Dr. Martin L. Blakely - Measuring and Improving Value of Pediatric Surgical Care: Should Surgeons Participate?

Colleague, uh, Doctor Marty Blakely as our first annual Weitzman visiting professor in, uh, Health Services research. And, uh, as far as a little background, uh, Marty is a truly a Tennessee product. So born and raised in Memphis, he attended medical school, did his surgical residency at the University of Tennessee, uh, did his pediatric surgery fellowship, uh, training in Saint Jude, and then was lost for a few years, uh, going to Houston at MD Anderson and finally came back to, uh, Memphis where our Nashville he's currently at Vanderbilt. And so, uh, by training, uh, Marty's a pediatric surgeon and an associate professor of both uh pediatrics and surgery at Monroe-Carroll Children's Hospital and uh Vanderbilt University Medical Center. And in terms of background, most of us know Marty as one of our preeminent experts in the field as it pertains to the importance of clinical evidence, and he has well over 100 peer-reviewed publications. His leadership has been evidenced by multiple committee leadership positions in both American Pediatric Surgery Association as well as Pediatric Nesquip, and he also founded the American Pediatric Surgery Association Research Committee. In addition, he has been extraordinarily well funded and currently holds not one but 2 RO1 funded NICHD grants which are looking at the timing of inguinal hernia repair and kneeates as well as adverse events in the same population, so. Marty definitely walks the walk and talks the talk as it pertains to outcomes in the health services research. However, that's not why he's here today. However, so today he's going to talk about improving value in surgical care. And so he is the director of the surgical Value Improvement Program at Monroe Carroll Children's, and over the past couple of years he's Really, uh, made a lot of headway in a big splash nationally in terms of improving the value of surgical care we provide. And that's not just in terms of the extraordinary work they've done at Vanderbilt, but also how he's able to really align surgeons and administration with this common goal. And so I think we have a lot to learn from what they've done and hopefully we can implement some of that work at our, at our hospitals. So we're really excited to hear what he has to say. Before I turn it over to Marty, I did want to quickly acknowledge, uh, Stuart and Jane Reitzman. Uh, who are responsible because of their gracious funding to fund Marty's visit today. As you know, the Weitzmans are tremendous benefactors to the hospital and have provided a lot of support within our own department for research and endowed chairs, and it's hoped with their ongoing support they will continue this annual lectureship. So with that, Marty, I'll go ahead and turn it over to you. Hey Sean, I found a nice uh iPhone up here. Well, thank you very much for that, uh, overly generous introduction. Uh, it is a real honor to be here. So thanks to Sean and uh the other leadership of the group, uh, to be able to come and talk to you guys. Um, I'm gonna dig right in. One of my, um, kind of negatives I tend to go on and talk too long. So I really wanna try to, uh, I'm gonna zip through the first part of this cause I think a lot of it is, um, You know a lot of this already. And I want to try to slow down toward the end and go into detail on one of the, uh, projects we've done, which is try to uh get a handle on OR supplies, uh, for appendectomy. So that's my intent. Try to leave some time at the end so we can have some sort of discussion. Um, it's kind of a crazy question, I guess. You know, should surgeons participate? Of course we should. You know, value is good, more value is better. And I guess what I was trying to get at, uh, get it on that was, uh, do we really have the incentives? You know, of course we should participate, but I'm sure you guys, you know, the capacity is 100%. You got more cases, more clinics, more family obligations and you can take care of. So, you know, is there really incentive for us to do this? Uh, just a quick disclosure, this is kind of in the spirit of over-disclosure. This is a startup company that's been around for a few months. So nothing in the talk I'm going to show, uh, has any, um, was any, uh, were biased by this company. It didn't exist at the time that the data were generated. So, uh, again, this is the part I'm going to go pretty quickly over. So Michael Porter, uh, everybody in this audience knows who Michael Porter is. Many of you probably know Michael Porter, have worked with him, but he's a Harvard Business School, uh, strategy professor, uh, famous in many different businesses, but he's really the guy behind uh, pushing value in healthcare. So, Um, the definition of value is condition-specific outcomes divided by costs. And other times you, uh, hear it mentioned as outcomes achieved per dollar spent. Um, that's a pretty benign-looking formula. I'll tell you it's very controversial, especially around healthcare economists. And you know, some of the criticism is, well, we can't really measure value. What is value? What is quality? And to me, I think um to me it makes a lot of sense once you get to a, a patient population. So I don't know what value is in medicine. But if I have esophageal atresia patients or Wilms tumor patients or orthopedic patients, you know, uh, or, or certain types of orthopedic patients. You know, I think you can pretty quickly figure out, well, here's the five outcomes that we think are really important. The families think those are really important. We can measure costs around that, which are totally different than if you're an elderly patient with lymphoma. So I think if you try to say what is value, you're right, it doesn't make a lot of sense. But conne it down to this condition-specific outcomes. So, uh, this is also from Michael Porter's, uh, New England Journal, um, paper back in 2010. And so why is measuring value of care so important? This is the stuff I'm gonna kind of gloss over. Uh, I don't have to tell you guys that we spend a ton of money on healthcare in the US. OK. This is all over the news. It's not sustainable. It's going to fall apart at some point. Uh, so we obviously need to do something, uh, to lower our costs. We need to improve our outcomes. Uh, it is true that in the US we spend about 9600 dollars-ish, uh, per person, uh, for healthcare per year. And that's twice as much as other high-wealth countries. And our outcomes aren't as good in many areas. In some areas, they're better, but they're mixed. So we spend way more money and we don't have a whole lot to show for it. And also we spend about 18% of our GDP. So that's underlying a lot of these things about trying to do something different. Um, so, so what about value? So if, if value increases, and I think it's very important when you think about value is this is not cost reduction. OK. So remember the formula. Whenever you think about value, remember the formula. It's outcomes divided by costs. When you start talking, talking about cost reduction, then you get kind of in the weeds and it can be rightly criticized. Uh, but I think again, if it's all about outcomes improving or staying stable and costs going down, then you're on a very firm footing. Um, it's, it's hard to do as I'll show. And I think on this third point, um, I mean, I, I feel like as a surgeon, we just recently have become more accountable for quality. Um, and I still think maybe we're not totally accountable for quality. We hold ourselves accountable, but people don't really know our outcomes, uh, in a very detailed fashion. And I think once you move from quality to value, we're just not accountable for value. I know in my own hospital system, if I want, you know, the fanciest antibiotic for some case that doesn't even need it, the nurses will trip over themselves getting that antibiotic as quickly as possible. If I want to pull the robot in and do something, go for it. And I'm never going to hear from anyone, hey, you just spent $10,000 on this case, and So I don't think we're accountable