Sandra L. Fenwick - State of the Enterprise

Chief Executive Officer of Boston Children's Hospital. Uh, she joined Boston Children's Hospital in 1999 as senior vice president and was appointed Chief Operating Officer, uh, that year and named President in 2008 and was appointed President and Chief Executive Officer in 2013. Prior to arrival, prior to her arrival at Boston Children's, she served as senior vice president of System Development for Care Group Incorporated. And prior to that, she served as, uh, served in a number of senior executive roles at the Beth Israel Hospital for 20 years. Um, she currently serves on the board of directors of many groups including Harvard's Weiss Institute for Biologically Inspired Engineering, uh, the Greater Boston Chamber of Commerce, Massachusetts Digital Health Council, among others. She's also a member of the Massachusetts Women's Forum and Women Corporate Directors of Boston. Today, she'll be giving an update on the state of the hospital. Sandra Fenwick, thank you. Oh, good morning, everyone. Uh, thank you again for the return visit. Um, it's a, it's a real pleasure to be here and, uh, I'm just trying to get this thing in so I can stand here. Um, I, what I thought I would do this morning is really try and, um, give you a, a sense of what we did actually last night at chief's meeting, and that is to kinda give you a sense of, you know, how are we thinking about what's going on outside this hospital. And then how are we incorporating that and where are we focusing, and then how are we taking a longer view out over the next decade, um, as things are changing so incredibly fast, um, you know, I like to think of this as sort of the perfect storm for us. Um, it's about the degree of change, the rapidity of change, and the uncertainty of change, and I think all of those things apply to healthcare these days. Um, so what I thought I would do is first and foremost, um, talk about, uh, two people whose shoulders on which we stand, uh, I think you all know, uh, T. Barry Brazelton and, uh, John Hall, um, who were giants here at the hospital. And I always like to think about looking forward, um, by starting with looking backward. Uh, this place is gonna be 150 years old, right, Mark, uh, next year. Um, and we have truly, uh, stood on the, on the shoulders of giants, and several of them are here and our, uh, leaders of our, in our, our various departments, but also are people who have made enormous contributions, not just here at Children's, uh, but globally. And so I just want to always say that this is not just about looking forward, but it's about respecting. And building on what we have built here and hopefully what we can preserve and continue to do here at Children's. So, we talked a little bit last night um among the chiefs about what we called pressure pressure testing our strategy. A year ago, um, we, every year we have a retreat with our board. You don't have to see all this, you'll see other slides, but I just wanna kind of quickly walk you through the bullets. A year ago, we said, lots going on, we need to step back and say, are the things that we're working on the right things to be working on. To position us, to strengthen us so that we can face all of those challenges out, outside our institution, obviously to some extent inside. And then we put a series of initiatives together and it was the basis on which we formed our goals. Um, and this is a restatement, uh, last year, about a year ago. Of, um, not only uh a confirmation at the very top of our missions. So we always want to say that even though we may focus on certain elements of our, of our missions, um, we have a four-part mission of community care, research and discovery and education. The strategic pillars underneath those, if you can't, can't read them, say, To be a destination for children who need our care locally and all the way through globally. And then on the research side is to drive research and innovation to care for patients and strengthen our differentiation. Those two pieces we felt were important to articulate as the two major reasons why we are here. The interchange or the interdependence of those two pieces, what we do to really advance care, but also the fact that we are constantly not only just pushing the boundaries of the um trying to find the right diagnostic tools, the right therapies, but also how important that is to distinguishing us as a place where patients do come, not just from within this community, crossing over even other institutions, but also are coming increasingly nationally and internationally. And then we worked on our, our strategies underneath that, how to make sure the patients still could get to us, um, experimenting more with our population health and how that whole aspect of care is changing, and then how do we look at our research program and say, We are not going to abandon basic science, but we are going to continue to try and help drive that more expeditiously, accelerate the ability to take our research, our discovery, and our innovations directly to patients. Um, and underneath that, um, our priorities are our people and our operational excellence. That means inside the organization, but also how it impacts and works with our patients. And so we ended up this past year identifying a whole series of initiatives under each of those 4, of those major priorities under care, under research innovation, around our people, and around operational excellence. And if you can read those, Sorry, it's a little dark up there, um, but under the care, uh, we focused not just on growing those complex patients nationally and internationally, but we also, and I know Bob has been a, a, a very important proponent of this, we also have to look locally. There is so much tumult in our market. Uh, with all the consolidation, with all the, the new