Super Bowl Grand Rounds (10/19/2022)

Well, good morning. Welcome to Pariop, what we were calling kind of super ball grand rounds. This is a concept that we, you know, our leadership thought would be interesting to do a couple of times a year and we've reserved dates and everybody's calendars. And the initial sort of intent and our continued intent is to, one day, talk about something that might be talked about in one of our individual departmental grand rounds, but that might be of generalized interest to everybody to have some super group of clinicians who are doing something really exciting, talk about what they're doing, we all learn from each other in a interdisciplinary fashion. We haven't gotten around to doing that because things haven't been in the usual state of affairs since we came up with that idea. So we've been using these sessions to update all of you on how things are going and where we're going in the operative and pair upper world. And we're still in a little bit of an alternative world. And so we're really glad to have you all here. It's certainly a pleasure, although this is hybrid to see people here in the folk and auditorium in person. Of course, lots of us are living in the hybrid world. All the people who in the room here are people that we do see in person all the time because we work in offering them together. But it's also nice to see some people who don't get to see clinicians too often in person. We also have lots of people with us on Zoom. This is being done webinar style because of the large crowd. But we do have lots of time. We hope at the end for questions and discussion, which will be taken in person from those here in Folkman. And we'll be taken in the Q&A. Is it the chat or Q&A, Catherine? Q&A. And the Q&A. Okay. So you can put your questions in the Q&A. And we will address as many as we can and we'll deal with offline. This won't advance. Let's see here. All right. So we're going to have some of the usual crew from oral leadership speaking to you, but we also have a couple of important guests. Dr. Churchill and Dr. Chang, our CEO and our chief medical officer are going to join us. We're thrilled to have them here. They're also specifically addressed some of the issues that affect the operative area that are that they have much more information about. So we're really appreciative of their time. Dr. Churchill is actually on a train right now going down the eastern seaboard doing some important work for us. And I thought this is important enough to to log in by Zoom from a train. So hopefully that connection will go okay. It won't be a tunnel when his turn comes. But Vini will be here to backstop any kind of technological failure. I really appreciate working with this incredible team of leaders in this in this time of stress. One person who we have seen here before, but who's on the zoom, but who isn't on the screen. Doesn't going to speak. Who actually did most of the work for preparing this is Catherine Tetchy, who runs all our business operations. So a pariapta and I just want to acknowledge all the incredible work she's done in keeping us in line. So over the last several years, we had all sorts of big changes. We had COVID hit us. We don't have to reiterate what that did to our world. And then all the falloff of COVID, the behavior health crisis, the impact on capacity, limited O.R.s because the hospital was full. Great anticipation of the new building open to increase our capacity, new equipment, new space. And then tough closing the children's hospital and lots of efforts around that to take care of all the kids in New England that need our care. And. And we were focusing on making the O.R. better or more efficient. And we had a lot of success with inventory management. And many of you put in tremendous amount of effort to improve our first case on time start rate, which actually did dramatically increase. And to diminish our turnover time, which we had a little trend towards improvement, but we hadn't really gotten there yet. And then our world changed. We're like a few years ago, our world changed. Catechismically with COVID. But the way our world changed for those of us who work in operating room and areas around the operating room. The change was the opening of the new building, which was so exciting and brought so many wonderful things and we have. We have a NICU. We have wonderful ice use. We have wonderful cardio. We have all sorts of great things. And we have some great new O.R.s. And you always anticipate with opening the new building or moving to new house, some punch list items. And some. You know, in this day and age, we all know about supply chain problems. So the fact that, you know, there wasn't racks on the wall to put the gloves on or the mass sun. It was, you know, expected kind of minor disturbances and we knew we, you know, get by that and everybody was resilient to make that happen. But what we didn't anticipate was how dramatic the changes. The physical changes. The physical changes that we plan for how dramatically they were going to affect our ability to take care of kids in the operating room. And I don't have to reiterate to all of you what those, what those stresses have been. You've lived them. You've improved them. And you're enduring them. And we are to, first of all, to acknowledge the pain, the frustration, the sacrifice. And the fact that although things are better, we are not there yet. We have a long way to go. And so we understand this is a marathon and we need you to keep running. Explain what we understand about some of the systemic sort of causes of disappointment, what happened, what's ongoing. Talk about some of the fixes that have happened that are ongoing that are going to take us to that finish line of being where we need to be. As good as we were before the move and way better to where we expected to be by having new facilities. And you know, it was kind of a perfect storm of what we're going through. And we're going to come out of this at the end better. The storm was caused by geography. We used to have everything on the third floor, all of our operating rooms, all of our periop areas, our sterile processing department. Everything was in one geographic area. And now we have two separate pods of OARS on the third floor. We have a cardiac suites on the sixth floor. And we have sterile processing in the stud basement. And that was anticipated. Everything was coming. Just dedicated clean elevators, dirty elevators. You know, many of you have been down to sterile processing. You may not have ever been in sterile processing. You know, in the old day in a prior 30 years, I have never been in sterile processing. It was something to walk around to get to the OR. Now I've been down the sub basement many times and many of you have. Of course, what we've learned is that many of the nurses have been in sterile processing all the time. You guys were sort of helping out and making it happen. And it's a little harder from a distance. And all of the people who are trying