Putting Safety Into the Genome of Healthcare with Dr. Peter Lachman

Why This Episode Matters

Patient safety has often been built around what happens after harm occurs: incident reports, investigations, accountability, and corrective action. In this episode, Dr. Peter Lachman argues for a more proactive and moral view of safety: one where teams talk about risk every day, anticipate who may be harmed next, and make safety part of the “genome” of healthcare education, leadership, governance, and frontline work.

Key Ideas Explored

•  The early safety event that became Dr. Lachman’s “big why” for patient safety work. 
•  Why professionalism and good intentions are not enough to make care safe. 
•  The shift from retrospective harm review to proactive risk prediction. 
•  The SAFE program as a practical way to help frontline teams talk about safety every day. 
•  Why safety and quality need to become social movements, not just programs or products. 

Takeaways for Quality Leaders

•  Treat adverse events as signals of system design, not simply individual failure. 
•  Build daily routines that help teams ask who is at risk before harm occurs. 
•  Make safety part of training, clinical reasoning, and leadership language from the start. 
•  Pay attention to culture: what people talk about, what they notice, and what they are willing to learn from. 
•  In low-resource settings, do not underestimate the power of people, relationships, and practical methods. 

Continue the Conversation

Dr. Peter Lachman on LinkedIn

Resources & Frameworks Referenced

•  SAFE program / Situation Awareness for Everyone 
•  Patient Safety Movement Foundation Kiani Fellowship 
•  The Institute for Healthcare Improvement (IHI) 
•  To Err Is Human (Institute of Medicine Report, 1999)
•  Crossing the Quality Chasm (Institute of Medicine Report, 2001)
•  Donabedian’s structure-process-outcome model 
•  SEIPS model / Systems Engineering Initiative for Patient Safety 
•  Safety-I and Safety-II 
•  Great Ormond Street patient and family safety reporting work 
• FlaQuM / House of Trust model 
•  Quality 1.0, 2.0, and 3.0 
•  Patient safety as a social movement

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Credits:

Host, Writer, and Executive Producer
Jason Meadows, MD

Produced by
Thrive Healthcare Improvement

Edited by
Milan Milosavljevic

Transcript

A Ward Where Deaths Disappear

SPEAKER_00 0:00

A great success story for me is Mozart Beak. They were having many adult deaths. It was about eight to ten a month, unexpected within the first 24 hours. And they went down from eight to ten deaths a month to one to two a year. And so it's not resources, it's about the people. It's about unleashing the power of the people to be safe.

SPEAKER_01 0:28

Welcome

Meet A Global Safety Leader

SPEAKER_01 0:29

to Leading Quality, the podcast spotlighting the people, moving healthcare forward from the front lines to the C-suite. I'm your host, Jason Meadows. He's a pediatrician by training, but his work has reached far beyond one specialty or one health system. He has served as Chief Executive Officer of the International Society for Quality and Health Care, was Deputy Director for Quality and Safety at Great Ormond Street Hospital, was a Health Foundation Quality Improvement Fellow at the Institute for Healthcare Improvement, has helped educate quality and safety leaders around the world through his work with the Royal College of Physicians of Ireland, the Patient Safety Movement Foundation, and several major Oxford University Press handbooks on patient safety, medical leadership, and quality improvement. But what makes Peter such a compelling voice is the way his career has followed the evolution of patient safety itself. His path into the work began long before patient safety had a formal language. As a young doctor in South Africa, he was involved in the aftermath of a fatal medication error that shaped his understanding of harm, human factors, and the limits of blaming individuals. Later in the United Kingdom, he worked through major system failures in child health, maternity care, and hospital safety. Then, through formal training at IHI, he found the theory and methods to name what he'd already been seeing in practice. That harm is not usually the result of bad people, but of systems that make harm more likely. In this conversation, we talk about the evolution of patient safety from professionalism and regulation toward system thinking, proactive risk management, culture, and co-production. We talk about the SAFE program, his work spreading safety practices across very different health systems, and his current argument that safety has to be embedded into the genome, as he puts it, of healthcare workers. The deeper question running through this episode is how we make safety part of the way healthcare thinks, trains, governs, and works. I hope you'll get as much value from this conversation as I did.

The Medication Error That Changed Everything

unknown 2:57

Dr.

SPEAKER_01 2:57

Peter Lochman, welcome to the show. Thank you. Thanks for inviting me. You're very welcome. And I I wanted to start at the beginning. You um have spent decades working in patient safety and quality improvement, and I'd like to know what first drew you into this work.

SPEAKER_00 3:16

Well, you have to go back uh to my work in South Africa as a young doctor. I never I I didn't know it was going to be my work in quality and safety. I worked in South Africa in the time of apartheid in a very progressive unit. I was head of child development. But even before then, as a young trainee, my first safety event was when a child or baby, young baby died because of a human factors error. And uh this is where the baby had came into our very well-designed uh Toyota's lean system kind of diarrhea room. And you had the entry point where the babies would be assessed, and then where the babies were in three different stages: those who required IVs, those who required oral, and those who were going home. And we're talking about 30 coming in during the day, 30 going out, and another 70 lying around on this that were assessed every four hours. Very protocolized, very standardized, way before we spoke about standardization. We were doing it in South Africa. None of us knew that how advanced we were in in lean thinking. We didn't call it lean thinking then. But the critical thing was that you had to make quick decisions and you had to follow the formula. So we were the baby would come in and I'd say, is the baby dehydrated? Yes or no? Usually yes. What percent? Five, 2.5, 5, 10. That was a get a guess, but we had guidelines of what they were. And then was the but how much fluids did the baby need? And was the baby acidotic, yes or no? And if the baby was acidotic, you had to give soda pick, and you had to give 5 mLs, 2.5 mils, you had to formula. I mean, it was everything was standardized. In fact, you didn't have to think much, you just had to follow the protocol. And this baby came in, 5 mil soda pick was requested, and the young doctor received the vial, injected, and the baby died. And I was the resident at that stage, a registrar, my first week of being a registrar, and I had to inform the parents that we had killed the baby. I didn't say it that way. Uh now what had happened is that in those days the flaw in the system was that potassium chloride and sodium chloride weren't accept side by side in glass vials. There were glass vials. Potassium chloride was red writing, and sodium chloride was why was black writing. So it was a human error. And the nurse in the rush, as you recall, there's 30 babies, they're very busy. There were a lot of sick babies outside, and they pressurized, broken the wrong vial, because sometimes you use potassium chloride and put it on, and the doctor failed to check. And yeah, that was a human factors error before we knew about human factors, and that was 1984. So it's way before the safety movement happened. I was introduced to my first major safety event, in which what happened was that uh we didn't have second victim support that Chris may have spoken about. The young doctor was put up for manslaughter, as was the nurse, because baby had died, they lost their jobs. I kind of sublimated and put it away in the back of my mind, then moved on to the next thing. But it was very traumatic when I think about it now, but it was going to influence my career path, in which I became involved in many, many uh rescue events uh over my career. Uh but that was my first safety event when I was a young doctor. And when anyone who's listening to this career path, okay, to this podcast, that each of them will have had a sentinel or an adverse event that would remind them of the what I can now call the big why. The big why are we in patient safety? Why are we in this work that we do? And I know my big why was that if that happened today, that young doctor would still be a doctor. That baby probably would still be alive because potassium chloride is now a scheduled medication. You have to go and it's kept separate from from the other medications because of its danger. People don't about it. Although when I go in Africa, I still find it somebody's still not locked away. I even find it in private hospitals, I find it there. Uh so that was my start. My start was when I was a young doctor, and then whatever I've done since then has been involved about quality and safety without even knowing I was doing it until I formally became involved in 2000, even though I'd been involved before. Oh, I can give you lots of stories if you want to, Jason. But that's the that's the start story. That's the start story. And then I recall uh there was a even before then I had another start story uh as a medical student. So so I there are many, many stories.