systems being, um, consolidated and developed, the question is how do we make sure that patients can get to us? How do we make sure we're not gonna get caught out, cut out of a, of an insurance product? How do we make sure that a system doesn't decide to build up their capacity and, and say we don't need children's anymore cause we can deliver it all internally. And so those are the kinds of things that we have been looking at. Who are the, who are the important decision makers, families, themselves, referring physicians, patients, government, all of those, and how do we ensure that we are at the table with every one of them, ensuring access for the patients that need to come here. And then as we look at the research, we're going to be going through a much deeper dive on the research side, um, really looking at not only where our areas of focus are. But what do we put in place to ensure that we can translate those discoveries, those scientific, um, uh, new, new findings into therapies and get them to the bedside and get them to patients faster. Um, and, and how are we gonna deal with all of these new therapies and these new high-cost drugs? Um, we are a place that's really the place that's starting with many of those. Uh, not only how do we set ourselves up to be able to safely deliver them, but how do we make sure that when they are $750,000 or $500,000 per treatment, that we are actually going to also get paid for them and that we have an open door with all of the payers to ensure that um we can do these things, but it also doesn't cripple us. Um, around people, um, there is no question that the people in this institution. are, um, what, what we are all about. I always like to say we are nothing without our people. We have a technology, we have space, we have facilities, we have tools, um, but we are absolutely nothing, uh, if we cannot recruit and retain and make this a community and an environment that's, that's a place that people not only want to come and be trained but also want to come and stay for their careers. And then we have a lot of work to do on the operational excellence side. That's internally, we know that on the administrative side, our systems have not been good for people who need to use them, but on the clinical side, we know that the, the electronic medical record, um, are, are, the work that, that we ask you to do both on the inpatient, the outpatient, the surgical side is really not where it needs to be. No one in this country has figured that out. But we have tried to put in place a strategic tenure, uh, uh, uh partnership basically, uh, with CERN and we've said the number one job for us is, well, actually there's 21 is to prevent downtime because of the, of the difficulty that that creates when that happens. And 2 is to improve the ability of our clinicians to use the medical record. We've started on the outpatient side. We've made a little progress. We know it is absolutely inadequate. We know that on the inpatient side, we haven't even begun to try and address that. And so that is really one of the major efforts around operational effectiveness, um, that, that we're working on. And then it's all the pieces that also interface with those that refer to us as well as the patients. How do we improve access? How do we improve timeliness? And we know that people like Steve Fishman have been spending inordinate periods of time trying to figure out how to deliver better service to those that we're, we're delivering, not just on the clinical side. We know we're working on safety. We know we're working on quality and high reliability. But how do we work on all of those other aspects of the experience of our patients where they are going to increasingly demand that of us, not as something additive, but something fundamental um to when they come here. So, we have put together, um, and again, you don't have to read this, it's just, uh, these are the things that in fact are gonna come out again, um, in fact, probably in the next couple of hours of our metrics. How are we measuring, uh, that we're actually making progress? These are not our goals. These are just indicators of are we actually able bedded discharges, surgical cases. Uh, if we start seeing a slide, it's not because people aren't. Wanting to take care of patients here. It could be because we have some major roadblock that is not allowing patients to come to us. So these are indicators that tell us um when there are things that we've got to uh do a deeper dive on. It also is what drives, unfortunately, the economics that keep this place afloat. And so it has many reasons why we pick some of these metrics, and then you can see some are red and some are green, um, and it allows us to say when they're red, we need to understand why, why in the staff and engagement are we going backwards and, and not making the improvement that we said we wanted to. We're not hitting the target. We're not making the progress, engagement and in people feeling good about this place. Why is it? What are we doing about it? We had a forum with about 300 of the managers, directors, and leaders, both on the clinical and the um and the administrative side in the fall, in the spring, in, in April. And we spent almost the entire session, about 4 hours, asking those questions and trying to figure out what do we do about it, not just how do we measure it. Um, we also are trying to figure out again, don't try and read this, just indication of this tells us when it's red, we're still not hitting month to month to month, but in the green, we are. And so, why are we so, uh, so successful in some areas and why are we not achieving what we set out to do in others, and then what are we doing about it? So that's just kind of what are, what are we doing and how are we looking at the current year. So, but, but the real question is, are we really