Speaker: Steven J. Fishman
''Let's start the quarry. '' Well, everyone ready to dig tout?'' Welcome to the booth. You enter 1, 9, 6, 1, 5, 8, 6, 2, 4, 2, 1, 5. This meeting ID. Good morning. Welcome to Grand Rounds across all of the perioperative staff and all of the operating services. I hope my screen is sharing. And I want to thank you for taking a time early in your morning. This is unusual to get this larger crowd together. We thought that we would give a little bit of a vision, a little bit of a popery is warning on where the OR is going, and a little bit of how we've dealt with the recent change in the world. I want to thank Captain Breyer and Todd Katzmann who are doing some behind-the-scenes work that we'll see. And I want to thank my co-speakers, Patty Hickey and Joe Cervero, as is a team effort. I'm the one advancing the slide, so if things don't work, you can blame me. So here's what we're going to talk a little about today. We're going to talk about how the OR leadership structure works. We're going to, we can't avoid what we've been through with COVID and the stresses that we've had and the tremendous learnings that have benefited us, that we hope to bring forward. We're going to talk about some physical changes. We remember looking out the windows of the OR lounge and some of the ORs, and we had that big, deep hole that we all watched with fascination, and then suddenly this iron girders superstructure came up. And then it got wrapped. And we don't think much about on a day-to-day basis what's going on inside that building. But we're going to talk about what's going on there and how it's going to change our lives in the operating rooms and how the workflow is going to be different. We're going to talk about some quality improvements that we're working on, which is a continuous theme throughout our institution and we're not letting COVID slow us down. We'll talk about equity, diversity, inclusion throughout the operating room environment, and then we'll talk about some paths forward. And we might have a little bit of a participation opportunity if we have time. Now, we've had a lot of changes in leadership. The fact that I'm speaking to you in this forum is a son of leadership as the relatively new search and achieve since July 1st, one of those things that just sort of happen in the middle of pandemic. We also have a new anesthesiologist in chief. I've just been told that my video is not on. Just one second. I'm not going to say my apologies. I'm not that you really want to see me. You want to see the slides. We've had some changes in leadership. Obviously, I'm a new search and achieve. I've been asked to step in as the anesthesiologist in chief. And we also have a new nursing leadership. Patty Hickey has been here for a long time, just like Joe and I have, but has stepped into an additional leadership role in the operating room in my apologies. We have had a whole new leadership structure developed in the operating room. But there are some things to stay the same. We could not go through such changes without stability. So many of you have been here for decades and some have risen into new responsibilities along with this new leadership structure. But we have really had to rely on those with continuity. And I want to specifically call out Lin Ferrari, who has really been running the operating room at a leadership level and all the daily nuts and bolts for a very long time. And Joe and Patty and I and the rest of the leadership could not could not possibly have moved forward without Lin's leadership partnership friendship. Lin knows where everything is. She remembers how things were done in the past and why we do things now. And without Lin, we really couldn't have moved forward safely, particularly in such a large scale leadership transition. The other person I'd like to call out is Catherine Tetchy, who not everybody knows in the background, but Catherine runs all the business operations for all of us. And it's really just an incredible leader and partner. We've been coming out of an era of real resource limitation and some pain in the operating room, which many of you have experienced. And the institution has listened and I think we can all agree that we're coming into a new era and COVID has helped bring this together. The leadership of the OR is really very quite very diffuse. The OR governance committee and the surgical executive committee are two of the sort of leadership governance structures, but really those are participatory. All of the chiefs serve on the surgical chiefs serve on the surgical executive committee and we meet monthly and that's really where a lot of ideas filter by directionally. And then the OR governance committee is responsible for policy, but really we try to work as a community to make such decisions. Now I'm telling not to worry my slides. I am totally failing. Maybe Joe could go over his slide and then I'll pick up and by that time maybe they'll. I'll be there in one second and a great apologies. By this time, there's actually no excuse for. Am I sharing? Yes. Okay. I'm very much apologize. So so the surgical chiefs play a role, but there's so many other people who play a role. And I'm going to pass it on to Joe to talk about some changes within his organizational structure. So as you mentioned, Steve, lane remains are medical director for perioperative services and the division chief for the main OR. We do have some new associate clinical directors, including Elena Brasso, Craig McLean, Steve Svetsi, aka Ziggy. The official clinical director for the pack you is Kathy Jones for ambulatory surgery is Sharon Red. We have