for value. Porter believes we should be. Um, so again, I'm gonna skip through some of this. Um, now, um, we've been working on this, uh, we, as in me and a few of my partners have been working on some of this value, um, Measurement and improvement before the current political administration. And right before Trump came into office, that there was a big push, a fair amount of momentum on bundle payments. And my view of it is in, in the volume-based world which we're in, we have been in and we're still sort of in where you bill a certain amount and it costs a certain amount per procedure. And you know, if you make a margin on that, well, let's just, let's just do more volume. Um, I think trying to focus on value in that sort of environment is a good thing to do. Uh, it helps patients. It helps institutions by having better outcomes and lower costs. But it's kind of more of an elective kind of exercise. Some people are doing it, some people aren't doing it. But as soon as you get a bundle that kind of comes your way. Uh, so now you're getting paid on value. It totally changes the game. So I was working with some of the adult orthopedic guys at Vanderbilt, and they had this, uh, kind of impending um, payment, a bundle payment for joint replacements. And all of a sudden they, you know, figured out that they didn't have all the, the skilled nursing facility in place. And so it just, uh, to me, value improvement, value measurement is really important now. But as soon as we get into more of these value-based payment incentives, it, it's life or death. I mean if you don't have a streamlined efficient system, uh, you're gonna be uh in a world of hurt basically. So. Um, so let's say that you leave today and your priority in life is to measure value and improve value for your patients. It's really hard right after that. So, uh, this is an article that came out, what, 6 days ago, uh, basically saying that all of our performance, performance measures are fairly suspect. So this was again New England Journal Perspective article. It was an internal medicine, uh, but basically they reported that there's over 2500 performance measures. Uh, in this clearinghouse. Most physicians don't really believe they hit the right thing. Um, they rated 86 of these things and about, you know, a third of them were valid, a third of them weren't valid. And if you're, if you spend all your time and all your money. Uh, trying to meet some of these measures that aren't really valid, you know, that could be a harmful thing. And I, I thought this was very interesting. And we spent $15.4 billion in the US reporting on these measures that maybe aren't all that great. And it comes down to $40,000 per position. So imagine if we all got $40,000 in our checking account. I do about 400 cases a year. So I get $100 per case that I can just measure my outcomes. So I could probably give my teenage daughters, you know, $25 per case and say, here's the definitions, and this quip definitions, scour these cases and give me a good report. And so I think it, it shows the inefficiency that, that was a striking. Uh, so I, I, I became interested in what is, what's in the National Quality Measures Clearinghouse. Like what are the surgical outcomes that I could look for. And kind of another hint of how we're doing is, oh yeah, this uh website is not going to be available after July 16th because of lack of funding. So I don't want to get you discouraged, but the point of this is, uh, once you really commit yourself to value, it ain't all that easy because the parts of the formula aren't terribly accessible. Now Bright Spot um is the Nisquip work that Sean has done. And I don't know if everyone in the room knows, but Sean has been the main driver, uh, nationally behind getting good quality data for appendectomy patients. And, uh, I don't get very many quality reports like this that just kind of come periodically without me generating them or me, uh, you know, some of my resources getting them. An example is, um, You know, is your institution compliant with American College of Radiology guidance for imaging for appendicitis? Well, none of us are gonna calculate this. So I, I raise this as a real bright spot, um, and congratulate Sean for pushing this, uh, because now, you know, each one of these, uh, columns on this graph, uh, is an institution. Um, and you twice a year can look and see, OK, here I am, and these are things to work on. Also, the uh Nisquip report for appendectomy has all sorts of other measures like SSI, sepsis. So the point of this is, um, you know, we do have, um, some sources of quality data, uh, but not as good as we would like. So if you read Michael Porter's, uh, stuff, books, papers, talks. Um, he is affiliated. His main partner is Robert Kaplan, who's a health care economist. So what these guys say is if you want to work on value, we've kind of got the quality outcomes figured out, which I just showed you, we probably don't. But they focus on the costs. They say if the value is hard to figure out, the cost is really almost impossible to figure out. So they've written a ton on this. Uh, this is a paper, uh, back in 2014. Um, the earliest I can find Kaplan writing on this is kind of 2000-ish, but it maybe it went back before that. Um, but you, you should know anyone that kind of wants to talk about value or think about value. And I'm sure most of you do know this already, that Kaplan believes the way that you should figure out costs is this time-driven activity-based costing. Uh, this is a paper, um, that several people in the room were on this paper. Uh, Children's, um, hospital orthopedics and, uh, plastic surgery was represented on this paper. Uh, so again, I just raised this as a, um, It's another kind of um just informative um bit of information on where we are right now in measuring value. Value, the quality outcomes are difficult. The costing is actually very difficult. This is an example of this TDABC costing. This is actually for appendicitis. This is a really great paper that I would recommend to you guys. It comes from uh Texas Children's. Where they actually went through this TDABC and I know you guys have done this here too in some different areas. Um, but it basically involves assigning, you know, specific minutes and personnel to the whole process of care, identifying opportunities. And, and I, I show this here as just an example of the process, but read this paper because they, in doing this process and implementing some of the changes, reduce their direct care costs by about 11%. So it's a powerful method. So who's doing this well? Well, I think, you know, this campus is doing it well. Again, I mentioned uh Porter and Kaplan. Uh, they're at the Harvard Business School. They got all sorts of programs. Uh, multiple papers have come out, uh, of this very hospital, uh, looking at various costs, um, in accounting, uh, and care for patients. Um, so when you give a talk, you need to kind of know your audience. So I'm coming from Nashville, Tennessee. Uh, where we are right now is 2.8 miles from Michael Porter and Kaplan's offices. So I think you guys are the experts on this. Uh, you know these people, you know, you know all about this. So I'm a little bit intimidated and talking to you guys about it since it's 1100 miles, uh, from Nashville to, uh, the Mecca, I guess. So, um, as I look, and this is not meant to be a compare, a scientific comparison of who's doing what and who's, who's the best. But as I look at the literature out there, University of Utah kind of rises to the top, and I would strongly recommend these papers that I'm showing, uh, because we're just going to hit the Uh, the very high points, but they'll all be, you know, referenced on the slides. So why did Utah do this? So University of Utah sits in kind of the middle of Salt Lake, and it's surrounded by Intermountain health. So if you remember, you know, with Obama, you know, Intermountain Health was one of his, you know, poster child for uh great care. I think they are. It's difficult to get in uh kind of downtown Salt Lake, so. University of Utah, uh, basically with, uh, Doctor Lee, Vivian