SPEAKER_01 9:31

Yeah, and and it sounds like the the way that people in charge viewed that story made had a huge impact on the trajectory of that that nurse uh and that doctor. And

When Safety Meant Being Professional

SPEAKER_01 9:44

how did people view patient safety? Uh, what was the prevailing view of patient safety maybe at that time and and in the couple of decades as uh until you kind of formally got into to patient safety?

SPEAKER_00 9:57

So so just remember, in uh when I graduated in 79, we uh it was presumed that being a health professional made you safe. We swore the Hippocratic Oath. That's what we actually did do that. First do no harm. I remember this ceremony, I can visualize it. First do no harm as we graduated. Uh, we had no idea what harm we were doing. Absolutely none whatsoever. We had no data, there was nothing called patient safety. It just assumed that by being a doctor you would be safe because you're professional. Professionals are safe. That's what was assumed, but we had no idea. Absolutely none whatsoever. I mean, a lot of the world now still has no idea, but then it was there's no such thing as patient safety. It was you will do be a be a doctor and you'll be safe. And that was it. And uh, and there's no safety in our training, even now, there's no safety really in the training. Human factors, no one heard about human factors in those days. So it was just assumed that you'd be safe just by being a doctor. Then you go into systems, and I must admit that I was at a very top-class unit uh hospital, this Red Cross War Memorial. We had really, really good systems. We had lean systems, even though they weren't calling it lean. We had safe systems, but no one was calling them safety systems. I wasn't being trained in patient safety. We weren't talking about like we do now. It was a totally different world. I did work in many different fields. I was in community child health in those days. As in when I my first after my training, I went into community child health for a few years and headed the child development. And a lot of my children I saw were from unsafe acts in in obstetrics and maternity, the highest risk area of medicine. So uh even though I didn't know it, I knew that that there was medical misadventure and medical harm, and I knew that it was there, but there's no no one had a theory or basis about it. And actually, patient safety really only started in 2000 as something really important with the human and in the UK with organizations with a memory. And uh that's when patient safety started roundabout then, actually, a bit earlier with the Harvard studies, even though, even though, even though if you now look at quality, uh quality really started with Codeman in 1920, and saying, well, we have to know that the the outcome, the end product of surgery, what happens to the patient. And and then there was the the joint commission started long time before, and they were all measuring in some kind of ways. So there were there were quality, if you look at the history of quality, there were things, but it still wasn't, it was viewed very much from a regulatory and professional point of view. If you're professional, you'll be good. And then you have to follow some regulations and standards. But how you reach those standards, which is the quality improvement part, no one was talking about it only really. Demon came into quite patient safety into quality in the 1980s. So in the 1980s, Demon got interested in healthcare and in uh and uh the start of the quality movement in healthcare started in the 1990s. It's not that long ago, it's 30 years ago, that it started in healthcare, even though done obedient started in the 80s. So it's 80s and 90s where things were starting. And I I'm one of those who can say I'm from just before the quality movement started, during the quality movement started, and here I am now.

SPEAKER_01 14:14

And so so with that longitudinal perspective from a time as you describe, where patient safety was assumed, and whether a patient was safe or not, if I'm reading between the lines right, it really had to do with uh individual success or individual failure. And then you mentioned 2000 being the year that you know really got into patient safety formally, which was a really important time. As you mentioned, two areas human came out the year before, and then the year after that, in 2001, Crossing the Quality Chasm came out. Was there a lot of optimism at that time that healthcare could become dramatically safer?

SPEAKER_00 14:51

Okay, just remember that those are very American assessments. There I was in South Africa, and uh to us human, I never heard of it. I was I was I was a uh I was an attending, we called it attending, uh consultants in Cape Town, running child development. Uh, we were very interested in systems and system control. When you're working in a political environment, we were very, very involved in social determinants of health way before the wet the upper income countries were. So we were very politicized in the way we looked at healthcare. So what you said, the health outcomes are due to political decisions and social determinants of health. Now, nowadays it's very fashionable in the upper-income countries to talk about social determinants of health. But we were talking about it 25, 30 years ago, doing things to decrease the social determinants. But the systems ideas that came in with quality and to err is human and so on. I only got heard about it when I went to IHI in 2004-5. So 20 years ago, I was in IHI. But before then, I was managing many different quality issues and safety issues out of theory and backing about it. So I was a leader and uh and I we knew we had standards. Um, so if I take it backwards, in 1990, in my early career was in Cape Town as head of child development at at the Red Cross Hospital, I had a good career path. I was quite happy. We were very innovative. I had a big interest in uh system failures, uh, particularly in child protection, and systems failures related to um related to um social determinants of health. So we always viewed it through that eye.

System Failures That Forced New Thinking

SPEAKER_00 16:51

And then when I uh then a nurse murdered a few babies in a rural area in the United Kingdom in Granson, and I had done some training, post-apartheid kind of training, uh went out to Nottingham, and then they asked me to come and sort out the problem for them. And what was happened was a total system failure, they didn't recognize it. The system had failed to allow this nurse to murder these babies, and she was giving the babies insulin, and no one noticed that, and then four died, and eight others were injured, and major inquiries, the like inquiries in the UK, and then they needed someone in to come and change the system, and I came in to change the system. So I went there in 2000 in 1994. I said, I come for a year or two to change the system, and I stayed on there for two years and told them that the system needs to change totally, and uh there's not enough children, and so so I worked with that that system and they eventually changed it as I recommended and closed that small community hospital where the problem happened because it was And if I could just interrupt you for one second there to clarify the the case that brought you there with the nurse.