clinical directors in the wall family, including aerial Mizrahi and those parts for Lexington, Linda Bullock is leading our efforts. And for the hospital program at Wal-Fam, Connie has does a fantastic job of tracking down what is a myriad of issues that have been coming up around that activity. Good morning, everybody. This slide represents an integrated team of nursing and patient care leaders across the full continuum of perioperative services in Boston and the satellites. And I think a highlight from the past year that has positioned us well for the future has been how Andrew Smith and Kelly Conley have established a wonderful team of specialty based clinical coordinators across the operating rooms and pack you. And I'd also like to recognize Hazel Boyd, who is now our director of sterile processing, which was formerly known as central processing. And of course, Catherine Tatchy, as Steve mentioned, who is critical to all that we do in patient care operations. Thank you. So, COVID, how has it changed us? Well, we all have so many ways in our lives and our patients lives that things have changed. Many of us assumed our leadership role during or shortly before the COVID pandemic has really been trial by fire. Now, I would be remiss if I didn't talk here about the role of Jim Casser. Jim Casser led our OARS in our institution, the surgeon and chief in so many credible ways, and his shoes are impossible to fill. July 1st was kind of a tough time to have a transition. And Jim did not fade away. Jim has said to me from the beginning, I will do whatever you like to help. And the two things that were so crucial going on in the operative environment were the COVID pandemic. We had to shut down OARS, we had to rent them back up and figure out how to do it and do it safely. And with principles aside of which patients would have priority to get back in the OARS from the backlog. Jim has continued to lead that in an incredible step, fast way. He likes to hang in the background, but I can't tell you what a friend, a mentor and partner he has been to me and continues to be. Another thing that we are going to talk about soon is the transition to the new building. And Jim continues to lead much of the effort in figuring out how we are going to do that. It is not going to be a small effort and all the ongoing initiatives that OARS started. COVID did pull all of us together. We really had to adapt. Society had to adapt. We have to develop immediate new protocols. We have created physical constructs, engineering, the EPMO and a prize project band in the office. We are just incredible in helping us develop social distancing throughout the operating room to allow us to continue care for patients. New scheduling systems, because we ran so many OARS, we are still running out of the different scheduling systems. We had many limitations on our practice with social distancing and PPE and figuring out who had COVID and how we take care of people safely with COVID or might have COVID. We had to get back into taking care of the 5,000 patients that were backlogged for surgery. We had to start doing Saturday and Sunday evening surgery. All this happened with complete cooperation, participation and enthusiasm by the faculty nursing and all of the people who support us in doing our jobs. I just wanted to say a couple things. I think backing up what Steve just said, but using this slide as an example, I think everyone recognizes our perioperative COVID algorithm, which essentially takes a number of different factors. Whether or not a patient has been tested, whether the test results are, if they are available, what their symptoms complex is, what their contacts are, etc. This is just unbelievably difficult to put together. It's taken hours on the part of just a huge number of people to put together. It continues to evolve. I think this is about the 8 or 9th iteration. There will clearly be several more iterations before we're done with COVID. One can imagine what we were going to do with immunization status and how that might affect this going forward at some point. As much pain as this has brought, I do think it's an example of what Steve just said. I just like to point out that putting this together and the continuing evolution, along with all the other workflows that had to be developed during COVID, really evolved just a huge number of people from a nursing side. It's just unbelievably great cooperation. I would just point out, Chris Benson, Naomi Renz, Crystal Stro, Andrew Smith, and just a huge number of nurses, along with invested anesthesia providers, Craig McLean, Nate Tai, Kathy Jones, Jamie Aten, Pete Cuvatsis, Ray Park, just a whole task force of anesthesiaologists. In our anesthesia techs, what I was just amazed at was we were faced with particular challenges. And in the course of half a day to a day, we accomplished things that would have taken us weeks, I believe, or even longer in the past. But I'm going to focus on overcoming a specific obstacle or challenge. I think is one of the really positive things we can take out of the COVID experience. And I would just encourage us that going forward in the coming years, we need to approach the challenges we are faced with with a sort of similar singular purpose. We can congratulate those who were part of this and our continuing efforts need to be focused sort of in the same way. Not everything has been COVID-driven. We haven't let COVID stop us from moving forward in the normal daily activities that are required, for example, in our culture of safety. We had already begun before COVID to develop a new universal protocol. We had many