Hey everyone, we need to talk for a moment because I firmly, firmly believe that there is going to be a new 2D Zelda game coming on Nintendo Switch. Now I don't know if it's going to be this year, next year I'm not sure when it's coming, but I do believe it is currently in development and I'm not even talking about the one that I thought might have been in the works by Grezzo, although it's possible Grezzo may be helping out on it. Let's talk about why. So I dug up an old article from way back in 2017 where Eugenomo did an interview in the lead up to the release of Breath of the Wild and we largely have believed over the years that they have combined the handheld and home console team together. But the funny thing is, this interview that all of us forget about with our assumptions plainly states that the teams are still separate even though they're in the same building, that the 2D internal, top down internal Zelda team never actually went anywhere and is working on a game. So first let's look at this because this is fact based evidence. This is my evidence, really the Brux evidence that I have, but we have some rumors now coming out from the likes of my good pal game over Jesse. I'll put a link to his video on this down in the description that we're going to go over as well that might further provide at least some sort of thought process that we're going to get this game sometime soon and some idea that's behind the game as most top down Zelda games, most Zelda games in general are built around a singular concept. Now let's get into this article and kind of revisit this from back in the day. So during an interview with the Legend of Sirius producers, this is on gameinformer.com I'll link to this article as well. It says that Sirius producer AJ Animo for our recent Breath of the Wild cover story, we had a chance to talk about his possible development shift at Nintendo. Since the Legend of Zelda Breath of the Wild is a massive project, we asked Animo if Nintendo considered fusing the Breath of the Wild team with the team that worked on the 3DS Zelda titles like Unlinked Between Worlds and Triforce Heroes. Notably Triforce Heroes was developed by Grezzo but also co-developed by someone at Nintendo's internal staff as well. And he said, we wondered if the studio thought this would speed up development of the upcoming console game. Here's what AJ Animo had to say. Additional clarification saying that the handheld development team will not be phased out because of Nintendo Switch. Switch will allow users to bring their home console on the go. But this doesn't mean handheld game development like the Nintendo 3DS will be discontinued. When asked Point Blake if there was a possibility that the 3DS Zelda teams are working on a new game for Nintendo Switch. Animo said, yes. We could stop there but there's some context. There is definitely a possibility. So going deeper into this he says there are definitely good things about the 2D world in play styles of the 2D world.  This Nintendo Switch style which is the evolved style of gameplay is not necessarily, I want you to think of it more as an evolved style of the 2D style for the 3DS team. I'm trying to make them think about a more evolved 2D approach. So yeah, that is what Eiji Anomo had to say all the way back in 2017. So we forget about this but he essentially said that one, the team is working on a new 2D Zelda game. Two, they're not combined with the Breath of the Wild team. Three, he doesn't want them combined with the Breath of the Wild team. And four, he wants them to rethink the conventions of 2D styling. And so when you think back on that, that was back in 2017. So we know they've at least been working on something for four years, if not a little bit longer. And we haven't had a release since, except for Link's Awakening. Now Link's Awakening obviously didn't rethink anything. That's basically just a different art style, like a Link Between Worlds, but in HD for Link's Awakening. And that was made by Grezzo. Now again, Grezzo could be helping out on a top down Zelda game like they did in the past. But the point is that even if Grezzo is part of that development cycle, the internal Nintendo team is obviously working at something. And in Link's Awakening, again, that's not really what this sounds like. This sounds like an evolved 2D style, trying to do something more. And what happened with Link's Awakening was basically the same 2D styling as a Link Between Worlds and Triforce Heroes. So okay, so what could this evolve styling mean? Well, this is where we get into Game Over Jesse today. Game Over Jesse has his own sources who have been correct on multiple Zelda announcements behind the scenes over the last six months. So shout out to Game Over Jesse here. Again, please go check out his channel. He's got a lot of awesome speculation about this and what this 2D Zelda game could be. But his source mentions basically one key important information for this supposed upcoming 2D Zelda game, which again, not saying this is going to be announced at E3, not saying that this is even coming out this year, just that, you know, this is inactive development supposedly. At least I believe it is. Again, Angie and Noah, you heard me say it. You know, that's the proof, as it were, that this game exists. But here's what Game Over Jesse's source is telling him. It's going to be a 2D and 3D game that uses elements of both. Think a Link Between Worlds but in a more original style. So if you guys remember an Link Between Worlds, you could merge with the wall and do 2D sections. Same thing with Super Mario Odyssey, if you remember. You could also merge with the wall and do 2D sections. I think that that's obviously not the direction they're taking here. And one idea that Game Over Jesse brings up that I do want to briefly touch upon is the idea that what if it's a pseudo third-person typical Zelda game, like we see with Ocarina of Time 3D, Drawer's Mask 3D, Breath of the Wild.  What you instead do is click in the right stick and suddenly you're playing it in top-down style. And it could be an item that enables this. It could just be a gameplay quirk, you know, a quick camera trick, whatever you want to call it. It's a distinct possibility that that would be one way you could do this. Otherwise, beyond all that, it's just coming up with our own ideas on what a 2D and 3D game that uses elements of both could work like for a top-down style Zelda game. Because obviously the top-down style is probably going to be present in it in some way, but how do we get it present and it with more 3D elements and a more, you know, take back the Spirit Tracks. There was a lot of top-down elements, but then some of the boss fights were these big epic, very, you know, 3D Zelda-like experience. So these are things that have already been done. So imagine trying to do something fresh on top of that. Also, as you know, there's an entirely different audience and an entirely different design perspective that goes into these type of games that he wouldn't want to take away from Zelda fans. So we got Link's Awakening. It's the question is always, what next? And I have argued for a while that what if this game that was talked about back in 2017 is coming to fruition? Because the idianoma essentially said that it's in development, but what now? And Link's Awakening, according to developer interviews, was not in development back in 2017. So if that team was making something back then, it couldn't have been whatever Link's Awakening was from Grezzo. So what's coming? Is it coming during the 35th anniversary of Zelda? We talked a lot about a 2D Metroid drop at E3. Is a 2D Zelda drop possible again? This is just my belief. This is my speculation. This is not a rumor. I mean, the Game Over Jesse stuff is factually a rumor. But my belief that this game exists is based on an article from 2017, an interview from 2017 from the series producer. Take it with it, what you will. I wanted to bring this back up as we're getting to that Zelda 35th anniversary time and I'm starting to wonder, are we finally going to see this one? You guys, let me know what you think about this down in the comments below. This is more of a discussion video of sorts. So thank you guys so much for tuning in. I am Nathan Rojas from Nintendo Prime. Be sure to tune in tonight, 8 p.m. Central time. We have a live stream for you guys tonight. Also over the weekend, I'm planning to drop a new Zelda video that rounds up basically every Breath of the Wild 2 rumor that exists.  But it's still kind of a fun video as we get into E3 and just kind of looking back at all of the fake stuff, all the stuff that I might have some legitimacy or none of it has legitimacy. It's still kind of fun to round up all of that crap, throw it in one video.  Again, none of the rumors are going to be things I subscribe to, but God, they've been floating out there for years. So we might as well put it all in one video for you guys. Don't worry though, I have some non-rumor leak discussion kind of videos in the works. One thing I'm debating, I'm bringing back. And if you made it to this point in the video, I really would appreciate your feedback down in the comments below. If you guys remember, here's the news. I'm debating on bringing that back with a new format. I'll give you a hint. This TV in the background is part of that format. I will probably be standing for those videos and all that. So we'll talk about that as a possibility moving ahead here. I just wanted to get your guys's thoughts on bringing back that series. If you don't know what here's the news is, it is essentially a video we would do kind of in the mornings typically where I would wake up and instead of doing my morning video or whatever that I typically do, I would gather up a bunch of news stories. Most of these news stories are very small stories. We don't really have a lot of big ones in there. And I would just combine them together and do a video. And there'd be appropriate imagery up on TV for every story that we cover. I will get into all of the stuff. There'd be sourcing, there'd be all this stuff on it. It would be a very highly efficient way to get news out. There are other channels, by the way, that do this kind of content. So I didn't want to necessarily copy what they're doing. And I know the set difference can make me stand out, but that's kind of the thing. That's why I want to ask you guys, do you guys feel like bringing back a here's the news, a prime news for our old school members? If you guys think that that's something worth my time, or if I should just keep doing what I'm doing now, granted, we're going to keep making these videos as we've been making them. But it's just something now that I'm finding a groove here. I maybe I could squeeze it in my schedule. And I just wanted to see what you guys thought about it. I know some people are going to be all for it. Other people are going to be like, wham! There's other channels that already do that. I agree. So yeah, I'm just kind of trying to find that happy balance to bring in some more other stories that exist out there that maybe aren't that big of a deal to make standalone videos on. So you guys let me know what you think about it. All right. I'm just, again, just coming up with the ideas. You guys let me know if any of them are worthwhile. Thank you guys so much for tuning in. And I'll catch you in the next video.


