Improving Patient Safety: Team Science, Big Data and Lean with Dr. Dan Low | Ep 18

Dr. Dan Low is the Chief Medical Officer of AdaptX and an expert in clinical systems improvement. Dr. Low has been in the field for more than 20 years and has published numerous research papers on patient safety, human factors, lean methodology, and medical technology. He has been invited to lecture on clinical transformation, physician engagement, continuous clinical improvement, and the use of real-world data to improve patient outcomes both in the United States and abroad. 

 Dr. Low is also a practicing anesthesiologist at Seattle Children’s Hospital and an Associate Professor of Anesthesiology at the University of Washington. In addition to his clinical expertise, he has been consulted on non-healthcare safety and team performance issues, such as improving U.S. Navy operations and commercial aviation teamwork.

Dr. Low is the co-founder of AdaptX, a Seattle-based startup that seeks to improve patient care with better insights from healthcare data. The company recently raised an additional $6 million in a Series A funding round led by Vulcan Capital and has raised a total of more than $11 million in funding.

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Dr. Dan Low on LinkedIn
AdaptX
The Checklist Manifesto: How to Get Things Right
TeamSTEPPS

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Transcript

Transcripts are machine generated and are NOT edited for grammar or spelling.

00;00;00;09 - 00;00;22;04
Brian "Ponch" Rivera
Some history between us and Dr. Dan Lowe. Several years ago, I connected with Dr. Lowe in Seattle. We went to the Museum of Flight. We did a presentation together, and I looked over at him and I said, Oh my gosh, I did not know about behavioral markers. I did not know about my own context as much as Dr. Lo did.

00;00;22;13 - 00;00;49;00
Brian "Ponch" Rivera
So we we learned a lot from each other. I learned a lot from taking a look at the patient journey, from following the patient journey with Dr. Download to see how awesome they're bringing in lessons from fighter aviation. Lean the Toyota Production System Human Factors into health care. So Dr. Dan Lowe, I want to start with the your new company mainly on what primary you're trying to solve and how are you solving it with ADAPT?

00;00;50;04 - 00;01;12;02
Dr. Dan Low
Great. Well, thank you. And thank you, Brian, for inviting me to the show. It's a pleasure to be here. So, yeah, great recap of how we met. Five years, five or six years ago, I started a company called Adaptive X. And the problem we're trying to solve was, you know, I've been in America now practicing as a physician for 12 years.

00;01;12;02 - 00;01;32;14
Dr. Dan Low
And when I first arrived here in 2010, most hospitals were still on a paper record. So every time you gave a drug, every time you tried to the blood pressure, every time you did anything, you put it on a piece of paper. So you can't do anything with that. I mean, it's you have a record, but that's it over the next four years.

00;01;32;16 - 00;01;58;03
Dr. Dan Low
By 2014, the whole country had now transitioned to digital health care records. The operating room is the last place to get it. So, I mean, so, Brian, you've been inside the operating room. You see, as a you know, you call it a VUCA environment, which is absolutely accurate, is high paced. So while you're doing this, how can you possibly be typing and using a mouse and charting at the same time?

00;01;58;27 - 00;02;19;26
Dr. Dan Low
And so the operating room was the last kind of bastion that kept paper because it was fast the chart with the pencil than it was to do it with a computer. But they figured out the technology. They've got all that data now. So for the first time now, we have 100% digitization of health care records. The problem now is how how do we use that data?

00;02;19;27 - 00;02;44;20
Dr. Dan Low
We have a wealth of data, but a poverty of information. Right. So the data is there. It's stored in a warehouse. But I as a clinician can only access it one patient at a time. So I wanted to solve that problem. How do I know if we're doing better or worse? How do I know if we change a drug from drug A to drug B that that's actually make adding value to patients?

00;02;44;27 - 00;03;03;25
Dr. Dan Low
How do I know if we change workflow or team structure, or how do I know that's more efficient? How do I know that that's better for the patient? How do we know if we're adding value to the system or taking value out of the system? So adapting the set up to solve that problem, that kind of access to the data.

00;03;03;25 - 00;03;09;10
Dr. Dan Low
So you can basically managed all these unmanaged processes right now.

00;03;11;05 - 00;03;15;04
Brian "Ponch" Rivera
It's all about decision making in health care or in the operating room, right?

00;03;15;19 - 00;03;44;05
Dr. Dan Low
Not just the operating one. We started in the operating room when now live in pretty much every area of healthcare you think of, from the ICU to the emergency room to urgent care to clinic. This is all your life is. It's all it's all flow. It's all of flow. If you think of it as a flow problem, it's all how do you optimize flow through the systems that you get the best optimal outcome in and you have less and less choices of which paths you go down.

00;03;44;05 - 00;03;50;25
Dr. Dan Low
So you optimize the outcome that you're after. And that's where our Intersect, I think. Yeah.

00;03;51;07 - 00;04;11;26
Brian "Ponch" Rivera
Absolutely. Looking at your Web page here, you have strategize, plan, execute, monitor, evaluate and adapt, right? Yes. For me, that's that's jumbo digital loop in a nutshell. And you're trying to improve decision making, decision support tools to help improve decision making. And I think you're using big data and a little bit of air to do that as well.

00;04;11;26 - 00;04;18;27
Brian "Ponch" Rivera
And like you just said, there's a wealth of information in there, a wealth of data, but a poverty. Poverty of information is a.

00;04;18;28 - 00;04;36;18
Dr. Dan Low
Lack of information. Yeah, we have a we that's what we don't have enough of. And it almost sounds like an oxymoron, right? How can you how can you be starving for information when you're floating in a sea of data? How can that be? Yeah, that's exactly where healthcare is right now.

00;04;37;29 - 00;04;55;22
Brian "Ponch" Rivera
Wow. So let's let's go back in your journey and connect what you're doing with that text. Back to where you learned something that I learned in the cockpit as well. And that was in the I think you were in a helicopter or emergency medical services progressed in the UK?

00;04;56;16 - 00;05;23;07
Dr. Dan Low
Yes, correct. So I had the privilege of working for a HEMS team helicopter emergency service just before I left the UK. So that's 28th June 2010 and it opened my eyes to what was possible and the real thing. I mean, I learned some really cool pre-hospital urgency medicine for sure. But the, the thing I really learned that two years is application of human factors.

00;05;23;16 - 00;05;45;22
Dr. Dan Low
How can it be that this three man hems team can do something in a muddy field in the rain faster, more efficiently, more reliably than I could in a well-lit O.R. with nine people. How could that be? And it was it was actually our base captain who taught us his name was Simon. He was an ex-military pilots. He was also you know, he was the he was the base captain.

00;05;45;29 - 00;06;07;14
Dr. Dan Low
He flew the helicopter, and he he taught us human factors from, you know, 20 years of military aviation experience. He distilled it into our medical team. It was a real honor and privilege to learn from someone like that. And so after that experience, when I came to America, I was I was tasked to bring human factors into health care.

00;06;07;16 - 00;06;17;16
Dr. Dan Low
I'm by the hospital. I was working at University of Washington and Salle Children's, and I started teaching these human factor concepts and how to operationalize them.

00;06;18;17 - 00;06;22;11
Brian "Ponch" Rivera
So what were some of the lessons that Simon taught you in the cockpit?

00;06;22;19 - 00;06;24;00
Dr. Dan Low
Well, you know.

00;06;24;00 - 00;06;24;07
Brian "Ponch" Rivera
It's.

00;06;24;17 - 00;06;53;00
Dr. Dan Low
Oh, it's a whole framework. I mean, it starts with, you know, well, first of all, I didn't have the language. I didn't have that matrix. You know, human factors, situational awareness, knowing what's going on around you, decision making, communication, teamwork, leadership that they're the domains. And you both know that. But what I didn't realize and I maybe had a at best, a passing familiarity, what those terms might mean, he broke it down to a behavior matrix.

00;06;53;00 - 00;07;20;29
Dr. Dan Low
Let's take situational awareness. You can do a behavior that accentuate your situational awareness, or you can not do a behavior and have poor situational awareness. One of those things is, do you attend the briefing right? Or do you brief before a mission? If you if you break your situational awareness, it's going to be every morning. We had a brief talked about the weather here, talk about no fly zones and look at the notes and report like what's out that is going to kill you today or your crew.

00;07;21;06 - 00;07;41;18
Dr. Dan Low
And if you know where those landmines are, how about we not step into them? Right. So it starts with that. And then during, you know, and then after the mission, you debrief again. So again, that builds situational awareness for your next mission. You do a hot debrief as soon as you land and drop off your patient. Everything's tucked away before you strip out your flight.

00;07;41;18 - 00;08;06;06
Dr. Dan Low
See the still hot debrief. Take 5 minutes. So, so simple things like that. You know, teamwork. There's a behavioral matrix for that. I didn't know. I just thought, oh, you could just kind of pick that up as you go along. But you can break it down to 12 behaviors. One behavior is for good teamwork or good leadership is actively support, solicits information from the crew.

00;08;07;05 - 00;08;07;17
Dr. Dan Low
Did you do.

00;08;07;17 - 00;08;10;17
Brian "Ponch" Rivera
That? And that builds and that builds psychological safety, right?

00;08;10;22 - 00;08;35;02
Dr. Dan Low
If you did it, that's a good leadership behavior. If you don't do it, then that's a bad leadership behavior. And that and he made it binary and it was like, open my eyes. It's like, you don't have to marvel your way through 20 years of being a physician to learn this. You can this these are skills that can be taught, they can be assessed, they can be reviewed.

00;08;35;10 - 00;09;00;15
Dr. Dan Low
And they you know, and it's objective. There's no it's not easy. We often think in health care, the technical skills is what you learn at medical school and the technical skill, what button to push on the ventilator, what lever to push on the on the machine. Yeah. Technical skills. Okay. Yeah, they are important, but the things that kill patients and cause patient harm are non-technical skills.

00;09;00;15 - 00;09;09;21
Dr. Dan Low
We've known that for 15 years, but yet we've failed to train systematically in non-technical skills or human factors. I use those terms interchangeably.

