Super Bowl Grand Rounds (3/2/2022)

Start for you. Okay, I'm in myself. I'm free. We're going to get you in a real set. Yep, one needs to know how I'll go back in. It's my self. It says it's recording. Can you talk to me at the top? I don't know. Yeah, in the very top where it says the port. I thought that we would have or leadership get together and talk a little bit about where we've come from in the last couple of years and where we're going. In the operating and periopper room environment, we have a very large number of attendees today. We've included people from throughout the operative broadly operative family. Some of you who are used to coming to some of these conferences who don't ever come to operative may find this less directly relevant. But we have so many more of our perioperative experts here with us today and talk about where we're going to or. This will be done in a seminar format. We currently have about 300 people and so to avoid the dogs barking and doing seminar. But we do want this to be inclusive. We will take questions and answers at the end that we hope there will be time to do so. You can type them in. You don't have to wait till the end. You can type in questions and answers anytime. A caption will be monitoring the questions and likely we'll take them all at the end. So we're going to talk about where we've come from and where we're going. And I do remiss at this moment if I didn't take the opportunity to acknowledge the shoulders of giants that we stand on. In the last week, we have lost two incredible giants in our operative history here at Boston Children's. Last Thursday, we lost Alan Reddick. The one standing chief in the history of this institution who started and ran out of permanent theology for decades. He also served as surgeon in chief as one of my predecessors. And just yesterday, only 12 hours after Alan was at the rest. And then he was a hardy-hendron pastor. And those who knew the two of their relationship wouldn't be too surprised that they did it together. And a hardy was, Dr. Hendron was the chief surgery when I was a fellow. His photo was both me. It was looking down at me. This is actually his office. And he trained so many Alan Reddick and hardy-hendron giants that will not be replicated. And if we could just take a moment for remembrance. Thank you. We're going to talk a little bit about the past in addition to that. But mostly about the future and how we're going to solve our challenges together and rise to new plateaus that we could have only imagined. Dr. Reddick and Dr. Hendron were working on our operatives. I want to start by thanking all of you. This has been an incredible, incredible last couple of years. And when you talk about frontline healthcare workers, you are in. You are in. And when you brought the children and our staff and our faculty and our families through is extraordinary. And we just want to celebrate what an extraordinary place you all make. Blossom childrens. From the depth of our heart. We thank you. Your selfless devotion to the children and to the institution to each of your smaller arenas. And is the true essence of the fabric of Boston Children's. I'm going to share some slides now. Okay. We're going to start by a little brief introduction to those of us on the screen. We're going to do this together. We're going to do a little bit back and forth. I asked everybody to jump in and they're up. Me if I forget something, nervous and important point, we'll be a little bit informal. That's what Canada's format. The leadership of our perioper various has really changed dramatically in the last several years. All five of us have been in the institution for a very long time. But all of us have somewhat different roles than we have had in the past. I became surgeon and chief the lower year and a half ago in the middle of a pandemic. Fortunately with the incredible strong support of Jim Kasser. Incredible shoes to fill and possible shoes to fill. Jim is still here guiding me to give advice on this talk less than 24 hours ago. And he is a constant beacon. The same day I became surgeon and chief Joe Cervero became chief of anesthesia. He's going to talk a little about the evolution in anesthesia. Patty is going to talk about the expansion and cohesion of the nursing and patient care services. Dr. Hickey has taken on the role now as senior vice president and associate chief nurse for many areas with the institution which she previously had. And she has been overseeing the ORS in periop and now she is doing so for all of our perioper spatial areas across the enterprise including our satellites. Those who know Catherine Cacci know that she has been behind the scenes and we've now brought her up front. Catherine is now vice president for perioper business operations for the enterprise. And she is an incredible supporter to something with this close to midnight last night. Thank you Catherine. And you're going to hear from Catherine and I want you all to know that you're going to see Catherine much more in the coming year. On a day to day leadership perspective in running the ORS we will all drive great strength for her leadership. And Mary Lanigan, an author who has had leadership roles in the partner of anesthesia and in in radiology anesthesia has now stepped in also to try to fill one big shoe out of two. Mary is now the medical director for perioper services and I say one because and Joe is going to talk about Mary's role and the other shoe that's filled. And I think at this moment we need to thank acknowledge champion and cherish the incredible leadership that the Ferrari has given to this institution. Joe will be talking about what Linda is moving on to now in a different enterprise role. But Linda has really had and many of us didn't notice it was just Lynn, right? Lynn just sort of ran the OR. But Lynn actually filled multiple roles, one of which is