Hi everyone, Joe for jaspyscasebreaks.com coming at you a 2019-2020 Panini Revolution Basketball Standard edition four box half of an inert case tiered random teams number four We got Nick Jaspy on the top camera there helping us rip remember the tiered teams right here Big thanks to these folks right here. Thanks to the teams right here. Let's roll it Let's randomize it one and a four five times from each list one two three four and Fifth and final time after five times. We got Joseph fest down to Nicholas Lali Five times. I said four and a one. Yeah, four and a one five times for the tiered teams Fifth and final time after five times. We've got the Grizzlies group down to the heat group Now we are backed up a little bit ladies and gentlemen So maybe a slightly shortened trade window anyone want to trade remember you got to trade the entire group Joseph fest with the Grizzlies Nets nuggets jack You got the Cavs pistons jazz Stephen Cohen wizard sixers blazers Corey bulls warriors Kings Matthew shear last Bob Mojo Celtics Timberwolves JC with the Hawks Hornets Raptors Matthew with the Lakers Rockets Pacers Louis Pelicans nice thunder magic Zach with the Knicks Spurs Clippers and Nicholas Lali with the heat Plus sons plus bucks. Let's order these alphabetically by team and we'll give everyone maybe 20 30 seconds or so To trade I got all the supplies I need here We got a glass. I didn't see the name. I just saw the word galactic Galactic alert I've never seen anyone trade a tier of teams. Although maybe one time Maybe I've seen it once like early on but I haven't seen it since Tears the tears are too good This is a great way to do it actually especially with all the how expensive these basketball products have gotten No one wants to get into a 30 team break Or whatever half the you know a third of the cost of that which is still kind of expensive Just to and buy three or three or four teams and end up with a three like worst teams But this you're at least Yeah, yeah, if you get the worst team you end you still have the pelicans exactly so I think this works out nicely Sharp sharp play. Good luck everybody. There's the final list TWC trade window closed Where's the galactic pack? I think that one you all right galactic pack back there Will find out otherwise the galactic will pop early Oh, sorry, that was when you were on the couch. There's Nick ripping packs right there all card ship in this Too many parallels and everything Donovan Mitchell lift off die cut for the jazz group Cavs pistons jazz Jack B No parallel on that but Nice and it's intact too. Some of these have popped a little damage. There's a autograph down there, too We got Nikhil Alexander Walker Astro, which is I think the most common of the short prints Gary Harris LeBron James's are pretty nice Deandre Hunter Fractal Julia local for And the autograph is no, that's the galactic Julia will go for it was in this box I know I thought pelicans too, and I was like, oh, this is a super short print still nice For Louie nice pattern in the background right here All right, and Jason's lively. Remember the main channel here is booked up for the night and in preparation for Mosaic and Bowman baseball this week. There'll be no Nick at night for four tonight. Maybe tomorrow Jason Tatum Vortex fractal Bama to bio Astro and Carson Edwards sunburst two out of 75 one a good-looking pattern right here reminds me of the sunburst color on a guitar on a geek and a supernova LeBron James and His teammate groove Kyle Kuzma Lakers couple Lakers cards there for Matthew Shearer his value has gone up Which is wild There's a Zion just a base of Zion and a die cut Zion lift off nice there you go Louie When it rains it pours So visit Jason at Jasper's breaks on Instagram live Best viewed on a mobile device There's Kevin Huter groove Nikila Alexander Walker Astro Bren Clark And we've got shockwave John Marant Terry Rose here Astro. Oh and another autograph That's RJ Barrett. Wow. Nice We're only two boxes in and that will be for the Knicks group Zach with the Knicks spurs Clippers combo Nice, that's a good group right there Got RJ be on there Grizzlies John Marant Joseph the Grizz net nuggets combo It's good combo to all good combos And you got Romeo Langford Schofield Luca Donchich vortex that's nice gore and draugage fractal another sunburst That's miles bridges 28 out of 75 sunburst and RJ Barrett fractal Nice and Michael Porter Jr. Second-year Astro Nice RJ Barrett Zach nice fractal parallel. That's a shorter print than those Astros Miles bridges is actually serial number.  That's gonna be for Matthew Shearer Fractal on the bottom there here is The last two boxes here in tiered random team number four Brandon Clark Astro We got Jimmy Butler Astro This cappella we got RJ Barrett shockwave That's a good and boy a groove Kyrie Irving groove Jamarant rookie Revolution card nice Grizzlies and you'd be surprised how well this stuff goes on a secondary market ladies and gentlemen This is nice cubic Zach Levine to 50 and there's car on the town's fractal Bulls Corey Once again, Nick's Zach fourth and final box We got Goga, but Todd's a Astro Jordan pool Dane Got to Marcus Cousins groove And RJ Barrett rookie Revolution nice It's RJ Barrett's are flying out of here Zach Trey young Marcus Aldridge and another autograph. It's PJ Washington nice The autographs are kind of few and far between in Revolution and like an eight box inner You can expect maybe Four three or four, but I feel like we found three already right here in the second half Hornets JC with the Hornets Porzingis Whoa nice Lori marketing impact to 149 Eric Bledsoe fractal We got a Luca Samanich groove and Joelle and bead Astro And that will be for the 76ers that's gonna go to Stephen Cohen I'm sorry that Joelle and bead this bull's card will go to Corey There you have it folks. That was tiered random team number four. I don't think I need to do anything else No, that's it. There you go. Nice clean break. Thanks for watching everyone. I'm Joe I'll see you next time for the next one. Bye. Bye


Last session of the day, and then I guess there's a panel at the end of the day or what do we have? Keep everyone guys are passionate you want to go to the end. Awesome We'll see all right well Hopefully we'll have a little bit of fun today this is an opportunity to run through a simulation where we can be It's going to be going from all sorts of chaotic to even more chaotic here as we get going so the Confusion from confusion to chaos So this is a value uncertainty game My name is Todd little VP of product development for IHS They took data analytics company Let's see if this is going Okay, I was gonna look at the jelly beans we do that if we still have time at the after finishing this We may do a little jelly bean experiment, too So how many of you were in the talk yesterday myth busters quite a few So I left you with a click cliffhanger here now what so we're gonna do a little simulation of sort of the now what so They're just a quick review of what I just went through yesterday First of all, we had a test.  We did a bunch of tests of different things Up and then we looking at whether we actually have how good are we at estimation?   I think we know that So is it understood? No, we are not very good at estimation. We're gonna experiment some of that today Significantly in estimation accuracy significantly improves as the project progresses is basically the cone of uncertainty That's pretty much not true either estimation uncertainties pretty much consistent Estimations are frequently impacted by biases. Yeah, that's pretty much true We're pretty good at estimating things relatively. No, we just suck in a relatively different way Velocity is a good tool Yeah, that's velocity or throughput cycle time. Any of those are also all good techniques For improving getting better data. We're a bit behind, but we'll make it up in testing. Nope. We're not gonna do that Scope creep. Yep, we got scope creep Having more estimators, this is the wisdom of crowds. Yeah, that can that can definitely help Or more people involved in the estimation Project success is determined by on-time delivery It some organizations it does unfortunately, but we want to move towards more value oriented outcome Oriented view and then estimation is waste. I'm look at let's consider that plausible so So now what so let me go through how I how I have coached teams to to work as I've found that this worked very well for me in Getting dealing with the trade-off of what's the right level of estimation? What's the right level of predict?