working on all the right things? So this is something we shared with our senior leadership, our chiefs, and then with our board. On the left-hand side, uh, you see that this is the market position, the great position that we have achieved as an institution. We are the destination for complex and rare disease. We are the preferred place in Boston for children. We, we take care of more children in Boston, from Boston than any of the other hospitals. We are also the number one ranked, not just hospital but pediatric research facility and in care and in research. So how do we preserve that? How do we preserve that position? And the place that then says this is the place for kids, this is the place that you want to come to, this is the place that donors want to make their major contributions to, and this is a place that people want to come and work. Um, we've worked on all of these things, but then if you go across, we said there are major disruptions that are going to potentially threaten us and threaten our, um, our position. We know that other places in this country are growing. So there's more kids, the ability to really just basically do well and continue to thrive without having to say, gee, our marketplace is, is um either flat in terms of the number of births and kids or it's declining. How are we going to stay ahead Of that scale for all of us is critical. We need to be of a certain size to be able to take care of the kinds of kids that we take care of, to have the breadth, the depth, the capabilities that we have here that other places don't. And we're seeing this all over New England where many, many places are coming to us saying we cannot keep good people, we can't keep neurologists, we can't keep cardiac surgeons, we can't keep even general surgeons. Because they're, there's one or two of them and they're trying to cover whole institutions. They have no colleagueship, they have no education, they have no ability to do innovation, and so we're seeing this all over New England where we're being asked to help. And so, how do we make sure that we don't get ourselves into that position and how do we go all the way over to the right and preserve 10 years out, the same place that we've been over the last many, many decades. So we've thought about what we are focused on, the important things that we've talked about as what we call no regret strategies. They're all fundamental. They're all must-dos, but the question is, are they all necessary? Is there anything we shouldn't be doing? Are they sufficient and enough to position ourselves and to take advantage of the opportunities and to overcome all of those threats that are out there? Uh, many of you, uh, have, have read about some of them and some of the things that are happening. All of these, whether they're what we call horizontal consolidation, so that's systems coming together, BI Leahy, partners continuing to grow, partners now continuing to grow across state lines into New Hampshire, into Rhode Island, and then there's also what they call vertical integration. Um, this is what Walmart is, is starting to do, where they're trying to get into the insurance business and they're trying to get into the care business. Um, and, uh, Amazon, Berkshire Hathaway, and JPMorgan really trying to figure out how they're going to provide soup to nuts for their employees. They've got, you know, hundreds of thousands of employees that they could then pull out of all the traditional ways that we have accessed and patients have been able to access us. So those are the kinds of things that we're looking at and saying that this is, this is massive change. This is massive disruption in this healthcare industry locally and across the country. And then if you really look even beyond that, all those kinds of changes are actually happening in most of the developed countries. And so we went through, and I'm not going to go through all of these, but These were the top critical uncertainties. Can you read them in the back? No, hard to say. Federal healthcare policy, financing care and shifts, the mass state dynamics that um I just talked about, the changing landscape that I also just mentioned, consumer behavior. We have a totally different population of incoming parents who think very differently about how they want to receive their healthcare. A lot of them want to receive it on their device. Many of them don't even wanna come in for care. They want to do it remotely. Many of them want, are, are happy, uh, never having to interface, uh, unless they are absolutely sick. And so how are we gonna manage those patients that are not the traditional way we've always thought about caring for patients, either upfront or, or post-care. Um, how, how are we going to interface with them digitally? All of those things that, uh, that we're asking those questions. And then what if we were to look over the next decade, what are the advances? What are the treatments, what are the cures, what are the procedures that are going to be new that we may develop or others may bring to, to the, uh, to, to the care model and how are we going to incorporate those into our, um, into our care model. And how much of it is going to be not only in the hospital but be pushed further and further out of the hospital. People are talking about outpatient bone marrow transplantation. People are talking about a whole host of these very high-end drugs not being even delivered in the hospital setting anymore. And so all of those things are huge implications for how we think about the future. So we went through some scenario planning. We asked questions about how fast is this all going to happen and how is this, how is society in this country at a minimum going to value healthcare? Are we going to invest as a country or are we going to shrink the healthcare landscape in the healthcare