SPEAKER_01 18:14

These were these were also accidental administrations of insulin or these were intentional?

SPEAKER_00 18:20

No, this was intentional murder. So she murdered she murdered four babies. Her name is Beberty Alet. It was one of the major cases that had a major inquiry. And I came as an outside set of uh hands to assess the system and that's and uh I still didn't have the training, and as I look back, it was a systems failure, not the nurses, was she was a cog in the system that allowed her to murder these four babies. And I learned then that what I teach now in patient safety, one death is a a tragedy, two's a coincidence, and three's a pattern, and that you can stop it after the third, and she went, she had she had about 11 in the pattern, and not it, not the first, not everyone died, so they could have stopped her much earlier. Unfortunately, there's a current one called Lucy, nurse Lucy Letby did the same kind of thing, they allege, and that was man memo babies in 2016 to 2018. So um, so the lessons often are not learned. But I came to the UK to sort out a system failure, and I was starting to get interested in how systems work and how you can design safe, safer systems, still without the the knowledge, because of course the I came there in 1994 and still uh to Earth Human hadn't been published yet. So we were still before patient safety started. So there was no science behind what I was doing, and I and I hadn't read Donobedian. That's but it's right, system process needs to outcome. Uh, that's for sure. And I hadn't read the Harvard studies. So because I was just here, I was working my way through this, and then the next big challenges were child protection challenges against systems failure, where this the system of social care and the system of health care, the system of the police allowed major challenges in health care, in outcomes of babies, and there was one or two big cases. One was called Victoria Klimbier, the bay the child who was to died way beyond after she came to our hospital. But it was a system failure in retrospect. But of course, they wanted to blame the individual, always the individual. Which individual made the mistake rather than what was wrong with the system that allowed this to happen. And so system theory hadn't started yet in 2000, with 1994, definitely my first big case. The second big case in 2000 definitely hadn't started. In 2000, I was at a hospital uh in North London, and I was head of pediatrics, became head of head of obstetrics in gynocarcology, mainly because there's a system failure. And uh I didn't understand yet the systems failure, and then we had a number of maternal deaths, and then people say, which which obstetricians at fault? No, no, it's not an obstetrician at fault, it was the system was at fault. It's only when in 2004 I went to IHI that I suddenly had my eyes opened and said, Wow, this is theory. But that's only four years after to earth human and to across the quality cast. So I got there very early on into the program. I was very, very lucky as an Archive Health Foundation fellow to sit in the same office as Don Berwick and Maureen Bessonano and uh and learn from Deming's disciples, uh Lloyd Provost and Bob Lloyd, etc., on Tom Nolan, on system theory, and that it's not this individual, but it's it's a system. In most cases, in the nurse who murdered the baby, okay. She was murdering the baby. But the system allowed her to murder the babies. The system could have allowed her to murder the first baby or the second one, but not the third. Can you see? So uh so I I so so so in 2004, my my whole focus, even though I was in medical leader beforehand, my whole focus changed to patient safety. So in the last few minutes, I've been telling you my journey from a very first patient safety episode, which in retrospect was my first human factors failure that I witnessed. I was a third victim, not the third, you know, even the second victim, I was the third victim, uh, because I was advising the second victim who caused the first victim. But I didn't even realize then till many years later that that was the starting point and that each of these cases that I was going to solve in child protection, and I was very much involved in child protection, were all system failures in child protection, not individual failures. And then when I moved out of child protection into back into healthcare, that all the cases I was dealing with were mainly systems failures. And uh the maternity cases in uh at the London Hospital were there were there were very good people there, but the system failed them. In the in the child protection case, the system failed them. And even though uh there is individual accountability, uh there was no just culture, and still now it's the same kind of tissue. So my my journey then really started on this over the last 20 years, that's what I'm more or less dedicated my my career to. And that's been particularly even more so uh uh the last five to ten years. Uh I've been trying to think of new ways of doing things.

SPEAKER_01 24:27

And I'm eager to to get to

Bringing Safety Methods Back Home

SPEAKER_01 24:30

that. I'm curious from that 2005 to 2006 fellowship period, how did your work change during and and right after that?

SPEAKER_00 24:42

Well, uh after 2005, I was at Northwick Park Hospital. I was a medical director and head of the obstitulates and pediatrics, dealing with these issues. And then when I went to IHI, I came back and I moved to Great Ormond Street in Roll 3. At Great Ormond Street, I was head of quality and safety, and I had a team that we could really develop new ideas that I'd learnt at IHI. So IHI gave me the theory. So now I came back with the theory and method, and so I worked uh at Great Ormond Street, the Royal Free, and then also at the National Institute for Improvement and Innovation, which gave me places I could experiment. So at the Institute, I was involved in developing the pediatric trigger tool for the UK, the pediatric early warning score. We were rolling that out until the date dissolved when the new government came in. Uh, we were educating quite widely. I was in the program, national program was delivering for them, with them, was on national was called leadership in in patient safety, called LIPS. It was very advanced training teams from across England, it was mainly England. I was also involved in working in Scotland then. And so from 2005-6, I was very much in patient safety because at Great Ormond Street we were implementing patient safety and at and at Roy Free, we were as my laboratory. So at Royal Free, a small uh a big, big, big teaching hospital, but the pediatric department, but it was my laboratory. And there we could test ideas that I would later on take to the institute or to the um for national or to the Great Ormond Street. So I was very lucky and uh in my role because I was then I had a role in patient safety. Uh it was one of the first roles in the country where you'd have a patient safety officer, and we called it a medical director in the UK, and where we where we were funded very generously by the board of the hospital to be innovators in patient safety. And uh over those periods we implemented many, many good programs at Great Orb Street and the Royal Free uh to innovate and be leaders in patient safety and quality. So I was very fortunate to do that in from 2005, 2006 to 14. And that was my major focus.

SPEAKER_01 27:38

I wanted

Share What You’re Seeing At Work

SPEAKER_01 27:39

to pause for a moment to invite you into something I'm starting with this podcast. If something from this episode connected with your own experience, where you've seen it work or not work, I'd love to hear about it. There's a short link in the show notes where you can share what you're seeing in your own work. It takes about a minute. I read every response, and over time I'll be sharing what we're learning together in future episodes and in other ways, and giving shout-outs during future episodes to people in the community who share ideas that really move the conversation forward. If you're up for it, I'd really value your perspective. Thanks. Can

Parents As Partners In Preventing Harm

SPEAKER_01 28:33

you tell me about that?