But now in the age of tick throws and where stagger pressures, that was so sick. How's it going everybody? Dato Dewey here, back with some more Dragon Ball Fighters ranked matches. This time playing another suggested team of Gojida Blue, Beerus and Krillin. From what I understand there really is no theme behind this team. It's more just a team of characters with godlike powers in the show, I guess. Ah, Krillin included. Alright, but now that we've not teched the Dragorush to make that one bad joke. Let's talk about Gojida Blue because he's actually kind of falling out of favor with a lot of people. Not that he was ever number one or super high tier or anything, but yeah, a lot of people are placing him pretty low on their tier list. That's given that we haven't really seen any real tournament gameplay going on, except no majors at least. We're going to spark here, see if we can't save Gojida for what it's worth. Get down, alright. Fusion match up. Alright, we're going to have to switch off here. There's no way we can confirm off of that. But yeah, a lot of people placing Gojida pretty low on their tier list, mostly just because of... Well, Gojida's normals aren't the best, including his standing light. It's definitely, it has always been his worst feature, at least to me. But now in the age of tick throws and where stagger pressures, that was so sick. I was talking about something else, but don't get me wrong. I saw all of that, and I wish I saw none of it. Oh, Beerus, why? Beerus, don't go out like this, man. Make him drop it. He ain't dropping this at an assist. Alright, never mind. Wait. At least he spent three bars for you, Beerus. That's pretty good. No. I just, I assumed he would hit it.  It ain't even like I didn't tech either. It's just that I was holding up tech. Wow, I am letting him go free out of these corners. You think you can tell I'm DP-ing? Let's go! I don't think you could tell. Give me, you know what? Give me Vegeta back. I'm gonna kick this man in the face. I thought for sure he would, um, I don't know what, I don't even know. I thought for sure he would level three is what I was gonna say, but take a little bit of this.  Don't make me spend two. I would have done it. I would have spent two if I had to. Alright, Jito's out of the picture. All we have to deal with is Goku GT and a B-Assist Goku. That 2M is, that 2M is gonna do a lot of damage. Okay, level three please hit. I think that's sliding. Oh, I hate that as well.  That was close to being sick. He did another good one. I thought he was gonna come in. I tried to, I tried to read him. I don't know why I did it. I shouldn't have. But he went forward back and I was like, here he comes forward again. And then he went for a Kamehameha, so it was clever. I'll give it up. He had some, I shouldn't ever do a beam against Goku. It's been, you know what? Goku GT is still very good, but he has been much, much rarer online. So I am so rusty against Goku GT. Let me know down below in the comments if you kind of feel the same. But I feel like with season two I had so much, I had so much experience against Goku GT and now it's all rust. And I definitely dreamed of being able to say that one day, but now in the clutch, I wish I had the experience back. Stop! Oh, we're dead. I was hoping he'd kill me with a level one, but we're gonna have to watch the full Super Saiyan 4. Dragon Fist. Alright, pretty rough first game. Not gonna lie to you. I think it was mostly just that we got off to such a bad start. Gojira Blue, I had a pop sparking. Granted, the sparking did come back to save us. We got Vegeta with Gojira, but... Oh, are we gonna, we might actually lose our halfway mark. That is if we don't, if we don't get at least one win, we'll lose our halfway mark. Oh! Alright, that's fine. We made up for it, but I was about to drop that like crazy. I'm kicked. Oh, that was a mistake. Just get me out of here. Just get me out of here. Oh, where are you going? No running away from Krillin. I'm about to go in. Here, let's kick him. Yeah, I got to see that in all 19 frame glory. Ah, my C assist. It's gonna be a while before that assist is back up again, too. Super Dash. Oh, come on. Oh, reward your boy with a knockout, though. I dropped it. That was on me. That was on me. Nobody has to take credit for that. Oh, EX Flash, not even Flash Fist. EX Rush. I don't know what that move's actually called. Don't level three. Thank you very much. I'm a spark here. It was a, it's a questionable spark, but I really want to get Vegeta out. I need to get this character lead. Don't do it. Don't do it. Don't level three. So cool. That, Krillin's my favorite character in the game. You guys know that? I would hope you do. He's on the banner. He's on the banner for a reason. This man is sick. Thank you for nerfing that. C assist, hurry up, man.  I wasn't blocking anything. Uh, Batsuko is a full spirit bomb. He has been charging. Oh, Dantek, don't believe his lies. Alright, that one hit, but we can still tech this. We can still tech, right? Now you can combo. Wow. That was rough. That was a lot of damage. Dude, I am not using your G to C assist properly at all. It's such a good C assist too, but no. Okay, he sparked. At least if he sparked, then we should at least be able to hold him off, right? Let's go. Alright, drag out that time, Beerus. Drag out that time. Level three him if you have to. Maybe I should have gone out into Gojira's. It's a longer level three, I think. Oh baby, that sparking timer's all mine. Oh yeah, dude. I never want to see anybody spark again. Oh, that spark, it's all gone. Alright, we're even. He's going to eX something. Ah, I knew it. I tried it down heavy. I couldn't tech that. Alright. It's going to come down to how good our defense is, whether or not we win this game. Because Beerus is most likely pretty dead. I don't think he's, is he dead dead?   Wait, wait, wait, hold on. You can't combo that move off the, you can't combo that assist off the end. No, don't give him half a bar. Oh, cheap. Alright, he's still got a character. Wow, he turned around so quick. Five bars in the back pocket if he wants to spirit bomb or do anything with that. Block the first. My GT, my GT experience is rough, dude. I can't, I didn't even remember that he could overhead after that.  Can I get a misclick on aisle five? Actually knock me away? It's not going to knock me away. Yeah, we're just dead. We're dead in a different way. Oh my, we're alive, we're alive, we're alive, we're alive. Don't doubt heavy me. Oh, he tried it. Let's go. Oh, oh, let's go. What's happening? I tried to eX DP. I should have been more patient on defense. Well, let's be honest, with what you saw there, could you have been patient on defense? You could, you should have been able to tell I was paying a gig like six hours ago. Okay, 2-0. I don't want to go, I don't want to go 0-3. That's why I'm a jump. Let's go. Finally a good start. Really, that's in combo, bro. Overhead. Yes, behind the back as well. Oh, wow, he really up teched buttons and I didn't catch that. Alright, that was on me then. I left a little too much time on the docket.  I tried to reflect. Thought he'd go for some pull stuff. Yeah, Goku GT is still really annoying. I'm like thinking about it. I was like, damn. Just because this character is not as popular doesn't mean he's not just as threatening. He's a little less threatening. Let's not mince words. He's not as threatening as season 2. He's still got the sauce if you want it as a bad reflect. We got to start thinking about an early spark.  Because as of right now, I think Krillin might actually be dead. Level 1, level 1, level 3. That might not kill actually. Final Kamehameha. Even if we do live, we have a- oh, we're dead. Couple of ticks left too, so it wasn't even that close. Alright, hold on. Iris, I want you to bring it home. There we go. Hold on, hold on. I'm just going to level 3. I want the hard knockdown. Is this smart though? Yes, it was smart. Alright, we got to kill all 3 bars we're worth. If it didn't kill, by the way, I would have regretted that decision so quick. Another good use of the sea assist. Finally coming together. I feel like I'm hitting my stride. I messed it up completely. Remember when I was hitting my stride like a solid 6 seconds ago? That's a level 3, isn't it? Yup, that hits about level 3. Alright, now this is where we use Spark, because this is going to be a lot of blue health.   Okay, okay, that's good. I'm just going to keep super dashing, bro. I'm not going to mince words. I'm not mincing no words. Oh, he got me. That vanish was unsafe. And he got a bar from base Goku- man, base Goku be assist. I really do like base Goku be assist a lot. It works really well with GT Goku. We lived. Trying to reflect. Tried to DP. That would have been so clean. Aw, no, that's huge. Got him. You trying to air to air, go genus jumping medium? That's crazy. You were asking for it there. Alright, let's play this one a little more safe. Okay, I wanted to go safe, and he wanted to go full out. Aggress, are we dead? No, that must not have been a level 3, but times 20 is still going to hurt. Connect, nice. Oh, what? I couldn't kill. I couldn't kill. I couldn't kill. I might have been able to kill. Why didn't I vanish? No, what a bad drop. Oh, I just panicked, dude. Oh, no, I should have EXed. Oh, there's so many options. I should have EXed it. I haven't played Gojira since the EX change. That was, oh, I should have light light eat.  I remember now. Alright, one more match. One more match. One more match. Oh, no, he's not there. He must have got the party poppers out, dude. The clean 3-0, he busted out the party poppers. He can't reach the controller through all the confetti. No, wait, come back, come back, please. Come on, I thought about all the ways I was going to win. No. This is a heartbreaker. This is a heartbreaker episode. Hopefully you guys did end up enjoying it, though. If you did, let me know your favorite moment down below. While you're down there, hit the like button and subscribe if you just enjoy the channel in general. Other than that, there's some videos on your screen. Give those a watch if they catch your eye. I have been Dr. Doi, and I will see you guys in the next one.


