Welcome everybody to what I know is going to be a really fascinating 45 minutes or so as we talk of not just the challenges we currently face within the patient's safety environment but also the actions that we believe are really important to consider and set that in the context of we've known for a long time what needs to be done and why is it so difficult for us to find the ways to do it? Now our conversation today is going to be with three truly global figures in the world of patient safety and in no particular order I'm just going to use the screen in front of me to introduce first of all Sir Liam Donaldson. Liam has been a figure of outstanding character in the world of patient safety over decades. I won't say how many because that will tell you how old he is but for many decades and certainly was at the earliest stages in recognizing the importance not just of appropriate methods of governance of clinical governance in healthcare but also that vital the vital role of the patient and their family in being able to talk of their experience and being able to share their experience with others so welcome Liam and I know it's going to be a great conversation that we have with you today. We're also joined by Jeremy Hunt. Jeremy Hunt as many of you know was the longest serving Secretary of State for Health for the NHS in the UK Health Service and for the UK government but also he's held Secretary of State positions in other ministries and governments and in particular in the foreign offices as foreign secretary and that may be relevant to us I think as we discuss about the importance of a global movement for improving patient safety and Jeremy has now spent many years not just in his own work as a minister and now as Secretary of the Health and Social Care Select Committee but also in learning himself of the importance of safety but also some of the elements that we need to introduce across our societies and our countries and thirdly to everyone in the audience for the Patient Safety Movement Foundation Joe Chiani who was the the founder of the Patient Safety Movement Foundation and through his his corporation Massimo and the foundation being that that that touchstone that that group who has kept the movement going who has continued to stimulate it who created the concept of reducing harm to zero and maintaining the importance of our drive to do that and that's created issues for many in fact the challenge to reduce to zero in itself is something that that people will often want to talk about so I know that we're going to have a great conversation from the three in the room and I hope I will be talking very little over the next 40 minutes or so so let's go back to the to the to as what we'd say in in the UK the batting order and Liam as the sort of the longest serving patient safety expert I think probably in the room today you've seen the challenges emerge over the last two or three decades and the actions that are put in place but now in your role as the WHA envoy and leading work on both the action plan for the next decade but also on many other different elements what what do you think are the the current challenges and and a couple of actions that you think will be important to introduce well Mike when I started on this journey I was Chief Medical Officer in the UK and we produced a report around the same time as the Institute of Medicine to her as human report and we called our report in the UK an organisation with a memory and at that time very very few people were involved in championing the need for safer care safety was seen as fire risks or hazards of tripping up on a on a loose floor tile things of that sort and when safety came in it tended to be referred to as medical error and that term became increasingly outmoded as we started to talk to the people in other fields like aviation who have achieved great improvements in safety but by concentrating not just on the individual error in isolation but on systems and the way in which systems make it easier for people to make errors and mistakes and also when those mistakes happen in a weak system the impact is much higher somebody might die or be seriously harmed so when we started it was a domain of interest of a very small number of people and then the number of enthusiasts grew and the number of passionate leaders grew and the number of researchers grew but my question always even when I'm talking to audiences today is how much do you think patient safety as a way of clinical life has penetrated the mainstream is it five percent ten percent fifty percent a hundred percent and most people put their hands up in the audience and they suggest maybe 15 20 percent of clinicians and others are practicing and following the philosophy and the concepts of patient safety so my big challenge for everybody in health systems around the world I think is how do we get better at moving from that minority of enthusiasts and champions to the majority so it's it's in an old cliche everybody's business patient safety is everybody's business thanks Liam thanks that that that will be the challenge isn't it and we often hear here um Don Boeck in particular talk about um workers getting getting it as work has to be done uh and uh the need to recognize that uh that this is as you said a way of life and not something to just be added on to um Jeremy you've you've you've borne the brunt of many challenges to to uh some of the chain changes that you wanted to bring about to improve the safety of patients uh uh in the UK system but and now you're working closely with with with Liam I know and with WHO colleagues uh to look at uh more of a global picture what's your views on the last particularly your interest over the last 10 to 15 years I think the first thing to say is that you know we shouldn't beat ourselves up and and say that we haven't made progress because I think there has been massive progress um I mean you can go back to the um hand washing campaigns that Liam did a huge amount to get going at the World Health Organization when he was Chief Medical Officer which was the start of much more focus on patient safety around the world uh you can look at areas where we've had specific focus in England for example on maternity safety where even though we had a very um depressing uh report published a few weeks back as to some things that happened at Shrewsbury and Telford Hospital over the last decade we've seen a 36 percent reduction in neonatal death rates a 25 percent reduction in stillbirths and you know these are very solid figures and this is very solid progress in the right direction and I would say that culturally um we we're halfway there we're not more we we now I think it's it's now quite normal in health care to talk about the dangers of a blame culture and how important it is to support support clinicians to speak openly and transparently when things go wrong the things that Liam was just talking about whereas I think you know if I think exactly 10 years ago when I became Health Secretary there were still a lot of people who felt that if there was a problem in the NHS it was dangerous to talk about it publicly because it would damage confidence in service and I don't think people say that now and I think people recognize the importance of openness and transparency so I think we have made progress I think our challenge is the pandemic has really set things back in lots of ways um you know in I'm just going to be parochial now talk about what's happening in in England but we have 6.2 million people waiting for treatment 19,000 people waiting more than a year for treatment 6000 people waiting more than two years for treatment and the risk you have with those kinds of volumes is that we go back into seeing healthcare as a numbers game and we we start thinking about statistics and not people and then the patient safety corners get cut and you start to see all the risks emerging uh that we know about only too well and so I think there's a real risk that as politicians focus on targets to get this backlog down before an election that some of the important lessons that we learned about safety and quality are unlearned so what would I say are the the three things that we need to to think about I would say that going forward globally there is a massive issue about workforce I mean the United States needs a million more nurses Germany wants 300,000 more nurses we need another 4,000 doctors just to deal with the backlog but globally the WHO say there's a shortage of 2.1 million doctors and the normal thing of just importing doctors from other countries when you need them is now stretching the bounds of what is being ethical I mean we have more than 300 NHS employees in England from Somalia and I'm sure they do a brilliant job but you have to ask yourself whether it is justifiable ethically for the UK to be importing doctors and nurses from a country like Somalia that needs them so desperately and so we have got to start tooling up our system start training more doctors training more nurses finding ways to dramatically increase because this demand with advances in technology and medicine is only going to increase and then I think the next big really radical change is technology and this is going to have a massive impact in helping the patient safety agenda and helping the transparency that underlines many of the reforms that we've all championed and I think some real thinking about how we could use the tech revolution to transform the safety of care delivered is really our next big step. Thanks Jerry so three key areas to work with and in the sitting in the chair next to you certainly in my screen we've got someone who leads a big technology revolution and has led it for a while now but you've also got some other thoughts I think Joe in terms of the other element that you mentioned about how do we incentivize the system to do what Liam said which is to have this as our way of life so that there is there is no alternative and I'm just wondering Joe what what you'll look particularly interested in your on your views about technology and how that will help us but also what about this issue about how do we incentivize systems to do better. Thank you thank you so much Mike first of all on the technology side the computers can do things some things much better than human and human can do something much better than computers one thing computers can do a really good job at is keeping track of things like trends like historical data so and with the advent of all of these cameras and sensors and biosensors tools like artificial intelligence or