SPEAKER_00 28:35

Yeah, uh, well, this is even before we co-production had come into the four. That co-production only came in in 19 four years later. I was always ahead of the game a little bit sometimes. So here we we thought that actually the people who know their children best are the parents, and they are with the child. And one of the things about Green Ormond Street, the parents stayed with their children when they were admitted, in many cases. And so we developed this tool with parents over a period in order for them to be able to identify potential harm before it happened. So uh the scoring tool, it was quite simple. It was uh we we looked at at a number of indices that the parents would identify with medications. Uh, were the medications given on time, were there the right dose, were there any problems with them? Communication was always a big thing with them. There were specific ones we had in that unit that we could fill out, they could identify specific ones. Anyway, so what would happen on that with that tool was at the end of the day, the nurse caring for the child and the parent would sit down and they fit out the form together. And what we noticed was quite interesting, is that nurse reporting of incidents went up, of potential incidents went up, and serious incidents went down. So reporting went up, but serious incidents went down. And it was before psychological safety that we didn't have that word, but we were building psychological safety because we were talking about patient safety. The other one is that more or less around the same time, we we had a partnership with Cincinnati children because when I said this in in in in at IHI, kind of didn't they didn't know us, interviewing the top hospitals. I went to Boston, Philadelphia, uh, San Diego, I'm on in San Francisco and then Cincinnati to see who who's the best in patient safety. And when I walked into Cincinnati, I said, wow, this is different. Just walking in. I could feel there's something going on here. So Uma Codigal and Steve Merton were the leaders there. So I said, I said to Uma, would you like to partner with us? And of course, Great Hall Great Ormond Street has got an international reputation, and uh it's it's the children's hospital, and we and I felt we needed to have a partner in uh helping me drive through the changes I wanted. So we linked up with with Cincinnati. And then I visited Cincinnati quite a few times, and there was a lot of cross-pollination who would come to me and we'd go to Cincinnati, and the CEOs got friendly and they come back and forth. So then when they published on the Huddles, we started doing them at Great Ormond Street, uh, which then we honed them at Great Ormond Street, and then we took it national in the UK, the Safe Program, Situation Awareness for Everyone. And that was started from the publications that Cincinnati brought out there, brought out two publications on their huddles. I saw what their huddles were like, and then I adapted them for the for Great Ormond Street and for Royal Free. We tested it out at Great Ormond Street and Royal Free. So there would be one in a what we called a smaller hospital and one in the children's hospital. And then we rolled that out. We had a big program funded by the Health Foundation in 2014 to 16 on the SAFE program. It was called Closing the Gap in Patient Safety. And so I uh rolled that out, and that's then I've taken it around the world into Ireland. And I think I think that's actually my biggest impact of anything is is the SAFE program. And and that that program, which we started at Great Ormond Street, we started seeing increased reporting, but decreased harm, decreased CAPSIS, decreased VAPS, decrease, you name it, whatever we're going, we were decreasing and making the hospital much a much safer place. And because people were talking about safety. So if I look back in my career, there have been a lot of innovations, and but I I like to think about the safe program. Uh this is on the safety side. Uh on the quality side, it's the Flocken program. But on the safety side, I like to think the safe program is a way which brings together all the series of patient safety to the frontline staff and allows them to be safer uh without them thinking about it. If they do it, if they do the safe program every day, they will have a safer program, a safer outcome. So uh so that's that's my passion, really. That one, the safe program.

SPEAKER_01 33:58

And uh yeah, for for our listeners who who heard you uh you know share just now about the the safe program and then Flockham, uh worth mentioning that I I believe you're the chair still for the the Flockham board and uh had a big role in uh in designing that along with Chris Van Hocht, who was one of our recent guests. And listeners can go back and check out that episode with him. I I would be curious to know about uh about the safe program in terms of the you described some of the successes you had. Uh I'm curious about the spread. So spreading to other countries and maybe what proved universal and what proved very context-dependent, having to be changed and adjusted for different places.

SAFE Program And Proactive Risk

SPEAKER_00 34:40

Well, actually, it's theory, uh, as I say. It's like gravity. Apples fall to the ground in every country. So the safe country work safe program works in every country. The biggest problem is time. Do we have time in the day to talk about patient safety? And I'd argue, yes, you do have time every day to talk about patient safety, because you're saving time if you're talking about patient safety. So I've done it in um in Australia, Argentina, Sudan, Mozambique, Mozambique, and no resources. In Mozambique, we use them, we amend it in each place as context. Context is always important. Started doing it in pediatrics, but when I moved in Ireland, we've trained over 100 hospital teams, from obstetrics to medicines to EDs to uh pediatrics to psychiatry, just teaching people how do you talk about safety looking forward? How do you come to reactive to proactive management management of risk? The premise starts like this is that we work in a very high-risk environment. When I trained, we were coming out of the period in which the patients died from one condition. So, for example, in the entire when I graduated, we didn't have surfactant. So babies over a thousand grams didn't under a thousand grams, but we didn't even bother to ventilate because we didn't have surfactant because we knew they were going to die. It was straightforward, it was it was very difficult. The young doctor said we're not gonna ventilate. Now we ventilate 250 grams, but in those days, a thousand. That is it. Then surfactant came and in comes the baby survived. And with the survival, we now get line infections, vats, we get all the other things from that survival. So we created all these safety issues on the neonatal side. Now I can go to the other part where most people die, the elderly. So now people live longer. So what happens? We create a whole lot of safety problems for the people who live longer. They fall, they get dementia, they get delirium, you know, when we bring them to hospital. So now we are false programs, dementia programs. We create the programs because of our success in medicine. So the more successful we become, the more complicated it has become. And we're playing catch up. And so what we've done mainly in the big mistake in patient safety was that it was about managing risk retrospectively. Someone got harmed, who did it? What went wrong? Rather than doing it proactively and saying, well, we get it right most of the time. How can we predict who may be harmed? Who's at the highest risk of harm in the next eight hours? And that's what the safe program is about. It's about identifying risk before it happens. It's based a lot on the theories of Charles Vincent, who actually uh and Al M. Alberti, well, Charles came to Greater Ormond Street and studied us as one of those case studies in these in 2012 on measuring patient safety, and they came out of the a whole theory, and uh, and then out came Holnagel a few years later about saying we may also have to look at what we do well. I put the two theories together, where they called it safety one, safety two, and then Charles broke a paper on proactive health care with an alberty, and I put all these theories. My idea was that how do we get frontline staff, clever people, who want to do the good work, how can we get them to do it as part of what they do? And so uh so we developed a safe program, and that evolved over the years in different ways. So in the first year took me six a year to teach it, and now I did it in six months and shorter periods, held it down. If you say what I what has happened, it's very focused. You know, what do they need to do to be safe? How can we get them to be safe? The first step is getting the pick why. Why are you in healthcare? It's a moral responsibility to be safe. It's a moral responsibility. That's why we're in healthcare. And okay, what harms do we, what do we do really, really, really well? When do we do and then what don't we do so well? Well, that's the adverse events, who do we harm? Understanding it, contextualizing it, and then moving to the solutions, uh, a reliability theory, what we do well, stand operating procedures, how do we follow them and why not? We don't, what's the reasons, human factors analysis? We use the SEEPS model, systems engineering and patient safety that Pascal Curry on, and so they can start looking at the work system. Do we have the right patients? Do we have the right people to care for them? Do you know what their tasks are? Can they do their tasks? Do we have the right equipment? Now we get to the context in low and middle income countries that don't have the right equipment. How are we going to mitigate the right equipment? How do we organize ourselves? What's the environment like where we're working? Which are the risk factors? And then what are we learning? They do the cycle two, two, three times a day. And uh and it becomes part of their genome. And my a great success story for me is Mozambique, is that we went when I went to Mozambique in 2016 working with the health service executive in Ireland, and I was at ISCRA at that stage, another part of my career I haven't spoken about, but I was at ISCR and I made a part of my work to go to Africa, and and uh Ward said there were they children would die. Uh adult Ward, they were having many, many adult deaths, and they counted them as so it was about eight to ten a month, unexpected within the first 24 hours. And I was just in the middle of the SAFE program. I just taught in the SAFE program, and of identifying proactively who may deteriorate ahead of time and intervening beforehand using the those cycles I've just went through. And they went down from 8 to 10 deaths a month to one to two a year. What does that mean for your listeners? That means over 90 families had a father or mother survived. And we even asked them to check what happens after 48 hours. Did they die after 48 hours because they wouldn't know that they lived? And then what happened when what happens after COVID when they ran out of the monitoring? We used something from Australia called Between the Flags. What happened when they ran out of the monitoring forms and they said to me no? So we've internalized it. This is what we do now. We do it every day. And so it's not resources, it's not, it's about the people. So I've that realized when you asked me the question about safe in different contexts, it's about unleashing the power of the people to be safe.

