Let's talk about what is Preventable Harm. In our JAMA paper talking about preventable harm from Venous thromboembolism or blood clots. We suggest that performance measures could link a process of care with an adverse outcome, when defining incidences of preventable harm. So what does that look like for VTE? It means patients have a VTE event, they have the incidence, they did not get prophylaxis for that blood clot, and that's what we all agree on is preventable harm. We should have done a better job and we didn't. So we talked, we came up with a suggestion and CMS listened. Dr. Pronovost and I actually went and met with Patrick Conway who at the time was running the program for CMS, and this then led to this implementation of the "meaningful use" criteria, which are the ways that we're supposed to be using our electronic health record technology to improve patient care. So the "meaningful use" criteria, there are many different ones, specifically those related to VTE, there are six. VTE one through six and VTE six is the incidence of potentially preventable VTE. So what does that mean? The definition from CMS is that this measure assesses the number of patients diagnosed with confirmed VTE, so those are the patients with the event during hospitalization, not present, or suspected admission, who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. So what does that mean? It's exactly what we suggested linking the bad outcome in this case VTE with a poor process measure or in this case VTE prophylaxis not being performed. That's what we're pushing as a definition of preventable VTE. Now you might ask is this issue of surveillance bias that we've spoken about before a problem in surgical patients as opposed to just trauma patients. The previous data was really about trauma patients exclusively. But now when you think about it, maybe that happens in surgical patients as well. So here's a paper that looks at that issue. We looked at about 2,800 hospitals, about a million Medicare patients undergoing 11 major operations. These patients are undergoing vascular surgery, cardiac surgery, neurosurgery, GI surgery, cancer surgery, urology, a wide range of surgical types. And what do we see? That when we break up hospitals by the imaging that they're performing, you'll see that as hospitals do more imaging for VTE they find more VTE events. As they look for more DVT imaging or doing more DVT imaging with ultrasound they're finding more DVTs. Same thing with PE. The more you look the more you find applies not just to trauma patients, it applies to surgical patients as well. We've also found that the process and the outcome don't exactly correlate. So you can't just look at one and not the other. They're both very important. But as you can see, as you're improving the process you would think that the outcome would improve. If you're in a hospital that is giving prophylaxis perfectly to 100 percent of your patients, why don't you have the best outcomes of the group? And as you can see that's not the case. So there really is no association between the process and the outcome. In fact, if you break out hospitals and look at the hospitals that report 100 percent perfect VTE prophylaxis performance, and compare them with the bottom quintile or the lowest performing hospitals they have nearly identical median VTE outcome rates. The outcome rates alone are not going to be entirely useful. The prophylaxis rates alone may not be useful, but maybe combining them is a better approach. So public reporting of VTE has been a moving target for many years. We used to have those six VTE measures, they're now moving over to the electronic quality measure, they'll be changing in the future as well. VTE six however is the last lone remaining measure requiring chart abstraction for VTE, and that's this definition of potentially preventable Venous thromboembolism. The American College of Surgeons is an important organization for surgeons like myself, and we have had a tour, they've been pushing quality and safety for literally generations and decades. And there was a roving tour that went throughout the country talking about the lessons learned from quality improvement. And here the six lessons are listed. I was honored and privileged to be able to speak when the tour visited Baltimore, with the leadership of the American College of Surgeons, leadership of our institution with our hospital president, my chair of surgery at the time Julie Freischlag, and the Senator from Maryland Ben Cardin who came realizing the importance of quality and safety both in surgical patients as well as other patients too. And we really were pushing that VTE causes 100,000 deaths annually, and Johns Hopkins is actively working to define the term "preventable harm" and improve care for all patients.