world? Are people going to think about us as a liability? To be managed as opposed to an asset that is really fundamental to the success of this country, to the people, to our future, to the society, um, to business, to jobs, and so those are the kinds of questions we've been asking ourselves because it's not 100% clear how over the next decade these, um, these trajectories are, are going to occur. And so we've tried to then say, what would it look like if we shrink and it's slow or we shrink and it's fast, or we invest in more NIH and more healthcare and we try to really advance and we, and we respect and preserve what the academic medical centers are really bringing to this country. And what would that look like if we were able to say, take off some of the shackles that are around our ankles these days and allow us to really contribute versus the the reverse, which is what happens if we continue to feel this unbelievable pressure of reduction and shrinkage. And so those are the kinds of things we've been asking ourselves, and we've been taking this deeper dive, um, continuing to say we need to do the must-dos, but also We need to think about what those 10-year scenarios are going to look like, and we came up with um some themes that we think are going to be critical as we try and navigate uh the next several, um, the next several years. The first one we said was And I think our board and those of us who are in a session with the board said, boy, you are one complicated organization. You make decisions rather in an arcane, complicated way. How are you going to disrupt yourselves first? How are you going to change the, uh, keep the best of how you've been able to innovate at the local level, but also standardize and, and be more nimble so that you can pivot, um, and make decisions and move and discard things that may not be, uh, uh uh something that you can continue to do. We've been doing this in, in large measure. We've moved so many children out of this hospital as we have evolved from, you know, surgery that, that we now have moved not just um uh to from ICU post-care to uh to regular units. Uh, we've moved them to outpatient. We've moved them from Longwood to, uh, to Waltham and Lexington. So we've been on this journey, but the question is how fast is that going to move and how fast can we adapt. Um, everyone has said, people, people, people, how do we make sure and what do we need to do to, to focus on bringing in people like you, the best of the best, and make sure that they want to be here. It is hard these days. We have, we have so little to put. You know, as we're trying to figure out how to put resources into technology, into new facilities, into um work for our patients, into services for our patients to then think about what do we need to do for the people who are here, and that's something that everyone board, board absolutely said, boy, you can't take your eye off this ball and you have to learn and understand what it's going to take to continue to do that. Um, again, we talked about redefining our research. Can we do everything that we're doing today given the limited resources we have? We continue to have donors want to continue to support research here. 60% of what we have raised goes to research, so we're not, not able to do that. I think all of you know we're in a, an incredible capital campaign. It's raised already $1.2 billion over the last 789 years. We will continue that process beyond the campaign. We need to continue to focus on reinvesting in people, in clinical and obviously in our, in our research, but where we will focus and how it will get translated to care is critical. Um, Digital and AI, uh, this is going to be the wave of the future. Not only what we build and do internally, but who we partner with, and the last one underneath there is about partnering. We know that whether it's, uh, moving care, moving, uh, or, and, and partnering across the whole continuum, whether it is moving science to the bedside. Uh, Whether it is uh incorporating digital and AI internally into our tools or externally as we interface with our patients, we can do some of that. We can be creative. We've got wonderful people here who have wonderful ideas for new ways of doing that, but to scale it, to actually get it so that it's something that isn't just a, a whole series of apps that people can't even find on their iPhone. Um, those are the kinds of things we need to think about how we're going to, uh, do a better job of. And then number 5, investing in identifying where along the care spectrum, we are going to focus. Um, you know, we cannot possibly be everything to everyone. If you think about the, the, you know, the community, being in health centers, being even in the home. And uh really working all the way up primary care. We don't own our primary care system. We partner with them. We partner with our PPOC, we partner with Atrias. We partner even with our competitor, um, uh, primary care systems. Uh, the question is what, what role will we play across that whole continuum? People keep saying you need to be in the schools, you need to be, you know, in the community, you need to do something about housing, you need to do something about food, um, you know, how much can we solve as an institution recognizing that all of those things are critical to the health and well-being of children and their families. But where can we devote the appropriate resources when we also, also want to take care of those kids that nobody else can. Those kids that are here in the city, across our state, across the country and, and around the globe that have no other options, and those are the kids that we also believe we should be caring for. So, we've got a lot of questions about where along that continuum, uh, we can also make impact. So those are the things that we have, um, we've talked