expert systems can be really effective in turning a one sigma clinician in detecting a problem to a six sigma clinician detecting a problem so one of the challenges though to create those tools has been a lack of cooperation by my peers the Medtech company and at some point it was me as well where we were hoarding our data the same data that we were that were being purchased pulse oximeter values radiology information the companies that made these machines wouldn't share that data with other people that could take all of that data aggregate them and make some sense about what could happen in the future based on the past the trend data is incredibly informative that human beings are hard to look at for them but it's easy for computers to look at but you need access to that data so one of the things that we tried to do with the patient safety moving foundation is to remove that barrier one of the commitments we asked for for Medtech companies was to share the data that their products were purchased for so that eventually it a new ecosystem is created for developers to create those predictive algorithms and I'm happy to say over 90 companies signed that pledge including giants like Oracle not on Surner as well as GE Phillips and of course Massimo but you know to take a big step back to talk about the second question about this aligned incentives concept that we talked a lot about at the patient safety movement foundation I want to just step back for a moment if I may to kind of tell you what I think has been the critical milestones in this journey of patient safety and why I think if we want to keep it going we need certain things that will hopefully will be self-governing and kind of the perpetual machine if you will so I think a key milestone was that to air is human report by IOM I think another key milestone was Dr. Peter Pronovost's checklist on CLABSI that showed if you did put the evidence-based systems in place you could get incredibly better results another incredible milestone was what Jeremy Hunt did with the ministerial summit on patient safety and of course what you guys did at NHS together the transparency movement that has already paid handsomely and of course I think President Clinton's CGI initiative taught us something that you can create a commitment-based organization you know the price of the showing up to a meeting isn't just what you paid for the meeting but a willingness to commit to doing something to help so putting all that together we created this patient safety movement foundation and I think maybe what we brought forward besides all of those lessons was a unification message that whether you're a medtech company like mine or a hospital or patient very important patient advocate or in the government we needed to work together to solve the rest of the problems which takes me back to the commitments we asked for we asked for hospitals to commit to zero we asked medtech companies to share their data and universities to begin making patient safety part of their curriculum and where we haven't yet achieved our objective are three ideas one is love bringing love to the patient not being afraid to love your patient and that you get too emotionally involved some people think it's a bad thing I think it's a great thing and then transparency which you got in the UK but we don't have in the rest of the world and aligned incentives as which is sorry a long way to come back to what you asked me to begin with the aligned incentive idea is very simple whether no country that I know of is 100 private some of them are 100 public most of them are half and half like my country here in the US so given that the government is paying for some of this care if not all of it I think we could put together something that will be self-governing and self-propelling and that is to pay hospitals even when they make mistakes if they put the processes in place to avoid that mistake that medical error and not pay them for anything when somebody gets hurt or dies when they haven't put that process in place I think something like that could have a huge impact and get us over this chasm of the choir doing the work but not everybody else in the church okay thanks Joe thank you so I'm looking to my my colleagues no one's interrupting you so so that means that they're there and then breathe that's why I'm happy what you're saying so um any any thoughts on on on the from the three of you on what each other have said um about a sense of a sense of purpose and direction in this in this field now then I'm particularly interested in so we we also sorry I'm particularly interested in the work that we're not doing uh and the settings that we're not particularly looking at so we spend a lot of time looking at our hospitals we spend a lot of time looking at within the processes within our hospitals to improve majority of our patients are not in hospital majority of our patients are carrying long-term conditions with them having multiple multiple meds on them most of them a lot of them have concurrent issues with their mental health with their physical health I'm just wondering where are we in terms of this debate about challenge for both in terms of the vulnerable groups the hard to reach groups but those that are haven't been really looked at closely in terms of the safety agenda and are we doing enough on that area Liam sorry yeah yeah Mike you asked me to react to other others comments and I'll pick up I'll pick up Joe's comments straight away because he raised something very important this question of data and I remember being asked to look around a hospital in England where they'd installed automated monitoring system so the nurses didn't have to do the observations and it two things struck me first of all the nurses loved it and they didn't have to be data literate the output was such that they could easily understand what was happening to their patients but when I said to the CEO of the company who was demonstrating I said to him you must have millions of data points here you must be able to look at these patients and predict from the data which patients were likely to deteriorate and we know very well that about a fifth of the avoidable deaths in hospital are caused by one reason or another people not spotting deterioration in an acutely ill patient whether it's sepsis or whatever causation it is they are acutely ill they're getting worse the nurses are busy they miss out observations the the charts get lost and one way or another the patient isn't rescued in the terminology that tends to be used so I just wonder why we can't um people could call it big data but why we can't get these large number of data points assembled and analyzed and and used to be able to intervene upstream to prevent people from suffering harm or death thank you and so I would naturally sorry Joe I would naturally then transfer that that debate into learning from across the last recent years in the pandemic to to those exactly those points and data points out of hospitals as well so where we can learn learn for earlier intervention both for the recovering patient but also the ones that haven't been able to get into hospital in the first place sorry Joe I cut across you well I I totally believe what Liam is saying and I and I believe hopefully if not sooner in a decade we will be there we've we've suffered from lack of connected devices and electronic medical records being just billing machines not being really electronic clinical records and I think that's all changing and I think you know companies like Massimo we're looking at precepts as algorithms by coalescing all the data not just SPO to impulse rate but temperature respiration rate and other information from the lab including going back to even the phenotype of the person and their historical data so that we can help predict those problems and I think many other companies are going to have that and I think part of the opening to do that has been this willingness to share data that we began about a decade ago that I think will pay off incredibly well in the future okay thanks Jeremy I can see you nodding but also itching to get in here thanks I just feel that you know all of us um have been passionate patient safety advocates because we feel that there's a particular horror in um medical error that means that someone dies or is harmed in a way that was completely unnecessary so what the public tend to think about with medicine is a disease for which there's no cure someone dying because they have a brain tumor and there's nothing you can do about it but what we all uncovered in our contact with medical with the medical world or in our medical careers is is this horror which the public aren't really aware of is which is the extraordinary amount of avoidable harm and death but I feel that to make sure that patient safety remains mainstream we need to think more in the way that Joe's talking about about how we can make ourselves part of the future because one of the problems is that people are looking at advances in medicine and they're saying well I understand what you're saying about avoidable harm and death but we're just going to make a few advances in terms of our ability to interpret genomes and we're going to be able to save millions of lives just like that so shouldn't we really be putting our effort into to these things and I think um particularly the prevention agenda is one that people are really thinking very very hard about and I think from a patient safety point of view we need to be really embracing prevention as the ultimate safety for patients if you if you give someone care that means that they don't get it in the first place I mean that is that is the safest care you could possibly give them and I just think that there are many many ways that that is going to happen so in technology for example I think it's quite interesting to think about how we are going to move to a world in which people's decoded genomes sit on their medical records in a form that a doctor looking at that medical record can interpret easily and then can talk to people about their genetic predispositions and so I don't want to move away from our core purpose which is to eliminate medical error and indeed I've written a book on it which all of you three gentlemen figure in and um the title of the book is zero so I've been very inspired by what uh Joe's Joe's big campaign of getting to zero by 2020 which sadly we didn't quite get to but it was a brilliant ambition and I wrote a whole chapter about saying why we should get to zero but I just feel that we need to find a