Good morning and welcome to day three our final day of NACU next for this year We always like to check on you as we head into the home stretch If you are anything like me, you've got distractions Email messages and to-dos piling up. It's easy to jump back into the work and just keep carrying on But you're here this morning and continuing to fill your cup So take a deep breath Recognize it's all going to be there when you exit this conference and go back to the daily grind Take this last precious day to learn absorb grow and improve invest in you Make sure you synthesize everything you've been exposed to this week here at NACU next Dot the eyes and cross the T's on your notes while it's all fresh and start to think about how to translate learning into action Use this information to help continue your journey with quality learning and application So what's in store for today? Well NACU is thrilled to have partnered with the patient safety movement foundation on a content collaboration for this final day of NACU next This collaboration is even more relevant as we lead into tomorrow's world patient safety day Reminding us to take pause and to honor all the efforts underway to help combat medical error and the injuries and even tragic Fatalities that come from it. We know medical errors in hospitals are the third reason leading cause of death here in the US Just behind heart disease and cancer and globally it is believed medical errors kill more people than HIV Malaria and tuberculosis combined We know health care quality is one of the strongest antidotes to this unfortunate reality And we are excited to bring you more from that perspective the perspective of the patients We all ultimately serve today through some rich content and sessions Before we dismiss into our day I want to make sure you are aware that NACU can support your broader Organization on its journey to higher levels of workforce readiness around health care quality competencies I mentioned this because I know as just one employee at a system of thousands of employees myself It can feel daunting at times and almost like I'm shout shouting in the woods To be talking about quality so broadly across a diverse organization of employees at various levels With various levels of tenure or lived experience in the industry. It's hard to get everyone on the same page NACU is here to help NACU offers what it calls team training which are modules and resources that non-quality professionals can consume To help really set the deck for you and establish a common baseline and vocabulary around quality It could put some wind in your cells and believe me it won't at all break the bank. I know budgets are tight right now You can learn more about that by visiting the team training section of NACU's website Or simply send an email to team training at nacu.org and our staff will send you some information that you can circulate internally a Few quick housekeeping reminders as we prepare to dismiss into the day First remember to complete your evaluation to earn your CE credits Second don't forget you have access to all these sessions plus two dozen additional on-demand sessions until October 23rd 2020 and finally be on the lookout for more information soon about health care quality week coming up in mid-October NACU will be providing tremendous resources and tools to help you advance this noble profession and help you get everyone back at your facility or system Excited to take quality to the next level Let's make the most of this last day of NACU next Without further ado, I would like to introduce Michael Ramsey who will be kicking off our morning with a short the powerful opening session Dr. Ramsey is chairman of the department of anesthesiologist and pain management at Baylor University Medical Center and past president of the Baylor Scott and White Research Institute Following Dr. Ramsey's opening session our next speakers will include David Meyer the executive director of the MedStar Institute for quality and safety Helen Haskell the president of Mothers Against Medical Error Mike Durkin senior advisor on patient safety policy and leadership for the NIHR Imperial College Patient Safety Translational Research Center Leah Binder president and CEO of the leapfrog group and Steve Muething chief quality officer and the co-director of the James M. Anderson Center for Health Systems Excellence at Cincinnati Children's Hospital Medical Center and professor of pediatrics at the University of Cincinnati College of Medicine Please join me in giving these speakers a warm welcome Carol, thank you very much for your kind introduction and it's a great honor for me to be here Talking in front of the National Association of Health Care Health Care Quality My name is Mike Ramsey and I'm the chairman of the board of directors of the patient safety movement foundation And I'm also chair of the Department of Anesthesiology at Baylor University Medical Center I have no conflicts of interest related to this topic So the patient safety movement foundation was founded by a california businessman in in 2012 Joe Chiani and he's involved in the health care industry And when he became aware of the number of errors being made in health care and the patient harm and mortality associated with those errors His industrial background where particularly electrical engineering He wants to apply the same principles that they apply In engineering to health care in other words find the most safest protocol And mandate it have it put into practice so that We use the safest techniques And the safest protocols on everything we do So we can eliminate patient error and patient harm and patient death So with that We have a summit every year except of course this year with cove it Where we bring leaders in from around the country and around the world to present Safety topics that we can apply to health care. And this is dr. Tedros from the World health organization That's topical at the moment because they've got patient safety day coming up next month on september the 17th and we're here to create free resources for our hospitals and patients and our solutions which we call apps Which are really protocols that We can apply to various Areas in health care where errors and patient harm occur more frequently an example would be that Houston Methodist Came up with a protocol for reducing central line infections. They were able to reduce it to zero and prove it And so that was something we embraced So we will create these protocols That have proof associated with them that can show that they eliminate patient harm And so that's the premise behind what we're trying to do And we as I say we bring together the leaders like dr. Tedros And we look at the problem that we're addressing Which she's estimated from johns hopkins to be around 200,000 preventable patient deaths in us hospitals a year 200,000 and 4.8 million globally It's the third leading cause of death in the united states behind heart disease and cancer And the 14th leading cause of death globally more than tv malaria and hiv combined And the cost is as unbelievable To health care in the united states, but also in the world And so tremendous savings financially as well as In patients lives if we can fix this problem And so what have we done so far since 2012 to 2020 our goal was zero preventable deaths by 2020 Well, we're there now and we haven't got down to zero But looking at independent audits of the lives saved We estimate there are about 366,353 lives saved where people instigated these apps or these protocols Into their hospitals and health care systems and we've also asked health care companies technology companies To open have an open day at a pledge where they share the data that their monitors create Not the ip but the data so that These monitors all speak to each other if you look into our operating rooms today There's still many different boxes almost black boxes We call them with patient data appearing on them if we can integrate that data We can pick up abnormalities occurring to patients much faster And so now we've got a large number of companies sharing that data so that we can integrate it and help use artificial intelligence To help predict when a patient may be getting into trouble And so we have now Political leaders as well involved because for a politician You know, this is both sides of the house You save lives you save money which politician would not get behind that And we've had great support from president clinton a vice president biden as well as jeremy hunt Who ran for british prime minister this last time? And these leaders have helped us Try to get to our goal of zero And now having got to 2020 where we're not there yet We can no longer plan or no longer hope for zero. We must plan for zero And the hashtag plan for zero is a link that you can link on and see where we are in this venture Now just to bring in front of you some of the more awful medical errors that have hit the news in the last year or two And see this one from vanderbilt where the nurse gave the wrong medication It's supposed to have given a sedative to a patient going into a mri scanner But unfortunately gave a muscle relaxant so the patient couldn't breathe and that patient died And you can see cms threatened to terminate vanderbilt's Medicare contract after this fatal medication error And I bring that up because one it just shows in real life these errors are still happening But two what is the solution? Is the solution to terminate vanderbilt's Medicare contract or is it to look at the process and correct the process Here's another one a houston hospital replaces leadership after blood transfusion mistake. Well, again, there's a punishment associated with this error And will that lead to better transparency about hospital errors health care errors? Or will it lead to people shutting down and not talking about them? Which is really this the practice at the moment We need high reliability organizations in our health care systems. We need leadership there We need a culture of safety. We need non punitive environment. We want accountability You know, if you vary from a protocol that's been shown to be the safe protocol Absolutely, there needs to be accountability But on the two areas that we've just talked about neither of those errors were Done intentionally. Nobody cut a corner there It was a process. They wanted to take care of their patients But the process wasn't safe And we need these standardization and hardwired safety protocols in place like they have in industry like we have in aircraft Flying as well in that industry Those parameters are out there. We need to hardwire them into health care and Cause all our health care systems to be high reliability organization Lucien leap came up with this comment a number of years back The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes We need to put the protocols in so the mistakes don't happen Then if you cut a corner, absolutely will make you accountable But if you go with the protocol mistakes should not happen So how do we change the culture and its leadership? And here's one leader who did that in the united kingdom. This is Jeremy Hunt He decided that doctors who make honest mistakes shouldn't be disbarred shouldn't have their license taken away They'll get more support to eradicate those Mistakes that will put the protocols in place in the national health service in the uk So that it's a safe health care system And that's one of the first times that at a national level This has been put in place with great results so Where are we now with the patient safety movement our vision now is zero preventable patient deaths by 2030 and focusing on eliminating preventable harm as well as death in the health care system across the world by creating a sense of urgency and Getting these best practices out there so that people know How they can prevent these Errors and prevent harm and prevent death So we have nine strategic aims in the foundation prioritizing safety with patients at the center promote dignity compassion and respect in health care Aligning everyone who influences or touched by health care And those have us all aligned in these protocols so that everybody in the system will speak up If there's a problem promote transparency. So we all learn from mistake Realign the incentives to achieve safer care Bring patients and families and caregivers all together around patient safety Create these protocols which we call apps And and promote them put them out there so everybody Can learn from them keep them as living documents so that if you can show us a better protocol and Move it we'll put it out there. We'll change our apps and have this Super highway where technology companies share data as well So how do we get there? What's our strategic plan? It's funding, of course We have to have funding to be able to do this It's creating awareness So that across health care systems people Understand the safe practices. They can download them. They can get online and see them immediately and Institute them in their hospitals. We want legislation so that The elected officials can promote aligning incentives with safety transparency and preventing harm and we want to partner not just with hospitals and Patients but industry as well. So we create a safe industry just like the airline industry Where we investigate rapidly any problems that occur And if the protocols are not followed Uh, we obviously intervene at that point, but if they were followed Where did they go wrong? How can we make them better and safer? So these apps are out there. They're blueprints to safe care. They're online They're educational resources