SPEAKER_01 42:30

And it sounds like such a rich framework for operationalizing the talent and the skills and the dedication of people already working on the front line. You mentioned the uh the word you know, genome, bringing it into the genome of healthcare workers. And I know that's something that you've written about as recently as 2025 for uh medical education and what medical education has to do to embed patient safety into the genome of future healthcare workers. What

Putting Safety Into The Genome

SPEAKER_01 43:01

can you tell me about that?

SPEAKER_00 43:03

I got that idea. Well, then the most big story I've just told you is that in 2023, when we went back there, they told me it was in their genome now. They said we've internalized it. So now that I let's genome. And then when uh I was commenting on a paper, I reviewed a paper on psychological safety, and then the editor asked what the journal said, Would you write the paper? And we came up with this idea about the genome, and it all derived from what those Mozilla Beacons told me, that they had internalized patient safety where they worked. They didn't have to think about it, it's what they do. Okay. So I started thinking about this concept of genome with my colleague uh John Fitz Simons, who's uh who I work with Close in Ireland, and uh and the kind deal about the genome is that. That if you insert something into the genome at a young age of the young doctor or nurse, then that's what they do. They don't say I don't have time because that's what they do. So that's the metaphor. The metaphor is the genome. And saying, well, health and medical education has failed because it has not inserted quality and safety into the genome of the future or healthcare workers. Just as it's going to fail by not inserting how to use AI safely into the genome of medical workers or future. I mean, it's not doing now and says, oh, in 10 years' time, you better tell them how to use AI, then it's far too late. So it's always the education is too, it's always behind. Why? Why is it behind? Because they say, oh, we don't have enough time. But I don't need to know in the old days when I trained, I had to memorize the crep cycle. Nowadays you don't have to memorize a crep cycle. You know how to use the crep cycle because you can have it on your iPhone, you can ask Claude, Claude, tell me what's a TED cycle or chat GP, and out it comes. You don't have to memorize anything these days. That's it's one of the dangers, of course. You have to understand how to use these things and under interpret them. AI is not going to replace you, but AI is going to help you understand things and apply them. So it's the application, same with patient safety. We've got to insert it into the genome from an early age, and that means that when they come into medical school, it's the same stream as physiology and pathology. So it runs alongside physiology and pathology, patient safety and human factors. It's not it's taught as a separate science, but interwoven. So my idea of how you would do it is that that for the medical student, when they say, This is a typical thing, they'll say, please examine Jason and tell me what you find. Then they say, Well, I was taught, well, Jason comes with this condition, the anatomy, this is how I was taught, the anatomy is in the cardiovascular, the pathology, the pathocyptology is atherosclerosis, the pathophysiology is then I say the safety issues are can you see straight away, along with anatomy, pathology, pathophysiology, the uh then you'll say, or or even you'll say the differential diagnosis is, and the in within that is the safety differentials, these are the high-risk things for him, and this is the what the medications we're going to give, and these are the risks of the medication, the medication safety. So if if it is a care of the elderly, it'll be thinking about in this person what are the risks of this person falling because I give them this medication. Not saying we have to have a false program, but of the doctors thinking about, well, uh the most common causes of faults. I'm not a geriatrician, but the most common causes of falls are delirium and uh patients being given sedatives and medications that cause them to fall. And then they have a false program to prevent falls. I said, Are you ridiculous? Just start thinking about it proactively, and you won't have you'll decrease the number of falls, amazingly, if you start thinking in a different way. And not only have to have that false program, you just have a proactive medication risk program. So it's moving like safe program then says to people, where you work, what are the harms that happen? What happens? Tell us the lived experience of your patients, or as we call them, the people sometimes known as patients. What is the lived experience of those people? That's right, not of patients, and what's the lived experience of the people providing care, sometimes known as doctors and nurses, because of course your people, and and what is that lived experience? And of course, they'll come back and say, This is what happens. I'll say, okay, let's decide how we can co-produce in the safe program, how we can save through a safer environment and come together to eliminate those harms. And they eliminate them. Some people are doing falls, some people are doing doing uh uh clubsies, other people are doing deterioration. Uh, the whole idea is proactive management, proactive management. Because when we get to the S, the this what will we be safe in the future, that's the prediction. What's going to happen? Who is going to fall before they fall? Who is going to have a medication hub before there's medication? Who's going to deteriorate before they deteriorate? So it changes the game. And and I really believe that if every clinical team was talking about safety in this way, we'd dramatically decrease patients' events, adverse events. We wouldn't talk about adverse events in the same way we do. And that's what I said earlier, I think safety went the wrong route to spent all this time talking about adverse events what it's wrong, rather than looking at proactive proactive risk management.