medical director for perioper services that Mary has stepped in so beautifully. And I think that when you see Lynn in the hallways in the OR, please, please, especially her thanks what she's done for this institution for our ability to take care of children operating is unparalleled and we owe her incredible benefits. So I wish we could have this life and if we were in the folk, the auditorium, we all be standing at an applauding for for Lynn right now. And I think we can do that 300 of you in and in your own environment. We just got to talk briefly about the people that we work for and I have two groups of people I work for. The surgeons in the department surgery and all the staff in the department surgery to make their missions move forward and I work for all of you broadly in helping to lead with this group, the operating room, the travel environment and training or governance. But in that sense, my role is really representing these individuals, the chiefs of the surgical departments and surgical specialties. Again, most have been here for quite a long time. You know all these people. Since we last had a gather like this, we have a couple of new people stepped up the leadership. Carlos Estrada, we welcome as welcome to this ascension as the formal chief of urology, also a descendant of alleretic. And most recently our new chief is Martha Murray as a chair of orthopedics and sports medicine stepping into the huge shoes of peer waters. So these are the people I work for. Steve, Steve, I'll go ahead and give you a minute. I'm not supposed to be muted. Can you hear me? Yes. Okay. So as Steve mentioned, Lin Ferrari, who I would echo the thanks and applause for. You can't hear me, Steve. Can you hear me, Mary? We can hear you, Joe. Yes, we can hear you. Okay. Lin filled the two positions that are now filled by two different people and that includes Craig McClain, who is acting currently as our division chief for perioperative services or the main OR division. I think people are pretty familiar with Craig. He's been a leader in our neuro anesthesia area. He's filled a lot of different roles has actually had a national international leadership positions in global health and now will be leading division. This particular position is actually aimed at the Department of anesthesia specifically. So he is in charge of the human resources within the division of our main OR. He's in charge of faculty development for those folks who work within our division in the main OR. He'll be leading the sort of efforts around staffing for anesthesiologists and CRNAs and he'll do program development within our Department of anesthesiology and the main OR division. We have the next slide. Along with Craig, there's a number of folks who work to help make the division work appropriately and that includes the social clinic directors for perioperative anesthesia. Alaina Brusso, who's actually taken on a lot of new responsibilities for both daily scheduling and our vacation and call scheduling. Steve Ziggy is also involved from that perspective. We have a social clinic director for the Packing and Kathy Jones, where I think people have noticed this doing a fantastic job over the last couple of years leading our efforts around the guidelines and protocols within the Packing. Sharon Red is the clinic director for ambulatory surgery and at WALFAM both Ariel Ms. Rocky and Bill Sparks are our associate clinical directors and do a fantastic job and have been doing that for quite a while for WALFAM and will be actually helping to lead the effort at optimizing the WALFAM utilization going forward. Our Lexington satellite is led by Linda Poulick. We've been doing that for quite a while. And the hospitalist program at WALFAM is led by Connie Halk, who will be joined by Amy Vincent, actually as the associate clinical directors for hospital program at WALFAM. And I just want to recognize as well at this point that we do have a fantastic leader for our anesthesia technicians and that is Jamie Ticaro. Next slide. Mary Landrie, in happier times, or had a happy time. Mary is actually serving as a medical director for par operative services and that I think this position as opposed to Craig's position actually is aimed at specific protocol guideline development and workflows within the very time. Within the various areas that we provide care and that includes the main OR the satellite locations WALFAM and Lexington radiology GPU Dana Farber, Jimmy Fund clinic, Brigham and women's basically all the different areas that we're providing anesthesia. Mary's position is actually supported by Boston Children's and she reports in this position up to the OR governance committee and hospital leadership. And as opposed to Craig, she's really focused on the protocols and guidelines within the OR itself. Craig's position is actually more aimed at management of our human resources and the planning within our department itself. I know this has been a little bit confusing because Lynn filled both these positions so seamlessly over the years. And I thank both of them for taking these positions on. I think what has motivated us is the growth in our department and the complexity of the services we're trying to run now where we think at this point it's actually better filled by two people as opposed to one person trying to do both. Finally, I just like to acknowledge Lynn once again and just remind people she has stepped into a position with the Children's Hospital leadership as associate chief medical officer for Boston Children's Hospital where she should be working on safety and capacity issues. And within our department, she actually serves as vice chair for strategy and planning and she's really working hard on helping us figure out everything that needs to be done for our collaborative efforts with the Franciscan Hospital, the tough collaboration and the evolution that we're seeing