way to embrace tech and the tech revolution in in our patient safety movement because I think that's what is getting a lot of attention. Okay thanks Jeremy thank you Joe open arms for that conversation. Open arms I love the title of your book I can't wait to read it Jeremy and I and I hopefully it'll inspire a lot more people going back to Liam's comment earlier that 15 to 20 of the people know about patient safety hopefully your book will get us a lot further because it will take the whole village sorry if we're using that too often to solve this problem we all have to do it. I think Jeremy's spot on I think you know of course I have an engineering degree and so you know what do they say every if you're a hammer everything's a nail but yes I think technology will play a huge role in preventing problems hopefully fixing things at home so you rarely have to go to hospitals and doctors and they're not as overwhelmed they have more time to give you the care you really need instead of wasting time with things that they don't need to do and also helping with the prediction and you know Jeremy said it right now with cancer with genetic sequencing people that can afford it get the right therapy there are 600 types of cancer not just a few and to know which one you have can really dictate the best course of action so the future does look bright but we can't just let it happen accidentally we've got to together push it there. Yeah thank you Liam you um I'm sure you're going to say something about something but I also want you to think about the reflecting on particularly with regard to your role within the WHO and some of those areas some of the systems and nations and states that maybe not as as fortunate as others how are we going to be supporting them because unless we do that then I think we're we're not going to tip the balance in terms of the global impacts. I'll say something briefly about that Mike before I do I just wanted to also comment on things that I've seen Jeremy doing and also Joe and in a modest way I hope myself as well which is to recognize the power of the granularity of the patient experience and when I went to Joe's conference in in California and watched the number of patients who'd been victims of harm who were part of his conference it had an incredible impact not just on me but everybody there and Jeremy has done so much in not I can't imagine any other health secretary in history that has met patients who've suffered harm and talked to them and understood their experience and then communicated it to others and I've watched with the WHO patients for patients safe for safety program I've watched audiences in tears seasoned doctors and nurses listening to the patient's story now you can't measure that but there's something about getting to the heart Joe talked about love and the heart is as one patient told me where you love from and I think that connection between the granularity of the patient's experience and the big strategic picture where we're trying to push major change is very important on the situation of the low-income countries I think the the key link there with avoidable harm is basically to access to care and the big goal of the WHO and and many other global health agencies is universal health coverage that doesn't mean everybody gets health care free but it means that nobody is denied care who needs it for their health and well-being or nobody is financially ruined because they fall ill and that goal of universal health coverage as Jeremy said earlier we have to embed our patient safety ideals into that bigger ideal of providing universal health coverage for for everyone but certainly lack of access to care in in the large slices of the world is the biggest cause of avoidable harm I've also got hopes that that through the WHO in its convening role will be able to accelerate the process of the global patient safety action plan which is a key formula for setting out almost a decade of work do you want to say anything about that because I think that's that's going to be a for a number of countries that don't necessarily have access to politicians and leaders such as you three it gives them a frame too within which to try and work to create that appropriate environment yeah and a lot of people were involved in that from countries around the world experts so there's a lot of buy-in but also a lot of ownership because so many people played a part in in producing it so I think what I found in working with WHO over many many years now in general the high income countries feel they can do without WHO's advice but within the middle income world and the and the low income countries they are very very grateful for guidance and help and support and in on the whole tend to value plans like this and they act as a big guide for them going forward and I think that's what will happen with this global safe patient safety action plan yeah but one thing I would like to add to what Liam said is you know the same way a lot of those low resource countries went from no telephone directly to the cell phone if we could get these low resource countries where they're going from no access to care to hopefully access to care that has patient safety in it to begin with and still and what I'm talking about is there are about what I call 30 to 40 standard operating procedures that if you put in place then human errors which were all made don't have to lead to medical errors and most hospitals around the world don't have them all some have some of them but boy wouldn't it be a great opportunity from day one as they create their healthcare systems to to a hard wire that patient safety in it yeah yeah it's fascinating you should talk about operating procedures because Joe because I was a party to a conversation yesterday with a hospital it is struggling with what we have in in the UK called never events and and one of the elements that they introduced which has reduced their number dramatically is is what we over here called loxics or local operating procedures and when Jeremy was Secretary of State he introduced a system of a national operating procedures and also those that would be adapted locally and they are starting to influence it's very interesting how some but some hospitals doing and other hospitals not doing it so it's this variability I think in implementation that is is currently not helping our patients but also significantly not helping our healthcare workers our staff who are also implicated so often without reason actually in the errors that are being made Jeremy you mentioned the issue of culture and healthcare and healthcare workers and often the system is being the issue rather than the individual have you got any more thoughts about this because you've reflected on it I would just say that you know as we sort of think about things that are changing in healthcare so whether it's genomics or technology or the aftershock of the pandemic I think it's really important that we don't forget the central goal which our campaigning has started to move things towards but which there's a lot more work to do which is that in the airline industry they managed to create extremely high safety levels by putting in place systems where mistakes were learned from quickly and they managed to stamp out largely stamp out a blame culture and we haven't done that yet in medicine but the goal would be so huge for patients if we had a culture in which we self-corrected where everywhere in any hospital anywhere in the world when there were mistakes instead of people asking which doctor or nurses to blame people said what went wrong and how can we make sure it doesn't happen again now that is a very very much harder thing to do in medicine because when people die people naturally want to look for a person who is responsible and attach blame it's just it's understandable whereas in the airline industry most of the time in those situations you're dealing with near misses so it's it's more straightforward to say we're not going to blame anyone when you haven't and as we saw and I'm sure you've all seen the film Sully but when you when you end up with near misses that are dramatic there's still an overwhelming urge to try and find someone guilty even in the airline industry but I think that is a very big goal which we should carry on aiming for because I think that would be as we move into the tech revolution the genomics revolution there are still going to be all these errors there are still going to be mistakes there'll be different types of mistakes but doctors nurses midwives are still going to get things wrong and if we could learn that lesson from the airline industry the oil industry the nuclear industry about creating a positive learning environment where people aren't penalized for speaking openly and transparently I feel that is really as much worth aiming for now as it ever was I love that and by the way something terrible has happened in the US a nurse in Tennessee who made an error has been prosecuted criminally and when when you do that the learning culture goes away it stops people from wanting to report problems and learn from problems and I believe as I've looked into that problem at that hospital there was a system failure that unfortunately her human error ended up becoming a medical error but to criminalize people is a terrible terrible thing and we got to we got to do something about that yeah Liam thoughts on candor then nice easy question for you how can we have true candor and at the same time protect our protect individuals like the nurse in Tennessee well I think it links back to what Jeremy was saying about the blame culture you can't have candor if the result of surfacing something is likely to lead to you being disciplined or punished or or have a stain on your career so that you don't progress your career anymore but we have to do more simply than admit the error and apologize I think you have to then work with patients and families to show them that we are learning and we need them to help us and there will always be bitterness and anger and grief at the beginning but what I've found is that many families who've lost a loved one due to have some sort of harm avoidable harm if they're given time and listen to and respected they will often want to help and I remember vividly one occasion talking to a mother who'd lost a child and the hospital had had fallen over themselves trying to express apologies and remorse and in the end they came up she told me with a big idea they were going to plant a tree in the hospital garden and she said to them I don't want