00;09;10;12 - 00;09;34;03
Brian "Ponch" Rivera
Right, Saskia. Yet soft skills in human factors, team science crew, resource management. We all it depends on the group we're talking to. So let me there's a couple of things that you told me a few years ago, and I think a lot of people in your industry are familiar with the Checklist Manifesto and your experience. Can you talk about your experience in learning what a checklist does when you're when you were working with SIMON?

00;09;34;19 - 00;10;03;24
Dr. Dan Low
Yeah, so he told us checklists. I learned checklist 101 before I worked with him. I didn't know that these things have a name. There's a there's a challenge response checklist. There's a redo checklist. Now you're both smiling. You get well, of course, how could you not know that? Right. But in health care, when I told Gawande first wrote The Checklist Manifesto or Better or Complication and Complications was his first book.

00;10;03;24 - 00;10;35;25
Dr. Dan Low
And here's the It's All Go One Day was the champion for introducing checklists, right? The concept was right. The execution and operate how you operationalize that. If we had a do over, I think we would do it differently. You've got to teach the building blocks, like right from the basics. When I first arrived at Seattle Children's, we had the show, the World Health Organization checklist, because we were told that if you put this checklist on the wall in your operating room, you'll save X thousand lives.

00;10;35;25 - 00;10;57;23
Dr. Dan Low
Yeah, but that's not right. And it was this huge. It was a manifesto. It was a document. It was really wordy. One of the things that former surgeon Chief Doctor Solan at the time, he brought in some pilot, Boeing pilot trainers and said, come look at how we do a checklist in the operating room and give us your feedback.

00;10;58;20 - 00;11;20;08
Dr. Dan Low
After they saw it three times, they just walked out. They said, We've seen enough. You guys don't know how to use a checklist. We literally had one person just going, Well, yeah, we're chopping off the right leg or, you know, the right kidney and we don't need antibiotics, the rest of that. And that was get it. Let's go.

00;11;20;08 - 00;11;48;29
Dr. Dan Low
That was it. My job because I had some expertize in this was to help system teach them how do we do it how do we convert that 2000 word document into a 12 word document? How do we make it into a response checklist and this concept of having the junior member of the team issue the challenge and senior members of the team or different hierarchies that be responsible.

00;11;48;29 - 00;12;14;23
Dr. Dan Low
The response this was was important. Having the quietest member of the team lead the checklists. Yep. Activates that team member gives them situational leadership for that 30 seconds. They're used to speaking up so that if something happens an hour later, they've all they're used to speaking out. They're used to being activated. They're used to being, having being heard and being able to speak.

00;12;14;29 - 00;12;54;21
Dr. Dan Low
So it was a very deliberate kind of flattening of the hierarchy, just like we learned in CRM. In aviation, too steep. A cockpit gradient is very, very dangerous. You get to flat. There's also dangerous. That's another problem. But you know, in health care, we had a we had a very, very steep o.r. Hierarchy was and we've had some pretty serious across the world, pretty serious complications, you know, catastrophic complications like cutting out the wrong kidney, even when there was two people in the room, knew that what was happening, they didn't have a voice to speak up that didn't have a there was no there was no structure in that team that allowed them to have

00;12;54;21 - 00;12;58;10
Dr. Dan Low
that voice, even though they could see something bad was happening.

00;12;59;17 - 00;13;10;25
Brian "Ponch" Rivera
So one of the things I observed when I got to spend the day with, you know, Seattle Children's Hospital is it's I believe you had at some younger doctors where you got interns.

00;13;11;13 - 00;13;12;20
Dr. Dan Low
Residents or fellows.

00;13;12;20 - 00;13;37;22
Brian "Ponch" Rivera
Yeah, residents. Yeah, yeah, yeah. So and I do remember this, me not being too smart on what's going on around me in that type of environment. We didn't have our masks on, you know, the type of environment we were in. And then a nurse stopped by to say, Hey, we need to put our masks on. And then I believe one of the residents was having troubles getting a I.V. into a patient.

00;13;38;12 - 00;13;59;23
Brian "Ponch" Rivera
And I just remember how the residents were able to challenge you on on some of the procedures and, you know, here I am looking at a hierarchy inside of an organization. I know the hierarchy. And they're able to to challenge you and push you around a little bit and speak you know, speak up. And I think that is something that you create through human factors.

00;13;59;23 - 00;14;29;02
Brian "Ponch" Rivera
Training is you create that environment where anybody can speak up. Yeah, yeah. And then the transition from anesthesiology from the room that the patients prepped and the operating room is pretty powerful because there's a handoff there. Right? There's yeah, there's communication happening. There's one team going to another team. And I also saw this and I was the the doctor that was going to do the the procedure came in and started asking everybody why they're there, which included me, right?

00;14;29;02 - 00;15;01;07
Dr. Dan Low
Yeah. Yeah, yeah. The first thing. Right, the first thing you have to do your team is you have to activate the team. And so that was built into our checklist at the time. The first thing is team introductions. You have to say your name and your role and if you just say that's your now activated your chance of saying even as the observer, Brian, you could have said, hey, is that like supposed to be flashing like your chance of saying that is so much higher if you've already spoken up in front of ten people?

00;15;01;24 - 00;15;19;07
Brian "Ponch" Rivera
Yeah. And I just say everything I saw that day, it reminded me of life in the cockpit from the time we start planning to the debrief. Right. How we get better. And then then we went on a tour. After that, you show me some of the artifacts on the wall. A lot of them are lean artifacts, which we could dove into in a second.

00;15;19;19 - 00;15;27;01
Brian "Ponch" Rivera
But one of the most powerful artifacts you had up on the wall and this is right before the morning, I don't know what you call it, a daily brief or.

00;15;27;11 - 00;15;31;05
Dr. Dan Low
We have a daily huddle or stand up huddle.

00;15;32;12 - 00;15;36;26
Brian "Ponch" Rivera
But on the board there you had s bar, remember situation background from A and.

00;15;36;26 - 00;15;39;07
Dr. Dan Low
R assessment recommendation. Right.

00;15;39;25 - 00;15;58;13
Brian "Ponch" Rivera
Right. Just just a basic communication approach. Right. So it sounds, you know, kind of funny that these adults who are well trained have to learn how to talk to each other and have these reminders on the board of of ways to communicate. Right. Can you talk to us about the adoption of that inside of health care and.

00;15;58;13 - 00;15;58;25
Dr. Dan Low
Yeah.

00;15;59;24 - 00;16;00;03
Brian "Ponch" Rivera
Yeah.

00;16;00;18 - 00;16;30;16
Dr. Dan Low
Yeah. I think, you know, I think having tools and a structure to communication you're right. I mean, you've got these highly, highly trained adults who've been to a lot of school. Right. And highly functional, very skills. And yet you have to give them a communication tool. And the reason for that is by standardized being the communication, the format of it, the reliability goes up.

00;16;30;16 - 00;16;54;05
Dr. Dan Low
So you both know that in every industry, every industry, the more you standardize, the less variation there is. You also know that the less variation there is in any industry, the quality goes up. So we learned that. I mean, you don't have to look very far. Go. We're in Seattle, go to Starbucks. They taught a gazillion people how to order coffee if you ordered coffee in the wrong way.

00;16;54;05 - 00;17;11;25
Dr. Dan Low
So my drink is a double tall, double tall latte. When I arrived in America, I didn't know what that was called. I said, I want a kind of that one, the 12 ounce one, and I want two shots. And I want that kind of foamy milk thing. And they'll go, Oh, you want a double tall latte and that, and they'll correct you gently.

00;17;12;03 - 00;17;32;06
Dr. Dan Low
And the next week I went in, I said, Yeah, I'd like a latte with two shots. And they go, Oh, you'd like a double to a lesson. They would repeat it. And what they're doing is that baristas are trained to teach the customer how to communicate so that and if you make that communication, Chris, not only is the orders come through faster, they're more reliable.

00;17;32;06 - 00;17;54;28
Dr. Dan Low
Your chance of making a wrong drink is lower. So you waste less resources and you don't make the loan and they make money. That's for ordering coffee. You look at how we order drugs. If I ask a resident, Hey, Dr. So-and-so, can you push 20 milligrams of propofol before we did this training, I'd get this. Well, did you hear me?

00;17;54;28 - 00;18;16;26
Dr. Dan Low
Did you do a read back? You know, did you verify it? Did you tell me it's done? Now, if I say, Hey, Brian, can you push 20 milligrams of Propofol, you'd put your hand on the syringe. You could. Then you wanted 20 milligrams of Propofol. Yeah, copy that. Give that. And they would ask for a confirmation and then they would give it and then they said milligrams of propofol just hit the line.

00;18;16;26 - 00;18;48;08
Dr. Dan Low
Thank you. They would actually do the rate back as well. We have to teach them that assignment taught me that in aviation he didn't always fly rode tree rings. He used to fly fixed wings and he said, hey, if you look at a fixed wing aircraft and you're shutting down an engine, if as a fire engine one, a well-trained crew will say, fire an engine one, the copilot might put their finger on the extinguisher to shut off engine one, and he'll say shutting off engine one, but won't hit the button until the pilot gives the secondary confirmation.

00;18;48;11 - 00;19;11;25
Dr. Dan Low
Yeah, go for it. That's the right button, right? Like he said, a well-trained crew will take that extra quarter of a second. Well, we should be applying that same degree of finesse to how we communicate in health care and SBIR. The commerce thing I get called for at three in the morning if I'm asleep and among call is the ICU resident is calling me because there's something bad happening.

00;19;12;06 - 00;19;28;07
Dr. Dan Low
And usually the conversation used to be, I'm sorry to wake you up. Hey, hey, my name is so-and-so. I've got this. And they'll start the story. I don't want that. You don't have to be polite to me. Give me the situation. I've got a six year old who looks really sick and injured at the bedside. Okay, start with.

00;19;28;07 - 00;19;49;09
Dr. Dan Low
That's okay. Now my shoes are on and I'm walking, right? And so we teach them, give me the situation. I've got a six year old who's having a severe asthma attack background. We've given 20 doses of albuterol. It's assessment, it's not responding recommendation. I need you here to do a crash. Intubation. That's great. So that. That's a nice, crisp communication.