right now. And also planning for need them, which will be coming on board in the next two to three years. We really are already benefiting from Lynn's experience and insights concerning workflows and management, etc. So thank you to her for taking on those new roles. What I'd like to share is. Good morning. Thank you, Steve, Joe and Catherine. It really is my pleasure to introduce the nursing and patient care operations leadership that will move forward. I think everybody knows Andrew Smith, who's the director of the main operating room and Julie Bull, who's the satellite director for nursing and patient care services in perioperative. The director of the cardiac operating room is Jason Thornton and our director of Pachyprioth and surgical liaison programs is Kelly Conley, care coordination clinic is Mary Gibson and the director of nursing for our satellite operating rooms is Ellen Barth. We have a number of specialty based clinical coordinators and they include Chris Benson in neurosurgery, John Brundage and Robin Duggen for the Pachyprioth and liaison program. Shella Buckley for Ophthalmology and ORL Kathleen Corrigan for Eurology, Eileen Coil for Orthopedics, Katie Franklin and Claire Burke for cardiac Eileen McGillis for general surgery, Naomi Rent for dental and interim for plastics and Doreen White in the satellite OIRs with Samantha Stanley in our satellite pack you in perioperative programs. Thank you, Patty. And as Seiford said, I've been somewhat maybe more behind the scenes and that's true for a lot of the administrative leadership. Of course, the administrative leadership is part of the team that you may see every day checking in the patients, helping to coordinate the daily flow. But in addition, there is a lot of our team that is actually behind the scenes. A few that I want to highlight in the leadership role is Elvita Pentella. She's the manager of perioperative billing and she does this across the enterprise. It's actually a team of two people who are responsible for all billing review for all operative care at Boston Children's. We have an extremely strong and experienced patient services administrator, Chris Darrell. He oversees the satellites with a strong leadership for perioperative services, but much more. He supports a lot in the satellites beyond even perioperative services. And I've recently hired Marie and she's the patient services administrator for Boston and I hope a lot of the Boston team is starting to get to know her. Marilyn P.A. Dre, I also want to highlight. She's the enough patient services administrator role for the cardiac OR. The last is to recognize the ISD teams and the leadership for the Boston, Maynow, or cardiac OR and GPU. This led by Greg Six and the Lexington and Wal-Tham OR is led by Andy McDabbit. With if I can speak just briefly to the support services groups, we want to highlight that there's also more and more behind the scenes that are part and present in the team, but supporting the care that's being provided every day. We want to highlight the Sarah processing and perioperative operations leadership, Hazel Boyd for Boston and Ryan Pratt for the satellites. Many of you in Boston may have gotten to know out to Jesus over the past year or so. He is formally within the supply chain group, but really core to the work that's being done for the operating rooms in that position does exist solely today in Boston. But he's the manager for perioperative logistics and distribution. It's really important that we recognize our environmental services team. They are so core to the daily operations and a lot of the transformational initiatives that are happening in Boston that leadership is directly done by Carmen, Bethwayna, Dillingham and Elio Nguyen and then in Wal-Tham by Christina Rogers. So one of the things that we're facing is an increasing need, an increasing need to provide services to children in the operating rooms and in the procedural suites. There is a small sort of sampling of the risks. One is we've got a backlog. We've been sort of choked back over the last couple of years and fits and starts depending on social distancing requirements, availability of beds in the ICU, the available beds on the floor with the huge burden of over capacity at the hospital is basically including right now, which is an incredibly critical level. As the pandemic hopefully wanes further with international travel open, we know there are many medications who want to come to Boston Children's for care as have been done in the past. So there will be a backlog of demand and not of our departments have slowed down in their development of specially programs, faculty recruitment, building the next generations and all of these programs and faculty experts. Our drawing additional patients to Boston Children's and then we've all learned recently that toughs met the center has decided to close the tough Children's Hospital formerly the floating hospital and. It all that is obviously there's a fresh high off the press, but it's likely will be seeing some incremental volume as they have asked us to become the preferred provider in their network for advanced pediatric care. This is just a general picture of operative cases in operative minutes over the last several years and you can see there was a general trend prior to the pandemic of increasing case load and increasing total number of operative minutes and we all felt that we all felt how take things were hard it was the schedule and every chief once more or time and we're trying to find ways to do it and then boom. COVID came and you can see what happened in the spring of 20 when we had to shut down and then the recovery and the recovery is interesting if you look at the top you know we're still not doing quite as many cases as we were pre pandemic. But the minutes have recovered all the way up and have expanded beyond where we were before why is that