you to plant a tree I don't want you to put a plaque up on the wall in memory of my son I want you to commit to learning so that this never happens to anyone else and that's what most patients do so I think we we don't just we're not just open about what happened we don't just apologize but we say to them if you if you're able to help if you're willing to help will you help us to turn this round and produce a sustainable permanent elimination of this form of harm thank you Liam thank you that was a great opportunity from that that family and that mother um we're coming to the end of our our period of time so but I just want to give you all a chance to reflect um on a couple of things but one Jeremy you mentioned that uh despite our um uh the efforts that have been made that and are concerned that more needs to be done a lot has been done um so we should be quite positive about some of the influences and the changes that have taken place um for us by in every setting uh and certainly in terms of the global impact on on safety with and I'm just wondering whether each of you could think about what you think it would be uh your positive message uh about uh our safety agenda and our positive message about our future with regard to how we take this ongoing uh commitment forward shall I start well you're the practice politician Jeremy so I'm sure you've got you can do this I want to go steal my points um so um I just I think the first thing to say is that and I'd be very interested to know if Liam agrees with me on this as a clinician but I do believe that healthcare is getting safer I think that you know if you look at the direction of travel compared to you know 20 years ago I think that overall despite all the pressures we have and even coping with a pandemic I think healthcare is actually getting safer we sometimes two steps forward one steps back but I think it's getting safer and I think that we should always remember that culture change is sometimes painfully slow but it's worth aiming for because in the end the only permanent change is culture change and that's the only change that is ever really embedded and I think that culture change is beginning to happen um so I I am personally um optimistic I think that there's been a lot of progress that's been made I think there are lots of challenges um I just want to give a plug for um my own um uh charity in the UK patient safety watch because what we're doing is something very simple with Aridazi and his team at Imperial and and Joe's giving us some support in in doing this but we're doing something very simple we've commissioned Imperial to do two things um and they are going to do this every other year so one year they are just going to publish what they estimate is the total number of avoidable deaths in the NHS in England and where they stand and where the most effort should be made in order to reduce avoidable deaths so we will have in one place an authoritative study that quantifies the level of avoidable death and I think that will be a very important addition to the debate because it will be something with impeccable academic credentials that allows us to get our head around the size of the problem and whether it's getting better or worse and then in the other year so that they'll do one year in the other year they're going to publish a global patient safety ranking which ranks all the countries of the world by the safety of their healthcare system and that will get us all discussing which of the countries we need to learn from is there some innovation in Sweden or Japan or Switzerland that we could be learning from and and I think that will also create helpful debates so I think all these things I hope will make a contribution but I think this is a time for renewing our efforts and renewing our ambition thanks Jeremy thank you um and no doubt we'll see some fantastic results from from patient safety watch uh Liam well in one of my new roles as chairman of a new health body in the northeast of England um I'm going to see whether all of my rhetoric over the years can be put into practice and um one of the things I just want to leave you with one thought I think I've we've all read and talked and spoken and listened about all aspects of patient safety over the years and but there'll be a few things that stick in our minds and one of mine is the the book by um Carl Weik and Kathleen Sutcliffe called Managing the Unexpected it's about high reliability organizations and they they um out they list the criteria of high reliability organizations and there's one of those criteria that I really love and it chimes with what Jeremy said about aviation the thing about aviation is they now have so few accidents that they've so I said well what how are we going to learn there's no accidents to learn from and basically um this criterion of um Weik and Sutcliffe um answers that question they say a high reliability organization should make a strong response to a weak signal of failure and to me that's a gold standard as I visit all the hospitals in in my region in this new role I'm going to ask them show me an example of where a weak signal that there may be a risk somewhere in the system you've pounced on it and dealt with it and put in place the action necessary because to me that's the test how far upstream are you anticipating and preventing great thanks Liam and I the reason I was turning round was because I was looking for the book uh which I happen to have I don't think you can see it on there hey Jeremy where's your book what about but it is it but no for everyone who's listening print yeah I'm afraid okay but Kathleen Sutcliffe's book is very it's a very good and car lights very good so thank you Liam but also good luck in the good luck in the north as they say over the next next period Joe what positive messages have you got for us in terms of our our sense of our purpose direction and I really do embrace what you've talked about love and I know that a great hero of mine of Ada Stonobadian always talked about that as being a key a key part of of any system made up of individuals and individual processes that it was the it was the ethical values of the individuals that were held within that system that really made the difference and and he purported love was being absolutely key to that so what are your positive messages for us well I I definitely have one but before I go there I love what Liam said it's that jumping really excessively to a small signal is key if that's part of an amazing culture and I see at a hospital I'm involved with and they're amazing and of course with what I really think Jeremy the reason you can do what you're doing in England is because of that transparency law that you created so kudos to you I hope many more countries will follow it because once the data is there you can learn from it and nobody wants to be last so it creates a nice competition for the for the right things one thing that I know Mike you're aware of many of us here are aware of WHO is has been working on a paper that unfortunately reports that patient safety got hurt a lot during COVID pretty much everything doubled or even got worse on all fronts of patient safety and I and maybe it's because of my own bias but I think what probably was the biggest difference between before COVID and after and during COVID was the lack of families being allowed in to be advocates for their loved ones and you know until we all learn to love strangers there is somebody who loves that stranger it's their family and that person also can be an extra help for the lack of nursing and doctor shortages without the skills but you know it wasn't a play-doh who said the best doctor is one who gets sick a lot well families know their loved ones and I think we can do a lot better learning from that lack of family and embracing them in our hospitals to be advocates for their loved one but I'll leave you with a great great hopeful result so Liam I hope the challenge is on that you get the same result I did in a smaller place children's hospital of Orange County I joined the quality committee several years ago and I'm on a member of board directors and shock implemented every standard operating procedure we know of we call them apps by the way they're on the patient safety movement foundation website and they also before they implemented them they decided to tie the bonus of the faculty a third of it to zero if we achieve zero at the end of the year you get a third of your bonus you don't you don't once they did that the hospital already had a wonderful culture but they went through all the apps the procedures mark green the parts they were doing yellow and red what they weren't doing with a mitigation plan to get on the green and in the first year they didn't get to zero and to their credit they didn't say this is ridiculous let's get rid of it the faculty said let's double down let's increase the bonus factor to it and I'm happy to report over five years now they've been at zero so we know that you could get to zero and get really close to it if you put these standard operating procedures or evidence-based practices or we call them actual patient safety solutions at our foundation you can get there so that's I think maybe the message of hope that just put them in place and measure before and after and see what happens great that's a fantastic story and a great example for us Joe to move on from our time is up it's amazing how quickly 45 or even 50 minutes goes when you're listening and I was always taught to take every opportunity you can to learn something every day so listening to you three I've learned a lot today and so thank you for that it's also been very entertaining so thank you for that and I hope that all of you are at the summit who are listening to our conversation will take away some the messages that we've discussed but also that it gives you confidence that you're doing the right thing and that there are lots of opportunities for help from different avenues and different individuals so may I thank Liam, Jeremy, Joe and also I have to say in the background Isabel who's managing the recording for this interview or fireside chat thank you all very much for giving up your time and thank you for your ongoing and continued commitment to help improve the safety of all our patients and our healthcare workers so thank you all very much and I hope you have a very good and pleasant rest of the day whichever time zone you're in thank you very much thank you so much Mike thanks to see you all bye everybody look forward to seeing you all again soon


