The learning system and you can see it has three parts, and here, TMF is an expert in learning systems. And so we're sharing some thoughts here. But again, we need to integrate the fine work and capability TMF with our own. I think we all know that learning is a key not only individually to life but to organizations. We hear a lot about the term, a learning organization and there's been much written about the learning organization and its importance in terms of not only doing our best, but also to be a place that we feel good about, because we know that we're getting better every day. So the first domain in this is to learn and learning, If we could go to the next slide, through that great. The learning it's really a complex thing. It's something we've done our whole lives, but I think it's really important to be open to new things. As Amelia pointed out of having curiosity is a key both individuals, groups, and an organization in general need to value curiosity, to be listening as we talked about earlier in terms of, personal accountability spending time listening and hearing from others and being especially interested in how and why questions, because those are the things that help us to better understand why things wind up happening. Observation is something that I can relate to in my career as something that clearly understands a lot of time talking about, observing normal operations. But I would strongly recommend this to everyone to go to any kind of environment whether it's the emergency room, waiting room or even just looking on a grocery store and how they check out people, you can learn an enormous amount just by observation and to understand what the current status. And they will have to give you ideas about ways in which perhaps things might be able to be done differently. Learning is really a science and there's many books written about how we do this and we'll talk more about improvement models that exist. But I think it's really important for us to be committed to fixing our defects and understand why things happen, the Human factors that drive motivation of individuals to do different things. And a key element of learning, A learning system for surgery for example, will be in a very short time after a surgical procedures is done. We strongly encourage that there's a degree, where in fact, the team learns from the work that they just did together and there just are three things they talk about, what went well, as an opportunity to celebrate success and to thank the members of the team. What didn't go well and should we do differently next time, which again doesn't point the finger at anybody but really simply says let's figure out what we can do. And the other part of it is what did we discover that others need to know about, another element of a learning system, which is sharing what you learn with other. Amelia any thoughts on this. I always think one of the most important questions to ask when we talk about learning is, what's the operational definition of learning that we're working to and I say that as an experienced [INAUDIBLE]. I guess I call myself a failure expert. I worked in the field for a long time now and in health care, both here and overseas, and there were so many times where I have participated and led what I would call the traditional approaches to learning that we've embedded in health care. And sometimes the way that we've embedded them and our commitment to those more traditional approaches like for instance, doing lots and lots of root cause analysis, investigations and has become our interpretation of learning. A reframe of that is just to say, we still have to dig in. We still have to do the sort of curiosity piece and appreciative inquiry and bring in some of the new approaches that Don's was mentioning and add them to that. But the definition of learning is that, I do something different as a result and I can track that something has changed as a result. One of the phrases I'm guilty of chanting quite frequently is, activity is not improvement, just because we spent a lot of time doing the investigation doesn't mean that we got better. And it would be really wonderful if it did because we are certainly all spending lots and lots of time reporting adverse events investigating them writing up reports, et cetera. That the invitation here is just to for us to take a step back every so often and just ask the question, what did we learn? And are we now able to apply that learning in a systematic way. And I think that helps us to continue the evolution of the very valid and important learning processes that have been implemented all over the world, in health care that continue to improve them and take them to an important place where we actually change what happens as a result. And so that brings us to the next component, which is improvements itself and in learning and improvement in two areas where we have tended in health care just to highlight a slightly different point. We've tended to give these jobs to specific teams and create silos by giving those jobs to those teams. So for instance, in the past I've held the role of Patient Safety officer, a Patient Safety Executive for organizations. And that didn't mean that I was the only person responsible for patient but it sure made it look that way. One of the pieces here is also about taking what we're describing under the learning system and doing what we described on the personal accountability, which is to create an individual accountability for everybody to participate in the learning system. which means that we give everyone the skills, the capacity, the know how, to be able to reflect on what they're seeing and learn so that everybody's job is to not only do their job, but to improve within their job and help to share and disseminate that responsibility amongst all of the individuals and not leave it just with the named teams themselves. And so on that point we'll move on to the improvement slide, please Victor, and talk a little bit about this. I don't mind which improvement methodology is the go to one certainly. I've used Lean Six Sigma model for improvement, experience base coat design there are plenty of them out there. And they're all good for different things. The question really comes to, do we have a methodology in place as an organization, as individuals, as teams that helps us to translate the insights that we gain from our processes of continuous learning and then test those insights using a structured improved methodology to make sure that they are then going to drive the improvement we want to happen. So the difference is that instead of doing an adverse event and I end up with an action plan and the action plan says, I'll communicate this to everybody in the organization. And then I take a box and say that I've done that instead of doing that, I might use improvement methodology to say, I have a