it's not because we're slower we hope but because we're actually taking care of more complex patients. During a pandemic many families will choose or we have chosen not to operate on children with sort of less time sensitive requirements or or elected things but those that are complex need to be done and those tends to be longer cases and so you can see that our minutes have been have been increasing. So where we're going to find you know the ways to to take care of more patients well that requires two things that requires space which we're going to talk a lot about the two minutes but also requires people and and all of you can recall at times in the couple years ago certainly in longwood and more recently in the satellites where we have had a tremendous strain of not having enough people to do that. And everybody felt like there was a huge load on their shoulders but this slide it's just it's a bunch of decimal points I understand but if you just look at the number of people that work in the period of area across our enterprise there's 422 of you. This is an enormous family takes an enormous my work this does not include the surgeons and as these all of us and you can see the institution has made an increasing commitment over time we need you to do what's going to be required as we move forward into the next environment with more patients more complex patients and a new environment. To get there you have done so many things compatible for you. Thank you Steve just a huge shout out especially to our clinical coordinators who really embraced and coordinated the preference in up over the last year and the case card implementation with the entire operating room and interdisciplinary it involved both team and solution. We had cross functional process work flow simulation and really incorporated iterative improvement into our daily operations so that is real success and we are focused on sustaining that well into the future learning process next slide. FS project milestones are nicely mapped out here from 2019 to our present the Hill critical SPS enhancements and our coordinated case functionality is improving many services have implemented SPS and others are working well to fill out the best of the best. So we are going to do a lot of work to facilitate that process and the case cards are being delivered to the entire operating room. This is just young Joe Kim's latest map shot of our surgical and procedural scheduling application. You are familiar with this and the surgeon requests are linked to searching that procedures materials and it really produces a request summary to assist in the schedule is workflow who are so critical to the success of this process. Next slide please. And the SPS features include case material selection and reference card use is also being incorporated into the daily workflow and next slide. Okay, we are going to talk a little bit about our physical plant we need people and we need space. This is our current longwood blueprint of our ORs. Okay, second to stare at that tricks we are going to go through an evolution of where we are going in the next several years in longwood. We have stable space in Lexington, in Waltham and we are attempting to expand the number of hours that we can use those spaces to accommodate for more children. Many of you have participated recently and I want to thank John Mirroff for his initiative in getting information from all of you and having group discussions that are starting to see how we can maximize the efficiency of utilization of our satellites. We will have need them coming on which will have a whole nother block of ORs in several years but we need to get to there. So how are we going to do that with what we can expand? Well, this is our current ORs on the third floor and the box to the left that's just a dotted line is the hail building. We all remember when we used to look out the lounge window the hole that was done it was a really deep hole and then the superstructure started coming up and then they blanked out the windows. You kind of forgot about it right because you couldn't see anything out the OR allowed. And then those of us like in my office from saying now I have a window where I watch the whole structure go up and then they covered it with windows and you can't see inside and what's been going on there for the last couple of years. It's spectacular what's going on in there and we're going to get you all in there. We are going to open on time in June. We're going to move our ORs and I'm going to go through taking a little bit of the mystery out of what the ORs are going to look like. The first day is going to be like going to a new school. You can't find your locker. You can't find the cafeteria. So we're going to talk about how we're going to make that safe and enjoy. So as you've oriented yourself to this, you can see the blue dot is where the front desk is. You can see the locker rooms and we can see the south building ORs and the old main building ORs. All of these pictures are going to be generally the same framework and we're going to show you which changes. The numbers on here and the wording of what goes in each room is not so important. I think even day we may have an ophthalmology in one room and the next day we might have orthopedics in that room. So don't focus on the names of these particularly we go into the new building. We do have names on the rooms that you'll see. That was mostly done for the construction people to figure out which closets are near which room so that we could store tables and see arms and things like that. But there's not always going to own in these rooms just like nobody owns them now. So here's the first evolution. This is June. This is the end of June and you can see that the south building ORs are current nice ORs. The cardiac ORs, the big ORs, the MROR, most of the orthoores, all those are now great. Why is