Today we're going to talk about something super nerdy called a QFD. QFD stands for Quality Function Deployment, which I think is about the worst name of anything I've ever heard. You know I love a good spreadsheet and I love metrics, so this is going to be really fun. Imagine you need to make a decision between several different options. There's a lot of different criteria on which you might base that decision, and each of the different options meets that criteria in different ways, some better, some worse. With a QFD, you define those criteria, then you decide how well each of your different options meet that criteria. In order to do that, you assign a value to it, a 1, a 3, or a 9. And I'll show you why it's 1, 3 and 9 and not just 1, 2, 3. In addition, you look at how important each of those criteria are to you. That's separate from how well the options meet it, it's what's actually important to you, what are the most important and least important things in your list of criteria. Those also get a value of 1, 3, or 9. There are people out there who live and breathe for QFDs, and they know that there's a lot more to QFDs than what I'm going to show you here. This is sort of the very simplest possible form you could do a QFD. This is going to make a lot more sense when you see how it works, and we're going to do a demonstration of a QFD using the decision of which MacBook you want to get, a 12-inch MacBook, a 13-inch MacBook Air, or a 13-inch MacBook Pro. In this QFD example, I'm going to show how you could decide between a 12-inch MacBook, a 13-inch MacBook Air, and a 13-inch MacBook Pro. The first thing we needed to do was come up with a criteria against which we're going to judge these three computers, and I've listed them here. Now you may think of other criteria that you would find important, and you could add those to this, but these are the ones I did just to start. So we're going to look at the retina screen, weight, speed, RAM, disk, force touch price, iSight camera, and multiple ports against each one of these types of computers. The first thing you do is you assign the objective value for that product. Now this isn't really an opinion as much as it is a fact. We have the retina screen, and I'm going to judge the 12-inch MacBook about how well does it meet that criteria? Well, it meets it perfectly. It has a retina screen. Therefore, it gets the highest possible value, which is a 9. If we look at the 13-inch MacBook Air, however, it does not have a retina screen, so we're going to give it a value of 1, and you'll see I've added some notes here so we can look at how I decided the values of each of these. So this isn't something subjective, this is simply a fact. The MacBook Air must get a 1 on whether it has a retina screen or not.  Now the next line for weight, you might be able to have some argument with me because I'm going to give the 12-inch MacBook a 9 because it only weighs 2.03 pounds and I gave the MacBook Air a 3 because it weighs 2.38 pounds. You might not think that's enough of a difference to say it shouldn't also get a 9, which is the best value you could give it. In this case though, I have held both of them in my hands and that 17% difference is surprisingly noticeable. Finally, the MacBook Pro is the most heavy at 3.48 pounds, quite heavy in comparison, so it's going to get a 1. Now I did put something across the top here where I said all of the objective values are for the maximum available option. So when you get down into speed and RAM and disk, I looked at each one of these for the best you could possibly buy it. On the criteria of price, I decided to look at the least expensive models because that was what you would be looking for if you were judging price, if you were price conscious. After you have finished assigning the criteria and assigning the objective values to the things you're comparing, the next thing you would do is you would put in the subjective value to you. So a retina screen is that important to you? If it's super important to you, you give it a 9. If it's kind of important, you give it a 3. And if you could care less, you would give it a 1. I promised up front that I would explain why it's a 1.3.9. And I'll show you why when you put a value in here. Let's put a value of a 9. I'm going to hit Enter. And you'll see that the MacBook gets an 81, the 13-inch MacBook Air gets a 9, and the 13-inch MacBook Pro gets an 81. The values have dramatically spread apart. So if this were the only thing you were judging it on, you could see that the MacBook and the MacBook Pro are highly desirable items versus the MacBook Air to you. Again, this is the value to you. Each one of these is multiplied out. So let's change this up a little bit. Let's give this a weight itself. Let's give it a value of 1. So you can see 1 times 9 is 9. 1 times 3 is 3. And 1 times 1 is 1 on the MacBook Pro. So let's just keep dropping those in. Let's just randomly go 3, 9, 1, 1. I'm going to try to put a 4 in and watch what happens. I got an error signal there because I didn't put in the right value. We'll put in 3, 1, and 9. When you get all done, you can tell that with the values that I put down as important to me, the right answer here is that I should get a 13-inch MacBook Pro. My next likely candidate would be the 12-inch MacBook and finally the 13-inch MacBook Air. But you can see that by using a 1, 3, and 9 to evaluate the criteria and then a 1, 3, and 9 for how important those are to you, the correct answer simply jumps out at you as a dramatically higher number. And that is how a QFD works.  And so I've created a short link to the Google Doc and you should be able to change the subjective values to what you like and watch how the spreadsheet changes. Have fun with this and if you'd like to see more of my work, please head on over to podfeat.com and check out the No Silicast podcast.


A race between revolution and robotics. Notes from the edge of the narrative matrix. Basically, we're looking at a race to see if the deterioration of material conditions inherent in capitalism leads to mass scale revolution before the plutocrats have the technological and legal ability to roll out robot and drone security forces. We're fed nonstop messaging that we're inadequate unless we buy certain products. That mass military slaughter is normal. That madness is sanity. And that you're the problem if you can't keep your head above water in a system that's designed to drown you.  The problem is that while not many people really benefit from the status quo, those who do are in a position to influence everyone else. So you get a nonstop barrage of media pundits, movies and TV shows acting like everything's fine. And this shapes our entire culture. What we need first and foremost, more than socialism or anarchism or any other ism, is real transparency. We need people's vision of what's going on in the world unobscured by government slash corporate slash financial secrecy and propaganda. Once we can see, we can figure things out from there. How can we navigate toward a healthy world when we can't even see what's happening? Militaries understand that you need intelligence before you can act efficaciously. You need to see and know what you're dealing with. Truth is hidden and obscured from us precisely for this reason. That's what Assange was going for when he founded WikiLeaks, a tool to help the people see and know what's going on in the world so we can act in an informed way. That's also why he's in prison.  Whenever I say the U.S. is the most destructive government in our world today, the only people who argue with me are those who simply haven't thought very hard about how many people have been killed by America's current wars and sanctions regimes.  What?  Okay, well, can I have two trillion dollars over the next 20 years to murder people in Afghanistan for no legitimate reason? Sure, why not? Most of the time you hear someone crying about people being oppressed by a tyrannical authoritarian foreign government, they're really just crying because they want those people to be oppressed by the tyrannical authoritarians in the United States government. Capitalism is responsible for the historically unprecedented level of human thriving today. Also, anything you say to criticize our current system is invalid because this system isn't real capitalism. Both of these things are true for me somehow. I don't like the US ruling the world with nonstop violence either, but if it wasn't us, it would be China. No, no unipolar global hegemon ever once existed in human history until three decades ago. Stop thinking of it as some unbreakable law of nature that there must always be one. Saying you can't end the US empire because China will replace it is the same as saying you can't stop raping someone because then someone else would rape them. Westerners act like the desire to conquer a planet is some kind of inescapable inherent trait in human DNA because it's more comfortable than considering the possibility that it's a mind virus that is unique to our society. The idea that China wants to become the next unipolar dominator assumes, A, China has the same values and interests as Western imperialists, and B, that Beijing is looking at the US empire eating itself alive and thinking, yeah, that looks awesome. That could be us someday. Many people say China openly wants to replace the US as the unipolar hegemon, but if you actually examine the sources of their claim, it's always just China saying it wants a multipolar world, and Western propagandists falsely spinning that as evidence that China wants to become the next unipolar dominator. Not even Hitler wanted to take over the entire world, he just wanted to expand Germany's borders and dominate Europe. That's why he was fine with the prospect of a Japanese empire throughout Asia. Acting like taking over the planet is an inherent drive within us all, is a total propaganda fabrication. An adept manipulator doesn't always need to feed you lies.  An adept empire doesn't always need to topple governments by military force. They prefer to manipulate the nation's people into doing it for them. The saying it's easier to imagine the end of the world than to imagine the end of capitalism rings true, not because it's inherently hard to imagine the end of capitalism, but because vast fortunes are poured into propaganda campaigns to keep us from imagining a better world. The lion's share of the propaganda machine's energy goes not into manufacturing consent for new toxic agendas, but into manufacturing consent for the systems that are already in place.