00;19;49;09 - 00;20;09;21
Dr. Dan Low
We even teach them if you want it. Even crispier. Start with the recommendation. It's the military thing. Bottom line up front, give me the recommendation and I need you to bedside by bed, you know, on floor five. Yeah. Bed space 27. Right now start with there and then give me the aspire after that. Right. So, so wait, wait.

00;20;09;21 - 00;20;11;20
Dr. Dan Low
But these are skills we have to teach.

00;20;12;28 - 00;20;35;27
Brian "Ponch" Rivera
Yeah. So Doc Low, that is a very solid approach for a chaotic environment where we act sense response. I need you to do this and I'm going to tell you why and then we'll have a conversation about it. Right. And that's supposed to, you know, the passive aggressive let's have a you know, let me kind of kick around what I really think and maybe I'll get to the point later on that doesn't work.

00;20;36;05 - 00;21;03;00
Brian "Ponch" Rivera
So there's nothing wrong with that type of heavy command and control. And you can't you can train your subordinates and the people around you to do this. It's called distributed leadership, right. We want people to lead all the time. And that's I think that's a great example of what most corporations don't understand is you can't incorporate these into your two day to day work environment.

00;21;04;26 - 00;21;12;07
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00;21;13;29 - 00;21;26;24
Brian "Ponch" Rivera
Talk a little bit about something else and that is your experience with the Toyota production system. I believe you went over to Japan, you spent some time with TPS, right? Because every every health care organization had to go in. Can you can you walk us through that?

00;21;27;08 - 00;21;49;13
Dr. Dan Low
Yeah, it was it was one of the most it was a two week is is the highest growth period I've ever had in my life is two weeks in Japan. I the lean is training for lean leadership. My hospital sent me over there my previous my chair at the time or chief was doctor within months and he said, you're going to Japan for two weeks.

00;21;49;13 - 00;22;05;07
Dr. Dan Low
And it was over my 40th birthday. I didn't really want to go as I have its other trip planned and yes, no, no, you're going. And I said, Well, really, I have to go to Japan to learn this is why. And after the third conversation, he kind of shook me by the shoulder, said, You are just going to go, you're going to learn and it's going to blow your mind.

00;22;05;07 - 00;22;29;07
Dr. Dan Low
You going to come back and it all came true. So what I learned in Japan, so it was a is a lean training trip we went to see I lost count a dozen different factories who had at different stages Berlin journey the most the young factory who'd been doing lean have been doing it for 15 years, the most mature have been doing it for over a hundred years.

00;22;29;07 - 00;22;54;05
Dr. Dan Low
So we ended up at Toyota and as you see, that maturity and and agnostic of industry went to a cookie factory, a furniture making factory, a dual making factory, and eventually a car making factory. But once you learn how to read a production line, read the floor, you can see these concepts. And we and so you know, simple things.

00;22;54;17 - 00;23;19;27
Dr. Dan Low
Someone who's that medium mature is a high end furniture factory. I remember standing, watching and this this concept of going again. But they say, go see the work. Don't take photographs, go see it, go watch it. Just observe. You can draw in. So but really look at it. Don't take videos on your phone. Look at it. Really see what's going on.

00;23;20;08 - 00;23;39;26
Dr. Dan Low
I stood there for 20 minutes watching one person work. His job was to take the chair and put the primer on the chair before he passed off to the painter who actually put the nice finishing go. But he primed the chair before he primed the chair, he squared that they made sure that the legs were square. This there's no point in priming a chair with one key if you have to go to cut it again.

00;23;40;09 - 00;23;57;05
Dr. Dan Low
And so he would do this work and I'll say how five chairs went by. None of them had any defects. I said, Why do you bother checking? Because why do you get once every two weeks I'll be a chair. That's a bit wobbly and it's not quite squared. And then some of my colleagues, American colleagues said, How so?

00;23;57;05 - 00;24;17;24
Dr. Dan Low
Do you have a feedback system that you fill out a form to tell someone there's a defect? And the Japanese furniture maker said, Why would I do that? Why would I fill out this corporate form to say, there's a defect? No, I'm going to go and find my buddy Brian, who gave me that chair and say, Hey, this one didn't work.

00;24;17;24 - 00;24;43;08
Dr. Dan Low
And he'd go, Oh, you're right. And he would fix it, right? So this, this concept that I remember, the Japanese work is like, wow, you do that in the hospital, you send a series of letters and emails that goes right up to this through the director level and then come back down rather than have a conversation. And so that was that was enlightening how they how they inspected, how they made autonomous teams.

00;24;43;08 - 00;25;04;10
Dr. Dan Low
I remember going to a dole factory, had two assembly lines. They had production board visibility, just like we have in that fix. Now, what is your output today? We're supposed to make $65 or whatever it was, and it's now 11:00. Are you on target? Are you off target? We were there about 2:00. They had 3 hours after the working day.

00;25;04;18 - 00;25;34;19
Dr. Dan Low
One line was about going a little bit slower, both the work, both sets of workers could see. The other line was slower. They diverted two workers to the other line to help them. They didn't need a manager. They they were just they were on autonomous flow. If you create that visibility so people can see what is happening and if you create that culture that if I can see what's happening, I'm empowered to help.

00;25;34;26 - 00;25;56;05
Dr. Dan Low
I'm going to help. They finish the day when both lines finished on time. So great. And we need more of that. And then you go to all the way through to Toyota. And I remember standing when you go to the Toyota factory, you're standing at the top and you're walking over. And I remember observing those two stories. One was that one guy was trying to put a wingman on.

00;25;56;05 - 00;26;23;01
Dr. Dan Low
And after about 60 seconds, it didn't go on. He pulled the end on, called the whole factory stopped and a little and the light starts flashing and it starts to play this kind of like tune. And a supervisor comes down and he's looking at the part. He helps him do it, and then the line starts again. But he's like they, they, they are aggressively going after defects and flow.

00;26;24;12 - 00;26;45;21
Dr. Dan Low
And I said, well, what happens now? Because well, that supervisor is now going to log that and say that happened and they know how many times that happens and they're going to go back to root calls and go, Hey, let's not have that delay a frontline worker, stop the entire factory floor for 4 minutes. You you know, I've not seen that in health care, right?

00;26;45;21 - 00;26;48;22
Dr. Dan Low
It's like when something's wrong, we kind of we thought.

00;26;49;06 - 00;27;15;02
Brian "Ponch" Rivera
Why is that? What? What? So you have a lot of egos and I'm I say this in a kind way. You know, these are well-trained people that spend years in a university studying. They have egos. Right. So how do you get that type of personality or persona to pick up these concepts of human factors and these simple concepts that you're you're talking about now?

00;27;15;09 - 00;27;18;23
Brian "Ponch" Rivera
How how do you do it or how hard is it to do in your environment?

00;27;18;27 - 00;27;53;28
Dr. Dan Low
I think it's it's challenging to do because it requires a we have to reframe mindsets as physicians. If you look at the last, I don't know, 100 years of physician training, it's all we're trained to value our autonomy over pretty much everything else to a fault, our ability to do what you're trying to teach industry, to work as a team, trying to achieve a common goal, acknowledging that I might not have all the answers, I might be wrong.

00;27;54;12 - 00;28;16;00
Dr. Dan Low
Acknowledging that, hey, if we decide to do something in a standard way, clinical standard work, I might not agree with it. I might have an opinion that something else is better, but being able to go with the flow said, well, well, let's try it and let's measure it. And having the faith that the system will say, hey, in six days, six weeks, if this is not working, we're going to tweak it again.

00;28;16;00 - 00;28;47;05
Dr. Dan Low
We're going to modify the SRP, the clinical standard would have. Yeah, but so it's a chicken and egg situation and you have to create the system where people don't think the autonomy has been taken away. So you came to see me at Bellevue. We have the probably the most robust clinical standard work. If you put your kid in to have a tonsillectomy with me, you get exactly the same drug combination as if they worked with Gene or my partner Tim or with Lean to the MG.

00;28;47;09 - 00;29;06;25
Dr. Dan Low
It's dialed in. But because we all work together and what we've done with ADAPT now is when we all work together, we measured the result of our outcome and so we tie in. If you do this piece of work, you get this outcome, Oh, do we like this outcome? Do you want to do it and move it up or down if you want to move up?

00;29;06;25 - 00;29;28;27
Dr. Dan Low
And then what should we make? We used to make tweaks every three or four years. We now make tweaks every three or four months. Our ability to learn that kind of like that learning cycle where I showed you said, you know what is just so much faster because we're monitoring and we're evaluating and then internally, what does that mean?

00;29;29;02 - 00;29;58;16
Dr. Dan Low
And then you can adapt and adapt and adapt. So we've been we've been able to learn so much faster. And I believe we're at a point of a revolution, right on a point. You know, you've we're just talking about this a couple of weeks ago. If you if you win back the clock to the 1980s, the big thing we did in medicine was that we started monitoring patients, little pulse oximeters blood pressure cuffs before, you know, in the seventies, you'd look at them, go, well, what color is your eyes and is your lips pink or blue?

00;29;58;23 - 00;30;22;04
Dr. Dan Low
And honestly, when the pulse oximeter came out, people say, I don't need that. I can see if he's blue, that's bad and he's pink is good. I mean, that's where we were in the seventies. In the eighties, that technology enabled you to monitor your patient. And if you can measure an oxygen saturation, which now you think everybody has, you can buy one for $20 off Amazon, put it on your finger.

00;30;23;10 - 00;30;48;09
Dr. Dan Low
If you could monitor that oxygen level, you can manage that right? You don't have to wait till it drops until you're visibly blue. I mean, if you're visibly blue, you're one step away from being visibly dead. So you don't have to wait that late. So this concept of the ability to measure what matters and to do it rapidly, that transformed health care in the early eighties with as patient monitoring got better.

00;30;48;22 - 00;31;12;12
Dr. Dan Low
The next revolution that happened was patient safety. So they took all the things that shouldn't happen death, you know, wrong side surgery, you know, giving the wrong drug, whatever it was, they started documenting and collecting. How often does that mistake happen? How often does that happen? And they started rigorously going after those errors and so designed system to stop those bad things happening.