different types of posters on the wall and laminated cards. And there was an initiative before COVID to modernize this, improve it, and unify it. We did not let COVID stop us. So there really have been just as Joe listed a host of people who participated in this. And now many of you may not have noticed, but you showed on your daily cases, we have on the walls in all the ORs, the new surgical safety checklist for the universal protocol. As well as I'm not showing you here a whole new fire safety approach. And in the laminated cards that the syphiline nurses have, that's on the back. And you should already have noticed the change in process. We cannot forget the importance of our day to day safety operations, even if they seem trivial, even if they seem routine, even if they seem a little bit like a nuisance. I can assure you safety events and close calls continue to happen. And for those people who are involved in them, it really is devastating. I can also tell you that many have been prevented. You don't know the denominator of events that might have happened. I can't do not have been through this, but I personally had several near misses avoided by paying attention to the surgical safety list. So thank you for the enormous teams that have put this together. So we have developed a lot of resilience throughout the hospital, throughout society, and particularly in the period of areas throughout COVID. So with a new leadership structure, a new era, and all of this resilience that we have learned as teams that we have, we recognize that we can change much of change comes from listening to those around us, empowering the teams that can make change and letting them do their jobs. We as a leadership team vow that we will listen to you. The many hundreds of you that were on, we will listen. At the end of this discussion, if we have time, we're going to have a little participatory opportunity where on your phones, you'll be able to do a poll and we're going to ask these questions. So you can think about these throughout the rest of the talk. And we're going to ask the questions, why do we do this? You fill in the blank? Something that you wonder why we still do that. That's outmoded. Why not? Why don't we? You can think of an initiative that would make us better at doing what we do and anything. So we'll have hopefully a little time for some screaming on the screen. So we'll see live everybody's suggestions. Now, as we talked about, we are going to look different when that hail building opens. This is kind of a cartoon of on the left, you can see the new hail building on the right is our existing structure. But within that structure, we are going to have a phased renovation. The building is the building of what we live in, that's going to look the same. We're going to modernize the old O.Rs and we're going to have a lot of new orgs you can see, 10 and left in new building and 12 in the old building. We will end up with on the third floor, one additional room as well as a whole lot of pre and post-op rooms. I'm not going to numerate all those four interventionary empty suites. They're going to come up from the second floor, four procedure rooms. On the sixth floor, we will have all the cardiac facilities. So we'll have six brand new O.Rs for cardiac surgery, significant increase. We'll have six cardiac cat labs, cardiac MRI and a dedicated cardiac pack you. Now, if you look at this cartoon, you might notice something missing that is ever present currently on the third floor. Can I ask everybody to mute if they have forgotten. There are lots of people, hundreds of people on. There's no sterile processing or central core storage. That is going to create a significant requirement for process change. That's going to be in the sub-basement of the hail building. So we are really preparing for what that is going to involve. We're going to have to have the equipment put together in advance in the sub-basement. There will be a dedicated elevator that will come up to the third floor and the sixth floor. In order to prepare for this, we've had a massive many of you have participated in the overhaul of the preference cards for the various procedures and surgeons. That is required to make sure that we know what equipment goes in the cart. We've also developed over years preceding this and most of you are using this a new scheduling system, electronic scheduling system where the surgeons themselves process their cases instead of writing on sticky notes and handing to a schedule. And all cases except for same day add-ons will be scheduled through this SPS system. If you learn to develop customized templates for the common cases, it's really very efficient to use. This now interfaces with surgeon that increases efficiency for our skewers. This also feeds the procedure codes that a surgeon chooses. I think I'm going to do this operation. And I say thank you because sometimes you change. That goes to patient financial services, which goes to the insurance company's pre-authorization and fills into the quality and charge capture system, which allows you when you finish an operation to see the code you've already picked. You don't have to look them up. You just check on them and automatically does the charge capture for insurance companies. All services now except for GI are already live on this and everybody will be required to do all the scheduling except for same day add-ons by April 1st. So many people have worked on this. It will be impossible to list everybody. But I do want to call out young Joe Kim, who has been the physician champion for this. And he has done this in just an incredible