Lee, uh, who you guys may know as well, uh, because I believe she has a Harvard connection, um, I think, uh, with the business school. But, but this is interesting because she was CEO of the hospital, dean of the medical school, and so from, from that very top powerful position, she said, you know what, the way we're going to compete with Intermountain is we're going to compete on value, and this is the way we're going to do business. And we're getting rid of the word QI because we want it to be value improvement. So every single project. That looked at outcomes had a cost component. And we weren't gonna out access Intermountain. We weren't going to make it fancier. We were going to deliver better care at lower cost and that's how we're going to do business. So it's pretty remarkable that, that, that would happen. I mean how many papers come out in the Journal of American Medical of Informatics with your dean as the senior author, a JAMA paper with your CEO as the first author. It's already pretty remarkable, I think. So, uh, what they did, um, getting back to the, uh, idea that institutions don't really know all of their costs. They agreed with that. So they developed this thing called the Val-driven Outcomes VDO as a software. So this is an accounting software system where for every one of their encounters, which is over a million encounters per year, they uh figured out how to assign all of these costs. So the costs of the providers, the cost of the, you know, facility, the imaging, the whole thing. Um, this is a pretty technical paper. So, um, you know, you can dig in it, uh, yourself. Uh, but, but at the end of this, uh, they had a solid cost accounting system. Um, that they could assign cost at the patient and encounter level that they didn't have before. And then this JAMA paper is a pretty short-term, how are we doing paper. So just a few points on this. So again, getting back to why I'm so amazed at this video software thing. They did it all with existing resources. So they didn't hire a bunch of McKinsey consultants or a bunch of, you know, fancy people. I looked around. They had 10 people in the beginning that made it up to about 20 people. These people already work there, uh, multidisciplinary group. They've got a really strong Informatics core there. And the amazing thing is in 6 months, they had a software system going. I, I can't seem to get anything done in 6 months. So that's pretty impressive. Um, and they used all sorts of cost accounting methods. So the TDABC is in there, you know, all sorts of different, uh, and feel free to dig into that paper. So what kind of impact did it have? So in the JAMA paper, I think this is also, uh, for the clinical researchers in the room. This was a pre and post design, which is not the highest level of evidence. Um. Prospective observational. So to get that sort of study design in JAMA with impact factor of 44, um, it must mean you, you have a very important message. Uh, there's a very important, um, concept that, that you're studying or very important findings or maybe you just happen to know someone on JAMA board, but I doubt that. So they looked at uh joint replacement, hospital lab usage, and sepsis. And they had a really big impact. Uh, so again, the providers are totally in this system, this value improvement. So and care is getting better. So with joint replacement, length of stay goes down, cost goes down, the hospitalists, uh, change their practice, uh, sepsis, um, and also in this paper, it talks about how they pick opportunities, uh, and it's a very objective method. A couple of other pearls. So as surgeons, we're in a really good spot for this whole value improvement um effort because our care is very expensive and, and that's a big opportunity. So it was true in Utah, you know, the highest cost um department for inpatient care was surgery. Um, the second highest outpatient was surgery. And they're also getting to the point where we don't really know how to measure quality. They had an innovative thing where they got, so let's picture like cabbage, for example, coronary artery bypass grafting. They got all the CV surgeons together, the cardiologists, the nurses, I think some families, and they said, here, here are the national metrics that people use. Um, let's pick some of those that you think are most relevant. But what do you think would be perfect care? Um, and then that probably some of those were not represented in the national measure. So let's say there's 5 things for cabbage and there's 5 for joint replacement. So they had this perfect care index, which I thought was, uh, very unique, very novel, something you could measure. And that's a part of their value equation is. Did you get perfect care as defined by uh these uh content experts. So interestingly, and this is one of the most fascinating things to me about this whole value thing is the idea of incentives. And that's kind of what when I started to talk, you know, do we really have incentives. So at Utah right now. Uh, these physician-led improvement efforts are, are strongly incentivized. So if you come up in pediatric surgery with an idea, um, that gets vetted and, OK, go, you're going to start implementing it. If you're at Utah at the end of the year, if you have saved the hospital system $100.50 dollars goes back to your department. So all departments have things on their mission that we would like to do. But we don't have the resources to do them. So it doesn't go to your salary or anything like that, but That's very strong incentive and that is really an innovative medical center that can do that. Uh, a lot of medical centers want the savings, uh, but they're not so much into the sharing part. So I think that to me is an incredible statement from them. And the last thing about Utah, so, uh, Rob Glasgow is a, a minimally invasive surgeon. Um. At Utah, he's the chief Value Officer. So it's kind of cool. They have a chief Value Officer. And I was talking to him last week and he said, hey, check out this new paper. So, uh, May 3rd, Harvard Business Review. It goes over some of the same stuff. So, uh, the bottom line though is, um, The, the headline of that was, if you want cost reduction in surgery, show the surgeons the cost data. And I'd be surprised if you tell me that you get good cost data at the patient level for the care you give. Maybe you do. Um, but I can just say in the 18 years I've been practicing. Um, I've never gotten any cost data until a few years ago when we started working on this. So it'd be great if you get that, but um it's, it would be unusual. So what are we, what have we been doing? So, um, so I'm working with, um, I, I got a, a master's in Business recently, uh, a couple of years ago. Um, so I've always been an outcomes guy. I've been terribly interested in variability of care. So if you do, if you do treatment A and I do B. Why is that? And how are we doing? You know what, that's been my interest, uh, you know, forever, I guess. Um, and so with the business background, I really became interested in cost, but the most important thing was I hooked up with one of my classmates who has exquisite access to cost data. He's incredibly smart once he gets to the data. So he and I have teamed up and are working on this value thing. So what we want to do, and this is totally not novel, uh, nothing I'm going to show you today, um. It is very innovative, uh, but I think it's still important. So, we've, you know, what we want to do, which we've not done yet, is pick a condition. So let's say appendicitis, and to think about that whole cycle of care. And this is, again, this is not any new news, but it's just not ever done really. So we wanted to look at the cycle of care. And look at each one of these things. So you got a healthy kid typically who then becomes unhealthy with abdominal pain, finally gets to you, gets diagnostic evaluation, gets treated. Part of that's the OR and then they get better. So we want to look at each one of these nodes and say, well, what's going on now? What's the variability with each one of these things? What adds value, what doesn't? And I'll tell you we haven't