00;31;12;28 - 00;31;14;01
Brian "Ponch" Rivera
Why are we now?

00;31;14;22 - 00;31;44;25
Dr. Dan Low
Now we're in this third revolution where we have data that only ten years ago you could only dream about having all digitized and we're just starting to scratch at the surface of, oh, my gosh, if I changed that drug by 10% or, you know, drop it or increase the dose, but what does that do to my outcomes? And we're now able to understand it at a level that's not people telling stories in the coffee room, as you can see on a chart.

00;31;45;01 - 00;32;09;19
Dr. Dan Low
And again, once you can measure something, you can manage something. So we have all this just like in the eighties, you had all this unmanaged low oxygen levels, like they must have been hypoxic patients, so unmanaged, you put a pulse oximeter onto those patients. Now it's being managed. Now the outcomes get better. We're seeing the same thing across large groups of patients that we have the ability to do that.

00;32;09;19 - 00;32;11;28
Dr. Dan Low
So it's a very exciting time to be practicing medicine.

00;32;13;06 - 00;32;36;16
Brian "Ponch" Rivera
So now you're blending big data with the human factor. So that's kind of how I see this working out in the future is you have to work the other technical thing now you understand that we understand that we're getting more information is this what you're aiming for is to blend the all the worlds that you've been in touch with, the aviation world, with the lean world, with the medical world.

00;32;36;16 - 00;32;39;19
Brian "Ponch" Rivera
And this big data world is are these merging together? Is that.

00;32;39;29 - 00;33;02;20
Dr. Dan Low
I think so. I think, you know, as we were I was talking to one of the trainees this morning. I said and he's you know, is a fellow and he's starting his career. I said, I wish I was you. You are entering a landscape that has never existed before. You're entering a landscape into independent practice where you we you have this data at your fingertips.

00;33;03;06 - 00;33;28;00
Dr. Dan Low
What took me 20 years to learn, you could learn in 2 minutes. So this concept of digital aging, you don't have to have done that procedure 20 times to know the recipe that gets you the outcome that I get. You can learn that in 2 minutes. You and the example he gave you that I just looked across the 72 anesthesiologist that we work with who do this procedure.

00;33;28;04 - 00;33;51;02
Dr. Dan Low
And I found the best person I want a copy. I said, That's great. They've on average been practicing 10 to 15 years. That's 800 years of experience. And you went straight to that person. Does that the best? I'm going to copy them. You just you use it became Yoda you you just aged 800 years. I mean that's how long it would take you to figure that out.

00;33;51;14 - 00;34;16;27
Dr. Dan Low
And so I and this is now this is going to happen faster and faster. I believe we're about to accelerate what we can learn. There's in medicine and health care, not just like, you know, working faster, working more efficiently, but what therapies work better, what the nuances. And we're finding the position to kind of figure that out. You're right, Ryan.

00;34;17;05 - 00;34;40;06
Dr. Dan Low
Like it takes there's the technology piece. There's the I can show you. This is a better way to do it. Where's the human factor space? If I know that there's a better way to do it, what stops me as a human being from doing the better thing? Ego, pride. How can and so how can we shape our teens not to take it personally?

00;34;40;11 - 00;34;57;24
Dr. Dan Low
Hey, it's not my own. My outcome isn't as good as the best person in the group. I'm going to be really offended, and I'm going to defend my way of doing it to the death and come up with clever arguments why I shouldn't do that. How do we go from that to, Hey, Brian. Well, what you're doing is better.

00;34;57;24 - 00;35;13;20
Dr. Dan Low
You're getting a better outcome. Can you show me how you do that? Can you coach me? I'm going to start doing that and I'm going to come back to you two weeks later. I'm going to share my outcomes. If my outcomes aren't matching yours, can you give me another session? How how do you how do I get from there to there?

00;35;14;15 - 00;35;17;08
Dr. Dan Low
So and how would how do we do that at scale?

00;35;19;02 - 00;35;22;09
Brian "Ponch" Rivera
So stay staying in that theme.

00;35;22;09 - 00;35;22;27
Dr. Dan Low
You know, one.

00;35;22;27 - 00;35;23;26
Brian "Ponch" Rivera
Of the big lessons that I'm.

00;35;23;26 - 00;35;24;16
Dr. Dan Low
Taking away.

00;35;24;16 - 00;35;32;00
Brian "Ponch" Rivera
Is that this is universally applicable. And when you're dealing with those types of personalities that you just described.

00;35;32;00 - 00;35;34;27
Dr. Dan Low
I imagine that at some point you've run into.

00;35;34;28 - 00;35;36;02
Brian "Ponch" Rivera
Someone being extremely.

00;35;36;02 - 00;35;41;15
Dr. Dan Low
Resistant or extremely dismissive. And I wonder if you have a.

00;35;41;20 - 00;35;42;14
Brian "Ponch" Rivera
Anecdote.

00;35;42;14 - 00;35;43;24
Dr. Dan Low
About a conversion.

00;35;43;28 - 00;35;44;27
Brian "Ponch" Rivera
To seeing.

00;35;44;27 - 00;36;19;19
Dr. Dan Low
The light to adopting this. Yeah. And for somebody that didn't adopted and it led to it led to something less than optimal, something disastrous. I have a couple of stories I can share around that. The first is I'm sorry to one of the projects that's been happening at Seattle Children's, led by Dr. Liz Hansen. She's one of my colleagues is she's figured out how to reduce the carbon emissions from hospital, from the operating rooms by about 90%.

00;36;19;19 - 00;36;44;02
Dr. Dan Low
So the the fumes that we give off from the anesthesia gases are incredibly toxic. 2000 times worse than CO2. So as just as the operating room, we account for seven or 8% of the total emissions from the hospital. And she she cut that down by almost 90% in a year. The way she did it is she showed the variation in practices and she showed on a plot.

00;36;44;02 - 00;37;06;10
Dr. Dan Low
Where do you all for some people are high polluters. Some people are extremely low polluters and some people in the middle. And she showed that variation and then she made people care. She said, So you know that if you use nitrous oxide at that rate, you know that that's still in the atmosphere. 104 years from now, your great grandchildren will be breathing that in or having the consequences of your decision.

00;37;06;15 - 00;37;29;19
Dr. Dan Low
With ozone depletion and global warming because of your choice today, what you're doing has a 100 year lifespan. So she made people care and then she measured. Now there's one or two people in the group who either don't believe in climate change or just didn't care, and they refuse to change that practice. Over this 18 month period, the group has got tighter and tighter.

00;37;30;10 - 00;37;59;29
Dr. Dan Low
The variation is less and less, and they and their emissions got lower and lower. If you fast forward now 18 months fossil to the day you take the worse I'll say that the highest polluter in today in our group if if you teleporter him back in time he would have been the best person two years ago. So even so sometimes even though you have folks who don't want to get on the program like boating, that is, you know, a rising tide lifts all boats.

00;37;59;29 - 00;38;23;23
Dr. Dan Low
Right? If you move the group, the group magnetism, group momentum, you will drag people even if they don't want to be don't even know they are. You can drag them along. So part of this kind of like evangelism, whenever you're trying to change a system, you know, I had some great advice a few years ago. It's like, you know, there's going to be ten or 20% early adopters when people go, wow, that's a great idea.

00;38;23;24 - 00;38;46;26
Dr. Dan Low
Let's do that. Are those are champions. Go after them. There's going to be that middle tier, the 40, 50% who go, wow, I'm I'm going to go the flow. Right. So but they'll they'll be they'll be influenced by that ten, 20%. And then there's the 10% at the back end who are actively opposing any change and said, don't waste your energy there.

00;38;46;29 - 00;39;04;09
Dr. Dan Low
I mean, listen to them and empathize, but don't waste don't make that 10%. Take 90% of your time you know, go after the people preaching to the converted. Right. Don't go after them. Go for that 20%. And that's where you're going to get your change. You know, go after your chant.

00;39;04;09 - 00;39;08;23
Brian "Ponch" Rivera
And then and then a theme that comes up with us a lot is speed.

00;39;09;00 - 00;39;14;10
Dr. Dan Low
And it seems that you're able to speed in advanced things faster by taking.

00;39;14;10 - 00;39;17;24
Brian "Ponch" Rivera
This approach versus the the, you know, the quote unquote, old way or the.

00;39;17;24 - 00;39;44;12
Dr. Dan Low
Status quo. Yeah, the speeds at speeds. Yes. Speed to value. So adapting is all about speed, devalue, you know, a typical hospital system, you know, a 253. But hospital has probably spent 350 to $400 million standing up the electronic medical record. The current state is the average doctor, average clinician in those health systems, you know, who can spend $400 million.

00;39;44;20 - 00;40;00;22
Dr. Dan Low
If you have a question about I want to manage this process better, I want to make this thing better. Best thing is, well, what's your baseline? You need to get some data. And then the second thing is you need to do a small test of change. And if that test of change is good, you measure it. Did that work?

00;40;00;22 - 00;40;23;10
Dr. Dan Low
Does that not work? If it weren't, let's do some more. But the step one is get that baseline data. If the average hospital is 6 to 12 months to get that baseline data. So before you even start thinking, how can I tweak the system? You have to wait a year. Okay, Mark put it on your calendar. Bryan Next year we're going to talk about this.

00;40;23;10 - 00;40;45;05
Dr. Dan Low
Right. So and then once once we talk about that, I'm going to give you some and then we'll start a thing to make that thing better. How does that feel right. That's a great way to disengage your work force. If you put a 6 to 12 month barrier between them getting access, the ability to use the data that they they answer every day.

00;40;46;19 - 00;40;49;04
Brian "Ponch" Rivera
And as a layman, I suspect.

00;40;49;04 - 00;40;52;03
Dr. Dan Low
That this increases.

00;40;52;03 - 00;40;56;26
Brian "Ponch" Rivera
The quality of the care that you're bringing, because oftentimes you're up against time.

00;40;56;27 - 00;41;14;10
Dr. Dan Low
Right? You're up against the clock when it comes to saving someone or helping someone. So I imagine this helps straight. Yeah. Whenever we try to improve complex systems, as you know, you don't take a unit dimension. We're going to make this measure better. You want to take a family of measures, you want to make this better, you want to make that better.