SPEAKER_01 50:03

Yeah. And as you're alluding to, that's that's uh been very slow to change. Uh I'm curious how that idea about embedding safety into the genome has been received. Are there any any uh med schools reaching out wanting to do that? I can imagine, as you're kind of anticipating there, some of the some people pushing back and saying we we don't have enough time to teach you know the anatomy and the physiology and everything else, but but this is deeply, deeply important. And so I'm I'm curious if that's uh any med schools have taken you up on that.

SPEAKER_00 50:36

I I've got no idea. I've got no idea. It's from my first publication, medical education journal, and I haven't had feedback from them. But I'm talking the safe programs are immediate work, do it while the healthcare workers. The genome is just beforehand. So you can stick it into the genome when you're training your residents, so you can do the same time. It's never too late to put in the genome. Never too late. Put it that way. So while it's for medical schools, really where I'd like them to start. I'd like also when the residents or registrars are being trained that they get it into their genome. Of course, we also have to do it for the attendants and the consultants because their genome is deficient, because they think they've got it, but they haven't. And the idea about safety is that you have to talk about safety every day. As I said earlier, it's a moral obligation. It's not a it's not a something you do when something goes wrong. It's about safety is our business, not healthcare. Healthcare is very complex. Our business is keeping people safe in our healthcare system while we treat them. And it's changing the terminology, the way people think. And I should be really very despondent because after 25 years, healthcare has come a long way, but not far enough. It has to change the way we think. And the genome is my latest idea. Okay, so it's a metaphor, is that you've got to do it early. And so, challenge to medical educators to think how they do it. So I can see some medical schools have got patient safety as part of the curriculum, but not every medical school will have a professor of human factors, a professor of a department of human of patient safety doing research into patient safety. In the United Kingdom, they you're supposed to do patient safety as part of your work and uh to get appraised, but still it's not it's an add-on rather than what we do. It's what we do. It shouldn't be an add-on. And and and it's a change of thoughts, and it goes back to culture and how people think. But the genome is my latest idea. So uh I'm hoping so I'm hoping medical schools say, yeah, that's a great idea. Uh we we go in because genomics is very popular these days. So uh maybe they understand the metaphor and and apply it.

SPEAKER_01 53:20

Yeah, I think it's a stickier metaphor, uh, I think it's a stickier metaphor in today's conversation. There's two other groups that I think you're probably interested in uh in inserting this into their genome, as it were. One is, as you said, uh, people who are already practicing, whether it's physicians or or other healthcare professionals. So I'm wondering if you can comment a little bit on that through your work as a fellowship director for the Patient Safety Movement Foundation. And maybe at the at the same time you can tell me about your work with boards and how boards can enhance safety or not, and and how we kind of put that in the genome.

Training Fellows And Building A Movement

SPEAKER_00 54:01

Yeah, okay. So let's start with the uh the genome is what I'm doing. Now I'm I'm I'm I'm actually looking at ways we can do genome. Remedial genome therapy, I guess I called it. That's uh so a few years ago, I was asked if I'd help develop a program for the Patient Safety Moon Foundation on uh for an international program. So they're an interesting group because they uh they uh they're like a social movement and they they developed they developed patient safety solutions, but no way of interim. And they asked me if they could I could help develop a fellowship program if they had started or or helped do it. That was in 2003. So I said okay, they're based in California. So I direct their program for early to mid-career healthcare providers. So we take any healthcare provider uh from doctors, nurses, pharmacists, uh, occupational therapists, physiotherapists, whoever wants to apply, who's involved in healthcare and delivering clinical care generally, from across the world. And I'm really aiming at low-middle income countries, but do this year I've got someone from the US, and I've had previews, see, and I've got someone from Belgium, from Chris's team actually, uh on the program. And we started with four, then we went to six, then we went to 10, then we went to 12, 18, 12, then to 18, and this year we uh we want to go up to 32, so we've exponentially grown each year. I've trained 45, and it's about inserting the genome. So I've worked out a program of what do they need to know uh as leaders in patient safety, which is the what's the material for the insertion, and we spend a year doing that, and we use a uh each year the program has evolved because when you go from 4 to 18 to 36, too, you've got to change the way you deliver it. So in the first four first four year, first one year or two years, I was delivering a lot of the stuff, and then I decided a flip class and it's better when we get to 12, and then when we go to 18, like this year, the last year and this year, they go into learning sets or three or four, and they have a mentor for the learning set, and the mentor mentors them in the learning set, and then they present and they teach each other, but they also learn reflective practice. Uh, so this is where I see if it's it's working. So every month they have to write two reports for me of reflections on their learning of the previous presentations, and also of a project they have to do, so I can see if they can apply what they're learning. And and the idea is to really see how we can insert. And it's a model that people can take and apply at scale. Uh, and now we're scaling up, we're scaling up at the moment. Uh, so I'm going to see what happens to 32, and then uh then people copy nothing's copyrighted up because I have a very detailed program in which they learn the different theories of patient safety, but then also learn uh the stuff we teach on FLACOM, which is co-production and quality and so on, so Chris would have spoken about. So we start with that equity, quality, person-centered care. Before we don't even talk about patient safety, it's all rather free, then really about going to culture, and then we go into the technical part of patient safety, and then we end up with well-being of staff. So uh, so it's a it's a very uh intense, it's kind of these are people from uh so we have from Africa, Asia, Latin America, Eastern Europe, the Eastern part of Europe, and one or two we take a year from the upper income countries. Uh, because I was really focusing on those who don't have because if you're in the USA in many, many programs you can go on. And this is totally free. We were fortunate Joe Chiani, who started the Patient Safety Movement Foundation, from his foundation, he feels uh he funded it and continues to do so. He this has now become a big part of what Patient Safety Moodle Foundation does, and and they can apply, and what they get is from me, they get mentoring in terms of monthly feedback, then they get an individual mentor who's a previous fellow because we're trying to build the movement, so a previous fellow does it, and and actually this evening we have a guest speaker for all the fellows of all the years. So we now at a stage in which we're saying, well, how can we get this to be a fellowship that lasts forever? Because what is a fellow? Uh, if you read Lord of the Rings about fellowship, and uh and this is what I'm trying to build this idea of this international community or practice of fellows who are learning from each other and supporting each other. So can you imagine that uh, for example, in Latin America this year, this year, because I I I this is my latest iteration of thoughts. I have before I had one for one or two from Mexico and one from Brazil, but this year I have uh I have Argentina, Peru, and I think this Argentina, Peru, and Nicaragua meeting as a cell. Argentina, Peru, Nicaragua, and then they are mentored by the previous ones from Brazil and Mexico. So now you have Brazil, Mexico, Argentina, Nicaragua, Peru. Okay, and next year I'm going to look if I can get one or two other countries, and now in Latin America, I'll have a nexus of pediatric leaders across different countries supporting each other. That's in Latin America. There is a lone USA person uh in California, and he's linked into the Latin American, so he's learning Spanish very quickly if he doesn't speak it. And then then if you look what I'm doing in in what we're doing in Africa, we have a North African uh uh West African and an East African group because we've got quite a few from Kenya and and Uganda and Ethiopia, and then we've got the Southern African, Southern and West African group, then we've got a group in the MRO region. So what are basically building groups across the different uh WHO regions? So each WHO region, PAHO for Latin American Americas, Afro, Euro, MRO, CRO, etc., will have a group of six to ten fellows by the end of next year. Or may need up to ten. There will be 60 that we're trying to, I'm gonna try to equalize them out, supporting each other. And then working together as an international group of fellowship. And that is setting to the genomes, and their job is to do likewise with their working, is to take and then teach and continue the program and start a social movement. Because the other idea I have about patient safety is that one of the problems is that was a product, but it needs to be a social movement, just like climate change is a social movement, and uh and people need to be seeing it, it needs that kind of spread. So you need a lot of network theory and community of practice theory to get it spread. And that's what we this is the innovation I'm trying to do with the Patient Safety Movement Foundation. Uh, throughout my career, I've been very fortunate. I've had hosts who've allowed me to play around with new ideas. So the Patient Safety Movement Foundation is my latest place. Great Ormond Street was a place I could innovate, National Institute was an place that could innovate, uh, where I was allowed to think about different things. And of course, I haven't spoken about ISCR, where I was CEO for five years, where I could innovate new ideas to develop patient safety and quality. So in each of the organizations that have employed me, I've been fortunate that the boards have allowed me to do that. So that's part one of your question. Part