theory that if I communicate this to everyone in the organization that it won't happen again. I can then communicate it turns out people sometimes read the communication sometimes don't really remember it. And so then the adverse event occurs and I know because I've applied improvement methodology that my theory of change wasn't the right one. And so by applying methodology here it's all about testing our assumptions and saying the actions the interventions the changes we're planning on making, do we have data to support the fact that they are the right changes that are going to create the outcome we want to create. And again, highlighting the importance of using Human factors principles here in the way that we design those changes. So although we're talking about a learning system every single piece of everything we describe today is a balance, human beings and systems and processes. Very complex human beings working in very complex cultures and very complex health care that is continually changing and very overwhelming. And so we have to continually have people and systems side by side and our solutions and our interventions have to marry those two things together. And be very cognizant of the fact that no matter how good you are and how hard you try, all human beings will make mistakes. And there are things that we can do to make it easy for people to do the right thing and hard for them to do the wrong thing in the way that we design changes and interventions. And the last point I'll make about improvement and I say this again is a guilty party here. I've been the person who's working in improvement. And one of the things you notice after a few years of working and improvement is that all you have to do is add to the list of what people have to do every day and very, very rarely do we take things off the list and say, hey five years ago, we came up with an action that was now everybody has to fill a tick box or this screen or use this checklist. But guess what it didn't actually work. So can we take that out of the system and free up a bit of head space and capacity for people so that they're not doing the things that were very good well-intentioned interventions but that actually didn't create the outcome we were wanting it to create. And so that one of the biggest crimes of improvement enthusiasts is that we're really adding new projects, new priorities, new tasks and that really our job is to take them away to simplify them. And when we get to talking about implementation, which I'll pass back to Don now, that we use implementation and reliable design processes to do just that and simplify things as much as possible. So anything you'd like to add done before you take over? I think I can't emphasize enough the importance of taking things of low value of the plate because they tend to stay there. Jim Collins has a wonderful concept he calls it, "Stop Doing List" and in fact, you might think about googling him and learning about it. It creates bandwidth for doing things and if we just add and subtract, people will run out of time and energy to be able to do things that we want. If you we move on then Victor to the next implementation. Implementation is really taking these good ideas and designs and putting them into action. Another term you might use is execution and those doing so is something that I would encourage people to have some formality with. Make sure that people know what the change is, write it down, put it someplace. Create a job aid for someone who has to do something different. Not everybody was in that meeting that designed the improvement. So make sure that the improvement is communicated clearly to others. We tend to jump quickly to policies, which are complicated and sometimes hard to implement. But much of improvement can be rapid cycle improvement, where small touch of change are implemented or it could be a very large change that's being implemented. And then that is particularly important to be able to have people know what they're supposed to do differently and what things they're not supposed to do. And so and key to all of that is to be tracking two things really is, the impact of the change that we've made and hopefully a good measurement system for that. But also the degree to which the change is actually implemented because sometimes we just presume because we tell people please do this, that it happens and I guarantee you from a hard won personal failure that if one assumes that everybody is going to do something just because you've said it, is usually a recipe for failure. So I think there are giant tones of books written on how one executes and as Amelia pointed out, whether you're dealing with Lean or Six Sigma or agile or any of a variety of other methodologies for executing improvements. Those don't matter as much as simply making sure that the people who are supposed to be doing things differently know what they're supposed to be doing differently and why. And so I would emphasize that as a very practical component of that and if it works, don't forget about the last step, which is spreading it to other parts of the organization. In the last six months that I worked in a large health care system, I went to every unit and ask them the question, what do you think you're proud of here that other people don't know about? And we collected 61 wonderful improvements that no one else knew about. And so we actually created a program for implementing these more broadly because in fact those simply felt that once they fixed what was going on in their unit, they were finished. And indeed I suppose maybe they were but it's wonderful to be able to share those successes more broadly and again, I want to emphasize the importance of celebrating success. Even if they are small successes, are very important to build the community of the work setting. Any other thoughts Amelia? I mean, I think just reflecting on the number of priorities and initiatives and projects that they never quite make it past the pilot phase and so that these three things, sit together and learn, improve and implement. Learning the important question is, how will you really be the steward what was going on here sufficient to be able to make improvements. Improvement is have we tested and do we have data that shows us that we haven't just changed something but we've actually improved it. And implementation speaks to are we now able to make that improvement sustainable, reliable, normal practice moving forward, which might also involve us removing the old way of doing things from the system. And the three sit side by side here, but everything that we're identifying, every opportunity, every defect, cycles through all the time and mirrors what is happening on the cultural side of this wheel, which is that you still have to have a culture that allows the learning, the improvement and the implementation to take place.