way, operationally and from a leadership perspective. This is one of the silver linings of COVID. When we had a shutdown on our ORs to just urgent and emerging cases, we had a lot of personnel who wanted to keep working and being productive. And you can see the massive ramp up in the preference card re-halls that happened immediately in April when the world changed. Can you take it one? Yeah, one of the most exciting outcomes has been the pilot launch from our Metro, Metro RAP to to our case card in a huge team was involved in this project. So as a proxy for the case card supplies are delivered on the Metro RAP until we move into Hale. Neurosurgery was a pilot for this and received their first delivery in June. And this work is continuing in collaboration between nursing, several processing and supply chain teams for Hale. It's a really great work. So this is one of the many initiatives that are going on. At the same time, the institution has charged leadership with operating them to develop some transformational opportunities, both in workflow and in terms of cost structure. And three of the transformational projects which have been initiated are improving our on time starts, improving our room to our turnovers and supply chain integration. We already have several months of work ongoing here led by the Enterprise Project Management Office who has worked with so many of you to have at the other end of this improvements that we will all notice. We won't have time to get these in detail, but we can talk about a couple. So some of the lessons that we learned in the cardiac OR from a Greenbell project are now being applied and tested across the main operating rooms. And one of our target is a 30% decrease in time between our late starts and scheduled starts for first cases. We believe that we can increase patient family and employee satisfaction based on finishing cases on time. So one of our is a frustration in all operating rooms. But if you feel a lot of frustration here and you wonder how it goes elsewhere, this graph, we won't go into detail, but is collaborative effort by the Children's Hospital Association where institutions share data and apply in fashion. And we're at the far right, usually being the biggest bar is the best. In this case, being the biggest bar is not the best. We have the longest OR turnover time of all of the major Children's hospitals. And we're going to do something about that. We're going to aim for a 20% reduction this year. It's going to take a lot of effort by many of you throughout processes and we thank everybody who's already beginning on this initiative. So as we thought about what to talk about and describe in terms of what's going to happen with the OR is happening now, what will happen going forward. We felt like we need to address the issues around big data applications, data acquisition and data processing. And I don't need to tell anybody on this particular zoom that this is ubiquitous in our lives. Big data acquisition and processing determines your shopping habits, your media use, and will if it doesn't already determine the fact that your car will drive itself within the next five to 10 years. We need to leverage this in the OR. Similarly, we are doing that to one extent and the other we need to continue to do that. There are many different data processing and data analytical efforts going on right now, including those by Peter Lawson looking at large amounts of physiological data and using that for predictive analytics. There's efforts such as Lynn Ferraris, Perry's Operative Surgical Home Group that is looking at risk classification for patients and care processes that may be dependent on the risk stratification for patients. And there are many others I just want to go through a few. One that was described not long ago to us by Derek Matthew from the Physician's Organization is the surgical variation dashboard. And I believe this will be something that will fundamentally change some of what we do and how we look at our work going forward. Next slide, Steve. The idea is to create comprehensive data sets of similar surgical patients coming through our ORs and then use an automated variation analysis to allow us to understand what's going on. We can compare various clinical metrics, issues and data around utilization and finances. And we can stratify this data using factors such as the number of procedures that are done, the age of the patients that are being worked on. And this can allow us also an ability to look at the surgical notes and do natural language processing to understand not only field defined issues, but issues that appear in written language. What we want to do is increase the awareness of the variation in practice that occurs, the supplies, the pharmaceuticals, the labs that are obtained, the imaging, the coding that occurs, and then the resource utilization. What's the variation in OR minutes, recovery time, length of stay, et cetera. In this particular case, the applications are being used to identify potential issues in charge capture for both the hospital and professional billing. But it can be used for a number of different purposes, looking at clinical care as well. How this will work, we're going to compile all the hospital and professional billing along with the clinical metrics that might impact, confound, or mediate that billing process. Then we're going to compare the variation and identify the drivers of those variations, including sort of the physician preferences, physicians themselves, the nursing components, the change in practice over time. How does that affect the utilization of resources, and