 Well, hopefully, we'll bring a little hope. This is really an opportunity to celebrate. For 10 years, the Patient Safety Movement Foundation has existed, and seated here with me and myself are leaders that have committed to patient safety and through adopting the mission and the recommendations of the Patient Safety Movement Foundation, we've actually made a difference in our organizations or even nationally. So I think to get started, I'll start with Kim. You're the CEO of Children's Hospital of Orange County. And you and your board made a commitment to adopt evidence-based practices to eliminate hospital mortality. And I wondered if you could share a little bit about your journey. You had amazing success. And maybe some of the lessons learned that you learned along the way. I would love to thank you, Robin. And thank you all for being here and the opportunity to share our journey. I'm going to talk about our journey pretty much from a leadership perspective and lessons. We have lots of lessons that we've learned. But I would point to probably the year 2000, when we all, I think, had an amazing and startling wake-up call with Deair as human and all of that work. And I think for us, it started to change the way we were thinking about things and having a broader recognition of the true responsibilities that we have. And as you've heard, I'm in a pediatric health care system. And our mission is to nurture, advance, and protect the health and well-being of children. And I'll focus on protecting. So I think who we are and why we're here and what our purpose is in life is about protecting the health and well-being of children. And this work just can't be underestimated, the importance of it. So one of the first things we did following, really looking at that data, was establishing a senior level leadership position. And we appointed Dr. Jim Capon. And I can't see, but I bet Dr. Capon's out there is our very first patient safety officer. And then we started layering in, if you will, leadership positions that were focusing on safety and quality. In the year 2008, we seated our first board-level quality committee. And I'm so happy to say our dear friend Joe Chiani actually serves as the chair of that committee today. And we started joining the patient safety movement, a number of patient safety initiatives that are focused on pediatric health care, because our patients are a little different than the adult health setting. So the story is really that we were searching for anything and everything that we could learn from others. And as health care leaders, sometimes it's hard to check our egos at the door and really take a hard look in the mirror and hearing stories like the one we just heard is such a special calling. So our journey has been over the past 23 years. After we seated the quality committee, we started looking at how we can make this a top priority for everyone in our enterprise. We all, I think, employ a lot of people. And how do you make this relevant to each and every person who's walking onto your campus every day and play some role in taking care of your patients? So we started building them into our organizational goals to reduce serious harm and reduce hacks and those kinds of things. And in 2017, we adopted a goal and put it in our management performance plan, which is a part of all of our leaders. So there are 220 of us in a plan where we have pay at risk. And we put a goal in there to get to zero. We'll have zero preventable deaths in our organization. And there was a lot of discussion around that. I'm sure all of you can relate to. It probably wasn't the most popular decision that was ever made because we heard a lot of feedback around how sick our patients are and disease progression and patients do die and all. But all of those reasons actually was, to me, the reason to say, we're going to take a stand. And we are going to take a solid stand. And we are going to make this a part of this particular plan. And I'll talk in a few minutes about what happened after that. My point here is layers and layers at all levels of the organization in a single focus on why we're all here. I'm going to move over to communication and culture because I think we're hearing a lot about a culture of safety. Blame all of that. That took really hard work because people watch us and they are looking at what we talk about, how we act, what we do. And one thing I've learned over the years is you just can't talk about the priorities enough. You might think you're doing it enough and doing it every day. But you've got to spread that throughout your organization. So communications, daily huddles, unit huddles, all of those kinds of things are embedded because we have much greater reach. I think we all know that now with the more people that we're bringing together, breaking down hierarchies and silos and all of that. So I'll just quickly tell you that through the course of this journey, we've decreased our serious patient harm by 95%. We did have a five and a half years period of time where we had zero preventable deaths and where we've reduced our serious medical errors. But you're noticing I haven't said we've completely eliminated any of it. So any percent is too much. And I'm really humbled, honestly, to be in a room and be able to share our story with all of you. I guess the last thing I would say is what we've been through with COVID in the pandemic has turned our world upside down, inside out. I think all of us were throwing everything we had