done that yet, even for appendicitis. We've worked on two parts of this. One is this uh kind of in-hospital treatment part, and then one is the OR. So, um, this is still trying to zip through some of the background. Before I really got into the value thing, um, when I got to Vanderbilt seven years ago, it seemed like our outcomes for complicated appendicitis just anecdotally weren't very good. Um, every M&M, you know, here's a kid with a perforated appendicitis and you come back with your intraabdominal abscess. It is over and over and over and over. Uh, so anecdotally, it didn't seem right. And then some of Sean's data provided us a signal that it didn't seem right and it, it's not right. Uh, you know, our complications are high. So what we did before the value, uh, was something you guys have done a long time ago, which is just create a clinical practice guideline. To try to get uh reduced variability in care of complicated appendicitis patients. So we did this, um, I think we did a pretty good job on the practice guideline development. We use the IOM has pretty nice, um, kind of recipe for how to do that. We again did this kind of pre and post thing that started July 13th. We didn't have perfect adherence to it, but reasonable. 80%-ish. Um, and what we showed was we really improved our outcome. So length of stay went down. Adverse event rate went down, uh, post-op, uh, intraabdominal abscess. Again, I thought it was high. A quarter of the patients, pretty high. Uh, it's down to 9% now, 9 to 10%, which is national norms. Uh, you know, we still need to improve some of this stuff. Uh, we essentially got rid of PICC lines, so 30% before and almost no one now. Uh, the point of this though is that once we did that, we felt good about it. Our patients didn't really know anything about it, but they were better off. Um, but it, but it kind of just fell into the, uh, abyss, I guess. You know, we presented this in multiple different forums, hospital administrators, various people, really, really got no interest. No one was negative toward it, but yeah, great. That's, that's your job. That's what you're supposed to be doing. Um, so part of this talk is what happens when you move beyond just patient outcomes to now cost data. So using that exact same cohort, and now I've got my buddy Andrew who's got access to all the financial information. We beat on that cohort statistically and with cost data. Um, and basically showed that, that better care that reduced variation and improved outcomes was really good financially. Um, again, this is the same cohort, um. This is about what we saved over a pretty short time period. Um, I think it was about 18 months. Um. What we also did on this, um, study that I think was a little bit unique is getting the cost data is very difficult. So again, I tried to do this before I had my business school contact and literally about a year into me trying with the existing hospital personnel that I get some cost data. So getting that hospital cost data. Um, even if you have a good hospital cost accounting system, which I suspect you do, it's just very difficult and it's not anybody's fault. You know, these people are not trying to hide the cost data from you. It's just that, that's not their thing. You know, they are, they're at capacity just like you're at capacity and their, their job never included giving providers cost data. It's more about, you know, the CEO needs these data or the US News World Reports around the corner, you know, it's, it's all these things. Um, but the point of this was it's almost impossible to get the cost data. So one of the things we ask in this is what about the fizz off the shelf already existing cost data. Um, that's much easier to get. It's much quicker, doesn't really depend on anyone else. Would it give you the same answer? And I think that's it, that's the only kind of unique thing here really. Um, so again, this is a table showing the hospital data. So we, we already said that we, um, Cut down on length of stay. Uh, the estimated total cost per patient went down $5000 per patient. Revenue did go down. So when you start talking to some of your administrators about this, they don't really want to hear the revenue going down part because that's, that's the wrong direction. Uh, but revenue went down a few percent, cost went down 40%, and the margin went way up. So if you see here, there's a $3000 You know, uh, profit or margin if you'd rather, uh, per patient. Um, and another analysis, the, the number I remember is before we did the CPG with all those different complications and treatments for it. And the cost and the revenue were in the $20,000 range. We were making them, the hospital was uh making about $400 per patient after all was said and done. And then after this, they were making about $4000 per patient. So it was a huge increase. So what Andrew and I did, and I, and this just shows the phys, fis data, the um Objective numbers are different. So again, this is about $5000 higher than the hospital accounting system said it costs. But the relative comparison is the same. So our point of this was that you can use PIS data. If you can't get hospital cost accounting data very easily, get with your fis person and at least we'll give you that initial kind of comparison. Um, so again, so Andrew and I, and my business partner, we then took this, uh, to the administration. Luke Gregory is our CEO, and, and we were very excited. We said, look, uh, we've improved care. We've improved your financial, um, performance. We really want to do this more. Uh, can you support us so that we can then go find, uh, something else? Uh, we'll look in ENT, we'll look at cardiac surgery. Whatever you want. We beat on him for about 6 months or maybe a year. Uh, and then he did finally, um, support us. So he supported us to about 20% of our salary. So one day a week, Andrew and I are in an office uh trying to find the next. Uh, value improvement. Um. Project. So I've already said all this. So the point is hospital uh patient outcomes is, uh, a lot of what it's about. We, we want to improve. Our patient outcomes, of course. But if you start looking at cost, you know, to me, I was a little bitter I guess in the beginning that the administrators didn't care so much about just improving outcomes. But I've come to believe and understand that They are under a huge amount of pressure to make a margin. I mean imagine running this whole place and the pressures that would go along with, uh, you know, all the financial things. So that's just their, uh, that is their charge. And if that doesn't happen, they're not gonna be around, you know, forever. So to me it's just all about aligning incentives. So once you can improve care and then go the next step to improve financial performance, you've got a whole new group of people on your team, uh, that are willing to give you some resources that maybe you don't have. Um, so it's not one that's good and one that's bad. It's just getting everyone more on the same page. Um, it's also important because these are multidisciplinary things. So all these papers that I've mentioned. You know, Eileen, you, you know, she was a big part of the CPG. Zach Willis is an ID fellow. This is a surgery fellow, uh, NPs, a couple of old guys here. Um, so, um, you know, it, it's a team sport. And I think, um, You know, it helps fellows be able to present stuff. It's interesting. Uh, so this is, and I think this is overcalling it. Like I don't really think we have a program exactly, even though I typed this on the slide. Um, you know, it's a, it's a nascent one. I, I think it's more doing projects right now. Uh, certainly, Utah has a program. That's a fantastic thing. Uh, we're just kind of getting started. Um, so one of the, again, I'm really interested in the incentives. So one of the things in, in economics, um, And this thing called the rational actor paradigm, OK, which is, it, it has to do with um behavioral economics. There have been Nobel Prizes around this. Uh, why do people act like they do? Um, so one of the things this rational actor paradigm says is if there is a problem, so let's say