to help may think it's unfamiliar territory when you go down there. But you have to realize that the people who work there, it's also unfamiliar territory. They moved into a new house and they have new equipment. And the microwave has different buttons on it. And it's stressful and challenging. And they were understaffed. So there were personnel problems. There were equipment problems that were non-anticipated. And there are process issues that are ongoing. So we're going to talk a little bit about that. And probably maybe our most important goal of this meeting, which I'll say open over, but I want to start with, is to thank everybody. It's impossible. I'm not saying the names. It is impossible to thank all the people who have worked together to allow us to. Take care of the kids. People have worked tirelessly and selflessly. After their hours, doing things that aren't their job, learning to do things that they. They know the nurses. All the nurses. I won't name names, but I will single out the clinical coordinators who have just been extraordinary, just extraordinary. And helping us get through how to understand the problems and help us solve the problems. The people who work in sterile processing materials management, talk about being under stress. They're the ones who are trying to deliver. They're the ones who moved into a new house. And the equipment didn't all work the way it's supposed to. They've been dedicated. They've been tireless. Now they have a whole bunch of new faces that they're working with each other and they're getting to know each other. So we thank you them. The environmental services staff. Our anesthesia technicians, the enterprise project management office who have sort of dropped almost everything else they were doing to help us. Figure out why the trains who are running and together running. I supply chain leadership to who has oversight of sterile processing. Our anesthesiologists who are working. On their academic days, their off days. Our surgeons who don't come home to the cases are gone. They may say that the OR schedule is going to end at five, but sometimes that means nine. We've all learned how to find equipment, how to wash the floors to help out. Just thank you to everybody who has. And continues to pull more than their load to keep us together. This is what makes us special. This is Boston Children's. I'm tired of apologizing and sometimes crying with you, but I'm so proud to work with all. So we're going to have a little bit of a dog and pony show. We're going to take turns up here. And Mary's going to go next. Hi friends, I'm hearing later, Gasser. I'm the director for prepare your service and an anesthesiologist for those of you who don't know me. So, you know, once again, to put pretty pictures on the experience that we all know and have lived before we moved into the hailed building. We hit sort of a steady state issue. These are sort of serves that have been filed about either material or supplies, you know, for either materials management or SVD. And there's sort of a steady state, you know, low level, you know, dribs and drabs of things that were wrong. Then you filed a service to try to make sure that things were going to be fixed and that you could look into those issues. As you can see here, end of June 2022 into July of 2022, when we moved into hailed that spiked. We went up to actually this was more than a three standard deviation increase in the number of serves that were being filed about either equipment or materials. This was huge and this is probably only the tip of the iceberg. These are the ones that, you know, we actually had the time to file a serves on as opposed to just sort of running around frantically and scrambling to try to get things fixed. So this was very real and we obviously needed to fix it. Again, this is another way of looking at it. This was a day that was being collected by our friends from the EPMO on the right hand side of the screen here. You can see the defect rate going back to the beginning of August. It was very this was sort of going around and surveying the nurses every morning on the first case and saying, you know, what were things right. How many were not right and just trying to get a quick, you know, numerator denominator. The denominator being all the kids that were going to be open on the field that morning. You can see it's kind of kind of messy and there's no sort of specific trends, but it was a very real problem on Sundays. You know, quite impressive indeed. Starting in the beginning of October, which you can see here on the left hand side of the screen. These were actually audits going on inside of SPD itself before the kids were put into the sterilizer and sent upstairs. Looking at the kid and saying, is this correct, wrap it up good? It's ready to go start processing the idea being that they would then start to catch the problems before they made it upstairs to the operating room. And so as you would expect, obviously, those numbers are slightly higher than the stuff that made it upstairs, but still, you know, quite wabry. You could argue maybe we're starting to see a trend towards improvement, but. Again, we do have a way to go, but now at least we have some data to inform us as we go forward on this. And again, thanks to our friends in the EPM over helping us that this OMPP is secure, I should say as well. So what's being done to try to fix this problem on the steril processing side. And I know it's been a source of intense frustration to our nursing colleagues into our surgical text. Who are every day feel like they are the final line between a bad event happening and an incorrect kid or God forbid an unsterile kid or contaminated kid. Actually coming in time, Texas patient and I salute you all for the incredible work that you've been doing and I thank you and I hope that soon we will be able to say, you don't have to quite be on, you know, 10,000% alert. There has been an incredible push for hiring as Steve mentioned before they went into that area on the understaffed side and very quickly recognize that and of course it takes a while to staff up. At this point, they have staffed up incredibly. They have hired 19 SPD and materials manager spokes. They have an educator, they still have four positions outstanding. They also have put in some interim leadership. They have brought in 15 experienced travelers from outside to try to supplement our, you know, workforce while everybody is getting up to speed. What this means is that's great. We got a lot more bodies down there. What that means is as of yesterday, 40% of the folks in our processing are new to Boston Children's Hospital. They are mostly not new to several processing, but it takes a while to get used to any, you know, individual system and figure out where everything is on the shelves. So we're hopeful what that means in the longer term and hopefully that does not need months, but you know, hopefully weeks. These people are going to get trained up. As I said, they're good educators. They've