at keeping our staff safe so we could keep our patients and families safe. And there's so much that's changed through the adoption of our evidence-based practices and the committees and the leaders and all that we really are stepping back and bracing ourselves because there's so much important work. So increases in registry travelers, a great resignation that's hit health care as well, telehealth, cybersecurity, all of those things are a huge wake-up call for all of us to really band together and to learn from one another. So I really am humbled to be here. Thank you for your honesty and your candor because there's so much more that we need to do and that we can do. Thank you so much, Kim. So Bill, as the CMO at UC Irvine, you made a commitment to zero harm and really led the organization. And how did that impact safer care at UCI? Thank you, Robin. I'm really pleased to be here and to share the story. Let me first start with how the UCI leadership learned about the Patient Safety Movement Foundation and then talk about some of the important changes that occurred in there. Sort of three main categories, culture and then in terms of event reporting and making that a little bit more transparent and then evidence-based protocols, those three areas. But the way that this started was with, unfortunately, a harm that occurred, preventable harm, was a young, an early 30s mother that was coming to us for a series of chemotherapy treatments and was intrathecal, which means that the chemo was going into the CSF. She brought her mother and her daughter with her for the first of these series of treatments. And soon after the injection, she had a severe headache, deteriorated, lost consciousness, and she never woke up again. And when we did the RCA, we found that she received approximately 100 times the therapeutic dose, it was a lethal dose. And there was a compounding error in the pharmacy, but there were a number of other steps that could have been taken, including a timeout to ensure the right medication and the right dose was given, a number of errors, which later were fixed, but this greatly impacted all of us at UCI. And so the next leadership forum that we had after this event, I mentioned to the CEO of the hospital and the chief operating officer and this chief financial officer and all the other departmental leaders that meet monthly that my wife, Bernadette, and I had attended the Patient Safety Movement Foundation the year prior. And by then we had already, Bernadette and I had committed to zero and we had deployed some of the lessons learned already at UCI, but the leadership had not heard really about this. And so I asked them if they were ready to take the pledge and I can vividly remember the CEO of the hospital, the CFO, the Dean of the School of Medicine, that they all took the pledge to zero harm. And at that time, it was zero preventable harm by 2020. Now it's, the goal is 2030, but within a year, we developed the evidence-based protocols that allowed us to have a solution for each of the Patient Safety Movement Foundation challenges. But in addition, we did much more and I'd like to just talk about some of those in the three categories. How did we change the culture? First, we even changed the department that I ran from quality and safety to patient safety and quality. The next was that we empowered everyone from the housekeepers to the doctors and nurses to the respiratory therapists and pharmacists. Everyone could stop the system. They could stop the line. Everybody was empowered. So we leveled the hierarchy and we did that through a number of other, I'm gonna call them tools that we used. One of them was developing a just culture algorithm and then policy. And what we did was we pictorialized this so that very thick lines would go to system problems. And very thin lines later would go to an individual. We recognize that no nurse, no respiratory therapist, no doctor would come intending to harm a patient. And when that patient I described that had 100 times the dose, the pharmacist didn't plan to make that error, but we didn't have a system in place to correct it and to catch it right. So this just culture algorithm and policy took a long time, but we got it approved and agreed to. And we use that also when we adjudicate the next piece to what we did to change the culture was we brought in team steps as it's developed by the US military as well as ARC as a way of improving the communication and improving the ability to work as a team. And so we brought doctors and nurses in and trained them to train others. And we went through the entire hospital with that. We continued that training by the way during COVID. But the next thing that we did was we lucked out professionalism. And so we participated with a couple of programs out of Vanderbilt, one's called PARS, which is a physician advocacy reporting system. And whenever a patient would report that they had a bad interaction with a doctor that would come in and then we would have a cup of coffee with a doctor and let them know that if most doctors don't have these and if you're having two or three of these per year, you are way on the end of abnormal behavior. And we would just with a cup of coffee usually be able to change behavior, but there were some recidivists that we had to do more and we would do anger management. We also had what was called CORS, co-worker reporting system. And so if there's a bad interaction between different nurses or respiratory therapists or doctors and