about, um. This is really just the summary of what we're going to be giving back to our board in the July board meeting where we've talked about transforming research and making sure that we really support the entire pipeline, basic through translational, through clinical, clinical trials, that we go big in digital and AI and we're going to be putting together a group that really creates a work plan, not just how do we support ideas across the institution. But where do we focus and how do we make the appropriate digital hospital as we think about the new hospital? Um, how do we make it more functional, um, and then how do we also use this with patients. We're gonna think, and, and last night we had an interesting discussion with the chiefs about disrupting ourselves. Um, what do we preserve? What has allowed us to be nimble, but what also has created a very complicated organization, uh, to work within. Um, we need to refocus our work in the the local and regional. We still have 65% of our patients, uh, coming from our local and regional areas. Yes, we're going to continue to try and bring patients here nationally and internationally, but we need to make sure that we are the destination for those kids as well, uh, for those kids who need our care in Boston across the continuum, but also those, uh, within the, the, this marketplace. And then we also need, um, it's not in there, but, uh, one of the big things that the board asked is how are you going to make sure That when you, when you, since 35% of our patients are on Medicaid, how do we make sure that not only in this state, but state by state by state, we can continue to have access to those kids who need our care. And then last but not least, there is no question, no matter what we do, that these elements of what we call our, our value proposition, uh, every payer, every referring physician, every business, every patient and family is going to be asking about um and assuming a level of quality, safety, reliability in everything we do as a basic minimum. They're gonna be looking for the kind of experience they can get anyplace in places that are now delivering it, uh, much more facilely than in some instances we can. And then we're going to be forced on price because everybody is, um, and I think if we think about those, those cross-hatched scenarios that this is going to be what people say, yes, it's excellent here, but at what price is it affordable for not just everybody but for businesses and and the like, and that's true of how we are actually dealing with. Embassies across, across the world. Um, they say, number one children's hospital, best experience. Patients come back and say this is where everybody should go, but then they put a gun to our, to our heads and say, at what price? Um, so all of these things are still going to be part of the equation and uh we need to make sure that we're continuing to focus on those. So I'm going to stop there. Um, I may just come down, so um I don't have to stand behind here. And uh just open it up. I think we've got another 1520 minutes or so. Uh, be happy to either answer questions about this, but I also thought that this was truly an opportunity for me to hear what issues you have concerns about or what issues you're dealing with and just open it up to the floor. Fenwick, I'd first like to, uh, thank you for bringing that message to us this morning. There's certainly some components of it that are troubling, but I think we need to know what our challenges are going forward. And before we open. The Florida questions, I'd like to thank you for the leadership you've provided here that's kept this massive ship headed in the right directions over the years of your leadership. So thank you for that as well. Thank you, Bob. This is, uh, for me. This is a labor of love. I, I absolutely love this place, and what inspires me every day is what all of you do, and I mean that from the bottom of my heart. Um, I, I could not tell you how much I wish I could solve every single one of your problems. When people ask me what's the hardest part of this job is knowing how many people struggle to do what they do every day, and I don't have enough resources. I don't have enough solutions. I can't fix the systems fast enough, but that's why I'm here, Bob, and um I'll do it until the day I walk out of here. Questions for Ms. Fenwick. Come on, you gotta have something you wanna tell me that's good, bad, or indifferent. Doctor Jennets and Rusty, I'm rusty, never, never shy. So I have, um, we all struggle cardiac surgery and the, the eat program and surgery in general. We have really critical restrictions on throughput on patient throughput. But unfortunately, it's everything. It's, there's not enough beds to get the kids out of the ICUs. There's not enough ICU beds, and there's not enough ORs and not enough OR time. How do we just improve, like, we need to make the whole system bigger. I mean, we need more ORs, more ICUs, and more floors. And, and maybe I'm really simpleton. I think in hospitals essentially ORs, ICUs. And a hotel. So is there a way to like Isn't there, isn't there a way to really invest in what's the important parts, the, the working machinery and then hire a hotel nearby to put everybody when they're recovery? So, so, Rust, Rusty, you're absolutely right, and I think we identified literally a decade ago, um, that we were gonna be in this place. And one of the frustrating parts is how long it takes to solve problems that we know we need. The regulatory problems in this state are crippling. Um, it took us almost 5 years to get approval once we knew we needed this, and now it is going to be, and we've been in the ground for 18 months, it's going to be another year before we literally see steel coming out of the ground because we are so constrained in this footprint. Um, clearly we, you