that? Well we're going to close those because those are all going to be renovated. St. Strains are going to renovate our newest ORs but when you see where we're going to end up at the end point you'll see why we're doing that. So come end of June we're going to have in hail 10 brand new, huge, beautiful operating rooms. You can see the MR suite is actually a double room. So what we're calling rooms 303 and 304 are two rooms and the MRI lives in the middle and it can go into the room. And unlike the current room 25 which really limits us to a small type of case that can be performed and people that can work in there. These rooms will be accessible to all surgeons for all cases regardless of whether an MRI is necessary. New technology for a new era. The obvious thing people are going to say here is wow we have two pods of ORs really far from each other. And that's true and we're all going to have to learn to do that. There is a corridor, I don't know if you could see my cursor. My cursor show. So this will be the new control desk. The old, the current control desk is over here. Found a room 14, 15, 16, 17. So here's where the current control room is. The new control desk is going to be centered between these. These are the elevators, the patients are going to come up. These are the reception. This is the family waiting room. And we'll have rooms on this side are old ones. And rooms on this side are new ones. Now one change since this slide was made, we've gotten permission because of our increased demand to actually these two rooms that are labeled storage rooms one and our current one and two are going to remain open until we're done with all of this construction process. So we will have access to what was planned to be one and a half additional noncardiac ORs per day. Now it's going to be up to three and a half beyond today. So those of you surgeons and chief are looking for more block time. Yes, we will have potential more block time, but it takes people besides surgeons to staff these. And so we need more anesthesiologists, we need more nurses, we need more support staff and all of that is threat. We just got the information a couple of weeks ago that we're going to run those rooms. So we will we'll we'll we'll be a little patient how quickly we can open those and we'll be talking about that soon in a block time summit of how we're going to use those rooms as fast as we can. There's new locker rooms over here. There's old locker rooms over here and throughout the phase of these diagrams, you're going to see things move around and it's going to be a little bit mind blowing how it's going to happen. It'll all make sense as we do it. I'll talk about cardiac in a moment. Here's the next phase about a year later, so the following summer. So now the South block, the South room ORs have reopened and have been all renovated. This fight's back to the right. Nice stores now. It's going to be nicer. It'll be just like the new ORs. And now we again, we have two pods of ORs. The old ORs are going to be closed, the locker room, the periop areas here, everything is going to transform around. But that's all I can be closed and you can see in gray. That's where we're going to start building interventional radiology suites was going to come up in the second floor. We're going to build procedure rooms over there, which I'll show you in a moment. Again, this is the new quarter. We've lost our procedure room. So the current room 15 will become a temporary procedure room. And now on to the next. Okay. So this is this is final state. And now we've got all our new hell ORs. We've got all these new beautiful pre and post out beds. We've got a new locker rooms. We have new waiting room. We have expanded all these old ORs in space into new pre and post out beds. We have IR suites. They're not exactly like this. It's going to be five IR suites and four procedure rooms. That has evolved a little bit and all the OS here. And this will be one long hallway through here, which will be accessible to us and to patients asleep. But not two families that will not be a public quarter. One thing that you may all be wondering about is the numbering system. Why do the numbers for the ORs keep changing? Well, part of that is because the fire department has this very specific rules about numbers. And the other is that we don't want to have an OR 3 inhale an OR 3 in the old OR suite. And somebody say we need a unit of blood in our three and have it show up in the wrong OR. So the numbering system is very well thought out. I'm sorry that we have three digit numbers, but we are. Okay. The sixth floor is going to be where all the cardiac ORs will open. And this will be all the ORs, cath labs, cardiovascular MR will all be in the hail building. There will be five ORs and a hybrid, including a hybrid suite here. And another one that will be ready to open at the last phase of construction when the last phase that we showed on the third floor is about when that last OR on the sixth floor will open. Just to reassure everyone, we recognize what if basically fundamental change some of this will mean for our workflows and just the back and forth of patients, etc. We also are particularly concerned about how do we assure safety and smoothness of the anesthesia and other workflows that will be occurring in these areas. So we will be simulating both the work and the safety events with the leadership of be sure that's cova Carlos, who knows Linda Bielick, Mary Landrigan, Prabhakar, Deepavara, and Catherine Allen. We will be over the next several months as those rooms open, really testing the systems that will be critical for stat and code recoveries of patients in those rooms. We will be depending on some help from Chris Benson and Naomi Rentch to coordinate the nursing efforts that will go along with those anesthesia simulations. And I would just make a plea here to the surgical