nurses that that was adjudicated also and we would solve that situation. So those were some of the factors were many more that we did to change the culture. The next was to make the incident reporting a little bit more transparent. And so two main things there, we developed a critical event management team that would look at all the IRs. We had already an automatic way of adjudicating errors, but who was overseeing this? So we made sure that this team would look at and make sure they were properly from a severity and frequency perspective adjudicated and improved our RCA system. And then when we stood up our daily huddle with all the individuals reporting out, we challenged them with one more factor, which was they needed to report out the day since the last breach in hand hygiene and the day since the last harm, including CLABSI, CAUTI, CDIF, et cetera. We went more than three years in our NICU without a CLABSI. We were able to extend all of these out and I know Kim's aware of this because we partner on our NICU work. And then the final thing was evidence-based protocols. And I'll very quickly just say that there are a number of these. And so not only did we do this for the Patient Safety Movement Foundation, but we did it for CMS STARS. We did it for the American College of Ceres and NISQuick program. We did it for the VISION. VISION is one of the most impactful because you can get data on a three-month basis, whereas CMS STARS, it's like two years in arrears to change things. US News and World Report a little bit longer. So with the VISION system, we went from 61 in the nation to 43 in the nation to number eight in the nation the last two years while I was CMO out there. They stayed in the top 20 cents, which is good. LeapFrog went from a B organization to an A for six in consecutive. Now we did start the LeapFrog while I was still the critical care director before I was a CMO, but we continued and persisted that. But during COVID, we continued with all of these programs. We didn't drop. We continued to do our leadership rounds and had a presence. And when you look at all those hospitals that have had at least 500 or more patients sick enough to be admitted, and at UCI, we had more than 3,000 in that category. UCI had the lowest mortality in the entire nation amongst all academic medical centers. And was, thank you. And was number five in the nation with shortest length of stay. In California, not only the lowest mortality, but the lowest length of stay amongst all academic medical center. So that's how the Patient Safety Movement Foundation helped us change our culture, safety and quality. That's awesome. You know, like UCI in 2019, Kaiser Permanente in Northern California also committed to adopt evidence-based actional patient safety solutions to reduce medical harm. And we started by doing a gap analysis against those standards that were written to make sure that our protocols, our structures and standards aligned with those or exceeded those standards. And then we assured any gaps were mitigated. And following that, we have had just continued progression in reducing harm even during the pandemic when we saw drift across the nation. Over the years, we performed very well on public scorecards. One that we really pay attention to is the leapfrog hospital safety grade. They assign A, B, C, D or F grades to around 3,000 hospitals across the United States based on their ability to prevent harm. And through our focus and hard wiring of these evidence-based practices, we went from 10 hospitals with a safety grade of A to 17 in the spring. And we're actually on course to have all 21 hospitals be a safety grade A by fall of 2024. Nationally, only 30% is gonna say nationally, only 30% of hospitals achieve an A grade. Now, while we have very strong bundles and protocols as well as we've taken advantage of technology, predictive science, there's so much more, as you heard, around structure, communication, leadership. And we assure that all of our efforts have leadership sponsorship. And like Children's Hospital, we tie our safety measures to remuneration. So your bonuses are at risk based on your performance against patient safety performance. We find and fix problems at the appropriate level by building in sensitivity to operations. And that's those daily tiered huggles from the unit up to the top. And this allows us to expedite our opportunities in real time to act to reduce harm, to assure that we have shared accountability for safety, foster vigilant focus on performance and then reward and recognize success. One of the things that we do is we have what's called the Good Catch program. And for every near miss that's reported, a card is automatically generated. We link that card message to the principles of high reliability and the error proofing tool in action at the time. These are personally signed by me and my executive director of patient safety and sent to teams and individuals. In the last year and a half, we've sent out thousands of these cards. So fostering this near miss reporting has allowed us to move upstream in harm mitigation by responding to early signals of risk rather than reacting to patient harm or a catastrophic event. We also really want to learn from our mistakes. And we've established processes to rapidly deploy mitigating strategies across our hospitals. This includes participation of patients in our event investigations. This was very uncomfortable initially, but they have really great perceptions about what happened