got QA folks in the room on every shift auditing this that we're going to start to see improvements. That's our hope. And we will continue to watch that very closely and make sure that that is in fact the case. And at the same time, there is as you all remember, I'm sure with the wet loads, road of maths, other issues, mechanical issues, which have been we think knocking on podium fixed at this point. As part of that, as many of you know, if you've ever walked in the hallway, I'm going towards the beta offices at 10 o'clock every morning, there is a daily huddle. We've got nursing, we've got SPD, they're inventory, other people from periop, we've got EPMO helping sort of coordinate and keep us honest in terms of the data who are constantly looking and trying to figure out what we can do to figure out and keep moving forward on on solving these issues, identifying and solving them. And again, thanks to all of you who have participated in that, it's often seems like an endless log where you're getting nowhere, but our hope is that we are starting to get somewhere. Now this all comes, of course, in the background of programs that continue to expand field surgery, Dr. Tammy Seared, morning, thank you for joining us. We'll be starting soon. We have been as much as we can utilizing our friends out in the suburbs. We now have the be happy paying catheter programs started in Lexington so that we'll orthopedic cases can go out there who need. Post sort of pain catheters, we've got wall fam all six operating rooms moving till five, which has helped a little bit. But at the same time, this is in a background of pretty impressive volume, this dip, which you can see in the middle of the screen is of course COVID in April of 2020 when we basically stopped doing almost every surgery unless the kid was dying in front of us. What you can see since and isn't an extra will rise back not only to where we were pre COVID, but in fact beyond that right over here in the very far right of the screen that tall bar is August of 2022 during the month of August of 2022 in the midst of all of this shenanigans with SPD in a new building and everything we did more cases than we have ever done at Boston Children's Hospital period end of sentence. If you thought we were working harder, we were. All right, obviously space has been an issue for us as you know we've got here we've got perfume now we've got beautiful new operating rooms we've got beautiful new ICUs. I think we all know that that has been an issue already we filled up our operating space we filled up our ICUs space, although more are still coming online. As we said before we're trying as much as we can to expand and optimize the use of our satellite facilities. At some point in the next few years hopefully need them will come up as well which will help us you know with more day surgery options. The transformational initiatives as Steve mentioned the bidding and you know we're sort of putting those on the back burner right now, but you know at some point we hope we can get back to those and again to increase our efficiency maybe get our work days done. In daylight hours and not continue to spread into the evening which has been exhausting for all of us and of course continuously looking after allocation of the operating rooms are the services that need the time getting as much time as we can get them. Just to know where we are this is where we are at the moment we've got the operating rooms in the main building down here on the bottom right of the screen we've got the hail operating rooms are on the left. Our next phase which should be starting hopefully after the new year i'm not sure exactly when is going to give us a bunch of operating rooms over on the south wing of what we'll then call for food with the hail operating rooms at that point we will go from 22 hours plus we have to flex hours which are using some days and to procedure rooms. The next phase will have those 22 operating rooms and go down temporarily to one procedure room in the final phase which you know I think we're talking about mid 2025 that you know that remains to be seen we will have a total of 22 operating rooms or procedure rooms down here in the bottom right and five interventional radiology suits will move up from the second floor. Obviously the footprints on those are still many years in the future and subject to some change. And I will hand it back to Dr. Persia. Thanks Mary. So what we've been focused on most of these which have been happening in our in our periop environment but of course we live with an ecosystem of the institution within the ecosystem Boston New England and greater society and all the air that viruses can travel around the world. So there have been all sorts of things that have caused over the last several years our capacity challenges like we were always capacity challenges in the past that's what we built a new building right. But then COVID came and cost also distancing and then the resultant you know exacerbation in our bill you know pre existing behavioral health crisis took up our beds now we have you know it's win just coming now we have RSV. Flu is going to come we saw a little COVID so the rest of the illnesses are filling the hospital. It turns out that not only in New England but around the country there's consolidation in the pediatric care. It's really hard to do what we do well and it's done better at scale. So some of the smaller hospitals around New England in a big hospital like Tufts are deemphasizing and diminishing the capacity to care for children which is putting more demand upon us. Those are all external sort of things that happen right that we don't have a lot of control over. So the last bullet is a good thing right we're a little bit victims of our own success we have worked hard over decades strategically to build the best programs to bring the best clinicians to make the most of each child's life. We've built all sorts of innovative programs that become destinations we are the children's hospital to Boston into New England but we're also the children's hospital to the to the country in the world and we have lots of people here who take your patients who don't live in New England very often. That is continuing it kind of slowed down during the pandemic the airplanes weren't flying people were restricted from traveling there was risk. Now the planes are flying again even over the oceans or international population starting to come back so we have all of these multiple factors that are causing this we saw a marriage that showed you we had our busiest month ever in the operating room. Which would seem like we're taking care of everybody the problem is we're not taking care of everybody there's some more kids that would like to and need to be in our operating rooms that you know are a little backlog that we hope to serve and everybody's showing the schedules around we have days we have enough kids we have days enough rooms days we have enough ICU rooms ICU beds and days we don't and so cases