know, there are people here who feel very passionate about the fact that we had to take the garden. But that was, that was, that was it. That was the most, the only place we could put something that connected to the rest of the ORs that made it not less efficient, uh, but we're gonna be another 3 years before we have what we need and we know we need more critical care beds. We know we need more ORs. Um, every single time I talk to someone, they say, But can't you get it now? Um, and that's one of the reasons why we've been pushing so hard to try and get more of the patients who may not need to be here, pushing them out to the satellites, and we're making progress, but, but not fast enough. Uh, we still have capacity at Lexington, we still have capacity at, in fact, we talked about that last night at MSCC. Um, we said here, uh, in fact, it was the, it was the uh OR, uh, governance committee report. We're looking at not only the ASA ones, um, the potential to move into ASA twos, how do we move up the, the, the pyramid to some extent to try and say we need capacity here for the things that can't go anywhere else and how do we open it up and use everything we've got in the system, um, and, and so we're, we're trying, Rusty, you know, some of it is we need everybody to be willing to do that. Um, not only can we create the capacity, but can we get people to do things that are hard for them to do like going out to Lexington or going out to Waltham. Um, so though we, we have, uh, 80 more beds coming online in the new building. We have more cardiac ICUs and we're going to add almost And convert almost what we'll have. Close to, I think all of those, close, those 80 beds are gonna be close to ICU compatible so that we can actually go there first, fix that, and then understand, you know, how we rebuild all, all that's below it. So more ORs, more ICUs, um, and, and, but, and, but. Um, it's still 3 years away, so we got to figure out what do we do to get there because you're absolutely right. The, the other danger is you start turning patients away, which we have been doing in almost every service when we hit those crises, they're gonna find new pathways and so it, we are all on the same page as you because that is really uh scary. If we can't, if we can't accommodate all those patients. Someone else may and someone else will. That's what I mean by my frustration of not being able to go like that and, and, and solve what I think are absolute legitimate needs that need to be solved for much faster. So as we redirect patients to the outpost, which is obviously financially uh acceptable, what happens to the workforce here, which is just dealing with the intensive care level patient endlessly, whether it's the PACU, the OR, and the trainees whose only exposure to pediatrics is, uh, critically ill patients. So, you know, I think that that is the challenge that all the major hospitals are dealing with, not just in pediatrics, but absolutely in pediatrics. Um, I talked to my colleagues and you probably too, to do too across the country. We're all becoming at the core, um, major high-intensity ICU level institutions. Um, it is happening everywhere. It is, um, It is becoming difficult. I talked to my colleagues at the adult institutions, you know, whether it's the Brigham or the or the BI or Mass General, they're facing exactly the same things. Um, they are all trying to move out into the community using their community hospitals, Newton Wellesley, uh, North Shore, uh, and doing the same thing. So, um, it is a trend that is here and it is probably all, as we talked about what we're going to be building, we're not building. Uh, clinics. We're not building ambulatory surgery. We're not building, um, you know, sort of low-end observation beds. We're building ICUs. And so how we, you know, when we talk about the workforce and the people, we understand this is one of the things that is, um, really creating that additional stress and burden here, but it's also occurring out in Waltham. Everybody went out there thinking their lives were going to be back to the way it was 10 years ago at the, you know, the lower complexity level, and we're pushing them at a higher level. So, the healthcare system is basically saying, What you are as hospitals, as, as, as surgeons, as OR nurses, as anesthesiologists, as um as GI physicians in their, in their procedures. All the new all the new startups, all the new entrants are eating away and pushing everything out to places that, you know, we may not even see anymore. Um, and so what they're demanding of us is to take care of everything else. And that's a trend that I think is only gonna continue, and the question is then how do we adapt? How do we adapt the training programs? I know that, that Alan and, and Laura, you and others are gonna be all thinking about as we think about, um, you know, how do we train, uh, not just, you know, residents and fellows, but how are we gonna train nurses and respiratory therapists and everyone else who is, who are only taking care in this institution. Of the very, very sick and don't see the hole anymore. And that's something that it's a huge implications for the training programs here. Don't have great answers, but I think you've hit on something that we all have to figure out as we think about how we're going to continue to adapt in this new world. I echo, Doctor Schoenberger, and thank you for coming here. Um, When I'm looking, when I look at the last slide, there's perhaps a low hanging fruit when it comes to uh disrupting ourselves and transforming research, uh, which is the recognition that there are essentially 3 different universes in research. There's basic research, medical research, and surgical research. These universes are different enough in the sense that they're funded differently. The resource they need, they need are