attached to them videos webinars white papers and They can be downloaded By any health care system any clinician any nurse any patient can download these apps They're the best practices and they all relate to Different parts of the health care system the body from the head from mental health To the chest airway safety to fluid and electrolytes obstetric safety pressure ulcers medication safety right drug right patient All these things can be hardwired and put in place And that's the foundation of what these apps are about So the road to patient safety success is transparency It's patient and family partnerships It's human factors integration Reliability culture core values and it's process design These are all things to hardwire safety that we can put into our health care system and optimize outcomes And we must do it is zero possible. Yes, it is with a culture of safety. We can do it This is my hospital health care system You'll see these on every email from the hospital You'll walk into any corridor in the hospital and see zero harm Signs posters up there to bring Safety to everybody working in the hospital and the patients And that little square clear square there is where you put your own commitment And you can change it from month to month We look at selected committed hospitals Then numerous of them out there now where they've instigated many of these apps There even some five-star hospitals that have instigated all of the apps In an effort to reduce preventable patient harm to zero And one hospital that has done it is the children's hospital of orange county That have even tied their director's pay reimbursement to instituting all these apps and seeing that they're in place Another area that we've now got to look at since cove has been here is we did a survey on What is the highest concern in health care today? And to our amazement is health care worker Health in other words we're seeing health care workers going down with cove it dying of cove it being afflicted with health with cove it and suddenly The workers are the patients as well as the patients and so we have to make our hospitals Safe to walk in and so that's another area that we're looking at and To do this is initially our health care workers did not have personal protective equipment now they all do And that's what keeps them safe What can you do Build momentum for patient safety plan for change. Don't just hope for change Make a public pledge that your institution that you go to will implement all the apps What is measured it improves What is measured publicly transparently improves faster? And join us for world health patient safety day on september the 17th Just link on to hashtag unite for a safe care And we've got now about three hours worth of video From political leaders health care leaders business leaders Leaders from all branches including entertainment coming on for 10 minutes sprints of Video to put together. I think what's going to be a very exciting and very helpful Three hours that we can all log into and see and it's going to be free So our hospitals should be safe havens not danger zones and we can make that difference Thanks, Mike It's great to be with you today On our session titled building a foundation of safer health care creating and sustaining reliability At the beginning we want to make sure that the audience understands that none of the speakers today have any conflict of interest to disclose Today's session will focus in on one of the eight health care quality competencies this one safety The competencies of safety are to assess patient safety culture apply safety science principles and methods Identify and report patient safety risks and events And finally collaborate to analyze patient safety risks and events We have three learning outcomes for today's session The first is that we want to reinforce what we've learned about patient safety And the impact on quality and outcomes over the last 20 plus years Discuss how the covet 19 pandemic has exposed the cracks in the foundation of almost all health care organizations And then finally identify the components necessary to establish a true culture of safety That is closely aligned with holistic continuous improvement process And a simple model for sustainment It is my pleasure to turn it over to Helen Haskell right now so she can kick off the first part of this program So i'm going to talk about high reliability And i'm going to start out by sharing a story Which i think is a story that some of you will be familiar with It's a story of my son luis Who died in the teaching hospital at the age of 15 I want to talk a little bit first about luis as a person because i think it's so critical that people understand the real lives behind Case studies luis was our oldest child. He was our only son He was The top student in our metropolitan area of south carolina one of the top students in the country He was an anthropologist a historian Mathematician he was a soccer player, which was his passion at the age of 15 And also a natural comedian. He kept the other kids in stitches which needless to say was a lot more popular with them than with his teachers We thought he was the most brilliant boy in the world We thought he would grow up to be one of the great men of the 21st century. We couldn't wait to unleash him on the world So when luis had just turned 15 his father and i took him to a teaching hospital For a minimally invasive procedure called the nus procedure to correct a condition called pectosexcobatom Which as a lot of you know, i'm sure is when the breast bone doesn't grow straight And it creates a concave appearance to the chest. It's a cosmetic condition for most people as it was for luis But we as parents thought it should be corrected. So we took him to the hospital for surgery As far as we know the operation went well But as soon as he came out of surgery We things started going wrong luis was not urinating and that was complicated by the fact that the senior resident in charge of his his case Inaccurately prescribed a very low amount of IV flu. It's something appropriate for a very small child instead of a 15 year old Who was already dehydrated So luis was and that was complicated in turn by the fact that he was taking a lot of pain medications He had epidural hydromorphone opiates in his epidural Plus um six hourly injections of catorlac insane pain medication, which is Very widely used in american hospitals, especially now since um, there are So many cautions around opioids But it itself is a high risk medication that can cause very severe side effects including kidney failure and bleeding and gastric ulcers with perforation And this last is what happened to luis um Three days after the house after his surgery he um What he he woke up in the morning, uh had a catorlac um injection At six o'clock on a sunday morning Half an hour later. He he was stricken with a sudden severe pain in his upper left abdomen area of his stomach The nurse was initially alarmed um, and then she came back and reassured us that it was A an ileus just a constipation caused by the opiates in his epidural And that assessment stuck All day even though it never really fit his symptoms Um, and it did not change as his symptoms worsened over 30 hours the next 30 hours of his life um With no urine output And in the morning when he woke up. Well, he never slept in the morning when the vital science technician came around He had no blood pressure That the nurses and intern spent Over two hours trying to find a blood pressure. They took his blood pressure 12 different times with seven different cuffs Could not find a blood pressure until the second year resident came from the operating room And announced that she had found a normal blood pressure A little while later lewis went into cardiac arrest Over 20 people came to the code But they could not revive him an autopsy the next morning revealed the ulcer that had killed him and Nearly three quarters of his blood that had um leaked into his peritoneal cavity So this is some of what they were missing his vital signs were in the chart, but not really being followed And this while it contains details that I haven't mentioned I just wanted to include it for the purpose of showing that one wrong assumption Can lead to a cascade of wrong assumptions. So the initial Assessment of the ulcer ulcer is an alias Blinded people to the fact that lewis was going into shock was developing peritonitis When they did test for acute abdomen. It was not a complete test. They forgot to do the CBC blood count. So never really realized what was going on And on and on they they misinterpreted the lab test ending up with delaying the code For putting in chest tubes for a wrong assessment And some of the cultural issues I also wanted to to touch on because These are common Not just in healthcare. They're common human reactions And it occurred to me as I was thinking about that this Today That really these are a way of avoiding having to deal with anything unexpected You just sort of put your head down. They're trends that we need to learn to overcome if we have a high reliability organization So let's talk a little bit about high reliability I'm going back to The original book Managing the unexpected with its five principles of a highly reliable organization So just to go over them briefly the first principle is preoccupation with failure Always looking out for what could go wrong being prepared Second is reluctant reluctance to simplify Not looking for easy answers because easy answers are often not the right answers sensitivity to operations Assuming that the people who are on the ground have knowledge that you need Commitment to resilience being prepared to respond to the unexpected expecting the unexpected And deference to expertise making sure that you have the right people Who can come and be in the right place when you need them So in louis's case preoccupation with failure If you assume that any deviation from the expected can lead to failure Shouldn't there have been routine vigilance for post-operative bleeding or infection? Isn't that why people are in the hospital after an operation? People can get so involved in the day-to-day Operations that they they forget the purpose and no one was watching out For something that might have gone wrong and what was really a relatively high risk procedure Low urine output shouldn't there be a pathway for handling low urine output again not an uncommon phenomenon and Clear training on action to take if somebody has Abherent vital signs such as undetectable blood pressure Looking beyond the easy answers. Well, I think actually this is sort of an easy answer Shouldn't there have been an examination of the patient before making an assumption That he had an alias which was made by someone who Actually didn't see louis at all. I think Um and the policy of revisiting assumptions about diagnosis when when symptoms worsen and this is this is common for a diagnosis to just stick Sensitivity to operations if there had been good communication between the nurses and residents and and louis's doctors This could have had a very different outcome If the parents We had had a way to call the attending physician It would clearly have had a different outcome and we put that in place in our state after louis died And critical care outreach just when icu nurses critical care nurses come around to the wards and check to see If patients need help commitment to resilience Shouldn't there have been if we're going to be prepared a rapid response team Clear rules on when you call a code clear rules on how to conduct a code so that it is not chaotic And a chain of command we had a traveling nurse in the critical period She clearly Was uneasy didn't know what to do um in In this situation And finally deference to expertise there were four potential experts in this situation The first was the uncalled surgeon who also happened to be a critical air Care expert if he had actually been called to come in he would immediately have seen what was going on with louis because he was Clearly going into shock Even i recognize that louis a surgeon who should have been They should have been able to contact him on the weekend. He knew the surgical history As I said, I was the only person who seemed to recognize that louis was going into shock But I didn't know what that meant. I had had first aid years ago. I knew what shock looked like. I didn't know That it could be a fatal condition And louis who was one of the brightest kids in the state who was very clear about a situation and had all the information anyone needed so This all happened a very long time ago louis would be 35 now Um, we can't change the past. We can't change what happened to louis But I still hear very similar stories Even now even after all these years of patient safety innovation health cares are remarkably stubborn culture And some of the issues I I've Been thinking about can be found in medical literature going back to the 1950s if not before Going over what ifs is really a common phenomenon among bereaved families It um, it gives us comfort. It it gives us the Hope that somewhere in an alternate world things were different Maybe somewhere in an alternate world There's a young doctor a young entrepreneur a young researcher Watching his mom give a presentation on a computer very far away on some totally different subject Um before turning back to work to continue making his own contribution to the world We can't save louis, but we can save others And in this new covid world It's going to be harder to do that than ever So my challenge to you is to use these tools that we have at our disposal Which I