then the inconsistencies in charge capture? There was already a pilot project done looking at slip capital femoral pificis corrections, looking at about 103 procedures over four years. And during that particular project, they're able to identify a large number of potential inconsistencies and supplies anesthesia and anesthesia billing, radiology billing, et cetera, showing us that there is just a huge opportunity here to really get much more consistent and successful concerning our operations. So also a lot of clinical data collection going on. I'll just highlight one that is centered in the anesthesia department, but is involving anesthesia, CRNAs, surgeons, and nurses looking at outcomes and factors. See if you could advance. This is the integrated outcomes database within our department. It captures data from preoperative, operative, and postoperative timeframes. Go ahead. You can isolate populations and compare care processes and outcomes using these large data sets. And then of course, we'd like to feed back to providers to allow them to understand the nature of success or failures of their work. From just a data strategy perspective, what this particular database does is takes information from our aims, intraoperative database, including factors around the care that's provided intraoperatively and the physiology that occurs intraoperatively. It combines that with information from the CERNER database, which includes demographic and other medical information about the patient. And then combine that with information from our epic data sources, which includes diagnosis and procedure codes, time data, et cetera. And then we can add to that any other information that is collected by apps that are specific to the care providers. That all goes into one large relational database that then if you can advance heat, allows us to put together this information in almost any way we want. But ultimately, we can provide real time feedback to our practitioners on the care parameters that they provided, the agents they used, the interventions that were made, and then factors in outcomes of the patients, including pain that was experienced agitation, nausea and vomiting, and then safety issues or adverse events. The outcomes become sort of obvious, and we can use these outcomes to actually manage or adjust care. The way that we actually show people this can be done in a lot of different ways. Here I'm just showing you some pie charts that are looking at care process and pain outcomes and patients for various surgeries. This could also be done with run charts, graphs, et cetera. And we need help figuring out what is the most useful way to show people this data over time. You can progress here, Steve. Next slide. There's also a larger project going on led by NilexMeda in our critical care unit called the Parioperative and Critical Care Center for Outcomes Research and Evaluation, also known as PC Core. And without going into the detail of this, it takes all of the information that I just outlined, plus a huge amount of data from our critical care services. And it has organized this in a way that we have an infrastructure that will allow us to benchmark what we are doing and care outcomes from our most complicated patients. We can actually look at clinical studies and trial designs that are now much more innovative and easy to do than previously. Essentially, we could look at any two processes randomized to one versus another wherein all of the data collection is done actually automatically. So we can do clinical trials very quickly and inexpensively going forward creating what others will call a learning healthcare environment. I think you're going to see more and more of this going forward. Ultimately, the outcomes and data analysis that we do with this will allow us to really understand predictive analytics and even perhaps some decision support going forward. Can progress here, Steve. One good example of this. I think Susan Gooby and a number of folks in our department have put together a blood management dashboard and database. In this particular case, what you're seeing is that everywhere and we look at all cases that are done in the OR and then specifically all cases where transfusions were involved. We can actually look at the course during the parioperative care where transfusions occurred. What kinds of transfusions occurred? What kinds of blood product were given? The percentage of cases that required those blood products, etc. Move forward here, Steve. We can also obviously look at which surgeries most commonly required. The transfusions, you can go forward, Steve. And probably most helpful, we can look at the variation in the types and requirements of transfusions that occurred during our care processes. And of course, you can look at this with respect to the surgeries that were done. You can look at this with respect to surgeons and asthesiologists and other care processes. I'm interestingly, Susan has led an effort recently to look at even outcomes from these transfusions looking at over transfusion, under transfusion, etc. And I think going forward, we're going to have a lot better idea about what our practices are and what perhaps appropriate and idealized practices will be going forward. Go ahead, Steve. I guess I would sort of finish my little part of this by saying patient reported outcomes are going to be a really important part of what we do going forward. We need reliable follow-up that goes into the longer term, not short term necessarily. And this can really be easily done as we're all answering questions about our results from the immunizations we've received. We