there's a problem uh in your department or there's a problem, um, At home, OK. So, who's making the decisions about that issue that's resulting in a problem? Do they have the right data? Do they have the incentives? So any problem can be solved by asking those three questions. So the next thing I'm gonna talk about which I want to kind of uh dig into a little more detail is the problem that we posed was high variability in OR supply costs for appendectomy. OK. It was all over the map. Uh, who's making the decisions? Surgeons. Now, It's not, it's not that simple because why do appendectomies cost so much? Well, there's lots of other people making decisions that drive the cost up like Ethicon, for example, or any other stapler uh company or any device. Well, they're, they're driving the cost up. We can't really do anything about them right now. So who's making the decisions? We want to focus on surgeons. Do they have the data? No. We already said they don't get cost data. And do they have the right incentives? In my place, no. Utah, yes. Um, so that's how we started this. Um, So again we're focusing on the OR. So what we did was we, the other thing is whenever you're going to do one of these projects, baseline data are critical. You know, you can't go to your group and say, hey guys, our outcomes for perforated appendicitis kind of suck. You know, they're not so good. Because what they will hear is, well, I'm sorry you're having trouble with those patients. Mine tend to do pretty well. Uh, or, uh, hey guys, our costs are all over the map. You know, it has to be data. Like you have to show them data and the data kind of have to speak to that without you even saying it. So we did that with this project. We did that with the other project. So we knew we only have 8 surgeons, so we're a smaller group. So we knew among the 8 surgeons, there was all kinds of different tools being used to do this one very simple operation. And so we broke the operation down into its components. So you've got to get access to the abdomen, you got to divide the blood vessel and you got to take the appendix out. It's not all that more complicated. So an example would be for the meso appendix. So you could reach over and get the reusable hook cautery. Uh, step on the pedal and fry that, uh, with good hemostasis. Now, it costs something. So, um, it's not zero like I'm showing here, but as far as the disposable cost, it, it doesn't count in that accounting system. Now, someone had to buy it. Someone has to clean it. Or uh what we were doing more commonly is you grab the stapler. So stapler is about $250. The load is, let's see what the stapler is. I'm sorry, $329. Well, that's what the load. So yeah, um. So stapler would be about 300 to $400 to put that across the blood vessels, squeeze it. It bleeds sometimes. I don't know if that happens here, but it's fine. And then sometimes after it bleeds, you get the hook cautery to stop the bleeder. Or if you're really fancy, you get the ligature uh for $500. Um, so you get the point. There's all these different tools that are available and there's nothing showing that one does better than the other. So what we did was, uh, we knew what everyone used. And we said, hey guys, why don't we, um, here's what we're thinking. Uh, why don't we have a high-value appendectomy where you would use two XL 5 millimeter cannulas, 112, you'd use the hook. At the time we said endo loops. Uh, only use a bag if you need it. Like don't, don't put a tiny appendix in, in a $50 bag if you can just pull it out through the 12 cannula. Um, and this was our recommended, uh, high-value appendectomy. And then kind of as a little more incentive, we said, oh yeah, uh, Utah has already done this a while back, um, and then Seattle did it before them. So it could be they're just better than we are, but, you know, so we, this was a, uh, laminated card. So the panel on the left is one side and this is the, the right side. Now, interestingly, to show you how things change over time, when we first started, um, To develop this. We said use the 35 Ethicon stapler which already had to load with it. Because it was, it was about $250 but it's super quick. It worked well. Well, before we ever got our cards printed, Ethicon discontinued that stapler. Who knows why. Um, but then they, um, they could give you a new stapler. So now there's a 35 millimeter stapler from Ethicon that's powered. They cost like $600. So the point of this is it, it changes. Uh, now you know about just right staplers that I think are about $800 that are 5 millimeter staplers. So the, this whole thing changes over time, which also makes it interesting. This was really my contribution to the project was the low-tech intervention. So Andrew Engelmayer, uh, he's more of algorithm. Writer. Uh, so he developed just a system where, uh, we would, um, seek through the enterprise data warehouse, the data we needed, the cost data. Uh, so, so first of all, you got to identify when the case happened, who did the case, the date of the case, the medical record number, all of those bits of information can be found. Um, he, he uses a SQL, um, You know, queries, which I'm sure a lot of you guys probably do as well. Uh, so we developed this thing called the AppyTracker. So this is an automated, uh, this is Tableau, um, you know, it's available. Um, you, you may use that or you may use different data visualization software, but it's, it's totally available. So what the Api Tracker shows us are the OR costs. So this is a selected month, January 2017. MRN, the provider, we blinded this, uh, the date of the procedure, surgery duration. So one of the pushbacks was, well, the reason I use the $600 ligature is I'm super quick and I don't wanna, uh, slow my time down, which would then be more costly. So that's a measure we have on here. We have costs during the procedure and you can see just on this random screenshot, we go from $203 for a patient to $1100. Um, this is replacement cost total which is had you used what we're kind of recommending, this is what it would have cost and we have length of stay, uh, which is an easily available uh data point. And then over here on the right side shows within this is filtered by month. Um, it shows some of the opportunities. So how often was the, you know, ligature used, etc. um. And you also can go by case. So here we've clicked on this expensive one, which shows what this use. Now, what we intended in the beginning, so we had, uh, 6 months of data before and then, um, we met with all the providers. And an important part of this is when you look at Utah and Seattle, they standardize their uh tool options. My group, let's just say that standardization does not come very naturally. So we decided we wouldn't try that because we didn't think it would work. So what we did this more surgeon-specific approach. So for example, one of my partners, he uses very cheap cannulas, but he uses staplers all the time, uses bags all the time. So for him, we say keep using your cheap cannulas, but think about the endo loop, think about the hook. That would be your uh value opportunity. Whereas someone else uses the various needle every time, step trocars every time, um, you know, maybe they already use Endo loop. So everybody had kind of a different, so we did a surgeon-specific approach. We met with everyone and our intention was to give them access to the dashboard and we ended up not doing that. Not for any reason, uh, you know, have them not look at it, but we, we just never kind of got around to it. So the way we gave surgeons data was monthly we would do some screenshots and we would show that to the surgeons. Some surgeons were terribly interested in it. Some didn't want to hear anything about it. So literally the data distribution was as old fashioned as you can imagine. Um, and, and it's a big opportunity for how to do this better. But we did have an impact. So this Elizabeth Speck, I, I unblinded her because she was such a star. So if you look at during the month of January, she did 13 cases. Her median costs were $194. Her baseline was $993. So, you know, she's trucking along here, very