different. Their MO is different. The partnerships they need with others to bring uh treatments to patients are, are different. But right now, the leadership uh of research in the institution is perhaps excessively consolidated. At least as far as surgical research goes, I think we are underrepresented. I personally am not aware of a surgeon at a very senior level leadership position. Perhaps we could consider having something like the Chief Basic Research Officer, the Chief Medical Research Officer. The chief surgical research officer, whether they report to the chief scientific officer, I don't know, but these are enough of a different world, each one of them, that I think we should consider as far as disrupting ourselves, having dedicated leadership to cater to them. So, you know, I think part of what, uh, Bob, are you a plant? Bob and I have been having these discussions, uh, uh, literally over the, the past year as we think about not only what are the infrastructures, what are the, what are the criteria that we use to evaluate different kinds of research and how do we allocate resources, space, and the like, um, and so, you know, I think you're raising a, an important question. I think all of this, and Bob, you know, I, I think as we go through this, uh, strategic planning process. Um, we have to make sure that there is representation on getting input into this next round to identify what those, um, what those issues are and what we haven't done to to sufficiently support it, and then figure out what will it take and how do we look at it. You know, again, on the research side, we are equally constrained. Uh, we're trying to find additional research space, um, in this area. I mean, we probably could find it out on 128, but who wants to go to 128? I mean, it's bad enough we're trying to get you to go there to do Waltham, uh, and do surgery, but, um, we are scrape scraping for 8000 square foot here and 8000 square foot there, and at best, we're going to be able to find a total of 16,000 in the next several years. Uh, putting up a new research building is going to be really a challenge for us because it is another. Probably At least a half a billion dollars, if not another $700 billion project that's not even in the planning works right now. So how we deal with resources, whether it is funds from the endowment to support research, whether it's space for research, it's the infrastructure that needs to be there to actually support the translational and moving more of this to the bedside. Um, all of those are going to demand more resources, and the question is how fast can we keep up with what's needed. Um, so you're, you're right, um, it is something that we need to think about and understand the various components, basic medical, basic surgical, translational, clinical, clinical trials, uh, and clinical research. Do you want to spend a couple of minutes talking about where Waltham sits in the future plans? I'm sorry, about where Waltham expansion sits in your current plans. So yeah, um, you know, one of the challenges we've had is, um, is really trying to figure out not only we had a plan for Waltham, I think many of you may remember that we had tried to put Waltham in place before, uh, the, the new clinical building. What we hoped was that it would, and we thought we were gonna add about 40 or 50 beds, Rusty, so, and ORs, so that it would bridge the gap between what we have today and the Hale Clinical Building. The problem is the regulatory process required that we actually go forward with the clinical building. First, because of the challenge that we had in getting that through, we were afraid we'd never get there, that they, if we did Waltham, they'd say, well, you're set, you don't need the new tower. So we had to flip and do the clinical building first, and the good news is we are at least in the ground on that one. Then the question was, well, what are you gonna do in Waltham? And we had such a backlash, as you remember, some of you remember all the challenges we had in getting The clinical building approved, they now are continuing to challenge whether in fact we even need to open the beds in the new clinical building. And we've got reporters going across the country, believe it or not, from the Boston Globe, wanting to know what everybody else is doing because maybe it's gonna say the Children's doesn't really need to complete the building and open all the beds. So it's raising the question about what we do in Waltham because we had planned on opening additional beds and more ORs and it's making us rethink, will we ever get approved for it? So, what we want to do is make sure whatever we put out there. To the regulators in this state is going to get approved and not get caught up and rejected as a plan. So the plan right now is to try and figure out how to solve for, for ORs for sure. How not to uh potentially add the uh additional number of beds that we thought we would and to figure out how do we solve some of the needs of some of the projects and programs here like orthopedics and sports medicine, plastic, GI that are also constraining what we do here, that if we could create more capacity there, would also open up and alleviate some of the challenges. So we're in the process right now. Uh, we hope to be able to, uh, uh, get approval both internally and then we have to go through at least one more year of approvals at the state before we can even get approval to put a shovel in the ground. So it is, um, There are other states, and I don't want anybody to think they should leave to go to another state, but there are states that don't have this process. They have a need. They make, they raise the funds and they go do it. They don't have this, these constraints that we have here in Massachusetts, and it's not just children's. I mean you can see what's happening with