can do this for care processes that occur in the period of time frame using text-based follow-up criteria. You can go forward, Steve. Essentially, we now in the anesthesia department have a text-based application called chat with childrens that allows us to get information from patients and families about the outcomes from specific pain control techniques, including regional anesthesia. And this basically pops up on their phone. They answer the questions. They send it in and it gets folded into a database that can be used for research, quality improvement, and actually put right into their electronic medical record. I would suggest to you that this will be broadened. And the efforts like disco or our chat with childrens will become part of our processes going forward. Basically, every surgical patient should have a customized follow-up that can allow us to understand the results of our work and then make it better. I would just finalize this particular part of this presentation by saying, you know, we have a lot of good technical infrastructure now, but technical infrastructure doesn't understand what's really useful and helpful for us going forward. And what we need is the people that are looking at this presentation right now to think about what is it that we need to know more about, what information would actually allow us to do a better job, and then utilize the infrastructure that we have to actually make use of that data going forward. I would submit to you that the success and even survival of our programs is going to depend on our ability to actually improve and data is going to be the way that we do that going forward. Thanks. I would like to acknowledge and recognize that the success of all that we have mentioned here today is dependent on the underpinning of a culture of equity, diversity, and inclusion. And we are committing to continue to improve the way we treat each other. Next slide. I would highlight one initiative that we took part in over the summer and that was consistent with the mayor of Boston's declaration that racism is a public health crisis. So we open to dialogue with the main operating room staff, focusing on underrepresented groups and facilitated by Dr. Stint Thompson and Jean Conner. We talked about and applied formal qualitative methods to understanding how we can continue to build and sustain a culture of equity, diversity, and inclusion in our work environment. We have focused groups really elicited rich qualitative data. They were 47 participants across all roles and these four themes emerged implicit bias, role and race, diversity across the OR teams and recommendations for building and sustaining a culture of equity, diversity, and inclusion. Next slide. And what's most important about this is the staff that we interviewed gave us great recommendations. They believed we were taking an important step with the initiative and they were clear that they did not want just us to be talking about it. And I'm pleased to present some of the actions that we have been able to implement this so far. They asked for a main operating room leadership document that stated the expectations of respectful communication and how we hold each other accountable. We were able to do that in September. They asked for a real time process for staff to communicate sensitive issues and receive follow up from leadership within one to two days. And we have implemented the real indicator that was used in the cardiac operating room and is currently used across the main operating room. They asked for a diverse advocate to be established to support staff with sensitive issues that may include diversity and race. And we're pleased to announce that Gwen Jackson from our main operating room will be the representative from a perioperative services to the hospital wide EDI council. And they also recommended education, which the hospital is now embarking on this month. It will be mandated education for all staff and faculty and called upstander education. So that has started this month. And they also mentioned increasing involvement of diverse OR staff in HR screening, interview and hiring. And that is also something that the hospital has recently included in our corporate goals and will be ongoing work into the future. That's like. So really communication, how we have changed and how we will continue to change is incredibly important to our future in the way we communicate with each other. And the next slide shows the official document that we send out from OR governance, where we committed to being an inclusive environment and ensuring that all team members experience a safe and respectful work environment. And we do not tolerate any type of abuse or disrespectful behavior in our perioperative areas or at Boston Children's Hospital. We are committed to listening to staff and to treating each other with empathy, compassion, self awareness, where we value each other's differences. Thank you. Moving forward, how are we going to change? What are the things that are important to us? As Patty said, the way we communicate with each other is so important. We need to speak respectfully. We need to communicate by directionally. We need to work as teams. And we need to learn from each other's teams. There are so many different venues within the perioperative arena that we don't all know what each other are doing. So we are going to initiate, and I want to thank Mark Proctor, the Chief of the Nursery Group for suggesting this along with some of the nurses that he's been working with, team meetings where the new sort of pause of nursing and support staff in all of the various