get rescheduled and juggled around and family changed their plans. This is because most of these external forces have caused an incredible demand for your outstanding service so despite opening a building. It's full we see all you know very frequently these alerts these capacity alerts and there's even a couple of code helps which is a very rare thing. And there's not a lot of levers that the hospital has had in this acute phase to control how many patients get get into beds and how we. And we provide services so the main lever to date has been. Rescription on elective surgical cases and I put elective in quotes is because like we don't do face lifts here right the children that we operate on have a reason to need an operation not to make it just saying please please put me on the anesthesia and under the knife. These are all kids who need something united today but it is some point and this concept of deferred care with three years ago when we had a slowed down because of COVID and we said okay well still you know so wait a little bit well waiting three years to you know would not have been a good thing so people wonder why we've even done as much as we've done well think about that kid if we had deferred kept deferring the kept it from that curve what got worse. And so it's been a very close balance of what we can do safely with the stresses that we have and getting as many kids cared for as we can right now the ICUs were pretty full we just open some more beds this week so we're hoping that will help but we actually have a cap of only three elective so called elective cases on the or a schedule each day that I know to are suspected to the nice you bed. Before the move before all these stresses it was seven a day so we have a bigger building we have more ORs but we have less to believe I see you beds now this overrides and we actually do more than three cases a day but that's how many were less sort of put on schedule in advance. So that's a challenge that you know I've been sort of carrying forward and saying what are we going to do how what are the opportunities so that the surgical families and and and our surgical family of those who take care of these children have an out besides being the only ones who have to sort of be the lever to allow the hospital to not be too far over capacity we are over the best but not too far. So Dr. Churchwell felt this was important enough to join us to speak about as well as Dr. Chang is it possible to feature Dr. Churchwell on the zoom so that we can see the speak now we have to remember Dr. Churchwell is on a train and so we hope this goes well if not I think it's going to back him up Kevin take it away thank you. Thank you Steve and I'm on a train so I'll speak quickly and I'll ask Vinnie to actually just fill in on the particulars of what we're working on especially internally in terms of our capacity you know the first thing I just want to do is as Steve has done and everyone has done is just acknowledge the work that everyone is doing every day this is an incredibly challenging time. This is probably most one of most challenging times that I've been involved with can health care and pediatric health care. And it's really our COVID crisis I believe in terms of what we're experiencing in pediatric. Not to say that in this type of environment that there will not be a beginning middle and end I think we're certainly not at the end and we're certainly not approaching the middle yet. But I want to thank everybody for what you do every day and the challenge that we're meeting. I expect that through this fall winner into the spring we will still be challenged. But I know that we will meet that challenge. And as Steve described, I see also that we have a great opportunity, as I look beyond what we're dealing with now in terms of our next three years, five years, ten years, in terms of what Boston Children's will continue to do and develop and put forward, especially from the surgical and operative standpoint. The issues that Steve described on this slide, I think are really important. I'll speak to a couple of them and I'll turn them on the others over to Vinnie to really talk through. But I just wanted to talk a little bit about behavioral health, especially externally, the Boston Children's. And that this is, as you know, a national issue, especially in pediatrics. It's an issue that for a long period of time we sort of put on the back burner, but it's certainly at the front burner in terms of what our kids are experiencing, how they're presenting to our Merge department departments and really extremists. And what we have to do in terms of supporting their care. We continue to work to develop space and programs outside of Boston Children's in collaboration to find the right spot at the right time for our kids with these issues. And I think that's one of the most important things that we can do to continue to move forward. You heard about our work with Franciscan Children's Hospital and that continues to move forward. We're working through the regulatory aspects of bringing festissants under our affiliation. And it made really good progress with the state. There's other work we have to do actually with the archdiocese, the, the Vatican, but that is also moving forward to really nail that down. But even as we do that, we're working with Franciscans to help them open up more of their capacity. I had a great conversation with our CEO yesterday in terms of where they're headed, in terms of opening more beds and how we need to be in close collaboration so that we can utilize those beds for our kids that are boarding to free up the right space and have those kids have to write care. That's just one example of what we're doing. As you know, the state has been really concentrating on this for the past actually two years. And the issue that the state has run into that we actually predicted was that we can find more space for our kids, more beds, but the staffing of those beds is going to be the key issue. And right now, the issue in terms of staffing of the beds. And that has to be continued to be supported and worked through. I expect that that will be the next year, year's challenge to really get it. So just to set up exactly from the standpoint of the pediatric care consolidation in England. You know, this is something we were predicting over the past 15 years. I think that COVID has pushed it in terms of adult institutions realizing and understanding the costs, the issues associated with staffing issues, the safety issues associated with keeping small pediatric units open. And how that is just becoming very difficult. I think over the last three years that is still going to be the case and from that consolidation. My goal and my job is to really speak to that to the state leaders, to the regulators, to get them to understand what's happening. And to get them beside us and supporting us in terms of what needs to happen to make sure that we can really provide the care that we know we want to provide for our kids