folks, the tax, the environmental services people that we really will need buy in and participation from everyone in these simulation events to make sure that we absolutely understand the needs, the response times, etc. And as you see the way things are spread out and changed, we will not go into those rooms until we're sure that we have systems that will allow us the kind of response that we have now and the safety for our patients that we will all insist on. And this is really a very important slide and so exciting for everybody on this call. After so many years of incredible effort, design, redesign, and work on the transformative sort that we have, the best, most sophisticated building really in the world for pediatrics, these states will help all of us get used to this space. Be able to test and practice clinical operations and everybody will be able to participate as a team in these day of a life event. And the three important dates are May 12, May 12, June 9. Please sign up through your journey. And even if people can't get to these day in the life events on these specified dates, we will make sure there will be many opportunities throughout the months of May so that everybody gets to get into the building and feel comfortable before the big day, four months from now on June 22. The block page booth will happen on May 10th and June 7th. Again, the real life will be involved in this day too. So really, it's a combination of so many years of work and really an exciting milestone. We look forward to bringing it to Hale. My turn. We want, among other things, we know what you guys have seen these blueprints. You can see that there is quite frankly a lot of mileage that will now be part of our days. I did suggest that we all get segues to get one part together and apparently there's no budget for that. One of the things that we're going to try to do, especially for the first week when, as Dr. Richmond was saying, it's going to be like the first day of school and we're going to be struggling to just deal with the logistics is we are going to limit the schedule for that first week. We're going to have all the rooms running, but we're going to limit them so that for the most part they are not going to be scheduled past two o'clock in the afternoon, anticipating that there's going to be some extra time between cases. There's going to be extra time just getting from point A to point B. If you have to transport, for example, up to the ICU, we realize that that's quite a long journey compared to what we have now. And we want to build in some wiggle rooms so that people get a chance to get used to this space and don't feel like they're running against the clock for that. And as everyone has already said also in the time leading up to that, we're going to be doing a lot of simulations of patient transports of emergencies and hallways of emergencies in the room and in the pack you so that we all feel like we have a good sense of what's going on. And this is going to be a work of progress and we're going to appreciate all of your input as we get through this first weekend as we inevitably find bumps in the system that we have to work out. So more space, spectacular people, what else can we do to meet the need, but we can get more efficient over the last couple of years despite a pandemic. So many of you have participated in these transformational initiatives. We challenged ourselves the institution challenged us to become more efficient in several ways. The three sort of big broad categories are inventory management. We hit a quick home run on that. The identification of best use of equipment, particularly how to record the use of and charge for them. First year out of the box already $600,000 per year of accruing savings to the institution just on that initial effort and that is growing and continuing. And then we want to get to patients in the room on time for the first case and we want to diminish the turnover time between the second and third and fourth. There's many cases there are in a room. So many of you have participated. It's impossible to list all the people who have been involved in this. I do want to make special mention of the leadership of the enterprise project management office, the SPS programming team. And all of you have seen, particularly young Joe Kim has been doing incredible service to us all in importing all this and the rest of you who have helped with this. Thank you. This is ongoing work. We're going to talk just a little bit about some of these efficiency. And this is an eye chart. This is the show. You have shown us so many different initiatives that can work within teams across teams with different drivers that you have convinced leadership need to be worked on in order to move us forward. We're just going to focus today on a couple of them as examples. Thank you, Steve. And just a couple of exemplars that we're very excited about and have taken incredible work by nursing patients here, physicians, surgeons in our 8-MMO team is a process to improve nursing standard work. There are new expectations of standard work for clinical assistance, our service, rub text and the circular RNs in our new system. Clinical assistance will be preparing the room with equipment and supplies. The surgical technologist and clinical assistant will facilitate turnover, yes, the cleaning. And in parallel, this is pretty important. Patients can be brought back to the operating rooms while the room is being set up for completion. Prior to this, we made for everything was set up and settled before patients came in. But we know that we can go out meet the family and bring patients into the room while a few other things are being done. So this really should help facilitate throughput and implementation of the flow coordinator role is something else that we are committed to staffing. We have piloted this in our initial highlights