hope you'll learn more about in this session And try to make the world a more reliable and a safer place Even when the unexpected occurs Thank you And david I'll pass it back to you Ellen, thank you so much for sharing louis's story. You and I have known each other for so many years And uh, I know how difficult it is for you to share that story each time But I know why you do it you work continuously Since louis's death to try to make health care safer for others So I and I know many across the country. Thank you for that I want to build on The foundation that helen laid down for us And how you really develop a true culture of safety Within a health system I like to start a lot of my talks with this quote. I think it is just so A perfect for what we're going through today Medicine used to be simple ineffective and relatively safe now it is complex effective And potentially dangerous I remember many years ago if you had high blood pressure You went you saw your primary care physician and you got a medication You came back a week 10 days later and either medication was working or it wasn't and and we'd make some changes Today we have had so much advancement in technology and diagnosis and medications Health care is doing amazing things today. People are living longer People are um living better The certain cancers we've been able to beat and think about surgical procedures procedures that we'd have to go into hospital for seven days Just 10 15 years ago now are done as outpatients But yet those advancements have not come without risk And the risk in inappropriate or inefficient infrastructure To keep up with the advancements and the rapid pace that we've seen in health care today Almost 10 years ago now We started a journey at med star health and we said we wanted to truly Change our culture to one of safety and high quality And at the beginning we brought an organization called health care performance improvement in and said we need you to help us and together We not only took their tools, but we built on a lot of the success They had seen and developed our own strategy for success around safety and quality It was built on five principles first Process design we had to make sure that we were following evidence-based best practice And at one of our hospitals or two of our hospitals, but at all 10 of our hospitals and our non-acute ambulatory facilities second We wanted to lay down the structure of a reliability culture We wanted to become a resilient organization that used the tools and techniques that have been proven in other industries to provide safe Care within health care As well as prioritize and put safety first We believed we had to build a human factors Overlay on top of that resilience culture and I'll explain more about the human factors side of it in the time I've got with you today Fourth we had to really Embrace the patient and family boys as Helen said in her story about Lewis She could have been a critical part of that team if she was just asked and I'll tell you Over the years I've learned more from patients and families and how to provide safe high quality care than I have for many of my colleagues So we had to really bring that patient voice into our story and into our mission And finally we had to put a transparent umbrella over everything. We had to stop lying to ourselves We had to stop denying that these things happen in health care. No, they don't they are solvable And there are solutions for them and we had to be open and honest with patients and families So we create a learning environment Helen talked briefly about high reliability in the five principles. I really like this definition It's a subset of hazardous organizations That have operated nearly error free for very long periods of time And many of you know those industries you look at aviation and the safety record they've had It's just been amazing and it didn't come without hard work, but they put their minds Set a goal and have really driven to almost zero preventable harm in aviation Nuclear energy is another example of that the Department of Defense What could we learn from those organizations that have made them risky? Yet ultimately very safe in their performance I used to Comment to my friends. Why is it in health care that we accept or have accepted Heirs and bad outcomes. I remember Seven eight nine years ago good friends very good clinicians Who would tell me that we couldn't get to zero preventable infections With central lines. They said it's just the risk in health care. We take care of trauma patients and brain surgery patients We do cardiac surgery and people are going to get infections and a rate of four infections per thousand catheter days We should be proud of that But yet there were people who said no, we shouldn't and we could do better and the keystone project was developed Which showed you can drive central line infections to zero And I think it's very important that all of us brace the concept that zero is achievable It's achievable in ventilator associated pneumonias. It's achievable in central line infections and it's achievable in other preventable harm scenarios We may not know all the answers today or we may not have the technology today But it doesn't mean tomorrow. We won't have that and we got to continue to push For that zero in everything we do when it comes to preventable harm This is one of my favorite slides and I credit Raj Watwani I saw him use this many years ago And I went up to him afterwards and I said Raj and Raj is is the director of the national center for human factors Engineering and health care at med star health. I said, Raj, where did you find those pictures? And Raj said Dave, there's a whole website out there. It's got over a thousand pictures of cars driving down the street With gas hoses hanging out of their gas tank and I went to that website and he was right.  We all make mistakes I know many times with atm machines and the cards and losing our cards and the things that The banks had to do using human factors applications To limit or reduce and now almost make it impossible to forget to leave your card One of my favorite stories is I said coffee up every night before I go to bed and I put the coffee grounds in I put the water in So in the morning when I wake up all I gotta do is hit the button and when I come back five minutes later Coffee is made. I do this every morning yet once about every two months I walk back into the kitchen and I find A pot of hot water because the night before because of distractions or thinking about other things I forgot to put the coffee in the coffee pot Again, those are airs that are just common. We make them every day James reason said we cannot change the human condition, but we can change the conditions under which humans work This is the essence of what human factors tries to do is knowing that we will make a mistake There was a research study that came out a couple years ago. They said pilots make one mistake per hour in the cockpit But those mistakes have been trapped through human factors applications through checklist through other things So they don't move forward and cause an air that can be catastrophic We've got to embrace rebuilding systems and processes and putting resources into Protecting those at the front line who go to work every day to heal Many times like all of us we can make a mistake at the front lines Here's a great example by another Human factors national expert terry fairbanks terry and his team did a study about a defibrillator This is a common piece of equipment. We use every day And yet in testing with this defibrillator, they found that in use One out of every five times in the heat of the battle when the stress is on and you use this machine over and over the person who says To give the charge and the person then gives the charge Hits the green button versus the red shock button They do this because our mental model tells us green means go. It's safe red means stop.  It takes two to two and a half minutes to reboot One of every five times this machine had been used That patient lost two and a half minutes that could have made a difference in saving their life We have to improve the equipment We provide and give to our frontline care And then we put them into situations like this and we say don't make a mistake be safe Our environment is just Overwhelmed with these types of situations and we've got to protect our caregivers Much better in the course of work they do every day They talked a little bit about transparency. We embraced what's referred to as candor I think many of you may have now heard of this ahrq develop toolkit It's out there in the public domain. You just have to go to the ahrq website and you can download the whole Candor toolkit. It is an amazing Program that allows you to learn and also follow Models like the ntsb and aviation was based on work done by many across the country But anchored on work done by the university of illinois in chicago in a program called the seven pillars It is a comprehensive patient safety program that uses Aspects of what we call a go team approach There are three go teams that are activated very similar to what aviation does when there's an accident or a mishap They don't wait for two weeks three weeks four weeks They immediately activate and send people to that site to understand what happened to do interviews And that's what candor is based on three separate go teams first We need to know what happened an event review That's based on human factors and ntsb like approach in second go team Is to communicate with the patient and family about what we know And sometimes we don't know anything at the beginning But they're as confused as we are and why care went in the direction we hadn't counted out So you've got to immediately start those conversations and third one of the most important parts is care for the caregiver No one comes to work to harm anybody and when things don't go right We all feel devastated and we need to support our people at the front lines And one thing I want to emphasize is candor is not a medical malpractice strategy programs that have implemented candor Have seen significant reductions in their medical malpractice expenses The candor is a patient safety program a comprehensive one that has proven to save lives It has numerous numerous secondary benefits like lowering medical malpractice Improving trust between patients and families The main thing that candor allows us to do is to learn immediately so we can fix our systems Using human factors approaches that make us better. So we don't have the same mistakes occur over and over and over again It also embraces a just and fair culture and we need that because we've known too many people Who have either taken their lives or left health care because we Blamed them for a mistake that led to harm That any of us might have made in the same situation under the same circumstances Lucian leap the the expert and father of patient safety Has said the single greatest impediment to air prevention in the medical industry is that we punish people for making mistakes We have to stop that and we've got to embrace and take care of our caregivers Sydney decker is one that I like David marks james reasons have all done tremendous work about fair and just culture But I love sydney decker's work sydney decker says just culture is the balance between the safety of science And accountability. We must ask what is responsible not who is responsible Yet we also have to have calls for accountability because if we blame the system or the process Every time that becomes anarchy and you can do whatever you want And get away with it. So we've got to hold ourselves accountable and those at the front line accountable Who recklessly and knowingly put patients at risk? When they're taking care of them we can't tolerate that we've got to be fair and just to those that are trying to heal But we've also got to hold those that are reckless accountable Again, so I encourage you to Read sydney decker's work. It's it's really quite impressive I will stop there Helen I'd like to turn it back to you. We've got an outstanding panel now That's going to continue these conversations and build on the foundation. Hopefully you and I have laid down so far Thank you, David. That was excellent Now I want to turn to our panelists we have three very distinguished panelists With us today who mike ramsey has already introduced to you I just want to Remind you of who they are. Dr. Mike Durkin Who is lower left on my screen? The senior advisor on patient safety policy and leadership from the institute of global health innovation in london Dr. Steve muting Chief quality officer co-director of the james anderson center for health systems excellence at cincinetic children's in ohio And lea binder president and ceo of the leapfrog group Which is a business group that rates safety and quality and hospitals and health care system Welcome to all of you. We're so glad to have you here I want to have each of our panelists tell you a little bit more about Their particular area of interest and and what they have done in it Over the years. So lea. I'm going to start with you Can you tell us a little bit about your background and about what you do at leapfrog? Sure. Thank you helen and thank you for your remarks today. They were Very moving and powerful and really inspirational to me personally. So I thank you I um Started at leapfrog 12 years ago. Leapfrog is a business coalition that aims to improve the quality and safety of Health care. We started with hospitals. We've now moved into ambulatory surgery centers as well We do so by publicly reporting on the performance