and give us insights as well as awesome solutions. We're deploying safety alerts. We call them SBARS for safety to rapidly deploy those shared learnings. And then we instituted a closed loop system where we actually validate that those mitigating strategies were adopted locally. Finally, a process to swiftly lean into drift. We have a model in our infection control program where we monitor regularly the performance on infections. And with early signals of drift, the team has a systematic approach for leaning in and course correcting rather than reacting to kind of exacerbated conditions when performance has really declined. We still have a lot of work to do though. And we're currently really focusing on building a high reliability culture and systems. We're formally training our leaders to the science of high reliability. What the principles of high reliability look like in operations and how to lead to reliability. We're shoring up our operating management system and you've heard those referred. Those are making sure that our huddles are really meaningful from the unit up to the regional office. Effective visual and daily management systems that keep our staff connected to the work so they know what they're doing today is impacting tomorrow. And then leader rounding with guided leader standard work. We are also assuring all of our improvement programs have a preoccupation with failure that ongoing system and operational oversight for drift detection and that systematic approach to course correct. I'm gonna go now to Susan. She's amazing. She's a PhD and a professor of anesthesia. And she's done incredible work saving lives through the continuous monitoring of cervical patients. And I wondered if you could share with us a little bit about that work and the outcomes. Absolutely. And thanks for this chance to talk to you about one of Dartmouth-Hitchcock's patient safety journeys. So for context Dartmouth-Hitchcock is a 400 bed hospital located in Royal New Hampshire where the state's only level one trauma center and only academic medical center. And in spite of our location we have very high patient acuity that's often in the top 5% in the nation. We were honored to be recognized by the Patient Safety Movement Foundation as a five star patient safety hospital. And prior to that recognition in 2018 at the Patient Safety Movement Foundation meeting we also made a commitment to continue to reduce failure to rescue events at our hospital. Those events are deaths of patients caused by serious but treatable complications that arise in hospitals. Many of the patient stories that you heard yesterday and today fall into that particular category. They are major sources of mortality in an inpatient setting. Unfortunately the story that we have in pursuing reduction of failure to rescue events began with the tragic death of one of our patients. This was a patient who came to the hospital for a minor surgical procedure which was successful. Afterward they received opioids for pain and anxiety medications which unfortunately caused severe respiratory depression and the patient was found dead in bed by the nurse when they came in to do vital signs assessment. At that point the hospital committed to making sure that that would never happen again to another patient and over the next several years with the amazing support of our staff we were able to implement several interventions. One of those was continuous monitoring in all of our medical surgical units. So that's well over 200 beds. I think we're at about 240 now. That system employs pulse oximetry to do that continuous monitoring. Importantly we pursued this not as the purchase and installation of a monitor. This was the development of an entire patient safety system. We employed systems engineering design principles. We performed human factors analysis. We developed very robust quality management principles and practices and processes that allowed us to monitor performance and improve performance over time. Our approach to monitoring which we call surveillance monitoring is specifically designed for this environment, the general care setting. It's a very task rich environment. We have nurses that are often four to one, five to one if not more whose attention needs to be drawn to the bedside very carefully so that they're not interrupted from caring for patients who need their attention. We do this by using a very specific alarm configuration designed again for that setting as well as directed notification that goes directly to the clinician that's responsible for caring for that patient. This ensures that there's a timely response but we minimize nuisance alarms and keep attention of the clinicians where it belongs. One of the other decisions that we made with regard to reliability when we were doing our design work was that we would use this system for all patients all the time from the minute they were admitted to the unit till discharged with very few exceptions. So this was based on our understanding that risk assessments would leave some patients out of the picture and the patient that I mentioned to you would have passed a risk assessment and they died anyway so we wanted to make sure that we addressed that. We've studied the system extensively over the last 15 years. One of our initial studies looked at patient impact where we showed a 48% reduction in transfers to higher level of care as well as a 65% reduction in rescues. We also looked at cost assessment and found that we could save over