00;41;14;15 - 00;41;32;05
Dr. Dan Low
You don't want to make this thing worse, and you certainly don't want to make this thing work. So you take a family of measures. So whatever intervention can you do. You need to take a family of measures. Am I moving the needle all in the right way? Some can stay neutral. That's okay. But am I moving everything the right and now we have the ability to do that.

00;41;33;27 - 00;41;37;05
Brian "Ponch" Rivera
Hey, Doc, how did you become familiar with complex systems? Just. Just curious.

00;41;38;18 - 00;42;03;12
Dr. Dan Low
Well, I think I started with the most complex system that is. The most complex machine I know. Is you a human being? So. And, you know so my background is I started as a pediatrician and then a neonatal allergist, and then I saw the training in anesthesia and critical care. And then later on, pre-hospital medicine, anesthesia is kind of my that's kind of where my heart is.

00;42;04;09 - 00;42;25;18
Dr. Dan Low
And when we deal with anesthesiology, okay, this is anesthesia. One, two, one. The first thing I do is I'll give you a drug that shuts off your brain. When you shut off your brain. That's your new your central nervous system, your central nervous system, your computer controls. All these other subsystems like your it tells you to breathe. So now I'm responsible for not only for your brain, but I'm also responsible for your your respiratory system.

00;42;25;24 - 00;42;46;19
Dr. Dan Low
When I sell off your brain, I also shut off inputs to your cardiovascular system. And it does weird stuff and suddenly you drop your blood pressure by 30%. So now I'm responsible for your central nervous system, your respiratory system, your current system, your cardiovascular system is intricately intertwined with your breathing system. And so what you do with one affects the other.

00;42;46;27 - 00;43;06;05
Dr. Dan Low
And so that's only three systems now we start talking about, well, what, what, what, what are the systems? Well, that's your neuromuscular system. So, you know, part of anesthesia is you get paralytic drugs. Now you can't move and then you can't shiver and you lose thermoregulation. And your renal system is now contingent on how much fluid I give you and your hepatic system.

00;56;01;20 - 00;56;20;02
Dr. Dan Low
So, I mean, take a take a simple example. So you've been to the O with me. You've seen when we inject the white medicine, the Propofol that makes people unconscious and it usually takes about ten or 12 seconds. While if I inject a syringe of that and 12 seconds later, the patient's still tal00;43;06;20 - 00;43;26;00
Dr. Dan Low
So now you've got six or seven or eight systems or and you change one and they all have knock on effects. The other thing else, when you do critical care, critical care medicine is all about system management of an individual human patient. When you have a disease process, a trauma, let's say I get out of my car, get knocked over by a bike.

00;43;26;01 - 00;43;43;04
Dr. Dan Low
Right. I had not have a head injury and I have to manage the head injury and what's going on to preserve my brain. But I also fell over and they broke my leg and I lost a bunch of blood. Now I've got to manage my cut so you can see how a trauma disease can affect multiple systems in a single human being.

00;43;43;13 - 00;44;02;15
Dr. Dan Low
So my lens into complex systems was learned by looking at, you know, just this one human being at a time. But that mindset, being able to manage complex systems and seeing into relationships is very, very applicable to looking at larger systems. It's the same thing, it's the.

00;44;02;15 - 00;44;29;21
Brian "Ponch" Rivera
Same lever. I believe health care is described as one of the most complex systems in the world. And yes, I can't remember who made that quote so. Okay. We know from our experience, our shared experience with human factors and sort of production system and now complex adaptive systems. So we understand leadership, teamwork, understand lean. We understand slow down a little bit about complexity in health care right now.

00;44;30;27 - 00;44;51;06
Brian "Ponch" Rivera
How difficult or how successful have, I guess, those that are pushing team steps and things like that, how well are they doing in health care to get people to look at their system or their teams and inject things like human factors, the team steps program?

00;44;51;06 - 00;45;12;19
Dr. Dan Low
I think it's yeah, I think it's it's highly, highly variable when it's done well and I'm very biased. But the place you visited, I think it does it better than anybody else is integrated. Those two things you just talk about, I think there's, you know, TPS teaches you Toyota production system. You need you need two things. You need process.

00;45;12;19 - 00;45;29;18
Dr. Dan Low
You need really good process and you need to constantly refine that process. You also need really good people and that's the human factors. And so when when you go to Toyota, they give you a lecture. It's two pillars of the roof to hold up the roof. That's TPS. You need people in process. You take people of the wrong mindset.

00;45;29;18 - 00;45;49;24
Dr. Dan Low
You give them a great process. The roof falls down, you give great process. You put wrong people in there, roof falls down. You have neither there's no roof. I mean, so if you talk to folks in health care and you say, you know what bugs you, it's it boils down to one of those two things and sometimes both.

00;45;49;24 - 00;46;18;02
Dr. Dan Low
So I think we have a as an industry, we have a long way to go to have robust ways of thinking about systems based practices, like getting your processes really dialed in. And then, you know, and a lot of that is, is, is a chicken egg. You have to have leadership that understands this and builds teams in order to support that work that those cross-linked somebody's got to the cycle, right?

00;46;18;02 - 00;46;22;13
Brian "Ponch" Rivera
Like the chicken you say chicken and the egg like someone's got to step up and break the cycle, right?

00;46;22;25 - 00;46;25;01
Dr. Dan Low
Yes, exactly.

00;46;26;00 - 00;46;31;24
Brian "Ponch" Rivera
So are you still in executives from all over the place to look at what's going on inside of Seattle Children's Hospital?

00;46;32;04 - 00;46;52;13
Dr. Dan Low
We were covered COVID shut that down for a bit. But the folks are gradually coming back and we're held up as an example of one of the most efficient surgery centers in the country. And people are stocking to learn about and see our systems. So, yeah, those those those groups are coming back slowly.

00;46;53;19 - 00;47;14;08
Brian "Ponch" Rivera
So when, when you and I toured, when you took me on a tour over there, you pointed out that many folks that come in there, look at the artifacts. You know, I've seen the spa on the wall and things like that. And I believe said that's not what makes this work right now. And it's it's the it's the interactions, right?

00;47;14;16 - 00;47;16;07
Brian "Ponch" Rivera
It's how they work as teams.

00;47;16;07 - 00;47;39;23
Dr. Dan Low
Yeah. It's an integrated system. Absolutely. It's and we used to say it said you're welcome to take pictures of all the artifacts you can you can have copies of all our checklists. You can have all of it. It's not a secret. It's not a trade secret. But what you actually want you want you need. That's how that fits into your own environment.

00;47;39;29 - 00;47;48;28
Dr. Dan Low
But you also need the people and the teamwork, the mindset and attitudes. That's what I can't take a photograph of. You have to see and experience it.

00;47;50;03 - 00;47;57;14
Commercial
You are listening to No Way Out, sponsored by AGL X. Now let's get back to your confidence in complexity.

00;47;58;28 - 00;48;05;10
Brian "Ponch" Rivera
How do you know you're getting better and what kind of tools and techniques are you using to improve team performance?

00;48;06;10 - 00;48;30;12
Dr. Dan Low
Great question. I think it comes down to what you and I talked about. Well, how we met and we're talking about other groups. Right. So but you know, observe, orientate, decide to do something at the key for me is what happens after you act. How do you know the thing you did is actually working now you can apply that to an individual patient level.

00;48;30;13 - 00;48;56;01
Dr. Dan Low
You can apply that to an individual health care provider. How do I know the thing I'm doing is better or worse than it was before? And you can even do that if you four health care systems. So if I asked if we all saw team a whole team of 2030 people to change their practice in a certain direction, how do I know that when they do that, that that is resulting in an improvement to the system?

00;48;56;13 - 00;49;03;19
Dr. Dan Low
And we do that with data. We do that with measuring measurement and data and real time feedback loops.

00;49;03;19 - 00;49;06;06
Brian "Ponch" Rivera
All right. So what are you measuring in your world right now?

00;49;07;00 - 00;49;29;11
Dr. Dan Low
So as a team, we start with in health care, we think about we work backwards. It's kind of an Amazon concept. So if you came to us as a patient or a family member just came to us, we would say, Well, what is that? What is our target? What are we trying to do? So if you're having surgery from an anesthesia point of view, I would like you to survive your surgery.

00;49;29;12 - 00;49;39;20
Dr. Dan Low
You must number one. Now, that's a given. We've made such advances the last 20 years. No one expects to die in the operating room. That is a very, very rare occurrence.

00;49;40;11 - 00;49;42;12
Brian "Ponch" Rivera
Same thing in aviation, right? Right.

00;49;42;20 - 00;50;08;14
Dr. Dan Low
Yeah. So if that's not the bar anymore, what is the well, what do you expect after the surgery? Would you want to wake up in a timely fashion? So time of recovery, you want to wake up comfortable so we can look at what are your pain school experiences? We want you to wake up so comfortable that the nurse doesn't have to administer you a narcotic because you know that you have all these complications associated with that.

00;50;08;14 - 00;50;32;13
Dr. Dan Low
So if you don't need one of a narcotic, when you wake up, you want to wake up so comfortable you don't have any of the common side effects. The commonest side effect is feeling nauseous or vomiting. And then from a surgical point of view, you want to wake up comfortable, discharge safely. And so and you don't want to come back to the O.R. you don't want to represent to the E.D. within seven days or come back for a second surgery within 30 days.

00;50;32;19 - 00;50;56;03
Dr. Dan Low
You don't want a surgical site infection, right? So you have these that's your target condition. Then if that is your true north and that's your target condition is everything you do, how you think about your team, how you deliver care, is that meeting those six or seven objectives. And so if you measure that and say everything we do, can we measure those six or seven things I just mentioned?

00;50;56;18 - 00;51;05;19
Dr. Dan Low
And when we make you change the system, which way do they move? Do they not move to them move down? Do they move up? So yeah. And that's what we measure at a system level.