of hospitals and comparing hospitals among each other So that the public can make informed decisions about where to seek care And also so employers and other purchasers of health benefits Can be wiser about how they spend their benefit dollars And can begin to reward excellence as opposed to simply fee for service rewarding Every service regardless of whether it leads to the right outcome And patient safety is perhaps the greatest example you can think of of where Fee for service and models of payment have been total failures Because patient safety is really about Care and services so to speak that you don't you never want to see happen These are things no one ever wants to have happen including the providers themselves Nobody wants to see the errors and infections and accidents happen And we certainly don't want to have to pay for them either But unfortunately our payment system has made that Has made a colossal error in just kind of just just constantly Paying for everything and not looking at these really important issues for patients So me personally I'm not a clinician but my interest in health care I think has and patient safety in particular has come from Watching family members particularly my dad Be overlooked in the health care system. My dad had excellent care. It didn't work out He died when he was 42 of a heart disease, but But nonetheless he did get excellent care except for the fact that when he pressed the call button They didn't come right away. There was a lot of talking about him as the case in that bed as opposed to this human being and I just remember that was one of the most uh I was young then I was in my 20s and it was the most uh devastating aspect of his disease Was the fact that they just saw him as this cog in a bed This this thing and here was my dad. This was such an important precious person and loved one in my life and they treated him as as not a real person as a You know as a Cog a thing and that really bothered me I think that if anything has driven my interest in patient safety because I do believe That problems in patient safety are fundamentally about not recognizing the absolute critical importance of every single patient 24 hours a day seven days a week no matter how detailed and how how um How simple the issue seems to be you should never uh, you always have time for the patient You always have time to wash your hands. You always have time to do the little things that will that Will make such an enormous difference in the life of that patient and their loved ones So that I think for me is what has driven my own passion around this issue Thank you lia. Um, that's very very helpful and very moving as well Um steve, I'd like to turn to you just to give us a little background about your Long and varied and storied career If you could sure well, uh, it's great to be here with lia and mike and and you helen and uh You know, I will just start by saying i'm a husband I'm a dad. I'm a grandpa and I and I and i'm a pediatrician who started his career First 13 years being a small town doctor and I share that because of your story helen You know, I think the thing I've learned throughout my career Is and as lia pointed out safety is personal Yes, we need to think about systems high reliability situation awareness, but When you cut through all of it, it's it's people it's personal My career has been varied. I came back to Cincinnati Children's a little over 20 years ago and eventually became the safety officer and Along the way I helped I was one of the people who were able to help start solutions for patient safety, which is now grown to almost 150 children's hospitals across the u.s. And canada all learning and sharing together the With the goal to eliminate serious harm, but In terms of high reliability and situation awareness I hate to say it helen, but uh, it really started my very first year as a safety officer with a story That's not dissimilar from louis. Um And It changed me forever and what it really kicked off Shortly after that event was a multi-year learning from researchers and experts in military Who taught me deeply about what they had learned over the previous 10 to 20 years about situation awareness and I would describe the next five to 10 years Was Cincinnati Children's Trying to understand what those military experts were trying to teach us Trying to figure out what might be applicable to health care and then putting it into place and eventually it led to tremendous Structural structural process changes That continue to play out to this day that started from that one event and I Although I would describe it as not done. We still have work to do but On the other hand, I would say it's what ought to happen when events like louis or or the event I'm thinking of happen. We owe it to the families to learn and Change and improve Thank you steve. That that was really great. Um Mike, let me turn to you and you had let you bring some of the international perspective and policy perspective to bear on this If you could tell us a little bit about What you've done Sure. Thank thank you. Helen and uh great to to hear steven and lia Before me and of course you and and and Dave so Yeah, I'll try and bring some international experience but my story actually is I'm a my my specialty was anesthesiology and critical care medicine and I did my training in in in the uk and then My first attending position And faculty position was actually in the states in the u.s Where I was offered an opportunity to work at yale, uh at the school of medicine there and and um at yale new hayman hospital And it was at that time and this was in the in the 80s And at that time we were just starting the If you like the early steps towards understanding how to analyze critical incidents And I was privileged to work with a fantastic set of of clinicians and and scientists at yale Who really opened my eyes? to The start of a process I think which for me has then kept with me over the last last decades Mainly learning that You learn more from the patient Than you do from your peers And that the patient is often the most expert in the room when it comes to Understanding what's going on In fact, their first visits to a doctor It are often because or a nurse are often because they've understood something isn't quite right um And then as we've all explained and I'd listened to on today's um Uh presentations and panels How often is it that the the experts in the room are the ones who haven't listened to the patient or the family who knows them best? So I spent uh many years happy very happy years in in the us and then I came back to the uk and um I decided I want to change some of the elements that we were working in in the system that I was part of And as you know, the uk is a national health service That looks after the uh the needs of its 60 65 million people And very much has one system There are opportunities to use other systems which tends to be 90 percent of the of the funded care is one system um, and I was given the opportunity to um become a executive director of the hospital that I was um then an attending at and uh, I started to also get the opportunity to develop what was part of a A collaborative system if you like um of learning about clinical governance How do we what structures do we need to put in place? To bother both monitor clinical performance, but also to support learning And then how do we then translate that into a a unified system? and that culminated in an approach At the end of the last century of organization with the memory and also with with others Working with the the end institutes of medicine in terms of to her as human and crossing the quality chasm So both both systems were actually coming together. I think to create that that environment Um, I then as far as my colleagues were concerned. I then I went very dark Then I I crossed I crossed the um the corridor and became um the Join the management system a little bit a bit more than they wanted me to I think But that got got me into Much more of looking at systems and the system management of the way the system worked And for me that ended up being um the medical director of the region that we were working in England and then of the south of england And then I ended up becoming the national director Of our patient safety for for the uk and for me many many stories many many stories um that Uh, you don't fill me with sadness often um that um things haven't changed as much as they should be and that we are Still finding out the same the same issues the same issues of lack of sharing of information that that um The what-ifs are built on the same elements of of lack of candor of lack of Really placing the patient at the center of our journey As I'm working as a collaborative team Uh with the patient in the in the center of that Um, I've got lots to say about about issues that we may want to come on to. Um, but I think that um Uh, I'll leave it there for the moment, but really really pleased now to be working now in Uh, um in this environment and uh working very closely now in with other global systems Particularly looking at lower middle of the countries and how we can help those systems. So thank you very much. Thank you Thank you, Mike. That was um, that was very interesting. Um One of the things that you all have said is talking about the personal The importance of the patient voice and I'm just wondering. Um Um How you think The patient voice could and should be elevated. I certainly have my own ideas as a patient, but um, But I'm curious what you all think would be the the pathway through Through the healthcare system Um We'll start with you, Mike, since you say that Yeah, I'll come in definitely first. So I think I I think our journey to to to that end To ensure that the patient and their family because it's it's the family around It's the primary caregivers are often around in the family. So that uh That that journey to understanding the role and primacy of of the patients and their family I think needs to be needs to be at Way short of of when we're talking to mainly trained professionals So this needs to be part of the journey that all our undergraduates all our post graduates Need to be by bought into So that the really we really understand in our learning systems Of the value of the expertise that the patient and their family brings To not only to their presenting Story But their ongoing journey particularly now as As our demographics are shifting into multiple long-term conditions Where our patients are often journeying between physicians and between nurses Who represent specialty interests for different long-term conditions? The patient is often the one person and the family is often the one person who carries all that information with them And so for some of our major concerns, I think globally Are around the management of long-term conditions the management of co-morbidity Resolve often around medical around medicines management and medicines reconciliation And understanding the the issues that are are faced by patients and and often our our Our systems haven't really given that opportunity So I think learning early on and making sure that learning progresses during all our training is a key one I think often the most difficult Difficult individuals to to bring into this conversation are those Are probably in my age the the senior the senior end Who have always done it this way and and find it very difficult therefore to sort of translate themselves back into that listening phase So hierarchy is a big issue And in some some settings around the world I think the other issue is gender gender is a very big issue And also ethnicity is a big issue in in many systems a bank understanding the role of the patient and The the nurse or the doctor and and the primacy of the patient as opposed to the primacy of the the expert So that will be for one one area for me would be education education education In that system I'd like to come on to leadership at a later stage because I think that is also another key A key element to this Certainly at a national level and therefore probably at most systems that are in place to Yeah, well, thank you. That's that's very informative and we will come back to leadership Steve what do you think about? Learning systems, which I know is what you've really specialized in Through your entire career and and how that Reflects on the the patient point of view and involving the patient tower. How do they intersect? Yeah, I Mike I just want to say as a pediatrician and a dad and grandpa. I agree with everything you just said, but My mind did go to how Families and In our case across all the children's hospitals really is a learning system a learning network Uh, how valuable that voice has been in the ongoing journey and the improvement part not on any individual patient episode but Helping us accelerate and for those of you aren't familiar with the term learning system or learning network There's a lot of publications both from the uk and from the us the national academy of medicine in us, but you know the way I would describe it is a Small usually group of people Come together and that's where the the families and the clinicians and the improvers Come to find each other and realize they all have the ultimate same goal and That they want to come together. They adopt a bold audacious goal and that in our case It's to eliminate all serious harm from every children's hospital they then learn the importance of social networking and because they learned that change and All of us tend to adopt New things based on what our social network is doing Sometimes much more importantly than what data tells us or even what we read in the literature And so the importance of building that social network In bringing patients and families in as part of that social network. Don't isolate ourselves over We're scientists in your patients. No, it's one social network. And then ultimately what really gets a Learning network going is sharing everything and most importantly data and then using that data to learn learn learn and learn from variation learn from positive outliers and ultimately to use that data to analyze And come to learn what are the best practices that are associated with reduction in harm And then adopt them and the amazing thing about learning networks is they're essentially creating real-time evidence And they adopt it quickly because they're creating the evidence. It's not somebody else's evidence It's our evidence. So why wouldn't we adopt it? And when it's us together, it's the patients. It's the researchers It's the approvers. It's the clinicians It's that power of everybody coming together and realizing they have the same goal Even though we happen to have different roles Thanks, that's terrific And now lia i'm going to turn to you.  