for the last several months. And it really is a role to help facilitate turnover, for improved efficiency and collaboration. But we really have designed pretty exciting processes to achieve the goals that have to do with our three initiatives. I like to add to that the leadership of the nursing teams and designing systems is spectacular. We are all recognizing that we're all here for a common purpose. We're all here to take care of the children as safely and as efficiently as we can. We're all excited to work together to meet these purposes rather than to wait for each other. And we're really excited moving forward into this new era. I just say from the anesthesia side, we've had a lot of different potential areas for improvement noted one issue that continues to come up as a pain point for late starts and turnover delays is the NPO guidelines that we have. And this is a really complex issue and it's not going to be easy to solve. But we do understand that with the evolution of our guidelines over the last couple of years, we have specific guidelines around solid food intake six to eight hours prior to surgeries. And we have noticed that parents have taken to waking up patients at all hours of the late night early morning in order to get them food so that they still have the six to eight hours before their one or two o'clock scheduled surgery. At that point, particularly during the COVID pandemic, we've had a lot of cancellations. And so at 11 o'clock in the morning when the two cases prior to that individual's case have been canceled, we now have a patient who is otherwise ready to go. But because they got up in eight pancakes at four o'clock in the morning cannot have their surgery for several hours. Because of that, we're sort of reconsidering what we're doing with NPO guidelines perhaps liberalizing some of the fluid intake and backing off on what we tell parents as far as appropriate PO solid intake. I've asked Elena Brusso and several other members of our department to take a hard look at what we're doing with our NPO guidelines consider all the implications of changes that we might make. And we will within the next several weeks come out with some minor alterations that we hope will actually improve the overall flow within the OR just based on this. And there are a number of different potential interventions I won't try to go into right now. Thank you, Joe. I wanted to highlight what we're planning on the block time summit. It's something that we have been envisioning to bring together surgical chiefs other operational leadership from the department. And we have surgical surgical and OR scheduling leads in order to look at how we assign blocks, how we could do it differently and how we can improve our understanding of the rules that play. Over time, we wanted to facilitate or support the trading of time across services. And there can always be some questions that come up. The second piece is really important to think about as we make this review really data driven is that we want to be optimizing the use of limited resources. This past winter has showed us how impactful the OR blocks are and the decisions we've made based on day of the week for the type of surgeries that are done on certain days. So, as I said, we have an impact that is in patient capacity. We want to help to optimize that use of limited bed resources and even limited equipment within the operating rooms. And what I said, we have a somewhat unique opportunity in that we have up to an additional 18 Boston blocks based on the three and a half new rooms that will be coming on board and as we can staff them. So, we have a key time to think of how much of the time should be designated to a service, how much should be open and flexible, and how frequently should we be reassessing it and right sizing the block allocations as volume and demand changes. And something that we've talked about this morning, an understanding and understanding of our success is really to turn how we can build and sustain the health of the work environment. If you look at the schematic in the lower right circle, there is real science and evidence to show that when these six every base domain and behaviors are alive and well in our environment, we are more apt to achieve. And we have skilled communication, authentic leadership, meaningful recognition, appropriate staffing, effective decision making and true collaboration and communication. We are set to really optimize our culture and our teams. We're pretty excited about this. We have shown great improvements in the way things are operationalized. And our primary focus, of course, is to ensure optimal patient family and team outcomes. We have exciting work and process to really better understand team perceptions across the satellite locations. For the last couple of weeks, we have been doing a formal clinical qualitative inquiry to really hear the voice of staff across the satellite. So that information can help inform our plan forward. And really, we encourage and expect staff in all of our teams to raise issues. Please, there will never be a question or an issue that shouldn't be raised if it's important to you. And really, we ask that you help us be part of the solution so that we can move forward in the way that we are doing into a very bright future. So thank you. So we want to thank you. It is all about you. We work for you. And we want to hear from you throughout the process, particularly the changes we're going to go through in the next couple of years in the physical plant with our new operational efficiencies. We want to hear from you. You should work with your local leadership. You should reach out to any of us directly. There is nothing as Patty says that we don't want to hear about and try and help. This is all about us as a team trying to help you get your work done for the children. I think there might be some