00;51;05;28 - 00;51;23;12
Brian "Ponch" Rivera
What I like about those, those outcomes, those measurements are they're focused on your customer, your patient. They're not focused on the number of personnel or the number of people trained in such and such or anything like that. Those are kind of important. Those are outputs, but you're talking about outcomes. And I think that's what ADAPT Docs does is really help people understand our outcomes.

00;51;23;13 - 00;51;23;18
Brian "Ponch" Rivera
Yeah.

00;51;25;01 - 00;51;46;21
Dr. Dan Low
Sure. Absolutely. So outcomes is one part of it. The other part is looking at the processes of care, right. So if, if, if you center your organization to measure those outcomes and drive towards those, now you can look at the you can adapt it. So you can also look at the processes feeding them, for example. So, you know, there's a huge drive to increase operating room efficiency.

00;51;46;22 - 00;52;07;27
Dr. Dan Low
We've made some huge strides. So in order to increase efficiency, there's certain things you probably don't want to do. You don't want to make you ask your surgeons to wield the scalpel faster. So that's kind of like safer type. So the time it will take you, how long it takes you to do that. But look at the little bits, the bookends before and after that, right?

00;52;07;27 - 00;52;31;15
Dr. Dan Low
So what are you doing? The knife goes in. What do you do when the knife comes out? How can you use an on minute? Is value 280 $200 a minute? It's a really expensive environment. How can you compress that time and do it safely while still still achieving those six or seven objectives? And that's what we're able to do, able to stratify the data, figure out who's doing it best.

00;52;31;25 - 00;52;53;04
Dr. Dan Low
And we have a surgical team. So they looked at the little bit of time before surgery starts, after the patient arrives in the O.R. and it was 13 minutes before the knife goes in. And during that time, it's work. They have to, you know, position prep and drape and do a time out that was two surgeons who are able to do that same work in 10 minutes out of a group of eight.

00;52;53;27 - 00;53;11;23
Dr. Dan Low
And with the with our solution they were able to identify those two surgeons as so they called it Moneyball for medicine. It's like I found something that we're doing, which is difference. Yeah. And before we copy, you just make sure that your outcomes are the same. Your two outcomes are the same. What is it you do that's different?

00;53;12;01 - 00;53;34;05
Dr. Dan Low
They were able to scale that across the team, save for about 4 minutes per case and they ended. They added 24 cases a month to their schedule because they could systematically harvest that time. So yes, we're looking at outcomes, but we're also looking at the care delivery system and what can we optimize? Where's the waste? What can you tighten up?

00;53;34;26 - 00;53;52;24
Brian "Ponch" Rivera
Yeah, it's the system that drives behaviors. Hey, I want to I want to switch over to something more OODA ish and maybe even mental health ish and. This is struck me a few moments ago so situational awareness and said, you know, a surgical team in your line of work, how do you know when when people have lost the bubble?

00;53;53;11 - 00;54;04;28
Brian "Ponch" Rivera
You know, just I mean, you can you see that in an operating room. Can you can you sense that? And if so, how do you help people recover from that lost situational awareness?

00;54;04;28 - 00;54;31;21
Dr. Dan Low
Yeah. So situational awareness, I think you need to be very, very deliberate about building team situational awareness and it starts it starts before it starts, you know, at 6:30 a.m. for us, we everyone at step one, everyone turns up to work on time. You can't just you can't roll in 10 minutes late. Right. The important thing is we have an early morning huddle, a morning briefing, so everyone knows what's expected.

00;54;31;21 - 00;54;46;02
Dr. Dan Low
What are the unusual conditions that we're expecting that day? Any any risks to patient safety, any risk to staff safety, any risk to operational efficiency? So those are specifically called out. And you can.

00;54;46;07 - 00;54;52;08
Brian "Ponch" Rivera
Looking at the external environment, like what the CDC is putting out as what's emerging around the world or I mean, no.

00;54;52;08 - 00;55;09;25
Dr. Dan Low
No, no, no. Just what is in our local environment. We have 26 patients to take care of today. And you run the list and you go, what if it's if it's a if it's totally routine, you know, expecting any turbulence or, you know, the speed bumps, that's okay. But if there's a couple of unusual things in there, you should call it out.

00;55;09;25 - 00;55;29;26
Dr. Dan Low
If you know that that 7:37 a.m., you can probably sidestep that or come up with mitigation strategies to make that go smoother, whatever that might be. Now in terms of so that's as team situation one is in terms of individual situational and as you boil it down to an individual, so now, now, now imagine the team is working there in the live operating room.

00;55;29;26 - 00;56;01;07
Dr. Dan Low
How do you know when something's going wrong? It's almost a philosophical question. Right. And we teach this all the time and we teach our team members. If what you are seeing with your eyes and what you're hearing with your ears, what you're feeling, tactile sense that the inputs coming to you, if what you're seeing is not matching with the internal expectation of what you're supposed to see, that should be setting off, you know, fire alarms in your head.

king to me, I'm now I'm like, what?

00;56;20;16 - 00;56;46;01
Dr. Dan Low
That is? That the reality is not matching my internal expectation. Something's wrong. Is the I.V. disconnected? Is it the wrong drug? Something's wrong. So being able to have a crystal clear mental map of what should be happening is really important. If you program a pump, we've counted this, it's almost 45 key presses to program a pump to deliver a drug.

00;56;46;18 - 00;57;04;02
Dr. Dan Low
Yeah, now you're doing that. How do you know if you've missed a key stroke like you didn't start and it starts flashing. That's delivering. How do you know if it's wrong? You have to be able to do. We call this the dims check. Does it make sense? We look at the number that comes up. This is infusing at 45 miles an hour.

00;57;04;11 - 00;57;29;15
Dr. Dan Low
Does that number make sense? 45 miles an hour? Does that is does that take a swag? It it does that make sense for this sized patient? So yes you work but always light does that are the inputs I'm getting from my environment matching what I think it should be now if you don't have an internal expectation, your ability to detect an error is very limited.

00;57;29;16 - 00;57;40;00
Dr. Dan Low
You're you're not like flying in fog. Right. And you're not going to know. You're not going to know you're going to fly to the side of a mountain until you almost crash. So how do develop want to be able to do that?

00;57;40;00 - 00;57;42;21
Brian "Ponch" Rivera
So how do you develop that awareness and others that don't have that experience?

00;57;44;07 - 00;58;07;03
Dr. Dan Low
So you build really strong teams with really, really robust clinical standard work. You have to have a standardized way of doing something. If it changes every single day, every single morning between cases and you have all this variability between teams, nothing ever looks the same. If someone is running that checklist in an entirely different way from someone else, it's going to feel off, right?

00;58;07;03 - 00;58;13;02
Dr. Dan Low
So how do you create robust systems that are repeatable and reliable?

00;58;13;26 - 00;58;35;03
Brian "Ponch" Rivera
And I think that's going back to your because this goes back to your Starbucks example, too. It's it's not just the technical skills that need to be standard. It's your soft skills approaches to right and absolutely. Okay. Hey, just go back to the 630. Stand up and let's talk about the bigger picture as far as mental health stress, the fact what's going on all around everybody today.

00;58;36;22 - 00;58;59;00
Brian "Ponch" Rivera
So there's there's I think there's more than just, you know, having that that trigger, that huddle, that that that morning stand up, if you will. We, you know, in aviation, we had to get certain hours of sleep. You couldn't have alcohol in your system within 12 hours prior. There's there's many factors that go into to peak performance. And I think, you know, your world, you have to be at the top of your performance almost every day.

00;58;59;00 - 00;59;18;13
Brian "Ponch" Rivera
I may be wrong on that, but that, you know, as a customer, you know, a patient, I want a high performing team with some of the best people on it as possible working on me. Right. I don't think that's always true in health care. And a lot of it could be driven by the amount of stress that's going on in our lives.

00;59;18;13 - 00;59;28;00
Brian "Ponch" Rivera
So can you talk us, talk us through what you know, improving at OODA Loop or improving how you perform, how dependent that is on your sleep, your nutrition and things like that?

00;59;28;26 - 00;59;55;13
Dr. Dan Low
Yeah, I think your performance is I don't think about this. So I think about, you know, our environment. I'm going to stay in the operating room. But you know, you could apply to any health, acute health care area, whether it be the emergency room or the intensive care. Anyway, it's a VUCA environment. Your performance, your to multitask is based on your capacity bucket, right?

00;59;55;13 - 01;00;25;12
Dr. Dan Low
And that and your capacity bucket is, you know, it's just a theoretical construct of how big is your bucket that allows you to do multiple tasks. That includes maintaining such awareness, that includes team communication, that includes the technical tasks of your job, your ability to do that, that capacity bucket goes smaller if you are sleep deprived. If he stressed, if you are scared, if you are hungry, if you are cold.

01;00;26;05 - 01;01;05;25
Dr. Dan Low
So it's about managing those resources, managing those elements as much as you can. So the things you know as an individual, it's your responsibility to come to work properly rested. You know, you shouldn't be out drinking at 3 a.m. if you have to start at least at 6:30 a.m., that would be irresponsible. So there's certain individual responsibility. The organization has a responsibility that you can't make people work consecutive shifts, like I'm not allowed to work two consecutive weekends because that would be working like five days and then and then two weekends you'd be working 20 days straight or something crazy.

01;01;05;25 - 01;01;31;18
Dr. Dan Low
So you can't do that. So in terms of like other things, you can manage fear and that fear is a is a good adaptive response. If as long as it doesn't become maladaptive, right? So it's okay to be scared in an environment this is going to be is going to be related to your experience and have you encountered this situation before?

01;01;32;00 - 01;01;53;17
Dr. Dan Low
But we work in teams and we see this in our trainees. You cannot drive. You cannot make them fearful. As a trainer, I can't make them fearful of me. They cannot be intimidated. They cannot be fearful. There is obviously a hierarchy, just like in any other structure, but my job is to reduce the copy gradient for want of a better word, right?

01;01;53;17 - 01;02;17;02
Dr. Dan Low
So make it. We should be on first name terms. We should be you should be able to talk to me. You should be able to question. You should be able to without fear. You should be able to ask if you don't understand. And it's my job to to create that environment. It's not the trainees job to step up.