What's going on y'all in preparation for doing a video that I'm planning to hopefully Presenting tonight. I ran across this statement that was made by an individual and hopefully if you watch my live You'll see who it is, but this individual told a guest that he had on his show That you should never marry a woman Who's older than you this guest has a wife who's three years older than than he is And so the the host told the guest you should never marry a woman older than you because when you do that You're gonna have problems because older women who marry younger men They have a lot of problems. I want to know what you thought about that If you're married and you're older woman, you're in your husband is younger than you whether it's by year It doesn't matter. What do you think? Let me know what you think about that in the comments below Is this individual right or is he out the lunch? Is he just tripping? Let me know what you think in the comments below y'all. I'll try to see something


Zvuk je začal. Zvuk je začal. Vse je to. Zdaj je početno. Zdaj. Zdaj. Zvuk je začal. Zdaj. Spojte se. Zdaj je početno. Zdaj. Zdaj. Zdaj. Zdaj je početno. Zdaj. Zdaj je početno. Zdaj je početno. Zdaj, ne brimalim. Pljusha, skala activated, Detekno, pa nekaj. Bono. To deserve po ghzjantovana. To Soge, tu ne ispešno. I Pirnega na companionsi. Pomočite tako, ker je vamosov ono vulnerabilities, počkaja, res ležitak, in nekako škoda, in nekako škoda se pograba v podsunju, pa se včkej, je to postajne pričo, tako v fórmu, da se občasili. Nekaj, nekaj, nicit, nekaj pa se postajne pričo, nekaj moment, postajnji v piekri, nekaj, nekaj, ki je, če, when the entropy dissipation is equal to zero, we recover that F is actually a Maxwellian function of V. Maxwellian, if you remember, it means the exponential of a second degree polynomial. Specific type of Gaussian, specifically it's a Gaussian whose matrix that you have in front of the V square is a constant times the identity. OK, so we have to check this. Traditionally, this is called the second part of Boltzmann's h theorem, so I think it's proposition 6, but I'm not sure about the number, so this is sometimes called the second part of Boltzmann's h theorem, so let's state the following. If the function B, which is sometimes called the cross-section, which appears in the equation at the end just before the integration variables here, is strictly positive, then the only functions for which the entropy dissipation is equal to zero are the Maxwellians, which are defined, as I said, by M is A plus, sorry, M is the exponential of A plus B scalar V minus C V square, or V square over 2, if you prefer. And actually the same holds for the Landau equation. I will not write down immediately what is the entropy dissipation for the Landau equation, we saw that in last lecture, and I will show it to you again in a few moments, but let me see immediately that the same property holds for the Landau equation. And as we will see, this is really the central part of the strict entropy structure of Boltzmann and Landau equation. So let me present the proof. So first, as this is called the second part of Boltzmann's HVRM, you can guess that this was already proven by Boltzmann a long time ago. One has to be a little careful there, because of course at the time of Boltzmann, people were not that interested in smoothness conditions on the function f. So the weight is written here, in principle, if you want to make a completely rigorous mathematical statement, in which space f is leaving, and you should first check that the quantity d of f is defined where f is leaving in the space you are speaking of. So of course Boltzmann was not that interested in that kind of things, and so when you look at his own proof, you can see that basically he was assuming that f was, let's say, of class C2 and to be more precise, it is logarithm of f, which has to be of class C2 or C3, which means somehow that you suppose that f does not touch zero, typically, let's say. So I will try to give you a proof, which is based on the proof by Boltzmann first, and then the second proof. In the proof, which is based on the proof by Boltzmann, as you will see, we will take a lot of derivatives, and I will comment at the end about whether one is entitled to really take that many derivatives or not. So let me explain this proof. So you start from this quantity being equal to zero. Now if you look at this quantity, this is the integral of something which is non-negative because the logarithm is increasing, like x minus y times log x minus log of y, and moreover, you have inside those two direct masses, which sort of fix the space on which the integral is really living. And so this exactly tells you that this is zero if and only if f of v prime times f of v prime star is equal to f of v times f of v star whenever the equalities which are written under the direct masses are true.  And this is due to the fact that we suppose that the capital B is strictly positive here. So this is a sort of global statement which is a consequence of the entropy dissipation being equal to zero. I hope it's clear from the formula.  So this tells you exactly that this can depend only on those two quantities or the same with divided by two if you prefer. I hope so, it is also clear. If not, you can refer to the so-called factorization theorem in set theory which is something which is proven in like five lines no more which tells you exactly this. But I think it's something which can be understood directly. I think it's a few things of it. So the first steps consist in writing some kind of functional equality or functional equation if you wish which tells you that the tensor product of f at two different points depend only on those two variables here which are momentum and energy and you have to start from here. Now imagine that instead of having this you have the same but only with the momentum. Then you could say that well in that case basically t has to be f because you take v star equal to zero so up to a constant t is f and you would end up with the traditional functional equality f of x times f of y is equal to f of x plus y and you would deduce from this by the usual methods that f is actually an exponential of something of lambda x, let's say. So this, now what I will show now is just a generalization of that. It's more complicated because now you have those two terms here. So the idea here is actually to try to find a good differential operator which transforms the function of v plus v star and v square plus v star square into zero without transforming too much the functions which do not depend on those quantities. Now once again, suppose now that t would depend only on this. This would correspond in terms suppose that v and v star are just one dimensional this would correspond to looking at functions which are radially symmetric in the v v star space. So the right operator to cancel it would be d over d theta in terms of polar coordinates which you can write up to a multiplication as let's say x, y cross product d over with a gradient is more or less the same as d over d theta if you think of it. Well anyway the point is to try to find the right one for those functions here and actually what happened is that the good idea is to look at something which looks like a little like d over d theta in terms of polar coordinates but to take into account the fact that here this has to do with translation in the space of v v star which has to do with Galilean invariance. So you try to get an operator which looks a little like this over d theta but which takes into account this translational invariance and the good choice is actually this one. So you look at the operator which is a cross product v minus w and gradient v minus gradient of w. So let me first here change notations and take notations which are compatible with the Landau equations so I will write w instead of v star from now on.  It's what is written actually here. So let's check that this is indeed a good operator. So let's take L i j and apply it to functions which depend on this. Notation is not very precise but I think it's possible to really understand what happens. So first I multiply v i minus w i by the derivative respect to v j of this quantity now this quantity it depends on v through this one and through this one so you get here the derivative of t with respect to the first variable this variable is vectorial so let's call it gradient 1 t this is the derivative respect to the group of variables which are here taken at same point plus 2 v v j sorry the derivative of t respect to the second group of variable which consists of only one variable and which I called therefore d t over d 2 I hope that the notation is at least vaguely understandable. OK? So it's like this and then I remove exactly the same quantity when I have exchanged g and a so v j minus w j times gradient 1 t plus 2 v i d t over d 2 and you can see that this point yes, yes, yes, yes, exactly so this is the I did not I wrote it sorry yes, yes, yes exactly let me write it more seriously so here I used only the v j I did not use the w j sorry for the so we get d t over so I start with the d over d j so it's d t over d gradient 1 plus 2 v j d t over d 2 and then minus d over w j so this is minus gradient 1 t minus 2 w w j d t over d 2 OK? and the same exchanging i and j so like this OK? cancel at this level and then the other part also cancels because as you can see you get v i minus w i times I mean he has got a product times v j minus w j and exactly the same in the line below OK? well so this is a good operator for cancelling functions but then you have to use it on the left hand side of the equation to see what appears at this level OK? so when you do this computation so if I compute now l i j applied to f of v f of w I get so v minus v i minus w i times so d over df over dj at point v times f of w minus df over dj at point w times f of v and exactly the same but exchanging i and j once again I hope that the notation is understandable by df over dj I mean the derivative of f respect to the variable number j, OK? and this I can rewrite as f of v times f of w times v i minus w i df over dj of v divided by djf divided by f of v minus the same at point w subtract the same term but exchanging i and j and I get exactly this quantity here so what is inside the bracket here I will now systematically denoted by q i j f of v and w sorry for the this notation which is a little complicated but the point is if I apply now this to this since f of v times f of w is equal to something which depends only on those two quantities we know that this quantity has to be zero we know now that this quantity is zero so let me project it here actually provided that f does not cancel I have just proven that starting from the entropy dissipation of Boltzmann this quantity here is equal to zero so it's quite coherent with the hypothesis let's say that the