stable before our intervention, and then she kind of plummeted. And so this is what happened pretty early on. Uh, so baseline went down about 70%. Um, and this was, again, this was, uh, kind of funny and interesting. So I started getting all these texts typically on Saturdays and Sundays when a lot of the appies are done. So this is from Adam Brinkman, who was one of our fellows who was a critical part of this. Um, who's now at Wisconsin. It, it shows how important the fellows and residents are to this process too. So Adam says, check this, convince Niblett. Neblett's about 70 years old, super good guy, works harder than all of us, but he, he's figured out how to do stuff in that amount of time taking care of kids. So he, he's very regimented. So convince Niblett to use loops and hook. He loved it, reusable ports, cheapest app to date, boom. And he, he takes a picture of the accounting thing. And to show you kind of my uh pessimistic worldview, you're a miracle worker. Uh, thank you both. So here's Spe, um, to show you, it just shows you what happens when surgeons get the data. She's digging into the details of how many gloves they opened. OK, so she's moved beyond the cannulas and the stapler and the this, that and the other, but why in the heck did you add 3 gloves for 4 for $4.50? Um, so again, it surgeons are kind of a wacky group of people, right? I mean, we're hypercompetitive. Uh, these people had no no financial incentive to change their behavior, but they're fighting over each other to, to do that. Um, So, um, this is again this early kind of look. So how did we, what do we really change? So if you look before, stapler was the most common thing and now hook was more common. Um, That was for the mesoapendix. For the appendix itself, 80% stapler, you know, so we changed all these things. Now one. You know, kind of cautionary tale is it's all about value. It's not about cost. So this was a very disturbing line right here where in the pre-period, we had zero SSIs, which I think maybe was a bit of a wacky six-month period, but that's what we had. And I can't remember what this one adverse event was, but it was not an SSI. And afterwards we had 4.5% SSI rate. So that was a, oh crap, that's not good. That's not what we want. Uh, so that kind of spurred me on before giving this talk to look at the next one year. Um, because I felt like that was, I think that was partly a random just measurement thing, but I think there, there is some legitimate association between, and this is an important pearl, I think, and, and if you're planning on doing some of this stuff is people kind of went beyond where we wanted them to go. So for example, as we said, use the Eocatch retrieval bag if you think you need it. Um, and a fair number of providers never use that. So they were dragging, you know, appendix out through the abdominal wall. I just feel like they, um, kind of went beyond, uh, where we wanted them to go. Um, so I think some of that 4.5% SSI rate is real. Um, and some of it was more measurement. Uh, luckily, in the next 269 cases, we're back down to more national norm. It still bugs me why do 1.5% of uncomplicated apps have an organ-based SSI. Uh, but those are the data. So I wanna, you know, be transparent. Uh, but I think those are acceptable. Um, I think I can honestly say that our outcomes have been maintained and our costs have been lowered dramatically. Um, now, it wasn't all surgeons. So again, this is the interesting part too. So if you look at all the green rows, 6 of the 8 surgeons are responsible for that big decrease. One of the surgeons, uh, apparently didn't really know what was going on. So he was stable before and this totally fits his personality. Great guy. Um, did his thing before, did his thing after, good to go. One surgeon went up a fair amount, uh, significantly. So, um, and that, so it's not gonna be everyone. OK. Another thing is and I find this very interesting too. So one of my big points is if you give people data that they believe in a near real-time fashion, they will make serious changes. But what happens when you stop giving them the data, which we did. We, we felt like we reduced the cost. We kind of took off the gas. And, and it's been stable. Uh, and to this very day, the mean costs are around $300 which is dramatically different. So I point to the administration. It's just like with the complicated Ay where we improve care and this, you set a new, it's like setting the thermostat. And there'll be some drift probably with new people, new tools, but it is true that once you set this down, it's, it's more a, a perpetuity type thing. Uh, and it just shows again, just a longer time horizon where they're still low. Uh, this I thought was interesting. So this is Speck, uh, who we love, Doctor Speck. She actually is now at Michigan. So it's a challenge for my Api population now because they're not getting the, uh, lowest-cost provider. And if the, if the person whose costs went up 20% does more and more appies, it's not gonna look so good. So, uh, that, this was her curve. This was all of the early adopters. This is my friend who took a while, but interestingly, uh, he now is a very low-cost guy too. So it just took him a long time. Uh, we also, we're not really using endo loops anymore. So another, um, kind of interesting thing about this is that's what we were using in the beginning. They're kind of clunky, you know, if you watch residents do it, no, no offense, but it, it's kind of painful. I'm not very good at doing it myself. Uh, so one of my partners said, hey, how about these Hemalock clips? I'm like, what's that? So that's what we're using now. Uh, it's super quick and it's actually cheaper. So there's these little pack of 6 Hemalock clips, which is the cheapest looking thing, but it's very secure. It kind of clicks. It's, um, it's kind of nice. So it's 6 clips, $35. And that's what got this guy, um, to change. So he didn't want to mess with the end of loops. Um. But he now uses that. And then here's our non-adopter. Uh, the point of this slide is number 1, they're going to be these folks. Number 2 is the status quo. If you're not working on value and looking at this, the status quo is not stable costs. The status quo is increasing costs. Um, you know, I don't think this person is doing this to tank the whole thing. I think he just uses what he uses and the costs go up and there you go. Uh, but it, but I think it's an important point. The costs do not stay steady uh if you're not trying to. Lower them. Um, wrapping it up here. So we use this, um, OR cost accounting system. It's called point of use. I'm not sure what you use. So when you do an appendectomy, there's the standard stuff they open and there's all the disposables. So they have that little wand where they zap it and then that populates a database called point of view system. When we first started doing this, uh, we found all sorts of inaccuracies with that system because what happens without a standardized, um, system. Is the nurses, their main desire is to help you out do that case. You know, they want you to be happy. They want a good day in the room. So they'll get the ligature, they'll get the step cannulas, they'll get all this stuff and zap it all, which populates the POU system. And then at the end of the case, if you haven't used it, they'll back it out. But oh yeah, the end of the case is a busy time. So we found about a third of the time. We didn't intend this, we didn't know this, but just by shining the light on the system, about 1/3 of the time, there were inaccuracies. So by changing Uh, nothing about your surgical decision making, but just by looking at that POU we cut some costs. And I, I, I, I, um, kind of, uh, compare this to going to a restaurant. So we were at the Capitol Grill last night, which was awesome. So imagine we go have that dinner and we leave and we never even looked at the bill. Like that was good. That was awesome. We would never do that, you know, so you look at the bill, like, hey, We didn't order the Lafitte, you know, for $2000. That must be the next room over. Um, so it's the same with the POU. So