01;02;17;02 - 01;02;25;14
Dr. Dan Low
It's my job to make it possible to meet, to have that conversation, create a learning environment. Yeah. You talk about.

01;02;25;27 - 01;02;42;28
Brian "Ponch" Rivera
You and I talked about psychological safety when I was there and the importance of displaying fallibility as a leader. You got to be able to show, Hey, yeah, I screwed up. I did this wrong or I didn't. I think we talked about that that that concept is that hard to do?

01;02;42;28 - 01;03;02;26
Dr. Dan Low
Is it hard to do you just have to have the will to do it. I don't think it is hard to do. We don't see enough in health care and it depends. There's geographical variation for sure. Even within the city, there's there's variation. And if you speak to folks and observe, you can see this variability of how well that's applied.

01;03;04;02 - 01;03;25;23
Dr. Dan Low
You know, psychological safety. That's a big topic dear to my heart. We talk we're talking about your your, you know, this construct. You have this kind of small circle, which is your comfort zone. You have this bigger circle, which is your anxiety panic zone where you're totally dysfunctional. And then in between your comfort zone and your panic zone, there's this thin edge, your growth zone.

01;03;25;23 - 01;03;45;24
Dr. Dan Low
Right? So right on the edge of your comfort zone. So how do so when we're training, how do how do I keep you right on the edge? You are uncomfortable. That's okay. Because are learning this is new. But how do I keep you just on the edge of your comfort zone just in that growth area, because that's your actual maximum growth.

01;03;45;24 - 01;04;03;07
Dr. Dan Low
If you if you're going to work with us for ten or 12 hours a day, you want to be in that zone all the time because that's when you're going to learn the most. And that's where all the lessons are going to be imprinted. That's where you grow and we can apply that. We can apply that now to our systems.

01;04;03;07 - 01;04;27;26
Dr. Dan Low
You know, I'm out of training. I've been practicing 25 years. I'm trying to find that growth zone all the time. Like, how can I improve my performance? How can I do that better? And there's always better, right? And it's never you never done. If you look at the top sports people, you look at the best tennis people, the best soccer people, they have a coach and they are trying to improve their performance.

01;04;27;26 - 01;04;52;02
Dr. Dan Low
Just because you won Wimbledon, it doesn't mean you stopped training, but you can still get better, right? So and the way we do that, again, it's your OODA loop, right? You have to have the feedback. How I do for my last five cases that I did, how did I do? I was just looking at that yesterday how my last 50 cases compared to the 5000 before, am I still performing at the level I want to be performing it?

01;04;52;26 - 01;05;09;08
Brian "Ponch" Rivera
But how does luck plan to the outcomes? And this goes back to, you know, we can make we can do everything right in an operating room or coming up with a product. We're working with the customer, but sometimes luck just isn't in our favor. So how do you factor luck into.

01;05;09;24 - 01;05;29;25
Dr. Dan Low
I think I think I think luck is a randomizer. And there are things you can do to increase your luck surface area so that things you can do to make you luckier. Right. And you probably can talk to that as a as a pilot, as you as you as you flew more you got luckier, right?

01;05;30;11 - 01;05;35;08
Brian "Ponch" Rivera
Yes. Because you realize how stupid the things you're. Yes, exactly. Yeah. So you're the dumbest idea ever.

01;05;35;29 - 01;06;09;01
Dr. Dan Low
So you stop doing some behaviors. You do more of other behaviors, and that increases your luck service area for the outcome you want. And I think it's it's the same thing we talk we have this this concept of pure random luck and yes, sure, every now and then maybe. But actually, I think it's things you do on a system basis that increases your luck surface area, that makes your chance of achieving what you want to achieve, whether more likely, whether that is, you know, starting a small business, whether it's starting a tech company, whether it's improving health care systems.

01;06;09;01 - 01;06;28;08
Dr. Dan Low
I think it's you just have to be systematic. And then if you think about luck service area, think about a piece of paper, it's like it has two dimensions. What are the things that drive the y axis? What are the things that drive the x axis? Can you do more of those things to increase, you know, all of the activities, the behaviors, the mindsets you need to do to do that, I think is a systematic way of doing it.

01;06;28;29 - 01;06;42;24
Brian "Ponch" Rivera
What about the application of team training, team science, teamwork, development in the with the administrators inside health care? Is that something that you're seeing an uptake in or is there rejecting? You know, culturally, that's not for us.

01;06;43;15 - 01;07;06;19
Dr. Dan Low
We are seeing it. You know, it's it's taken a long time. I think when we started talking maybe seven or eight years ago, these concepts that were taught in team steps, you know, simple communication concepts, you know, espouse remarks, they were almost you think, wow, you have to teach people how to do this. And we spoke about this earlier.

01;07;06;27 - 01;07;27;22
Dr. Dan Low
Like these are highly trained, highly skilled adults. And and they've gone to these highly paid positions. And yet you teach them how to formulate a speech. That's not just speech. You see it in emails, right? So, I mean, how many emails do you get? Like I get I just cleared my inbox. I had 200 emails this morning, mostly.

01;07;27;27 - 01;07;52;07
Dr. Dan Low
How do I cut through that chatter? How do I cut through that noise? We have to be trained how to use these communication tools effectively. And we and we're still developing the latest one I've seen come out. So everyone's familiar with S4, everyone's familiar with Rebeck's. Now, another one that's cropped up now is people started doing starting the emails with Bluff and it's like, what is that?

01;07;52;17 - 01;07;54;00
Brian "Ponch" Rivera
That's a military thing. Yeah.

01;07;54;10 - 01;08;04;08
Dr. Dan Low
Right. It was actually from a military customer and it's it's kind of like I've started seeing an uptick in that. It's like, oh, bottom line up front, okay, I.

01;08;04;08 - 01;08;09;25
Brian "Ponch" Rivera
Need you to do this. Here's a back. Yeah. And we actually it actually follows bluff with an S bar sometimes it's kind of yeah.

01;08;09;25 - 01;08;25;02
Dr. Dan Low
And it's like, oh, just give me the bullet. And I got it in 0.3 seconds. Okay, excellent. Right. So, so yeah, we do need these tools and strategies and I think we have seen a slow uptick, but not enough.

01;08;25;21 - 01;08;44;02
Brian "Ponch" Rivera
Yeah, it's funny, I was working with NATO's several years ago and that's not the way nikto like to write back then. That may have changed. They want to have a long write up and then the point at the bottom of like, oh my gosh, I'm as an American, you know, as a service member in the military here, tell me what I need to know up front and then I'll look for details as I need it.

01;08;44;02 - 01;09;16;29
Brian "Ponch" Rivera
Right. So yeah, and it's it's amazing how these little tools and techniques can work out for any organization. I got a couple of other strange questions for you. Let's see. So you learn a lot of this from aviation pilot out of the UK. What do you what do you what do you read right now to learn from outside your environment, you know, outside of health care, what do you look to or what do you you know, what are you inspired by when you read about training tools and techniques or anything outside of healthcare?

01;09;16;29 - 01;09;20;07
Brian "Ponch" Rivera
Where are you looking these days?

01;09;20;07 - 01;09;42;05
Dr. Dan Low
I'm I mean, I'm the last couple of years, I've been very, very focused on data and and how we can better leverage that. So a lot of it's still out of the academic journals. And really what we're trying to do is what we're seeing there now is more and more people writing about how are we using data? I'm less interested.

01;09;42;05 - 01;10;05;13
Dr. Dan Low
I'm still interested in the big you know, the big studies from the Mayo Clinic. Sure. But I'm more interested in. Hospital X from, you know, from Oregon. And you just did this to your system. I'm interested. How did you do that? Like A kind of small scale, narrow focus. How did you how did you improve access? Tell me that story.

01;10;05;20 - 01;10;26;24
Dr. Dan Low
And those those stories are coming out now. People are just beginning. It's like a digital revolution or data revolution that just beginning to really harness that data and go, wow, if I measure, X, Y and Z, that's the thing that I think matters. And I'm trying to drive to that outcome. And how did you do it? How did you communicate it?

01;10;26;24 - 01;10;46;25
Dr. Dan Low
How did you enlist the team or the stumbling blocks? And people are being more and more open about it's not this amazing success story. It's like I failed three times, but the fourth time I got it. And so this kind of it's you know, it's a realm of research now for quality improvement research. How do you do real world policy improvement?

01;10;48;13 - 01;11;08;19
Dr. Dan Low
And that's really I think it's a really exciting era right now. There's this concept, I don't know if you've come across it of digital aging and you come across this line. Yeah. So, you know, now I can learn something about my health care system that it would have taken me ten years of practicing within it as an individual, a decade's worth of experience.

01;11;08;27 - 01;11;27;20
Dr. Dan Low
I can learn the same thing in 60 seconds now because I have access to that. I can see outcomes across all my SO rather than having to figure this out over a ten year period of doing it one day at a time, I can learn in as fast as a Google search.

01;11;28;06 - 01;11;35;24
Brian "Ponch" Rivera
Yeah. Is there any danger in trying to measure too much from your perspective?

01;11;35;24 - 01;11;59;05
Dr. Dan Low
We're not in. I don't think we are. There's not a danger of measuring too much. I think that there is a danger of measuring the wrong thing. Yeah. And that's that's very real. So I'm a great believer in measure what matters and stop measuring the stuff that doesn't matter. Unfortunately, the world we live in has these historical tablets of stone, and they've always measured this.

01;11;59;20 - 01;12;22;25
Dr. Dan Low
And one example, one example from the operating room. For the last two decades, people have been measuring a metric called Ascot's. First case on time starts. And what it was is it's, you know, and it's on the surface it's saying, well, that makes sense. You're measuring like if you have an 8:00 start, how many time, what percentage of the time do you hit?

01;12;22;25 - 01;12;43;23
Dr. Dan Low
Do you hit the mark of the 8:00 stop? Right. It wasn't until I dived into it. Then you realize, oh, well, that's the 20 year metric and that's before we had electronics. And and it is a retired charge nurse who told me 20 years ago they made me run around the operating room at 805. And I just how many rooms had patients in?

01;12;44;04 - 01;12;48;19
Dr. Dan Low
And if I had ten rooms and eight of my patients, I have 80% ascot. Great.