logarithm of f is as some irregularity basically I suppose that f does not cancel now let's look at this identity this is just the cross product between v minus w and gradient f over f of v minus gradient f over f of w ok those are just the components of the cross product and so to say that this quantity is equal to zero exactly amounts to say that the gradient f over f of v minus the same quantity at point w is parallel to v minus w for all v and w and this is one way to as we will see this is one way to characterize the Maxwellian functions of v that is only the Maxwellian functions of v satisfy this inequality sorry constraint actually you can check already that if f is a Maxwellian then gradient f over f is an affine function of v and so if you remove if you take this function at point v and at point w and you subtract it, you eliminate the constant term and you get something which is linear and it gives you exactly v minus w ok so this is clearly satisfied by Maxwellians and the point is to show that it characterizes Maxwellians but before going further and keeping on writing down the proof of Boltzmann let's just have a look at the entropy dissipation of Lando so this I also wrote down at the end of last lecture and if you remember so this is an integral over now two variables so this is written in R2 but actually it's true for any dimension and inside you have the product of f at point v and w you have this function psi which is the cross section so here it's called psi so in the theorem here if you want to show the second part you have to support that psi is strictly positive and if now you say let's try to prove the proposition in the case of the Lando equation then this means exactly that for all v and w this quantity here is equal to zero but now this is a quadratic form applied to the same vector ok and this quadratic form is represented by your matrix which is semi-definite positive so this exactly means that this quantity here has to be in the kernel of this matrix here but this matrix is a projector onto the orthogonal space to v minus w so this exactly means that this quantity has to be parallel to v minus w so actually if you start from the Lando equation you end up immediately at the same level here and as you can see the proof of this part of the proposition is just a consequence of the proof of the previous proposition because there is an intermediate step at which you sort of transform the computation on the Boltzmann kernel in the computation for the Lando kernel ok so from now on we will start from here and prove at the same time both parts of the proposition ok so let me first describe to you the proof due to Boltzmann so as I said basically you take as many derivatives as possible so at the end you need to know for example that log f is maybe c2 or c3 we already took one point when we use this differential operator and now we will take two more of them so what we know is now that this quantity this equality holds ok for all different indices i and j so let's try to take derivatives for example respect to the quantity vi here so let's do it I take the derivative respect to vi of this and so I get exactly the term which is here which you can recognize at this level ok then inside this term you have a dependence respect to v so when you take the derivative respect to vi you will end up with vi minus wi which comes out from here and here this term does not depend on v so you just take the derivative respect to vi of this one and gives you exactly the second derivative respect to i and j of log f this is the derivative respect to j of log f so you take one more derivative respect to vi ok so that's for this left hand side and now let's look at the right hand side so in the right hand side it's easier because this term does not depend on vi ok i is different from j to take the derivative of this one so you end up with vj minus wj which is not changed and here you take one more derivative respect to the i variable of log f so you end up with this ok so when you did that somehow you destroyed the symmetry between i and j because you took a derivative respect to vi so the natural thing to do then is to take a derivative respect to j and then publish the symmetry ok so let's first start to do it with respect to wj so you take the derivative respect to wj of this quantity here this term does not depend on w so it disappears in this term you have dj of log f of w you take the derivative respect to wj you get minus the djj w then this one does not depend on wj so it cancels and in this one the only dependence is through this wj here which gives you minus di i log f of v so what you end up with is this equation here which gives you a link between the second derivatives of log f at point w and point v and this is true for any v w i and j so the function of w which is equal to the function of v so both are constants so it already gives you that the second derivative respect to the same index of log f are constants moreover those constants are identical for different i and j ok so you have already one part of the Haitian matrix of log f and this tells you that Haitian matrix of log f is made out of constants which are identical on all the diagonal ok let's now come back to the equation here and use and take a derivative respect to w i so if you do that this term cancels this one becomes minus di j of log f of w in this one only this term has a contribution and it's minus di j log f of v and in this one there is no w i so it cancels so you end up just with this and here once again you have you get a link between the second derivatives of log f but this time which are taken with respect to different indices i and j ok so this gives you the fact that first this is a function of w, this is a function of v so both are constants and moreover now you have a minus here and a minus here so when you add the two constants it should be zero so the constant has to be zero so this exactly tells you non diagonal part of the ancient matrix of log f is made of zeros so at the end of the day what you have proven is that the ancient matrix of log f is just a constant times the identity and you agree with me that this is exactly the same as staying as log f is a polynomial like this and so f is a Maxwellian and this gives you this point of course actually I didn't say that it's positive yet but of course the minus gives a hint so you're right I mean with this proof here you end up with all possible Maxwellians also the ones which are increasing very fast so then the whole point is that if you suppose that log f let's say is a c2 you have to add some kind of hypothesis like for example log f is this c2 and bounded but you could think of many kind of bounded above yes for example so you have many different kind of hypothesis which helps you to remove the possibility of having badly shaped Maxwellians so as you can see basically both man worked by taking successive derivatives of the initial condition on f and so his proof is a priori valid provided that let's say log f is c2 you have to add an assumption which tells you that you can get only positive c here and then it looks like it's not really sufficient for let's say modern analysis in which you hope that in if you look at the solution of the Boltzmann equation you hope that f has a certain irregularity but asking for c2 is really a lot so there is another way of seeing all of this which consists in saying that all of this was done in the sense of distributions and if you look at this then you can see that basically that log f is somehow locally integrable and that's it and you can do it exactly with same computation but doing it in the sense of distribution and you end up with a proof which is a proof of Boltzmann which is actually a sort of modern proof I would say however let me take two minutes to explain the what is the goal now and if you remember all what we did on entropy method is at the end to get an entropy entropy dissipation estimate so a link between d of f and h of f which here is integral of f log f so in some sense when you wish to prove an inequality it's rather a good idea to start to check what is the case of equality in the inequality and sometimes it helps you a little to try to prove when you try to prove the inequality and so if you have a proof of the case of equality which is exactly what we are doing now which is very robust let's say by small changes in the equality here then you have a hope that you can transfer it in an inequality at the end if the proof is not robust then most probably you will not be able to transform it in a proof of the inequality at the end and what is not robust in analysis in general is taking derivatives basically it's robust only if you are in an analytic setting if not it's not a very good idea so the word point is to abandon the proof of Boltzmann and to try to find a proof which is more robust so more robust means you have to sort of throw away derivatives and instead take integrals which is rather natural notion in analysis I would say so it's what we will be doing now basically let me before I show you how this can be done let me conclude on this proposition here by saying that basically we have now the strict entropy structure because we have the following let's say graph of implications what we just proved is that the Boltzmann of f is equal to zero implies in fact that the entropy dissipation of Lando is equal to zero and this implies in term that let's do it like this this implies in term that f is a Maxwellian this is just what we did in this proof but we already saw that f is a Maxwellian is let's say implying that the Boltzmann kernel and Lando kernel are equal to zero these were the remarks that we made in the previous talk so we know that if you look at the operator of Boltzmann and Lando we already have the two implications which are here was easy if you remember it consisted just in putting the Maxwellian in the kernels and checking that you get zero at the end and moreover if now you come back to the way the dissipation of entropies were computed you can see here that the entropy dissipation is integral of the kernel times something so it's obvious that you have an implication between those two things and also the same holds for Lando that is the dissipation of Lando is obtained by taking the kernel and integrating it against something so you have something like this so I hope it's not still understandable in this way we have made the totality of the circuit which shows that we have an entropy structure which is strict except showing that the entropy itself is the minimum of the possible entropies so for this let me write down again what is the entropy for both Boltzmann and Lando equation it is the integral of f log f and now if you take f which has mass, momentum and energy which are given and remember that those quantities are conserved in the flow of the Boltzmann and the Lando