surgical areas will meet once a month with one of the faculty members. So for example, a neurosurgeon will spend that morning in a staff meeting giving an informal sort of lecture on what they do and why they do it and have bidirectional feedback on how they can improve the care, allowing everybody in the team to understand more of the other individual's perspectives in the group. We will also be experimenting with a perioperative wide grant rounds. If we do it in the future, hopefully the person who's running the Zoom and advancing the slides will have more technical facility. There's a silly reason why I'm actually running the slides, but I'm not going to do that in the future. What we want to do is we want to learn from each other. So we will have what I think in some other institutions is called Super Bowl, where we will allow one or two of the various surgical set specialties to pick a topic and to promote the latest advancements in their areas. We can learn about what each other are doing right now, sometimes in the Boston Globe or on CNN. And it was happening right next door in the operating room adjacent to yours and you didn't even know it was happening because we are such a large institution with such deep, specialties that are possible to know. So we will have a rotation of allowing each of the groups to present sort of featured items of interest at these grand rounds and we'll invite a wide audience like we have today. This will really promote sharing and team communication. There's also been a shared morbidity and mortality process for those who aren't familiar with morbidity and mortality. This is a conference that most all hospitals have. It used to be amongst only surgical disciplines, but in our institution, we've now instituted M&Ms across all of the non-procedural disciplines as well. But we usually do this in our own silo. It's a closed room where you talk about the patients in a very sensitive manner that have had unexpected or maybe expected complications or unfortunately sometimes mortality. And we talk about what we can learn so it doesn't happen again. And you know, one of my favorite afferisms is the way we learn best is from our own mistakes. But the best way to learn is from somebody else's mistakes. And we do that. As surgeons, it's just part of our DNA. But we do it within our own silo. So a new process led by Jonathan Finkelstein, our chief of quality and safety officer and in the surgical arena, despite my Sean Rand Gell, is being developed to allow us to have shared learnings that each of the chiefs or their quality leaders will feed up some of the cases identified to show what what we learn because what we learn in the urology. Eurology M&M may be relevant in the E&T or L M&M or the orthopedic M&M or the general surgery M&M. So we're developing a process that will allow these key learnings to be disseminated to all of the surgical and anesthesia departments divisions and all of those of you who work so closely with us. Now, in order to improve, we have to ask questions. We can change. We have changed. COVID has been a huge demonstration. We all can recognize that the environment in the operating room has changed dramatically with additional resources and new leaders who have come to the fore. So we're going to try a little experiment and continue our path forward right now by asking for a little audience participation. We're going to ask whether it be thoughtful. There are hundreds of people on this Zoom right now. So if people participate, this thing scroll across the screen so fast that none of us can read it. That's okay. We will be saving this information and all leadership groups will review every suggestion that people enter. I've done this in my department and it's really been terrific to have feedback from everybody in the teams about suggestions. And sometimes it's the simplest little change you can make and just nobody thought about it because nobody asked the question. So we're going to empower everybody to give us suggestions. We want people to feel after this little exercise over that they can come to us anytime. They can come to us in person. My email will make it possible for you to do so anonymously. So I know everybody has almost everybody has a phone with them. Whatever type you have, I want you to open up your texts. Now lots of people get this wrong when we do these polls because usually when you text somebody, you're texting somebody that's already in sort of your address book and you just sort of tap on their name. In this case, we want you to send a text to recipient is 22333. So you type this up at the top of your message box, not in the message yourself that you want to send. And then in the text content itself, I want you to enter in Jen search. I apologize that this seems to come specifically to general surgery, which is because we use polls all the time frequently in my department and it was easy to sort of steal the infrastructure. And you will get a text message saying you're joined top cat, top cat's been session. Todd's running this in the background and he is the executive, Mr. Director of Forest Surgery. Now usually we're an auditorium and if somebody who doesn't know how to do this and you nuts the person next to you and say, how do I do this on my phone? I've never seen a text before. Unfortunately, we're not yet back in an auditorium. We can all be together. I don't think that I'll fit in the auditorium anyway. So we may keep some of this technology going. Okay, I'm going to unshare. And Todd is going to share. We'll see if this works. All right. And here's a test question. Okay. We want you to enter