So tell me how that works and and what you think the the gaps and the and the promises Well, I think the the main issue that we have to focus on to really see change at inpatient safety Which we have seen some change in recent years. I wish it were more, but it's still changed and that's actually a positive sign because we haven't been able to say too many positive things about movement in patient safety at least in my career before this so But I think the key issue is accountability We have to set standards and we have to be transparent about whether we're meeting those standards And I think we've come some distance in figuring out how to do that a little bit. Anyway, we have some measures We have actual ways of measuring progress in patient safety. We have some outcomes measures We have some public reporting of infections not not enough of any of these things for instance I see steve here. We don't have public reporting of of patient safety in In children's hospitals Unless it's voluntary and frankly and not enough hot children's hospitals are voluntarily transparent about it, but we we need much more we need for everything for nursing homes for For dialysis centers for every kind of hospital critical access hospitals and we need to see more of the progress Um publicly reported and and I think what happens then when we set those standards and we publicly report them Is that everybody suddenly sees how they're doing and it helps to make progress when you see how you're doing relative to your peers I think it also helps for the public to become engaged in the whole issue Because if I understand uh, the difference between two different facilities because I've seen them publicly reported and I understand They're not the same Then not only does that help in my own decision making perhaps perhaps it wouldn't perhaps it wouldn't contribute to my decision making maybe I just wouldn't be able to be concerned about that nonetheless, however I will articulate that to People in that facility to my doctor. Why is it that your hospital seems to have a high rate of infection? Compared to the one down the street. What's going on those conversations have enormous impact as well So setting standards and transparency allow us to Hold each other accountable for what we want to see in our health care system And motivate the change that we all want to see so I see hospitals like Like certainly Cincinnati doing incredible work with learning systems and um, I think high reliability health systems is a Incredibly important movement and I've seen Enormous progress as a result of that movement. So I I really salute health systems. This is not easy work and they've done that work I think what's now the next and most important next step really for all of us Is that we um, we publicly report the progress and we hold each other accountable for it So, thank you, Leah Mike, I want to come back to you. You look like you want to say something Yeah, no, I just want to support Leah Leah on that the public reporting Of of of data is absolutely crucial to the journey of improving of improving All elements of of safety And the wider elements of quality as well And I think that's a journey that that that many countries are just just starting Many systems are very nervous about it because of the some of the pitfalls that that they believe would happen But but actually there's a there's a huge benefit to all societies from public reporting of that data And we know that works in terms of driving individual clinician performance And it also is of huge value in driving organizational performance as well and improvement So Mike while you have the microphone so to speak Let's come back to the the topic of leadership that you had wanted to address earlier What do you think is the role of leaders and what is a leader? well, I I'd like to sort of just Get into that on a basis that So see you've mentioned the the the the learning network concept, which is absolutely vital For us in terms of how we do it and we've we've been able to do introduce a similar At a system level in in the uk with with 15 Safety patient safety collaborators who have called them which which are based on academic health science networks. So roughly about For our population of without 15 across the the 60 million or so population So create a local a local hub very much around five three to five million system Size with with tertiary and secretary hospitals as well as community systems in place and one of the things we we realized that we had to do that at that level was That it was paramount that leaders Needed to be engaged and involved and understand what was happening on the front line as well as the national line And so therefore for me the concept of leadership at every level Is crucial in the generation of a safety culture for a system And therefore the relevance of a safety color culture at a local level And so the local level can be the general practice The family doctor hub. It can be the local community health service system. It can be on the ward At a particular ward in an operating theater as well as at The the states at the county level or the state level or the national level But it's leadership at every level and that leadership at every level needs to understand the relationship that they have with each other So there is absolute respect Between leaders all the way through that pathway And it's only when we have that that actually we can really start to understand the role of leadership in terms of change And in terms of improvement in terms of giving permission. Don't you know, don't My my adage as many of others in this field are is that, you know, you ask for forgiveness rather than wait for permission And we must work in a in a system that is That our leadership has created a psychologically safe system so that we actually are able to to work freely Admit our mistakes Uh, not be blamed individually for it. Uh held accountable as lia says But given the opportunity to innovate and change and I think leadership is at the core of that Debate to how to set the climate for a culture that really can Can deliver the outcomes and outputs that our patients deserve So for me leadership is actually key to that And give the freedom for action and the freedom for action At the level where we need it most which is the relationship between the nurse the doctor and the patient Can I add one thing to that? I think it's a really important point, Mike But I would add that the leadership should be at the patient level too Patients ought to be leaders of their own care and ought to be empowered to take that role It's very difficult to do it when you're wearing a johnny and your butt's hanging out But they have to be able to do it because it's really critical at that moment And I think that um one of the issues you also brought up was I think disparities and understanding Uh differences in my ethnic differences gender differences in patients and how that can silence people I would add in this country certainly we've been Really awakened to the issue of racial injustice as well And how that can silence patients and I think we need to start to think about how do we empower patients more So their voices can be heard. They're the critical voice. I think in improving safety I know I absolutely lia I really believe that too and I suppose the difficulty often is this this taxonomy that we have developed um which often gets in the way sometimes so it's of involvement engagement empowerment, it's it's um it's it's all of those things But how do we how do you know one of the things we could do is really help by by um by thinking about What is the language we want to use the common narrative? That we can we can all support and help our patients with And No, go ahead. I mean, we're back. I would just let me make this your final comment if you can each give me about 30 seconds um, that would be terrific Well, I would add one of the things we're looking at is patient reported outcomes and how we can uh reliably incorporate patient reported outcomes into the overall health care industry but also in the way that we hold Providers accountable for care and how we report things and we haven't really figured out how to do that systematically At a national level, but we are working on it And I think it's it is just the voice of the patient is the critical element That I think has been missing and we need to find ways to elevate it Thank you Steve final comments Well, very briefly. I'll say as a pediatrician and again as a dad I've loved the focus on patients and partnering I will though put in one call That ultimately the systems we're trying to create is safety for all and it's safety for the staff And uh as well as the patients and particularly with everything we've learned during this covet experience is that We're all at risk these systems are dangerous for everybody not just for the patients And we need to be thinking about everyone's safety and partnering with our staff just like we're partnering with patients and families Thank you important point And for me, um, Helen, I would uh, I would go back to my point about um, creating The ability to create a psychologically safe environment Which supports, uh, the reporting of when things go wrong Admitting mistakes and that creates an opportunity for staff to really feel more valued And and be absolutely part of the process of improvement and reliability. So with a psychologically safe system Then there is reliability will follow Thank you all. Thank you to our panel and um, that concludes my questions. I think there will be more But I really appreciate you being here with us today and um I will hand it off. Thank you all for for being here. Thank you. Thank you Hi everyone Thank you so much to our panel and our presenters this morning for that moving and valuable presentation And thank you so much for tying into the n aq competencies as well And we are receiving such beautiful and heartfelt comments on our live chat And Helen, uh, so much positive energy sent to you from those comments as well. So thank you so much So we're going to go ahead and move into our q and a this morning and my first question is From jennifer and i'm going to address it to Helen and it is How do you address patient safety with those of us within health care understand zero harm, but unfortunately society at large is litigious You know I I come at that from the other side. Um, I don't think society at large is litigious It most patients are not Looking for revenge They are looking for answers. They're looking for improvement. Um, they're looking for some kind of Recognition that their family members or their life matter And that is what they usually don't get patient harm is really widespread and Very few people get any kind of Compensation any kind of recognition Of patients who actually seek attorneys About two percent get their cases taken and most don't seek attorneys because they often don't know there is a problem and of those two percent The vast majority do not prevail in their cases not necessarily because they are not harmed or because their harm was Preventable, but because the information isn't there to support what happened in the records This is really health care providers live in fear of litigation, but that's really not the situation outside of the hospital This is really one there's very little justice very little accountability for harmed patients And this is um, this is one of the darkest sides of health care but But there are programs Communication and resolution programs that have been developed over the years that help hospitals deal with patient harm in a humane way that helps both The patients and families gives them the compensation that they need people Almost never have any kind of financial compensation Even when they have been severely harmed people suffer financially enormously aside from everything else so Communication and resolution programs try to deal with all that i'm going to let david tell you more About the details of them because they actually are not more costly Um, I think you know the issue is it is up to the hospital the hospital has to behave in a um in a way that is really full of integrity and It doesn't work if they don't and patients are counting on them to do that. So david, um, could you add something to that? Sure. Helen. Thank you Yeah, our data back at the university of illinois just confirmed everything you're saying we were able to settle some


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