Boards, Culture, And Quality As Service

SPEAKER_00 1:03:21

two of your questions about the boards. So I chair three boards, two boards on one board. The first board is the FLACA board, which Chris has asked me to chat because that came from a paper I did with Paul Batalden and Chris on the multidimensional model, thinking what what is quality really about in the new age, and we published in 2000, 2021. And from that came the House of Trust and the Flacker model, which your listeners can listen to about thinking about quality differently, mainly because I was thinking with Paul Berteldon, who's a great thinker at quality, is why is it not working after so long? And with Paul, uh, we're currently thinking about the problem has been is that we treated quality as a product, not as a service, and patient safety as a product, not as a service. And products are transactional, and services are relationships. So we think trying to think a little differently of how we do that. And FLACOM is a good example of how they're transforming a product into a service, and so accreditation is a product, not a service, and so FLACOM is a service, not a product, and and that is the FLACOM board. The other board is I've been working with a group in India called the Consortium of Accredited Hospitals, CAHO, Consortium of Accredited Hospitals Organizations, and they had a social movement, and they were quite interested. I met them when I was CEO of ISCRA, and they're very inspirational, and uh they they they accredited hospitals, but no, they had to do more, and so they a social movement spreading across India. I work with two groups in India as well. Another group is in uh is uh a national um point of care of quality for neonates, and uh I go to them every year, and uh that's because India, of course, is so big, you've got to think of social movements to spread quality and safety. And and then the last one uh is a group in Africa and Kenya called Acquire, and they uh also bottom up safety movements, and they're asked to be on their board uh as the quality experts. And my idea of the reason why I agreed to do that was because I wanted to see how, because I've worked a lot in Africa, is there a way we could get a graph? Movement going for quality and safety in low and middle income countries, low resource. The resource is the people. So the India and uh and the uh Africa versus the Flaco, which is of high income, is that um it's it's all about how can we create these social movements where the people that's the doctors and nurses and the healthcare providers meet the people, the patients and their families, and co-produce quality and safety and get good outcomes. That's the future.

SPEAKER_01 1:06:44

And and from that, from the experiences you've had on these different boards, from you know the incredible volume of experience you've had in in patient safety, for listeners who might be on a board or want to expose their board to you know important ideas for how they can support safety work better. What kind of advice would you give to uh to people who are wanting to make the boards more able to support safety?

SPEAKER_00 1:07:14

I think uh the first thing uh at the bottom line, everything is about culture. It's about talking about your culture. What's our culture here? Not what's our vision state, but what is our culture like? What are we talking about? Culture is what you do, it's what you think. It's who you are, and it gets you outcomes. So I say the first thing for a board member is to be curious. Always ask questions, be curious. You have to have courage I say this applies to everyone, so curiosity, courage you have to always be someone who gives hope. People don't like negative stuff. You gotta give them hope. It's always gonna be better, even when it's not. People don't vote for negative, they vote for hope.

SPEAKER_01 1:08:16

Yeah.

SPEAKER_00 1:08:16

Well politicians sell hope, they get elected. Politicians sell negative stuff, they don't get elected.

SPEAKER_01 1:08:25

Yeah.

SPEAKER_00 1:08:26

So that's those three things curiosity, courage, hope, and always be transparent. Always be transparent and learn.

SPEAKER_01 1:08:38

Yeah, thank you for that uh that reflection. I um, you know, as I'm thinking about all the different pieces of work that you're doing with the Patient Safety Movement Foundation and and all of these other areas that we've talked about, if the work that you're doing kind of achieves its highest aspirations, let's say on the next five-year time horizon, what does patient safety look like?