a million dollars a year with surveillance monitoring just based on the reduction in ICU transfers when we use that system. Another organization have seen the same results as we have both in terms of the patient impact but also that cost effectiveness. So we think it's a pretty robust system. In 2018 we performed a retrospective analysis of I think it was 126,000 patient discharges looking at the 10 year period from the time that we began to implement up until the time of the study. And what we looked at was whether or not we had harm or death related to the administration of opioids which was, if you'll recall, what happened to the patient that I mentioned. And we found remarkably that during that 10 year period we didn't have any patient deaths when surveillance monitoring was available in use in our organization. So while we feel that that's a big success there's plenty of work yet to do. There are other failure to rescue types of problems that need to be solved. And we know that the technology that we use is important but we really think that the methods that we apply, the systems engineering methods, quality management processes that we put into place were really essential to the success and we think that those things can be used widely in hospitals to solve many of the complex patient safety issues that we have. And so my final remark would be really to be that we know that a lot of hospitals are using some of these processes but we really believe that building those capabilities and integrating them into healthcare systems is really important as we step forward to try to aim for zero harm to our patients. Thanks. Javier, he's an amazing national leader and I think through the videos we've seen his incredible impact as you've been able to impact safer healthcare in Latin America and the Caribbean countries and how do you lead safer healthcare from kind of that bigger national perspective? Because I have a lot of friends. I love that. I tell you. Well, first of all, it's a privilege for me. It's a great honor to be here, Robin. Thank you so much and best regards to Dr. Barker. And I came by the first time into 2016 with my friend, my dear friend, Joe Chiani and Sara Chiani. So we started to create a story with Mexico and Latin American countries with the Anperes and so many friends, Dr. Durkin, Dr. Ramsey. Well, I'm not, I don't have time for to mention David Meyer, so. And the problem was that we didn't have enough information, statistics. So when I met Joe Chiani and we started to study the statistics, I asked to the minister of health in my country, do you know how many do we have? And he said, I don't want to know. Because we don't know. So the first thing is to recognize that you don't have enough information but you know there is a problem. Everybody knows that is a problem. So the second is to create a culture related with patient safety. And I'm completely convinced that we've been moving forward step by step, but very slow. We organized a meeting, a private meeting with Joe and Mr. Testas, he was in a video from the Hospital Español of Mexico City with the director of the National Institute of Medical Sciences and nutrition, David Kersenovich and many others, the ex-ministers of health, three of them were in that private lunch and we started to discuss how can we involve in patient safety movement foundation. It was on December, 2015. So I came here in January of the next year and we create a network with, as I mentioned, before with my friends, with a little help from my friends. And in that context, we've had an advantage. I became to be a few years ago the chief medical officer of the Social Security Mexican Institute, which it means that it's a great network for to give you an idea, 77,000 physicians, 100,000 nurses to 1,500 medical units, 25 medical centers of high specialities, et cetera. So there's a patient who died, whatever the reason it is, and the press, the media is turning their faces and to say, you are the boss. What are you doing related to avoid that kind of things? And you said, my arm, it's not to control everything. So we need a responsible in every place. The chair, the head of the hospital, the chief medical officer, whatever. So I recognize also that we've been moving forward as I said before, we need to establish a chronogram commitment leaders in every place, every single place. Doesn't matter if it's a public hospital, if it's an academy, we are involved the Mexican Academy of Surgery, I'm at the executive committee there. We brought the Mexican Academy of Surgery to be a partnership with the Patient Safety Movement, the National University of Mexico, the School of Medicine, Joe Keane came to Mexico to affiliate that university, our Mexican Academy of Surgery, et cetera, et cetera. So it's a big network, but it's not enough. So we have to keep the effort every single day with every single person. But you can do that alone. You're not gonna finish, never. What we are trying to do is to transform this in a moral obligation. So you don't have any choice. If you have a public policy and it's mandatory, you have to do that because there's no other choice for you. So a few years ago, four or five, I don't remember, we polished with the Ministry of Health and the big institutions the WHO standards as an obligation for all the whole hospitals, private and public ones. The problem is who is going to follow up that information. Everybody has a lot of work. And suddenly, I don't know if you knew, but there