based upon that. So that's a piece of work that I try to do and I'm doing on a constant basis. The last bullet that Steve brought up in terms of strategic success. That's really based upon the work that you do every day. And that this is also children's hospital remains a destination for our kids. Kids who need our help and that's in the New England region. That's in the Northeast that's nationally that's Internet. The stories that I get every day about what's happening outside of us. And the desire of families, the buyers of individuals that are interested in the care of kids. For those kids to be sent to us because of the confidence they have in us. Of what they know what we do every day is something that it's hard to transmit to you, but I will tell you that it's incredible. But also tells us that we have a lot of work to do. How do we meet those opportunities? How do we meet those challenges? Is something that we're working on? Something that we continue to push forward in terms of how do we prepare? You know we have the DON for need them, ambulatory satellite. The end of the year so we can move forward. And that's work we've got to do. And that's one of the next big steps that I believe we need to have in place and going. So I'll stop there. I hope I was able to do that. My Internet Connection at times is unstable. That's what it says, but I hope hopefully I was able to talk with you. And what I'd like to do is turn over to Dr. Chang just to talk a little bit about what we're doing internally in terms of bed development, bed creation for the challenges that we have in front of us. Good morning everybody. My name is Vinny Chang. For those of you I haven't had a pleasure meeting. Now I'm the Chief Medical Officer here. I know many of you are used to this hour and your brains are functioning fine. I'm not so I apologize if I stumble a bit this morning, but Steve asked me to speak a little bit. He's pointing to his watch right now about time. So I thought I'd spend about 90 minutes or so just talking about the initiatives that Boston Children's. I just first wanted to give some context, not as an excuse because Steve mentioned this when he started right off. For years we were banking on the new building. We saw it go up. We thought it was going to be this awesome shiny tower and the solution to many things. And in many ways it still is, but it's sort of ironic that at the completion of the building things seemingly are worse now than they were even during the midst of COVID. And it's first some situation when it is one we had the Tufts closure which no one planned. But it's just a reality of the hospital to deal with and in six months, basically one of the oldest children's hospitals in this country shut down and transferred the care of their patients to our institution. I would say essentially seamlessly that we don't detect much in the way of patient suffering as a result of that closure. The second thing that I just want to put in context is really something that was an existential threat to our mission, our values and our providers. And that was just all of the noise around the gems program. Something we didn't have to deal with, but we as a hospital stood behind the commitment to caring for these patients. And I just give that as context because I think there's a lot of people who say, boy, what is the hospital doing at this time? We're trying our darnest. But there have been these distractors that we've got to keep the trains running and we've got to come up with solutions. So just in terms of some context, we are 404 beds before the hospital of the new tower went up. The original plan was to go to 433 as a result of the toughs closure. We went back to the state and said we need in more beds. And so we are actually 454 licensed beds. That increase from the 433 to 454 was actually larger than tough average daily census for their entire hospital that they were shutting down. So we had thought in many ways that we had accommodated both for the volume that we were going to get from toughs as well as the plan growth that we were building into the new building. We last week hit 462 patients in this hospital and those of you good at math will say that 462 is actually bigger than 454, which is correct. And that is the state that we have been in that we have been utilizing essentially every single space in this hospital to care for patients. Priority number one utilization of all beds that exist. So that is the Mandel 3 initiative, which I know all of you are familiar with and we are taking care of patients in recovery space overnight. Thank you to all of you who work in that area. The there were flex beds planned in the hail building as part of the cardiac unit that we are working diligently to increase staffing for. So those beds are built in a building we want to we want to use. We have a process every single day where we continue to review the doubles in our hospital to maximize the doubling of patients, which is still the largest patient dissatisfy with regards to being in the hospital. We are in the process of creating an alternative care unit to care for this increased respiratory burden that Steve alluded to. And I just wanted to give some context to that. So everybody is used to COVID last three years. Everybody is used to this notion of test positivity with regards to COVID. The COVID test positivity at Boston Children's Hospital last week was 3%. For RSV last week was 22% for rhino virus. It was 31%. So we are now seeing viruses that predominantly affect infants and toddlers. And while the overwhelming majority of these kids will recover fully. There are patients who need high flow positive pressure intubation and we are the backstop for that pediatric care here in Boston in the state and in New England. In terms of initiatives that we're working with the maximize Jeff Burns has created a sort of collaborative amongst all the pediatric centers in the state doing load balancing looking at the use of critical care and emergency beds through DPH. The critical care team has put together 24 hour transport consult line for people who are looking for a beds and we're helping community hospitals manage those patients. We've just expanded our emergency department into farly to the old cardiology clinic to give them more rooms. Both in terms of number and in terms of access during the day. And so we are working really hard to try and come up and solve the solutions to the slide that Mary showed with August being the peak was awesome. We feel like we were in some ways responsible for that. We were definitely responsible for the dip in September as Steve said we pull the lever and the lever is you said scheduled surgical cases it's all scheduled cases. It's just that of the schedule over 90% are surgical cases the overwhelming majority of things that we can schedule are things that come through the operating. I'm going to stop there. I just haven't started with thanks. I want to end with thanks. I tell people I have the best job in the world. I've