the BI and Leahy and you know we've got this huge partner system and the question is do we need another one and will they get stuck not being able to do what they need to do to survive because we've got so much opposition. So, it's a, it's an environment that, that we all have to figure out how to navigate to get what we need for this institution and that's what we're trying to do. Same with the Brookline Place, uh, we're trying to figure out, we're in steel, any of you who come around Route 9 see those, uh, see the steel going up and you also see the huge trucks that are all parked up if you Come in, um, all of those huge massive trucks that are lined up around that corner are literally what's taken the dirt, um, out of our, um, out of our project here. They're gonna be 80 truckloads that are gonna be taking the dirt out so that we can build this one. So, uh, we're playing havoc a little bit with the, with the community as well. Sandy, the, the picture you've drawn is, is, it seems incredibly complex in multifaceted ways. And, um, even with our size and our expertise and our endowment, can we do this by ourselves and, and what partners are we thinking of? And then, uh, To help us and then further, if this state's such a problem, why don't we go further outside the state, outside the country, maybe even the world like the, the Cleveland Clinic has done, like the, uh, the CEO who came here and gave the, the lecture on the, the gross lecture last week, uh, has done successfully. So perhaps you might want to comment on what we're thinking about in terms of partnerships to help us with this huge task. So, so Paul, you raised a great question. Um, you know, people feel as though, gosh, couldn't we turn back the page and become the smaller place that isn't as complicated and, and, uh, you know, we've gotten so big, nobody knows anybody anymore, we're spread all over the place. We're a $2.6 billion dollar organization. And if you talk to Tom Mihailovic. Who is the new CEO who trained here as a cardiac surgeon who was the lecturer last week. He's an $8 billion organization, and he said, what, what organ, he said, when we're too small. We are way, way too small. What industry in this country or in the world. It has the largest participant in that industry, less than 2.5% of the industry. The largest system in this country is $25 billion in a $3 trillion. Industry. And, you know, you look at any other industry and the consolidation that's happened so that people can survive and be successful, um, he said there's no way we can continue to be the size we are at 8 billion. Partners is now at 8 billion. So, can we, um, and we're the, probably the largest children's free-standing children's hospital still in this country. Others are growing pretty fast, but we still are the largest. Um, it is not clear that we can do this completely alone. Now, does that mean we're gonna have to become part of somebody else's system? I don't think we still want to do that. We want to remain completely focused on children. And we made this decision 30 years ago when Partners was formed. We have visited this question every decade, and we have found that many of the other children's hospitals that have folded themselves into adult systems become a very small cog in a very big wheel, and they get, they, they, they, they are incredibly important for those systems. Because they are very important for bringing patients in. They're very important for um uh reputation. They're very important for brand, they're very important for donors. And so they bring that all into the system and then they get nothing in return. They get no investment. They basically cut out research because it just is a burden and it's not really where all the big ideas are and the markets are. And so we don't want to end up there. We want to be able to identify and forge our own destiny, but Paul, you're absolutely right. The question is then how do we partner and who do we partner with? Um, those may be very different kinds of, of partnerships than the big consolidations. I don't think we'll ever take True partnering, real, that off the table because it's always there if you get to a place where you can't survive. But right now, that is not what we wanna do. That's not what our board wants to do. It's not what any of us in leadership want to do. Um, but we may have to change some of the things the way we've done. Cleveland Clinic has put a footprint, uh, in Abu Dhabi and in London and in Toronto, and they're thinking about new markets. Because they can't live just in Cleveland. As much property as they have, there are only so many patients who are going to travel, and they are going to put their footprint and build a footprint around the globe. Um, we may be able to do something with them in Abu Dhabi and put a little bit of a footprint, a much smaller footprint with them in some of these locations. Uh, we could potentially do that on our own, and that's what we're being asked to do by many of the other, um, countries and potentially even put some kind of relationship with other institutions even in this country. There are certain states that are really desperate for much better high-quality pediatric care. Not sure what we can really do. We're still small to be able to then take our people and distribute them. And keep our brand and keep the quality of what we do. Cleveland Clinic is 4 times our size, probably from a people perspective. 6 times, 7 times our size. Um, and so they have the resources to be able to do this. We can't ask you to, you know, do eat surgery one day and run to Abu Dhabi the next. And so, how do we think about doing this? And that's really one of the things, that's really on that partnership question. Final quick questions from. Now, I'd like to thank you again for taking your time to be with us today. Thank you all.