Dr. James Kasser - Patient Safety in the OR

I'm going to go back to you. Our closing is on line. We're going to move to the next room. Right. We're going to move to the next room. Okay. Let's see if we can get out of here. Right. We're going to go back to the next room. So, anywhere else, please. Okay. Just a little bit more. All right. Thank you. I'm going to move to the next room. Dr. We're here already on that door. Okay. Okay, You? Oh, Can somebody just check his there a line out there at the coffee and still a line? Well, let's give him a minute then. Pretty soon we're going to run out of rolls and the line will stop. I think we'll get everything. We'll give it another minute. Come on in front. It's a lot like church. Come on down. There's no collection basket today. Come on down. Receipts down here. Come on down. Come on down. Come on down. Come on down. All right. Thank you all for coming. This is only the third time I felt we had to do this. I think you're well aware of what's going on there. Another one deals with checklist and site market. This is really brought up on us by what's going on in the environment over the last couple of years. And what's going on from outside regulatory agencies. So we'll get into that. But I'm really glad you're here. And just as you're starting to think a little bit about your first time going to an operating room. And the excitement of seeing surgery happen and see somebody cured. It's unbelievable. And then think about for just a second. The first time you came to children's and you saw what goes on in the operating room. It's unbelievable. That's what we have to have every day. That kind of excitement and that kind of positive attitude. And we have to perform at our best in order to have them. Curgical volume has increased tremendously over the last 10 years. It's gone up consistently about 1.7 cases per year. And it's gone up in surgical minutes. Stress comes from the volume and the acuity. We want to have the safest environment anywhere for surgical treatment. We need to be air-free based on system performance and individual performance. Now, several years ago, the culture of safety survey that was done, that all of you filled out, identified clearly that there was concern about safety, was mostly tied to staffing. This has been amplified over the past year by nursing concerns, by surgeon concerns, and by anesthesia concerns. I think they were heard by the hospital administration. And there's a response has been made. Patty Hickey is going to talk a little bit about that as we get started. Thank you, Jim. Good morning, everybody. It's great to be here with this awesome team. I have, under the direction of Lara Wood, had an interim role for the last several weeks. And I just want to give a huge shout out because over the holidays, I think in memory, we had the largest number of critically injured children who came to our operating rooms, including a donation after determination of circulatory death. And to watch this team and what it took with meticulous attention to every detail for that patient and that family was really children's at its finest remarkable. So thank you. As many of you know, we were reviewed by Price Waterhouse and they gave us what I would say some very sobering, quantitative and qualitative data related to the state of the universe in the operating rooms. And this is one slide related to nursing that shows that our nursing turnover in the operating rooms has increased over the past five years from two to three percent in 2013 to 17 percent in 2019. And if we project out, we will need to hire at least 14 registered nurses and nine other surgical technologists and clinical staff per year to build for the future. The distribution of our nursing staff in the O.R. right now is a bit by modal. We have a group of the zero to two levels of experience, years of experience and some very experienced nurses with over 10 years of experience. We have a gap in the middle and we are all hands on Jack to recruit and retain and really build the nursing team for the future. So our improvement focus from a nursing and patient care perspective are really these three aims in our new director Andrew Smith Andrew. I think everybody knows with thrilled to have Andrew. And he has already been incredibly successful with our recruitment just over the last two weeks. We have several experienced nurses at different phases of interview and hire. We have incentivized our current staff to pick up more shifts so we can be sure that we match the needs of patients and teams with competencies and experience level of nurses. I can tell you that the focus of my research over the last 10 years has been on nursing experience and the health of the work environment. And we know that staff outcomes and patient outcomes are inextricably linked and that leads to our retention strategies strategies. There's nothing more valuable in our teams than experience. And we are thinking of and implementing a number of strategies to retain the best and brightest operating nurses at Children's Hospital. And something else we found from the data from Price Waterhouse was that nurses are expressing they haven't had the opportunity to advance professionally. So we have a number of connections underway of coaching opportunities. When I think about the professional advancement program at Boston Children's Hospital, the primary architects of that program were in our operating room 20 years ago. And that was Anna Kayley and her team and we still have that professional advancement program. So we are going to ensure that those interested will have the support to advance professionally. We also have a major digital campaign going on. I love this ad, heart expert, heart advocate, heart collaborator on nurse. But we know our greatest recruiters are our current nurses who are happy in their environment. So we are also sending people to conferences to recruit experience nurses throughout the country. So you'll see this ad with our own operating room nurses in different versions of this. And as