your favorite after we clear these some people gotten sort of ahead. Your favorite pizza topping. Now this one's a word cloud and we'll sort of get bigger words for those who like. Nice with the sausage emoji or mushroom emoji. Well, we have a chat vote for Alice. That's kind of cheating. You got a chat vote at the same time as a polar word vote. Now, it brings to my attention that if people don't have a smart phone or aren't able to make this technology useful, you can put the answers to these questions that we're coming to in the chat as well. All right. I don't think the real goal here is for us to actually find out what people's favorite pizza is. Although when we get back to the point where we can be together and we can have celebrations and we can honor people who are who are retiring after long careers or we just want to have time together and get back in the room. I think we now have information that will tell us what kind of pizza is to order. Okay. Next slide. Here we go. I want everybody to be thoughtful. You can answer as many as you like. I asked everybody to please be respectful. We're done with the pizzas and we want to know now. So some of these coming through. I'll bet some of you have thought of these. And now is your chance to say, even yourself, why did I ask this question? We're going to let this grow. We have time. I want people to take thoughts. You can enter in as many as you like. And we vow as a leadership team that we will look at every one of these and I can bet already that some changes are going to come in the way that we do things based on some of the questions that have been asking. How do you, while this is going on, I was just wondering you had talked about a suggestion box or the ability for people to anonymously put in suggestions and hard copy as well. Did you say that's actually in operation right now? Yes, Andrew knows where they so that's the real indicator in there's paper copies across the operating room and I defer to Andrew for letting us know where those are. So it can be anonymously or by name. So that's really important. So you can obviously approach any of us or you can email any of us and we will take your questions to leadership and get back to you. If it's something that you don't want to have your name identified with, that's fine. Use one of these real boxes that Patty's talking about. If you don't know where they are, please ask your leader in your region. You're going to go for Tom Brady here. Okay, so now I'm going to turn this question around it. If you have more, why do you think come to you, please send them to us or put them in one of the boxes. But now we're going to turn the question around, tell you when to stop this one and bring the next one up. I'm guessing if we sit here for an hour, we could keep having this things scroll. I firmly believe that much of the energy we can have for change comes from asking people not even what changed to make, but what bothers them, what irritates them, what do they think could be done differently. Now we're into why don't we, today? Why don't we require all serves and 17 briefing prior to surgery? It's a little bit of a different question. Why don't we have an update? Now while you're all thinking of these and entering these, I also want to mention if you haven't been in a conference or an event that uses these cell phone poles or if you have and you wish you could do it easily, the institution has purchased an institutional license for pole service. You can call everywhere, that's a company that makes this pole. If you need a password and a very small amount of education, we have people around the institution who are trained to do this. It's really not very difficult. If you want to know who the context are, you could email Todd Katzman and he will put you in touch with the leadership in ISD who will make this happen for you. We can run five simultaneous pole throughout the institution, which is never going to happen. But it's really very powerful to get feedback within your groups, especially because it's anonymous. We actually use this in our department retreats to vote on things and people don't have to identify in the junior faculty, you don't have to be worried about being influenced by the senior faculty or afraid to say something different. Now normally at the end of a grand round like this, we would be in an auditorium in Fultman and we would be taking questions and raising hands. It's kind of a different world now. We can have some questions if anyone wants to pop them in the chat while these are scrolling. And we'll see if we can handle a couple. We're almost at the hour. We want to leave this the wide don't we running. But if anybody has a question that any of us could answer, please place it in the chat and we'll see if we can take one or two questions. Although putting your questions in here is probably more powerful because it's recorded and we will address them. Okay. I think they prefer the electronic version versus they're typing to everybody. Todd, why don't we stop sharing here? And I will reshare maybe at work. Okay. So I think the theme here is that we want you to know that we are listening. We're asking for your input. We appreciate your input. We want you to spontaneously bring us your input. This operating room environment, our procedural environment is more broadly, our dependent upon all of you to help us know how to move to the future. We thank you all for participating after your input and I apologize for my technical failures. Thank you. Thanks. Thanks to everyone. Thank you everybody.
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