simple ones, that we just need to understand and we will communicate differently and that will trigger those errors to decrease and that will trigger the safety to increase. Thank you. So there are a number of additional excellent questions which I will pose to you after the panel ends because we're now approaching the end and before we close, we thought it would be good to follow Joe Candy's example of not just raising issues and discussing them and prompting thought, but actually to prompt action. And so we are issuing a challenge to you to help us move the needle right now. So we want you to think about what you are going to do right now. And by right now, I'll give it till, I mean Monday. When you get back to work. What are you gonna do Monday morning when you get back to work? To move the needle in the care environment where you work, to change the culture. This is a question not just for those of you who are in education, whether you're in technology or in clinical systems, how can you address these issues at home? And so we would ask that before the start of the next session, you tweet your responses and to at, move the safety needle and tell us what you plan to do. You've got right through lunch to think about this. And we will be looking through your answers and picking the very best ones and highlighting them tomorrow for you. And so that is the challenge. And we thought to help you with this, we might give you some examples of what we would do going back to our institutions. So I'll start by saying that at a medical school, I would go back to that medical school and look at the curriculum for those medical students to see how sufficient the content is in safety, how actively engaged it brings the students to be rather than simply passive information transfer. Now it's easy for me to say because we've already been doing that and we're planning to rewrite our curriculum and with safety integrated throughout all four years. But that's what I would do. Ron, what would you do? I think I wanna go back and focus on bringing the patient's voice to the students right from the beginning. I wanna incorporate stories in the admission process and find students who exhibit the compassion, the understanding, the caring about the patient right at admission versus just looking at what they've done in healthcare and their grades. I wanna find people with the inner compassionate leadership that is gonna make a difference in safety in the future. So my challenge at you will be, we already have the resources we can start today. Pick up the phone, call one hospital or nursing home or long-term care facility. The director ask him, get your risk manager or quality manager educated so they can train safe communication skills in their house and start today to prevent 80% of patient harm happening in their institutions without your triggering from the roots up a safety culture that's sustainable. Yes, Phil? I would encourage every one of us, whether you're in manufacturing, whether you are the head of an organization, whether you are a dean or director of a school, to go back and examine what each one of your people are doing to enhance safety within your organization. So if it's your sales force, are they just selling a product or are they selling safety while they're out there with your product? If you are an educator, are you moving your faculty to teach safety along with everything else that they're teaching? If you are in a healthcare provider situation, are you encouraging everybody in your system to include safety as they move forward in their daily effort? I think it's something all of us can do. Mike? It's getting harder as you move around the line. So for me, it's to go back and challenge myself, but challenge all the leaders that I meet and all the patients that I meet, that if we really are working within a just and open safe culture, then how do we show that? How do we demonstrate that through our error reporting system? And how are we sharing that error reporting system in terms of the data on it in an open and transparent way? And how are we using that to give courage and commitment to all our staff to be able to use that data in a very open system? So it's no longer that data is held within a computer in some dark dans, some dark corridor called risk management, but it's data that's open, it's shared, it's on everyone's laptop, it's on the whole local system and that for me would be the challenge. How are we going to do that? For the industry side, I think there's an even greater challenge for all error reporting to be shared in an open platform and that's the thing that I would like to see from the industry side. Thank you. Thank you. And the final word to Alicia. You made my job really tough. I love everything that you said. So I would just say, I would challenge you to go back and look at your organizations and look at the curriculum and see where you have patient safety. Where do you have infection prevention? Where do you have communication skills? And are they elective or are they mandatory? And if you're with a professional society in your continuing medical education, you know, yearly training and updating that you have to do. Are you requiring patient safety as a part of your continuing education? Because what we don't want is to come up with great curriculums, great curriculums that focus on including the patient, patient safety and then we have students who are learning wonderful skills and then to step into an organization that doesn't support that and all those skills fall away. So that's why I say, let's look at the curriculums but then also let's look at continuing education in the professional societies. Thank you. Thank you. So I wanna thank you all for your attention. I wanna thank Joe. Once again, everybody's gonna be thanking Joe for the next two days. But seriously, for stimulating all this effort and for the foundation for having stimulated this curricular effort. And thank you very much.