had the privilege of sending my entire professional careers here at Boston Children's Hospital. And the crazy thing is I'm surrounded by people who say exactly the same thing. The white part of our ID is all say something different. The blue parts is Boston Children's Hospital that is our common bond that is our link. We are here to care for patients and families at their most vulnerable. It's an honor and privilege to serve with you guys. The road is bumpy, but we will get through it and with that I'm going to turn it back over to Steve. Can we highlight Patty Hicky please? Good morning everybody. It's such a thrill to be here. Thank you. And for those of you who don't know me, I am the SDP and associate chief nurse. And I have the great privilege of working with each of you every single day. And just to take off on what you've heard so far, the reason we are here today and the reason we have been able to get through all of what we've gone through in last few months is because we have been together. Our patients are safe, they're well cared for. And the brilliance and pure grit in this room is the reason why. So when we think about perioperative services that in one enterprise, this graph shows how the hospital has invested in perioperative services. If we look at the last two years, 2021 and 2022, we have invested seriously in our satellite locations. So we can ensure staffing, experience and outcomes in the same way that we can in Boston for our patients and their families. Next slide please. Perioperative nursing has been front and center in some of this expansion. Our cardiac operating room double and moves to Hail 6. Our main operating room expanded across Hail 3. Collaboration has been amazing. Pre-op pack you expanded to 18 beds in Hail 3. And we're continuing to refine those workflows and be innovative about how to care for patients in that space. A big deal was made around the security of this huge building. Sometimes charge nurses can be alone at night surrounded by big beautiful hallways. So we had the clinical coordinators in all of our security staff in the hospital walk through to ensure that the entire third floor was safe with enhanced prox readers, cameras and the light. Mandel 3 has pivoted on a dime each and every day, fully staff and operational to take care of our kids. We've had our SPD transition issues and we continue to have those. We're helping SPD. We have dedicated Judy Jackson, a very expert operating room nurse and Paul Burke and expert surgical technologist to work with us. We've had a lot of work to do with our SPD staff and help design clinical operations, provide assessments over the last three months and make recommendations. So collaboratively we can ensure that we are providing the best service for the operating rooms and procedure areas. We've also been providing that support since we opened in June. We have a lot of accomplishments to celebrate. We also could ein an important part of our collaborative to celebrate our clients. educators to ensure that we give our new staff the best experience. Our satellites have trained 10 nurses and periop 101 and I'm delighted to introduce all of you to Megan Nolan, who's our director of Wall-Tham and Needham Nursing and Perioperative Services and she will join the team with Andrew Smith, Ellen Barth and Jason Thornton. So we have a great operating-owned team along with Kelly Conley and Mary Gibson. Several work groups have been established. Very important one, the Communication Work Group and the Medication Error Work Group, which have achieved wonderful outcomes. And even with all of this going on, our operating room nurses are disseminating knowledge with podium presentations, publications and posters. And in fact, Megan sold one the National Award. Megan works in the cardiac operating room and her presentation was core temperature monitoring during BiodeFAS. We have advanced the TRIEIGE team in the patient care coordination center and works really to enhance the esophageal atrija spine, global patients and preoperative optimization process. So a lot going on in spite of the challenges. And I just leave with this slide because none of this happens by accident. This happens because we have a team with authentic leadership, appropriate staffing, effective communication, true collaboration. And when we have these behaviors alive and well, like we do in our operating rooms, we are more apt to achieve optimal patient outcomes. So thank you very much and all of this contributes to finding the good. Thank you. Thanks for the convective podium and the Zoom, please. Okay. So thank you to everyone and it's pleasure to be with you. My name is Joe Corvira on the chair of the Department of Anastasia Diology, Critical Care and Pain Medicine. And I can talk about a hundred different initiatives, clinical projects, research that we're doing right now. I think what I'd like to do is just focus on our people for one moment and the primary challenge that our people are facing and that my job will be of the next year or so, which is getting the appropriate number of staff and our staffing numbers to the point where we can do all the work that we want to do. We have over 80 people that actually work in the main OR, 80 staff positions. We're down approximately 3.5 to four clinical FTEs. You can count the numbers a lot of different ways, but I would just say from pure clinical FTE perspective and that is as opposed to before the pandemic, so roughly two, three years ago. Fortunately, our CRNA numbers are relatively stable, although we could use probably two or three more to optimize our staffing right now. In the cardiac areas, I would say that we're roughly one to two people short at this moment. And I just want to emphasize and use this time to make sure people understand when we push back on expanding either programs or initiatives, et cetera, it's not based on lack of interest, it's not based on lack of energy, et cetera. It is strictly a resource and human resource issue that we're dealing with right now. Again, don't want to make excuses here, but I just want to try to explain the situation. There is somewhat of a national shortage of pediatric anesthesiologists right now. There's over 300 open positions of people across the country. At the same time, there are fewer people going into this sub-specialty, so we have a lot of open positions and not a lot of people to fill them with. We also have a situation where CRNAs are an incredibly high demand. They have options to go almost anywhere they want, both in the city and around the country, and we have a lot of work to do to attract and retain all of our providers right now. We do have a lot of people that have wanted to move to part-time since the pandemic, and that is understandable and in conjunction and congruent with what has happened in other industries and other areas of medicine. We've also had a couple of retirements and think people know Babu Koka, Charlie Nargozi, and Justin the last few months have, unfortunately, left our