equation it's what we saw last time if you take now the infimum of h when those quantity are given so you suppose that you have mass, momentum and energy which are given and you take the infimum it's clear that the Euler Lagrange equation related to that is just that the derivative of this with respect to f that is log f plus 1 is equal to the Lagrange multiplier's theory the constant times 1 plus another constant times v plus another constant times v2 over 2 so let's call it a prime plus b dot v minus c v2 or v2 over 2 and up to changing a prime in a prime minus 1 which becomes a we get again that f is a Maxwellian so if f is satisfying the infimum of the entropy provided that the conserved quantity are given we get again the Maxwellian which is the very last part of the proof of the strict entropy structure for both Boltzmann and Lando equations so now in order to introduce the very last part of the lectures which is in some sense the most modern part because all what I showed up to now has been known for a long time the point is to find a robust proof of this part here and more precisely because I'm speaking strictly of the Lando equation now of the fact that the entropy dissipation of Lando leads to f equal to a Maxwellian and we need a robust proof which hopefully will give you an inequality at the end so let's try to do that so if you remember the starting point when you look at the Lando entropy dissipation is that the quantity which is here and that we called q i j f of v and w is equal to zero for all i j v and w it's what is written actually here so we have to know that this quantity is equal to zero and we want to show that f is a Maxwellian out of this what we did previously is consisted in taking derivatives respect to various quantities in this quantity so we took basically two derivatives and it worked now we don't want derivatives anymore because we want something robust so the first thing to do is to take this quantity here which is rather beautiful because it's completely symmetric and to actually couple together the terms which depends only on v so it gives this part here the terms in which you only have w which gives you this part here which are mixed so you have part with w and v and the same with v and w and you put them in different places ok but it's exactly the same so I'm just saying that this quantity is equal to zero and the point is that there is actually a transform which starts from q equal this and which gives you the gradient of log f of v in terms of this quantity so the point is you know q in terms of this quantity and you want to do exactly the reverse you want to write this quantity in terms of q so actually the formula is written here so this is the formula which sort of invert the relation that you have above so I will try now let's to explain to you how we get this as you will see it's not very difficult once you know what to do we start from here q is equal to this so the first thing I do is that I multiply this q q ij by 1 and I take the integral with respect to w only so when I do this it becomes the same so let me write it like this ok so this is for this part here and sorry I multiply here by f of w so here I will get the integral of f of w dw ok so this comes from the first term here then I look at the term which is here I multiply by f of w and I integrate over w since this is a derivative dgf it gives you zero so this one disappears of course it's the same for this one because you integrate so you just get the integral of dif and it gives you zero then let's look at this one this one gives you minus dif over f of v times the integral of f of w w i dw ok and this one gives you the same but with the plus sign and you change the i in j and finally for this one remember that you multiply by f of w and you integrate so for example here it will give you an integral sorry of w times dgf you do the integration by part and you will get that you have dji times f and dji is zero so you get so zero and of course it's the same here because i and j can be exchanged so the last one does not give you any contribution so I end up exactly with the formula which is written here ok and as you can see this is a formula which links actually dif over f and this complicated quantity here is sort of a component of v cross product with gradient f over f ok so next step and this time I take my paper because I don't want to make any mistakes at this point this time I do the same but using now as a multiplicator not only f of w but f of w times wi wi being the i component of w so when I do that I try to I try to do the same so this term still gives me ok so this one is easy now next one I multiply by wi I integrate and by f of w the dj of wi is equal to zero so this one is zero but next one corresponds to multiplying by wi f of w so the f of w can solve and I get wi dif which after integration by part will give me exactly minus integral of f so here I will get minus dif sorry minus dj dif over f integral of f of w dw it's the one which is coming from this term here so next one I multiply by w and by f of w so I get actually it's better to put it here so I get minus djf over f of v times the integral of f of w wi square dw for this one I multiply by wi f of w so I will get little z so this one I put it here it's really better to do it this way I transferred it here sorry, I remove it and I will write the term coming out of here at this level here so it will give plus dif over f of v integral of f of w wi wj dw and then one has to treat the last term here so in this one I multiply by wi f and so I will get here wi to the square but once I integrate by part with respect to the j derivative it gives you zero so this one disappears and the last one corresponds to multiplying by wi here I do the integration by part so I will get plus wjf times nothing so let me check I really did the computation and just I didn't look at my notes so let me check that it's okay yeah that's it very proud so now I do the last one and the last one consists in doing exactly the same using now wj instead of wi so here of course you can do the same computation as previously but you can also notice that i and j can be exchanged and it helps you a little to write down the good formula so let's do it this way so I will get now wi djf over f of v like this times the integral of f of wjdw then there is a term with df over f which is the integral of f of w wj square which corresponds actually in this one in the other line is plus diyf over f of v times the integral of f of wj square w so this one corresponds to this one sorry, I wrote 2 times the same so here it's the term in dj there is a minus and there is wi wj here and for the final terms it's quite easy you get vi integral of f of wjdw and minus integral of f of wjdw i dw so basically you take this one you exchange i and j and you change the signs and you get it well anyway the whole point here is actually a system in which the unknowns are now indicated here in brackets so actually it's better to to use as unknown minus e.g. f so like this so in the brackets you have the unknown of a three times the quantity you want to compute which is di f over f but also the same quantity for a different index and this complicated quantity here which is v cross product gradient f so once you are here you just have to solve and to solve it you just use Kramers formula when is the determinant ok so now if you look at the formula here this is just in writing Kramers formula for this system and you end up exactly with this so for example you can check the determinant which is here which is composed really on those columns here that you can see so f times 1 w i w j w i w i w j w j square and the same here and it's exactly what you will end up with in the system the upper part is a little more complicated because you have to write down those terms here and also the terms which are here as a right hand side for the system so this is the part which appear in the column here because you are really computing the secant unknown in the system so the secant column consists of those things ok so now you have done what you needed to do that is to transform convert this formula here now you have d i f over f in terms of the rest and the case of equality that you wish now to show consists in supposing that all the q i j f the q i j f is equal to zero so if you rewrite it now if you take q i j f equal to zero you end up with the formula here and as you can see here you have a determinant in which v does not appear so this is a constant and at this level you have v which is appearing in the secant column non-ly so that this is really an affine function of v so you exactly ended up with the fact that the gradient f over f of v is an affine function of v which is of course equivalent to the fact that f is a Maxwellian one has to be a little careful here actually I proved that f is a Gaussian to be precise and f is a Maxwellian so what is the interest of doing this with respect to the proof of Boltzmann it is that as you can see I use no derivatives here this was done only by integrating and so hopefully this is more robust actually it is it is really much more robust than the proof of Boltzmann I would like to end this lecture by one small remark which is that I did as a bad student I did not check that what is under the division is not zero so one has to be a little careful here and one has to check that this quantity is not zero actually this quantity can be seen as a grad determinant but if you don't want to use that you can just think of what it means this determinant is zero exactly if those three columns are sort of let's say linearly dependent with respect to the measure f of wdw so this will be equal to zero exactly when f is concentrated on a hyper plane made of with an equation for the linear dependency of the three columns here so this is zero only if f is a direct mass on a hyper plane to be clear as soon as f is a function let's say l1 this cannot be equal to zero I hope it's clear completely sure I hope it's clear and so now this is enough for the proof for the case of equality but if you think then to a possible proof of an inequality you will have to estimate this determinant here from below you will have to show that this is strictly positive provided that you are in the right set of functions f and what is the right set of functions f but those functions which typically have a finite entropy that is such that integral of f log kf is bounded and what integral of f log f bounded provides to you is exactly let's say a quantitative bound on the fact that f does not concentrate on sets of measures zero like for example hyper planes so this is controlled by the fact that f has an entropy which is bounded which is given if you wish so that we are rather in a good shape from this point of view I think maybe it's a good time to stop the lecture and we'll see the consequences this afternoon