what we ask people in addition to, uh, thinking about your tools, on the way out, just get the, uh, circulator to show you that POU system. And that's, that's when, you know, Doctor Speck noticed the gloves and this, that and the other. Um, constant monitoring is key, and I, again, I kind of call out the just right staple. Uh, I think that's a fantastic tool for some neonatal lung resections or something like that. But to, you know, divide the Ay with an $800 stapler, it's just a little different, I think, um. Uh, one interesting thing, so I'm, um, again, I'm more of a clinical researcher. I've been amazed at this automation of some of these data visualization, uh, methods. So what, what I'm used to in the clinical research realm is you push, push, push, push a project, you're working, you've got some resources. But as soon as you stop pushing, it's, it's done. Like it's just gonna sit there. Well, with these, uh, data, you know, automated systems, so my buddy Andrew actually left Vanderbilt for about 8 months, came back, um, and the day he came back, we just kind of pulled back up the Api Tracker and there's, it's all there. Like there's no, you know, it takes a little bit of work on the front end. Um, but it's a very powerful, uh, cause it just runs in the background. So the APTracker data of all the cases that are done today, uh, will be available probably a couple of days from now. So you would get that. Um, so, um, I think another important point that I've tried to make is even without incentives, OK, I think we should have incentives. But even without incentives or standardization, you can have a significant impact. I do think standardization would make it so much better. Uh, and I wonder had we had incentives, you know, what, what would our impact have been? And I think right now it's doing this is, is not a very common thing. So I think that's it. Thank you very much. Yeah, I'd like to first thank, oh. I'd like to thank you for, for bringing this message to us. I think, um, it's, it's remarkable some of the improvements you've, you've achieved. Um, one of the issues that always comes up is what's the, the countermeasure and, and the discussions that come up in our group sometimes is, well, if you're not gonna use a stapler, how much is that gonna increase my operative time? So, um, when you've looked at the instrumentation, have you also looked at the. The OR, uh, time. The, the second thing is that, That obviously getting the data, I think is, is the most critical thing, and I think transparency is good. We all live with very competitive groups, and I don't know that you need incentives as much as listing what everybody's costs are, and then there's a self, self-drive that comes out. Are there other procedures that you're going to expand this too, because obviously getting the technology going is always the biggest challenge. Yeah, so we have looked at the OR time and that, that is a very good question. Uh, and a surgeon should ask, they should be skeptical of something like this. You know, if you said, hey, we're gonna do this great thing and It would be inappropriate to say, oh yeah, great, let's do it. Um, the, and we've heard that, uh, from several of our surgeons. So with Abby specifically, Um, we have some slower surgeons and we have some quicker surgeons. Uh, we, we have some ends of the extreme, I think, based on some of the national data. Um, and those guys are exact, they're the same pre and post. So the slower surgeons before they've changed their, uh, tools. They're still the slower surgeons. The faster ones are the same. And nobody's times are, um, significantly increased. Um, I mean, I think, um, we published this about a month ago, uh, looking at this specifically. I think the times were up like a minute or something, but Uh, so that was not, um. I mean, I think that's, that, that's good. That's comforting that you can make these changes. Um, as far as what we're doing next, um, we are digging a little bit into cardiac surgery right now. Um, again, looking, because this is an important point. So if you look at Utah, why did they pick sepsis joint replacement? So they have this thing called an opportunity index, which looks at the direct cost of care of a specific, um, Condition or procedure, um, times is coefficient of variation, uh, which gets you to this opportunity index. So they focused appropriately on very high-cost, um, procedures. Appendectomy, like we have lowered the percentage a ton, but if you look at the actual dollars, it's a very cheap thing. So we, we now are adding about 1500 or so to the hospital's margin per year for appendectomies. Uh, so it's, it's a bigger thing percentage-wise than it, uh, than it is actual do. So we now are looking, working with cardiac surgeons and trying to look at, um, some of their population because it's such a higher cost. Um, You know, procedure and conditions, the problem we're finding. Is, um, appendectomy is heterogeneous enough, but you can kind of get to a pretty decent population and the cardiac surgery is much more heterogeneous. There is one, paper I didn't show that's really good from UCSF which gets to your, uh, question about what to do next. Where they also, they had a surgeons score, scorecard. And they, um, it actually was a very nice study. It was a case control study. So they had orthopedics, neurosurgery, and ENT get the scorecards. Everyone else at UCSF didn't. And they um had about a 9% reduction in total direct costs in the three groups that got the scorecard. And like the point I've been trying to make, costs don't stay stable. The cost in the other group went up. So it is doable in other um. Procedures. We've not, um, since we're kind of working more for the hospital now and they're really tired of hearing about appendectomy. Uh, they, um, you know, which a lot of us are, I guess, but, um, so that's where we're going. But you know, it's on us to get the next thing. We feel pressure about that. So we're a minute after the hour, but let's have one more question and then we'll go ahead and have everyone come up who wants to say an accidental questions, uh, outstanding talk, Marty Jackson. Thanks, Marty. Obviously this is something we should definitely do, and it was a fantastic talk. I have more of a conceptual question. Let's say we look at your data as is, and I realize that there are some issues with the veracity of it in terms of whether it really isn't, is different or isn't. So you reduce costs by $500 per case an appendectomy, your SSI rate goes from 0.9% to 1.5%. So, that's your value equation, but how do you quantitate that? How does one look at that and say, OK, what is an SSI worth, and how do you uh determine that, uh, cause it's a lovely equation until you get to really it's rudiments, cause none of us want to have more complications. Yeah, no, that's fair, and I think I'm not concerned about where we are now, because again, I think um You know, it was actually 0 before, you know, that other one was something else, 0 and 1.5. Um, like I, uh, You know, we could differ on how important that number is. Um, but I think you could go to the next level, uh, to ask your question, what is the impact? You could go look at those 4 patients and then say, well, you know, measure the impact of that. I mean, I think what we don't have right now, which would be good, is a more objective product of that equation, you know, so if, if it's whatever the number is, if there's like a national thing, it's, oh this is a good value and this is not a good, we don't have that right now. So that's an opportunity. But the way I would specifically follow that, your question will be to say, OK, we had 4 SSIs in this cost reduction value improvement, uh, period. Let's look at those 4. And now if it was, um, you know, a patient came to the clinic, uh, 3 weeks later. With a wound that was kind of pink and no drainage and everything healed and we didn't, you know, we may give him amoxicillin or something. Like that's one bit of information. If it was a family calling and saying, I think, you know, so I think we could get to those, um, how important it is. Uh, we're