ranks, and we recognize and value all our folks, including those who are in the peri-retirement area. I just mentioned, again, this is not to try to make excuses, but we are not alone here. If folks know what's going on at Brigham, there are at least four ORs closed every day because of lack of anesthesia staff over there. There are also similar staffing issues due to lack of anesthesia availability at children's hospitals across the country right now. What are we doing in terms of recruitment? I would just say to you and ask for your understanding that recruiting pediatric anesthesiologists is not a short-term thing. It's not like we can just go out and hire some locoms to come in and fill out rooms on a day. As you all recognize, these are really complicated patients. They are difficult workflows. There's a lot of safety issues that we're dealing with. We need to get the right people here. I would offer to you that hiring just anybody and hiring the wrong person would be worse than not hiring at all. There's functionally one opportunity a year. We have to hire, which is when the fellows are graduating either from our program or other programs. It's not easy at all to get people to move from one location to another, although we've had some minimal success in that recently. I would just say to you, if you look back over the last couple of years where this situation has evolved, December of 2020, which was an opportunity, we had our ORs closed. I think it was very hard for people to estimate what were our needs going to be. Therefore, we had hired one person who subsequently left to be near family. In summer of 21, we had a fellowship class where many people had already identified jobs before they came here and left to go back to those jobs, or they were doing sub-specialty training. We did not have the same recruitment success that we would normally want. So far out of summer of 22, we've hired two people, and I think we have several more coming. I would offer to all of you, as you know, Boston housing prices, et cetera, are real challenges for us when we're competing with other places that have a much lower housing price. And we are working on that issue specifically. Currently, we're interviewing 10 different individuals for Fuller Park Time OR FTEs. There could be more to add to that. So I'm hoping, and it is my biggest responsibility to improve our overall staffing numbers in the next year. As far as anesthesia leadership is concerned, switch gears here for a second. I want to thank John Fjadjo for joining us just about a year ago. I think he's done a fantastic job as an administrative asset, but he also fills a really nice role in our ORs as well. Craig McLean has stepped up and filled a really difficult, challenging role of being the chief of our perioperative anesthesia division. I want to thank him very sincerely. Elaine Brousseau has become an associate chief and manages a lot of our scheduling and personnel issues I would also like to thank her. Currently, Craig is filling as a interim chief. We have a search going on, so natural search with four finalists. Craig being one of them, the three other really qualified people. And we are hoping that we'll have a resolution to the final appointment of this position by the end of the calendar either. I'm going to finish this by saying thank you to all of you for helping us do our job in a situation where we are challenged by a numbers situation and we are working extremely hard to fix that situation going forward. Thank you. Thanks, Joe. We do have some more content, but we actually think that hearing from you and answering your questions is more important. So I'm going to skip or breeze through a few more slides here. Despite all of this sort of mayhem that we've been living through over the last several years, so much of the regular sort of improvements of things have ongoing. We have new MPO guidelines which have made easier for families, has made easier for flow of patients. You can read these on the screen hundreds of things that you all do. On top of the stresses that we've had more recently, we heard a bit of it from Patty and Vinny about security. One new thing that you'll be noticing shortly is for the surgeons, when you book your cases in SPS, there's a way now for helping, this is to help with capacity management. Lin Farari and her team have done a very extensive analysis and project to actually predict how long a patient is going to be based on all sorts of factors. Not only the case you're doing, but there's a link here. We'll go through some of the time that you can't read this, but based on comorbidities and medications, how long the patient's likely to be. So it's going to really help with planning so we can use every bed, every resource. This is how we currently do pathology specimens and hairs that we're going to do it. We have big things come in epic, and we're going to have a chance to talk shortly. We're doing analysis of image capture and offering, which we know that's a very sensitive topic. I know we've said this a lot. We can't say enough. Thank you. Thank you. Thank you to all. And we're going to take a few minutes to take questions from people here, and folks in the person, if people have questions on, there's over 300 people on the Zoom. You can either were to type into the Q&A and Catherine, or we'll be able to catch you. We'll feed us those. Inviterate to come up and rejoin me here. We have a microphone you passed around. If anybody has questions in the room. If there's nothing in the room, I can start with questions from the Zoom. How soon? I'm sorry. Go ahead, Catherine. Hi. My name is Christine. I'm one of the general surgery nurses, and I was asked at our last service meeting to speak today to represent nursing's voice. I first want to say that this OR staff is the most knowledgeable and cohesive that I've ever worked with. I'm very proud to be part of the team in this institution, and I think the rest of the staff, you share that sentiment. We all know that the summer is very busy here, and we've just coupled that with the global pandemic and the new building. The obstacles we have faced have been significant. That being said, there are a few things that I wanted to address that are meant to be seen not as a complaint of our job, but as issues that we as staff need to have addressed. I had a case the other day where we had to open four sternal saws to be able to get one that was complete and safe to use. That led to looking at the sternal saws that live with the co-carts that were also found to be safe, unsafe and incomplete. If this was an emergency situation, that situation, it would have been catastrophic to the patient and to their family and to the staff. Every day we deal with countless issues with our instruments. We had a case that was put together the other day without four steps. This is the kit that we would use for a bedside X-flap. A force-up is the first thing we're going to use. To rectify that, we would have to go back to the OR or back to