we move forward today, we're going to hear about a lot of excitement related to improving safety because we know we're the best operating room in the world and we also want to be the safest. And that will be accomplished by our teams and supported through our processes and technology that you'll hear about today. Thank you. Thanks. So I think we've heard you. There's a response that's there and I think the environment is going to improve significantly. Now, the second issue that we want to cover in a major way really deals with a event that's have occurred in the past in the recent past in the operating room. There have been a series of events that have raised concern. A couple of these cases we could just cite without going into any details, but one in which a heart valve was placed improperly for a number of reasons, a proper fall overdose. And there have been a number of times when specimens are lost. Timeouts are a way that we can have structured communication where we can avoid these problems. Timeouts have been done, but they're inconsistent in the operating room at the present time. We've been cited by DPH and CMS for deficiencies. These make a condition of participation. That is for our hospital to continue to function, accept patients and remain open. We have to resolve these issues. We have no choice. Part of the hospital plan of correction is going to be put in an improved timeout. Initially, we were the first group in Boston to deploy a checklist. When a tool came up with this at the Brigham, we were leaders in it. The audits have shown high variability, sign in and sign out our frankly poor. And timeout is done, but not with rigor, and it's not done in a consistent fashion. For six months, we've had a group of us that have worked on timeouts. This group has a mandate to fix this as part of the plan of correction for the hospital. We're going to go over this today, making the case for it and what the changes are. We have no choice. We have to have 100% compliance. Sean? Good morning, everyone. So in fall, up to Jim's comments. I wanted to share some data with you regarding the last couple of years in terms of some of our safety events in the OR, which in addition to what what's shown a few slides ago, also suggest that we may have a pervasive issue, not only in terms of our safety culture, but also in terms of our safety practices. And a couple of the issues with this is that in addition to the DPH considerations, many of you know that last year, we did hit a milestone and we were verified by the American College of Surgeons as a level one verified surgical center, which is the highest ranking that one can get. We're proud of this because this not only represents the fact that we have the personnel and infrastructure to support this ranking, but also it's a two year requirement to demonstrate really exemplary quality and process improvement dedicated to patient surgical care and quality and safety. As part of this, we do have to carefully track events over time. And if we do identify safety trends, which again, a few you've already seen, it's really incumbent on us to address those in a multidisciplinary fashion. And so not only is it important for the DPH, but they're also implications to maintain our verification. So very important discussion this morning. So I wanted to share with you in that context some of our events were the past five years and these are never events as defined by being wrong site, wrong procedure, wrong patients are expired or wrong implant operations and it might be hard to see from the back of the room. We had to make the font a little small to get them all in here, but I did want to specifically acknowledge Alicia will let was our program manager for the ACS quality programs, including verification for putting this together and tracking these and not only in terms of the number, but also really digging down into the causes and the reviews to give us better insight on how you might prevent these in the future. So to kind of give you a sense and to take you through the slide in blue are the near misses and in red are the events that actually reach the patient in caused harm. And in addition to the number of never events were the past five years, there are a couple of other things that are pretty striking. One is the repetitive nature of some of these particularly in terms of our wrong site and wrong procedures as well as our implant related errors as well, putting the wrong implants in as well as putting expired implants in. The other thing that's quite striking is a lot of these events appeared to be concentrated in the last 18 months or so. And so whether or not this is suggestive in the last couple years of a deterioration of our safety culture and practices. It's unclear, but it's something we really need to consider and gives us also a lot of imperativeness to really address this over time. Now those were the wrong sites and wrong procedures so the never events, but are what's probably far more common are events that aren't associated with such severe harm, but essentially prolonged general anesthetic exposure. And also things that have impact efficiency cost and operative time and all these along with the never events are really constructed around a couple of consistent themes and that's really communication either the communication didn't happen or was inadequate. And so one of the things you may ask and comparing ourselves to other children's hospitals is how do our rates of these events compare and so we don't know that because those benchmarks weren't available. But as part of the verification program the next couple of years there will be a collaboration to put together to get a better sense of what these benchmark events will look like in terms of rates. So although we don't have external benchmarks for children's hospital we can compare ourselves to other high risk industries and perhaps the reference of this is going to be aviation. Now consider this that in the past decade there have only been one US airline disaster from a US airline on US