SPEAKER_00 1:09:02

As

The Next Five Years Of Patient Safety

SPEAKER_00 1:09:03

I said, part of me is very pessimistic because things aren't moving as fast as they should. Another part of me is very excited because we've come as far as we can. I think that we're at the next phase of evolution with AI, uh, which we've got to say, we've got to say, well, how's AI gonna help us be safer? How's AI going to help us? You know, uh, and I give you for example, it's early days still, but AI is going to have the right algorithms to help us diagnose sepsis earlier, for example. Or AI will be able to tell us who's at highest risk if we put in the features and they'll tell us who's at highest risk. But it's not going to be the answer. The answer is culture, of course, is that we have to have a safe culture. So everyone says uh more tools, electronic records, and all of that. Oh, those are expensive ways to have bad bad outcomes if you don't have a safe culture. It's all about culture, you see. So uh so am I uh I for me, for me, I think that when I look globally, when I look globally, people are starting to talk about safety, which is really good. The politicians are starting to talk about safety, the WHO has been talking about safety. But have I heard I'm just gonna I'll use um I'll use the UK and I'll use the USA. I haven't heard your Secretary of State talk about patient safety, in the way we talk about patient safety, and I haven't heard about our guy talking about patient safety the way I want them to talk about patient safety. So we have to get the politicians at the highest level to talk about patient safety and quality. They're likely talking about it when things go wrong or negatively, what we're doing, but it should be at the heart of what they what any policy is going to be done. And then we've got to really think about health care and how we've designed healthcare for the modern age. So I started when I was a child, we still had polio, then we got vaccinated and we had no more polio. We still had smallpox and we got vaccinated. No one gets vaccinated for smallpox anymore, but I've got a smallpox vaccination. No more smallpox, measles, mumps, rubber, you name it. Infectious diseases was what happened in those days. Now this was the age of infectious diseases when I grew up. Then we moved into the age of cancer. And now we move, that was the next age where we're sorting out the age of cancer. We're sort of in that area, but a lot of times now, and I can speak as someone who has cancer, is that we are in an age where people living are living. And because we've dealt with infectious diseases, we're dealing with cancer, we now got the non-communicable diseases that we're dealing with. So people are living, but they've got diabetes, they've got obesity, they've got all these things. But what has happened is that the healthcare structure hasn't changed. We still have these enormous hospitals, very big hospitals. The hermit card education hasn't changed at the scale it has to do, in order to create the doctors of the future who can deal with the problems of the future, the diseases of the future, which are going to be non-communicable diseases, because people are living longer, both in upper and lower middle income countries as well, because as they're going to get there rapidly as well, because as you get more wealthy and people living longer, so people go through. So what we have to do now is say, well, how can we treat people with chronic disease and not treat them in hospital, but treating the community? And that's where the work I'm doing with Paul Battelden, or the thinking I'm doing with him, I'm very privileged to be able to work with him now, is on how we think about not managing disease, but managing health. And how can we co-produce health rather than manage disease. Because I I really don't want to be seen, or a patient person doesn't want to be seen as a diabetic. They want to see as a person who's got grandchildren, who likes going to the theater, reads books, and so also so happens to have diabetes as part of the portfolio, but can live a full normal life because they can you see? And that's now changes it, changes the game. And I think we're still in the disease management system. And because we're in a disease management system, patient safety is still in that product system. So I'd like to see the change over the next five years. Now, you can't jump from one to the other strategy. You need all of these levels. So in the in the in the paper we wrote with Chris and Paul, and we spoke about quality 1.0, 2.0, 3.0, where 1.0 is accreditation regulation meeting the standards. Essential, you have to have that. Quality 2.0 is meeting the stand meeting improvements as Durand and Vemin and so on. And property 3.0 is the co-producing of health and looking how we can look at the architecture that you do that in. And I think that healthcare needs to rethink its what it's going to do, how we train the future, the future doctors and nurses to think differently about when someone comes to see them, but they mustn't be talking about the disease, but talking about their health. And of course, safety becomes part of it because it's in their genome. And they can how can you do this safely? And how can you work out the risk profile for individuals as part of the assessment? Uh, and and I think that I think we're getting there. My optimistic sidelines talking is that people are talking about this, and uh I see I see clinical teams now doing things differently, doctors are doing it, and and hopefully uh people are buying the books I've written, so so that will will uh will help them do it, uh, because that's another sign. 15 years ago, no one would have asked me to write those handbooks, but now they're asking to do it. So so that's the the kind of thing. So I see the changes. Um I'm very optimistic, uh, and I know change takes a long time, but since I started on this journey uh many, many years ago, at the start of my career, uh, the world has changed in patient safety. Has it gone far enough? No, but it's gone far away. And and I think that the next you said the next five years? Yeah. Well, I don't think we're going to be solved in the next five years, but we're away away on the way, going there. But everyone needs to start thinking differently. The people we call patients, because they're sometimes patients, they're people most of the time, the people we call healthcare providers, they all need to think differently about patient safety. And I I I'm I'm I'm lucky I get asked to speak on quite a few different conferences around the world. And each time I'm honing to my idea of what they have to think, how they want to think differently. I spoke to the Flackham group last week, and I came off this idea about the moral imperative. So it's a moral imperative, so it's about morality, it's about who we are in healthcare. And as soon as you start talking about people, that's the why. Why are we here? And safety and quality is part of caring.

SPEAKER_01 1:17:39

Yeah, I think that that vision and that that optimism is something that will resonate a lot with people listening to this conversation. And I want to thank you for taking the time to have this conversation with me.

How To Connect And Final Takeaways

SPEAKER_01 1:17:51

For listeners who want to follow your work, you know, I will include links to all of the resources that we've discussed today. But is there anywhere in particular that you'd advise people to go if they want to connect with your work or follow your work?

SPEAKER_00 1:18:04

Well, they can just go to the LinkedIn page and connect with me. That's the easiest way they can do that. You know, like I'm advantaged now that I'm kind of uh I'm kind of retired, but I'm not retired because I've got all these activities going on. And people can reach out to me and uh I always respond uh generally pretty quickly. And if as I said, if people people particularly in low-middle income countries want to compete for the for the Kiani Fellowship, they need to do so. And there are other ways that I can support them. My final thing is that I I was fortunate, very fortunate, that I was able to get onto the bus very early on when it started. So only a few years after after to earn as human, I was in quality and safety, learning about it, you know, in 2005, so five years later, I was there. And and now I've got the opportunity to give back. And um and that's that's my role, I see, is to be able to get the next generation of quality and pay-to-safety leaders around the world to able to take it on. And the more we can do, and this Kiami Fellowship, that's one way. Thinking new ways of of sending out ideas, that's another way. I I really think that uh it's what we have to do. And hopefully the podcast will inspire someone to say, I want to learn more. And they're welcome to contact me.

unknown 1:19:47

Dr.

SPEAKER_01 1:19:48

Peter Lochman, thank you so much for uh for joining me today.

SPEAKER_00 1:19:51

Thanks a lot, Jason. Great to be here.

SPEAKER_01 1:19:55

Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.buzzsprout.com or in your favorite podcast app. The show was written and hosted by me, Jason Meadows, edited by Milan Milosavievich, and produced by Thrive Healthcare Improvement. See you next time.