CPD, which is very far away from the ITUs. We have kits that come up with pens, alcohol swabs, rust, blood, bone. There are times that we can't find the equipment that we need or that equipment is on a shelf unsterile. We have a pharmacy that is dedicated to the OR, but we go to a PICSIS and it's unstocked. Meds are expired. We have to call the pharmacy multiple times to get the antibiotics that we need to start our cases. Everything that used to take one step now takes five and that is time that we are not with our patients. We're told to file serves to rectify these situations. Sometimes you could feel six serves in a day, which is very difficult to do if you're circulating or scrubbing a case. We do address these issues as they come up and we're told that we're heard. We've been in the new building, I would say, about four months now. We need to be more than heard. We need to have answers and solutions in better processes in place, to be supported, to be able to do the job that we're capable of doing the job that our patients deserve. Thank you. I'm sorry, I want to thank you for sharing. And thank you for the courage. It means something that your colleagues asked you to speak for them. We do more than hear you. Now a lot of people just heard you. Hundreds of people just heard you. One of the most important things, one of the most important things is that we all realize that the problems are not solved. I started with that. We had a huge amount of attention about wet loads, right? A term that none of us, most of us, had no idea what a wet load was. Until you guys started opening kits in the instruments where wet and we realized the problem with that. And an enormous amount of effort was going at the figuring out why the difference wet has been a problem before. That seems to be solved. All sorts of technological things in terms of parts that needed to be put in between the sterilizers and the steam valves. You don't want to hear about those details. I know way too much about it. As surgeons should know. But now that the instruments aren't wet, we still need to have the right instruments in the right kit, showing with the right place for the right patient, without you having to do five extra steps. And yes, the amount of time it takes for you to fill out the serves is time that you would need to do those other five steps. It's kind of a catch 22. We beg you to continue to do what you've been doing. It is your teams that have kept us going. It is your teams. We serve more kids in August than we've ever served before. Which is incredibly stressful. Yes, our staff is up in more people to do it. We have a lot of new people, not only in SPD, but in the ORS. You're all training people at the same time. We do more than hear you. The people who work down in SPD, the people who supervise, some of whom are, I promise you are with us right now on Zoom, are hearing you and there's enormous amount of action. I can tell you that in the C suite, the budget was opened to pay what it took to hire all those people that Mary showed you on a graph, 44% of our people who were going to speak to their new to children's hospital. That was really expensive. It was really red thing to do. That was not only because they heard you, because they responded to you. The problem is there's a lag right before everything's fixed. We cannot let up in our efforts and our commitments to get this not to where we were, to better where we were, to where we hoped to be. I know that's not good enough. I do. What you just said, some people are hearing for the first of second time, and some of us hear every day when we walk down the halls now for anyone. The hugs and the tears are real. We more than hear you. Thank you. Katherine, I think you had one. We're almost out of time. So I think we're out of last minute. Do we have an easy one? That was about as important as it could get. So thank you. Absolutely. So the question was around fetal surgery. And when can we expect that program expansion to start any ever? I will handle this one really quickly because we're out of time. Feel surgery. Yes, there's a tremendous amount of excitement. Our new field surgery leader is here in in Fulquin. Dr. Shamshasas or Shammi as he likes to be called. We are tremendously excited about this. This is a big deal, right? We take care of children after they're born. We've had a world class fetal center here for 25 years. We do the best imaging, the best counseling because we have the best specialist, the best postnatal care. We have not in Boston. Been a leader or really a big participant in fetal intervention while the baby is still in there. With the exception of the world leading an innovative cardiac valve dilutation and associated process that were started here. And spread from here. We're now going to not only do all the things that are done in other centers that Shammi has done extensively. And he led the center of Texas Children's One of the busiest field centers in the world. We're he already is working with people around the enterprise to do all sorts of exciting things that have never been done before. But because we haven't done this before, this was routine for him in Houston. And he is empty as if we need to do this safely. Because we all need to learn to do it with him. So we have dedicated nursing teams and know where as you know who have been developed world with them. We need to do it ethically, especially if we're going to get into newer things. And we don't we're not an eternity hospital, right? So we have moms coming in. We have to take care of the moms safely as we take care of the babies. So that has all sorts of implications for doing proper and safe anesthesia 24 or coverage. So we have a pair of nursing work. We have a mom recovering in our recovery room after a fetoscopic procedure. You know, we don't even know it's pretty routine in many hospitals since we don't deliver babies. Many of our nurses used to care for maternity patients, but they haven't recently. So there's an enormous program that Shammi and Patty and others are developing. I don't know if we have an exact date or equipment doesn't hear. We have some logistics, but we hope by beginning of the year. And so it's my best that we have everything to embrace to start doing cases here. So it's really exciting. We really look forward to taking that to know. Maybe that would be a topic for a real super goal, ball grand rounds instead of talking about sterilizers. Maybe we'll talk about the opportunities around the enterprise and field surgery. We're out of time. Everybody has to get to work. We want to thank you. Like the most important thing we can say here is thank you. We want to give you information. We want to acknowledge the stress. Trust me. Everybody here feels your stress. Experiences your stress. We can't thank you enough. And we have to just plead that we all continue to work at our highest capacities to keep doing what we're doing to take care of the kids. You guys are just, everybody is extraordinary. Thank you.