was a pandemic COVID-19. In Mexico, it was very, very complex. And I called some of my colleagues, my friends, and said, hello, are you alive? Yeah. So what happened with your follow-up in patient safety movement? I said, Javier, give me a break. People are dying. I'm busy. Can I help you? And I said, no, I'm at home, so I don't need you. I'm just asking, I'm wishing you a very good luck because people are always busy, very busy. Suddenly, when there's a problem, they're turning their faces to say, oh my God, yes, I forgot Javier, I forgot Kiani and patient safety movement. So how can we do that all the time to keep our, the same effort all the time? There's a different strategies. Presents, summit, publishing, media, regulation, networking with friends, it's real. And WHO, Nilam Dingra, are you there? Nilam, she was supporting us with Mike Durkin, Mike Ramsey, Joe Kiani. That network, I took this network of close friends to my country and to say, hey guys, this is the real world, our world and they are a team, they are friends. They can help us. So we brought my team to be a part of all of you. But this effort, we have to keep it in every state of the Mexican Republic. It's a huge country. So we need to keep this in mind to transform this as a mandatory rules, the standards of WHO and to spread the culture of this in every single country, or Central America, South America and Caribbean countries. It's a huge effort. We are not gonna finish, for sure. But we need ambassadors in every place and to bring them for the next summit every single country of Central America, Latin America because we brought them in another issue last March in Mexico City. Not to me it was there as a speaker, a member of our board of directors of this foundation and we brought 600 people from 30 countries of Latin American and Caribbean countries. So we have to increase our effort, to increase our network and travel more because COVID disappear. So we have a chance. Thanks Javier. I think you've heard, it's such a heavy task and how important it is for that local leadership that operationalize all the work and you kinda heard repetitive things into what's a successful model to operationalize with the communication, operating management systems that keep building that sensitivity to operation so we as leaders know what our performance is today and can lean in swiftly to course correct. And one of the things I wanted to bring up that we talked about, at least Sue and I did, was sustainability and how do you prevent drift and how do you sustain it? And did you wanna give a little comment on that? So building anything in healthcare is extremely difficult, right? Changed anywhere is difficult and in healthcare it's even more difficult. Sustaining performance over time and this system that we built has been in place, I think it was December 2007 when we started. And so even at our organization where we have really strong quality management processes associated with this system in place, we have seen drift, but because we had ways of seeing that drift and we have leadership that understands systems and understands if they pull certain levers, this is what's going to happen to patient safety. So when they make the inevitable, really difficult decisions about resources and what to do at the bedside, they have that in mind. And so I think in terms of patient safety, having some ways of understanding what's going on with the system, having that feedback is important, but also having good knowledge of how your actions are going to affect the system can also help when you do have inevitable drift, get you back on track and help sustain things over the long term. And I think that that can also go to the system level, not just to things like monitoring, but to broader parts of the system and systems of systems as well. I know that's what I've really learned over the last year, especially for my infection prevention team over the last several years, that ability to detect drift, lean and swiftly in a systemized way, so you quickly course correct wherever that drift is happening within your organization. We have 21 hospitals with a lot of units. And so we're able to see down to the unit level who's becoming problematic. Where is that standard work? Maybe there's some deviation from that so we can lean in quickly. And you have to have an operational owner, leadership owner to monitor and detect drift at all times. We just have one minute left and I thought this was a great question, but how do you define preventable harm? Who defines it? Is it the patients or the healthcare providers? And they didn't know if any one of you wanted to tackle that question. I'll jump in really quickly because one of the important things that happened when we started setting these goals was a deep discussion around what is preventable harm. And it was a very broad based discussion. So I think it's important to define it and we do have a definition, but the process to get to agreement around the definition was really powerful and had a lot of impact. So it's not easy and there are so many definitions. Are you looking at Jake? What are you looking at? So I'm glad you raised that issue. And I think it reflects back to our earlier discussions about a National Patient Safety Review Board and establishing standards for all of us to adopt instead of organizational standards. Thank you all for your participation. It was just really terrific and thank you Patient Safety Movement Foundation. Thank you. Thank you.