never gonna get back to the just pure math answer. Um, but I think that would work for me. Um. Because that tells you how impactful those things are. Um, so Outstanding. So unless there's actually a group waiting to come in, I think we can probably take a few more questions. Doctor Farri? Mm Hi, thank you. Just a very quick comment. Um, we actually are doing some of this work here and I wanted everybody in the room to be aware of it. For the past year, we've actually created a dashboard that looks at the, um, uh, all of the activity for the entire episode of care going from preoperative, um, testing, optimization, intra-op, uh, post-op, and then post-acute. And what we're trying, uh, uh, we do get the cost data. It's not automated from the data warehouse because it has to be reconciled and manually input. Um, we've done this for certain case types, um, trying to look at where the highest cost for the entire episode is. We haven't drilled down into the specific intraoperative costs, but it's a wonderful way to actually look at, uh, sort of what you're doing, and I think, um, despite The lack of incentive. I think when surgeons and certainly all care providers are given information about what the cost is where they've never really been um exposed to that before, it's really pretty telling and people are very excited to do it. So we've done it with spine, laryngeal cleft, um, uh, some craniofacial work, and happy to partner with anybody here if they're interested in doing it on any of the general surgery cases. I think appendectomy here might be ripe for that. Uh, any other, any other questions? I think that's important. You know, the OR supply costs with appendectomy make up about 15%-ish of the overall cost of care. So I think the biggest bang for our buck, and we actually are working on this too, uh, although not so much with the hospital because they're kind of tired of hearing about appies, but, uh, reducing the length of stay, you know, I mean, there's tons of groups for a long time that have been sending kids home the same day. Um, there's tons of evidence about that, and, and that would be the biggest cost if you could reduce that a little bit. Uh, thanks very much for a great talk. Uh, my question is, where do payers fit into all of this? Because, um, You know, when, when payers get a hold of the fact that, uh, the total cost for a given operation could be much lower than they are, uh, what happens to overall reimbursements and how, how do you conceptualize incentives, uh, kind of in a framework where we depend on third parties to pay for our healthcare costs? I think that's a great question. And so if you think about what have we done so far, um, You know, in some ways, it's a little underwhelming, like we had this big percentage reduction. But all we've done so far is we've increased the hospital's margin. Well, that, that's not where I wanna end. Yeah, that's great, because if I increase your margin, we, we know, our, our incentives are aligned. But I would love to go to the insurer, uh, and again, uh this is just me speaking, you know, Vanderbilt would not approve of any of this, but um it, we're in a competitive market, so, you know, we have a pediatric surgery group that competes with us, that's about 1 mile away. But what if we went to the, the insurers and said, hey, we know what our costs are, and you've been paying us, let's say you've been paying us, you know, $6000 or whatever it is. We actually want you to pay us $5000 but in return, uh, we want more market share. Uh, I mean, that to me would be how to leverage uh what we're doing. Um, so the, the pay, payers need to win. Um. You know, right now, the hospital is win, they're doing all the winning. Um. So, and then the patients, you know, once patients have more skin in the game with paying for their own costs, which they do now with high deductible health plans, um, if, if the, if the insurer pays less, um, You know, that, that way they could win too. So, um, I mean, I'd love to hear how you're approaching that from a, um, you know, children's hospital point of view, but I mean, those are my thoughts. Um. Because right now the parents are paying the same and the hospital is making more money. So I think in In that regard, I think a lot of us are curious. So we have some key members from our governance in the audience who know about the cost pretty well and how that's distributed. Um, so there's two levels, you know, one is the issue of reimbursement from the insurer, and the other is the whole concept of sharing the margin. I wonder if you can expand a little bit more on how you've discussed that at Vanderbilt and how we might begin to think about that here in other institutions. So Vandy is totally opposed to sharing the margin idea. Um, and I think I suspect most hospital systems are in that category. In fact, when we showed the data to Luke Gregory, who's a great friend of mine, he's our CEO, he's like, see, we don't need incentives. Your own data just showed that without incentives. But my point to him, OK, well, where's the next thing? Well, like, we got 70% uh cost reduction. Why is ENT and Ortho and why are they not doing these things? It's because they have no incentive. So we are very interested in it. So, uh, I mean, to me, it's about stimulating, uh, people to come up with it cause providers know where there's waste and administrators don't know that. They, they know a lot of things we don't know, but in our specific area of care, we can figure out where the waste is. And to me, unless it comes from those on the ground providers. Um, and I think that's, you know, you incentivize behavior if you want to happen more often. That's been around a long time, forever. Uh, but our hospital was, uh, Not so much into that. All right, we'll take the final question from Doctor Kessilia. Hey, thanks a lot. One of the interesting things that goes on here is looking at total cost for any of these procedures. That includes the length of procedure, cost of the equipment, length of stay, etc. And we've, we've developed tools so that we can track that. And if one gets into a global payment system where the surgeon's fee is part of that global payment. Then all of the cost, the length of stay, duration in the OR, all the rest of it becomes critical to manage. And so the incentive is really going to be there if we go that direction, and we're certainly gonna, go there in a number of cases. So, I think the incentive is, is gonna be there. An interesting thing that I saw in your data, your time in the OR, uh, OR time for the surgeons varied, uh, from 35 minutes to 71 minutes, 2 times variation. And in all the procedures we've looked at in every specialty, that's been the number. It's been 2 times variation with surgeons, so you get to surgical time, and then I saw your length of stay data was really pretty broad. You were on a simple app and you were from 1 to 4 days. Uh, where lots of cost drivers are there. So your, your scorecard is great, you're really on the right track, and we're, we're gonna try to catch up with, uh, better information to people, but it's really very good. Thank you. One last comment on that is, um, when you talk to surgeons, um, you know, what we've learned from this is what can a surgeon control? Cause when the hospital looks at, at OR time, it's not your time. So if you go in and do a twenty-minute acting, They don't see that, they're looking at the 39, 40 minute room time. And so you can control some of that if you can do a, if you can go from a 40-minute to a 30-minute, you've reduced part of that time, but it gets diluted because of all the other stuff going on. Um, whereas, so, so we think you can control some of that, but it's not totally under your control, but what you can totally control. Uh, would be the supplies, and then you also probably have maybe even more control over the length of stay just with, uh, proper discharge timing and, uh, so it, part of the message is, um, here's all the outcome measures and what can you control first. Um, so. Well, Marty, thank you for a spectacular talk and for making the visit from Memphis. Is here.