Dr. Kennel, and are very excited to be with you today to discuss the topic of HRO, from the point of view of assessment, um, where we are, and then really how we grow our maturity around that. So the high reliability journey, just like any discussion around how reliability can have multiple starting points based on your experience and your frame of reference. So, today we will discuss a from a point of assessing where we are and some techniques for growing our maturity in the space. On the next slide, we're going to see the goal for this session and it's really to understand that is a journey and to understand what each of the levels looks like. Let's take just a little deeper into this, go on the next slide. So, the goal of any how reliability organization is failure, free operation with stability over time, and to begin to understand and assess where we are, we have to put a little bit more context around it. Is based on what is based on what we see around this so we need a frame of reference for this. And for that, we really look to the goal of any organization, uh, from the space, uh, operational and culture and clinical. Uh, we're again, looking for failure, free operation with some stability over time and notice that. The goal here is failure free, not mistake for a big difference failure free meaning. No harm riches are patients not that the organization which is made up of humans won't make errors. If we were to try to set, the goal of humans will not make errors. We would be starting from the wrong point of view. So we really look for these goals to come from the mindfulness of these points that you see here. Uh, just keeping a mindfulness of operational status and of expertise of the complexity of the systems. I'm a mindfulness that there are potential failures out there with risk than defects and constant mindfulness of continuing, continuously strengthening our resilience to meet these demands. Let's look at the next slide and see what happened, uh, with Boeing. So we're probably all from very familiar, but in March of, um 2019 there were 2 plane crashes in both both of them, uh, involved Boeing 737 events. So rarely, is there a single calls for a plane crash? Like there were in these cases but in these cases, uh, there were no fail safes or these that were built into a specific system function, uh, and that function would allow the crew to know their true air speed and know their altitude. So they're basically fine blind and this resulted and missing the goal of failure free operations. And it did result in the death of 346 people. Um, when I make this next statement, I want you to feel free to. Put in the chat, any questions or reactions that you have so. As we would expect, you know, this gain national attention, and it grounded the entire line of planes that just recently, uh, 737 started flying again. But Just the same thing happen when 346 people. Lose their life and health care as a result of failures. Um, would you think that the same thing would happen? Would it ground. And bring everything to a, to a standstill if 3000 people that. Or 30,000, people that what if 300,000 people. Dad, well, the answer's no in health care. We can march own and quite honestly, on average there's about 400,000 people. Uh, annually who lose their lives due to failures in the operations, the clinical space, and the culture space and healthcare and on a macro level. This is where assessing maturity really starts. Let's look at the next slide so the pharmacy industry is really beginning to sound off on the balance between efficiency and safety and Wwe're really excited that they are in the age or journey the ability to to speak up. Um, when When is recognized that safety is being or is potentially being compromised is crucial and it's fundamental. This speaking up, uh, is also a key indicator in your assessment of where you are in start and your starting point on your journey at your facility. Think about these questions, does the culture and your facility support people speaking up? Um, if so. As evidence by what is their psychological safety when an issue is brought up. Is it met by a leader who incorporates appreciative inquiry or is it tap down. In the name of efficiency, these are key questions to determine your starting point as you move forward. Let's look at the next slide. So, there's really a Top characteristics of good leadership and these were identified and have been consistent, 350 years of study. And they are honesty, slash integrity number 1, a vision, and they share it, uh, competency, uh, leaders who inspire and, of course, leaders who are intelligent. Um, I love this the statement once you get used to taking the high road, putting values over expedience and treating Pete. People like people and and not the means it gets easier and easier every day to do this and you'll see in some subsequent slides. Uh. Uh, a good visualization of what that really looks like. So let's look at the next lab, Victor, so this is a very complex topic and as you can imagine, there's not simply 1 thing that makes it work, but rather the integration as a whole of many key factors, a doctor is going to walk us through 4 key components of high reliability that stand true despite.