questions. We have a few minutes for questions. I will thank you all for your attention. I apologize for a couple of technical glitches with my slide, not advancing. And I think my colleagues for dancing back and forth as they weren't in order. Catherine, we have some questions. Yes, we do. We have just a few. So what would happen if anesthesia and surgery are ready before nursing is ready and before the medications are complete? Do you want to take that one? So we should not come in the room until the nurses and the other folks in the room are clear that by the time we were to start the case, they would be ready. So the idea here is just that we can work in parallel. If people think that we are just simply not ready. We don't have things in the room. We're not sure they're going to get into the room. Then we shouldn't come in the room until folks think that is the case. I think what we're trying to get rid of is the idea or what we're proposing is that when there are clearly accomplishable tasks that the nurses are working on. That in fact, when we have a robust anesthesia team that we can agree that we can come in the room and the anesthesia team will attend to the induction of anesthesia and the nursing personnel in the room can attend to specific nursing roles. I think it's really important to recognize that there will be times when the anesthesia team needs the circulating nurse who needs other personnel in the room to help. And when that's the case, there will not be the option to come in until the nurses are completely done with other tasks. And if I could just say one other thing that we've talked about in this group, which is safety will always trump efficiency in the system. We are never going to be asking people to blindly just try to go faster. What these efficiency efforts are aimed at is just getting rid of needless wasted time within our day. That is not respectful of the nurse's time, the anesthesia time or the surgeon's time. I think we want to really focus on just doing a better job, a more efficient job, but not sacrificing safety. And if at any point nurse tech, ESD, anyone thinks, hey, we need to stop here for a second because I don't think we're actually safe or ready to come in. That is a perfectly legitimate thing to say and we need to all pay attention to that first and foremost. Thank you, Joe. The next question is about Lexington specifically. And with regard to the need of facility opening, will the Lexington operating rooms remain open following need? Wow. I'll address that. I was at the grand opening of Lexington when I finished my fellowship in 1994 is when Lexington opened. I was there for the ribbon cutting and I've operated there and seen patients there every other Monday for most of the last 30 years. And I've heard lots of times that we were going to close Lexington or we're going to turn Lexington over to the V.I. It's never happened. It's one of our most wonderful and most efficient places. The plan right now is indeed to expand our amateur capacity in the community in our current WALFM existence with more hours and in a beautiful brand new facility, much larger than Lexington. I involved them also in a very nice location right off the highway. So yes, that is what the administration is planning. But I've heard this before and in the meantime, we are so blessed to have Lexington as wonderful as it is because we don't even have a hole in the ground yet for need of. So we're pretty we know we've got hail right. House here is we can walk through it. We can see it. We're about to take tours of it. We're a while off from the so I would say let's just keep pushing forward and all of our existing facilities. Thank you. In regards to the additional rooms, we talked about opening additional rooms both in hail and being able to expand our capacity in the main building. Will we have enough staff? Well, do we have enough staff right now to fill an extra 18 just have another 18 ORs per week? No. I think Joe would tell us that I think how you would tell us that. Will we have enough staff to do all of that every day by the end of June when that space available? I'm doubtful. But the physical space will be there and as soon as staffing is adequate and again, they've just been given information that we have this space. So we've got to give Joe and Patty and their teams a little time to do to bring in an expertise to Joe and Patty. My thoughts. I would agree as Steve very encouraged in our work with recruitment to date, but I think no, we will not proceed with anything unless it's safe. People should not worry about that. We are working very hard to recruit and we will have appropriate staffing when we have clinical operations across all of these areas. Likewise from the anesthesia perspective, this is the quantum increase that we did not expect. We are ready challenged with the staffing that we have in the main OR. We are adding staff actively. We have several people who may or may not be coming on in the next couple of months from returning, etc. So we'll work with Craig McLean with Mary and with all our anesthesia providers figure out exactly how we can meet this potential need. You'll be hearing more about that and we'll be working on it as a department. We'll come to the block time summit. Those of you who are involved with that and we will talk about that. We're not going to obviously sign out those blocks and give you our time that you're expecting to put a patient in and there's nobody to take care of the patient that's not going to happen. We'll expand the assignment of that time as we have the capacity to do so safely. We're past the hour. I want to thank all of my colleagues for joining me in this presentation. I want to thank all of you for attending. We had a well over 300 people here. We want to hear from you. We're here to serve. Thank you and enjoy your day. Thank you. Thank you. Thank you.