01;12;49;03 - 01;12;49;11
Brian "Ponch" Rivera
Yeah.

01;12;50;07 - 01;13;10;21
Dr. Dan Low
But the whole industry is by your efforts. Hmm. Now you think, well, what's wrong with that? And I would turn that around and say, imagine you were Delta Airlines. And the only thing you measured was the percentage of time your first plane took off. Yeah, as a marker of efficiency. Now, great. If the first plane took off, does that mean the second plane takes off on time?

01;13;10;21 - 01;13;34;14
Dr. Dan Low
Well, third. And that's so, so, so, so, so. Yeah. So that's one example of why measuring the wrong thing. Yeah. You put too much emphasis on one metric. The other thing is the way you measure it and it can make you very, very insensitive to improvement at the start of the example, let's pretend that 50% of my room start on time.

01;13;35;05 - 01;14;00;14
Dr. Dan Low
Yeah, that's terrible. But the 50% are late. They were. They were 30 minutes late. So if you quantify it right now on time means you took off within or you started the case within 5 minutes. So if you're in them by 805, you win, right? But you're 30 minutes. Imagine you pulled a whole bunch of resource and everyone rejigged their whole workflow and now you are only 7 minutes late.

01;14;00;14 - 01;14;19;00
Dr. Dan Low
Well, that's a massive improvement. You went from starting 30 minutes late for half your to starting 7 minutes late. You should be congratulating the team. But if you measure effort, you're still 50. Only 50% of your rooms made it so because you put an arbitrary cutoff. If you don't, you either hit the mark or you don't hit the mark.

01;14;19;12 - 01;14;35;10
Dr. Dan Low
Yeah, yeah. And if you measure. So it's just another example. Sometimes we measure the wrong thing or put too much emphasis on one metric. Sometimes we measure in a way that makes you incensed. It's off to the team actually improving. And the corollary is true is insensitive to deterioration as well.

01;14;35;25 - 01;14;45;11
Brian "Ponch" Rivera
Yeah. So that's kind of the dispositional state of the system. Now you've got to look at where is it now, not the ideal future state and you start with the where you are now and improve from there. I think if that.

01;14;45;17 - 01;14;49;25
Dr. Dan Low
Makes sense and create measurement systems that are sensitive to improvements. Yeah, exactly.

01;14;50;06 - 01;15;08;24
Brian "Ponch" Rivera
Now this is these are great examples. And one of the it's funny when you're telling the story about escorts reminded me of my time in the in fighter aviation in an Arab space operations center where a general was having me track the number of times a tail, an aircraft would go flying, you know, because that that was a good measure to him.

01;15;08;24 - 01;15;26;02
Brian "Ponch" Rivera
And the logistics world in a fighter aviation world, you know, it's to us, it's how many effects we put on the ground. How many bombs can we put on the ground? That could mean one aircraft flying 20 times a day or two, aircraft flying ten times a day. So, you know, the metrics there, I'm like, it doesn't really matter.

01;15;26;02 - 01;15;46;19
Brian "Ponch" Rivera
Look at the outcome we're trying to achieve, not the, you know, the key performance indicator that you're used to. And speaking of key performance indicators, going back to when you and I were at the Museum of Flight and what we learned up at Seattle Children's Hospital with the behavioral markers, to me, those seem to be a great way to get leading indicators on team performance, right?

01;15;47;00 - 01;15;52;19
Brian "Ponch" Rivera
So is is that what you saw with the use of marker systems inside of health care?

01;15;54;11 - 01;16;20;11
Dr. Dan Low
Yeah, the uptake has been slower than I'd hope for. You know, it's we have behavioral markers. We don't do enough of that work. You know, we talked about this before. Like there are concrete ways of assessing human factors, behave as you do or don't do. And yeah, what I've seen, you know, over the last five or six years that there has been a roll out.

01;16;20;11 - 01;16;47;26
Dr. Dan Low
People have these safety tools. They behave as they're supposed to do. They're not assessed as rigorously as other things. So the things that are assessed, did you wash your hands? Are you wearing eye protection? So that and again, because they're easy to measure, right? Are you wearing one mask correctly? Are you wearing the right shoes? So that is no one is saying that you performed the time out correctly.

01;16;47;29 - 01;17;06;15
Dr. Dan Low
Did you give someone an opportunity to speak? Did you pause your work like. No. And I think it's the people are afraid to it, but they you know, even though they now know what they're supposed to do, we haven't seen robust measurement of those soft skills and that behavioral markers.

01;17;07;25 - 01;17;29;05
Brian "Ponch" Rivera
Yeah. And you know, after you and I connected in Seattle, we worked on what we call zone five. So behavior marker system for Team Lifecycles. And again, the the reason the uptake isn't there, in my opinion is in the industry I'm in or the industry's research are because people often lead with the behavior markers saying that these are things you need to do.

01;17;29;22 - 01;17;51;05
Brian "Ponch" Rivera
And, you know, from looking at them, you know, language is a little bit different and they, you know, they're mostly objective. But many people who aren't familiar with team team steps or team development, intervention and teamwork, development intervention, they don't know what good looks like. Right. So they just kind of use it as a on scale. I'm over here, I'm a high performing team.

01;17;51;05 - 01;18;04;00
Brian "Ponch" Rivera
I do these things. So, so yeah, I think there's a lot of opportunity in that space down the road and a lot of that goes back to you looking at me and saying, Hey, man, we learned this from you guys. I'm like, Yeah, we did do that, right?

01;18;04;20 - 01;18;32;13
Dr. Dan Low
Yeah, yeah, yeah, yeah. I think this is a it's a very ripe the field and and ready to have that conversation and ready for that work and you know we can improve our team performance so much more if we if we work on those non technical skills you know that's a term you know people use non technical and soft skills as synonymously to me soft skills has this kind of connotation of soft.

01;18;32;14 - 01;18;48;12
Dr. Dan Low
It's not that important. It's really important. And really the crux of, of, you know, making teams reliable, efficient, safe. Yeah. Consistent Yeah.

01;18;49;02 - 01;18;58;20
Brian "Ponch" Rivera
But, you know, from your experience and what you're doing in your industry, it's working, blending the data, looking at lean human factors. You know, it's working, right? These things are working.

01;18;59;22 - 01;19;28;06
Dr. Dan Low
Oh, yeah. It's it's amazing when it when it when it does come together and you put all of those components together, you put the systems based practice together, you put the measurement systems in place. You have a you have a group that is data driven that actually looks at is outcomes on a daily, weekly basis and then is expecting to change their protocols that people now at the solutions that you visited they expect three months later like what's our next tweak?

01;19;28;06 - 01;19;53;27
Dr. Dan Low
They are expecting the next change. And that is very, very different from most organizations. Number one, they don't work coherently as a group so that they don't pivot together when they change a protocol, people doing their own thing. So they have this variability that's unmanaged. The at the Bellevue Surgery Center is a very, very tightly coupled. And so when we make a move, everyone moves together and they are expecting to be in that growth.

01;19;53;27 - 01;20;09;12
Dr. Dan Low
So, you know, it's uncomfortable to make change, but we normalized, hey, every 3 to 4 months we're going to make a tweak and the tweak is going to make the system better. What we hope is going to make it better, we'll know. We've made plenty of tweaks that that didn't have the result intended. It didn't move the needle.

01;20;09;12 - 01;20;27;01
Dr. Dan Low
So then but at least you know well that that that doesn't improve doesn't add value to your patient care. Well let's let's do something else. And the one consistent thing is we will change. I do not expect to be practicing exactly the same way 12 months from now. That would be disappointing.

01;20;27;19 - 01;20;36;28
Brian "Ponch" Rivera
Yeah, there's no way out. And that's why we named this podcast. This you got to, you know, we got these features of the world. The only way out is really to keep changing, change your irritation, improve. Yeah.

01;20;36;28 - 01;20;40;13
Dr. Dan Low
Yeah. Love it. Yes. No way. Yeah, I'm going to totally adopt that.

01;20;41;11 - 01;21;05;13
Brian "Ponch" Rivera
Yeah. We'll give you the background on that. There's some pretty interesting things that John Boyd said about it and wrote up about the features of the world, you know, entropy being one of them. Numerical imprecision, mutations. I wish had the list in front of me, but that's that's there's just no way out of these realities of our world unless we learn how to change our orientation and improve performance.

01;21;05;13 - 01;21;20;17
Brian "Ponch" Rivera
And I think that's what you're doing. So, Duck, I want to, you know, thank you for your time. This has been an awesome conversation. I'd love to have you back down the road, especially, you know, maybe in 2024 as we look back to see how the world is changing. I think it's you know, every day it's it's crazy.

01;21;20;28 - 01;21;34;24
Brian "Ponch" Rivera
It's very crazy out there, actually. And I'd also like to know, can our listeners find you? And are you still taking executives to the hospital to show them what this looks like?

01;21;34;24 - 01;22;01;23
Dr. Dan Low
Yeah, the hospital has just is beginning to open up post-COVID. So we are a continuous improvement team hosts beginning to hosting groups, coming back if they want to visit the service and to talk about these concepts in a bit more detail, you can find me. I'm pretty easy to find. I'm on LinkedIn and dental OMD and yeah, you can get hold of me through you so.

01;22;01;27 - 01;22;03;23
Brian "Ponch" Rivera
You can adapt to your right.

01;22;04;06 - 01;22;14;15
Dr. Dan Low
And yeah, that fixed dot com you can, you can find my company on there. It's pretty easy. But yeah, I'll be happy to engage with any of your listeners who are interested. Thank you.

01;22;14;28 - 01;22;18;23
Brian "Ponch" Rivera
They don't have to come from the from the health care industry. They can come from any industry to look at it.

01;22;18;28 - 01;22;25;27
Dr. Dan Low
Not at all. So, yeah, we're happy to happy to engage any conversations from interested parties. Awesome.

01;22;26;12 - 01;22;29;17
Brian "Ponch" Rivera
All right, Doc Lowe, I appreciate your time and we'll connect down the road.

01;22;30;23 - 01;22;32;07
Dr. Dan Low
Yeah, please do. All right. Thank you so.