soil and that is despite having just over one third of a billion commercial flights. Well what if we flew like we operated well if we look at the rates of our never events here and these again are the most serious events that we look at we would have roughly 3600 commercial airline disasters every year. Now you might say well it's kind of ridiculous to compare an airline disaster with a never event but I think some of our patients parents would probably disagree with that. And I think we can probably all agree that we owe it to our patients to have safety culture that more tries to emulate the aviation industry. So one of the things that we really wanted to come across today is we did not want this to seem punitive and we definitely wanted to acknowledge that we are an incredible center. I think we are all very proud to be associated with this organization we do things in the OR that no one else can do. But again I think we have to acknowledge the fact that being the number one center we have to address and acknowledge the fact that our safety culture is probably mediocre best and something that we can all improve upon as a team. So what can we do to make our OR safer well the first is awareness and again it really comes back to knowing what these repetitive events are what are the themes. But in addition to that we should also be where what are the high risk procedures and situations that put us at risk. And these are some of the themes here again going back to that second slide and looking through all those repetitive events. There are some case types and procedures that are extraordinary high risk laterality based procedures without visible pathologies probably number one. You take that case and you add others and it becomes even higher risk multiple procedures when the consult attending is not the surgical attending when there are multiple operative sites and implant options available. When a patient gets to the OR and the site marking is missed or it's not there very very high risk and not to throw our trainees under the bus. But if the attending is not marked a site that's extraordinarily high risk for wrong site procedure or particularly when there are multiple procedures to do. The second thing we really wanted to cover today is the importance of communication again going back that the communication issue underlies most of the events that we see in the OR minor and major. And so following me we're going to hear from Dr. Waters who's going to discuss the importance of communication as well as some of his very important work to look at the quality of our communication in the OR here at Boston how we can do better. As mentioned earlier we put together multidisciplinary work group to take a look at our checklist we do have a checklist that we use. But I think we can all agree that it's mediocre at best in terms of how we use it and this is probably based on both our culture as well as it's not very ergonomic. And so this work group was tasked with really revamping revise in that checklist to make it better both in terms of the content to prevent some of these events that we showed before as well as it to really improve communication and make it flow better. And then so right now I'll turn it over to Dr. Waters to begin and talk about some of our communication issues and I think there should be plenty of time at the end to more questions. It's a pleasure to be here and I'm going to just introduce to you what we have looked at over the past couple of years. This is an outgrowth of work through the simulation program so Peter Weinstein, Katherine Allen, Chris Rusen. But most importantly everybody in the hospital so we're the only place actually that I know of in the world that's been able to wheels in and wheels out analyze our performance in the operating nursing staff anesthesia staff surgeons. And people did this voluntarily. We got legal approval CEO approval, etc. So I'm just going to show you some of the things that we've learned and this is an outgrowth of simulation that enables us to iteratively keep trying to figure out how do we get better what do we learn. So we not only learn some things that we did but we learned some things we can continue to do by watching how people are. Outgrowth of simulation, LaMakkeli, Ben Hayworth, doing a simulation with our nurses and anesthesiologist Travis Muthini as the watcher and coder. But we moved from that into the real operating rooms and I will tell you you got to have a burning platform but for us for me the idea is we should just really never ever have one of these again. And we can't justify this and yet somehow we continue to be resistant to the things that will help us not do this and they really come down to compliance adherence but mostly team communication and how do we build it. Just briefly I'm just going to run through this but we did real recordings of the OR audio and visual and then we had standardized scoring of this that's based on American College of Surgeons and International scoring. And we started out basically as a feasibility study looking at me so I made myself the guinea pig out in Wal-Fam with the team out there the nurses and anesthesia who were great. And then we moved on to the hand and foot and sports team and then we did this fine team this summer in Boston so I congratulate everybody who was willing to do this because that means you're highly professional. You're willing to look at yourself you're willing to get better and improve and that's who we are. And it's one thing to try and pick up a new game so this is me with my granddaughters and everybody's trying to figure out what this game is and how you putt but that's just us on a green trying to figure this out. But this is what our operating rooms write highly complex lots of people lots of teams and the first thing is if we don't learn how to communicate when it's not stressful when it gets stressful we're less likely to be able to manage this and that's been shown time and again. So we looked at it and we use these tools so they're validated tools called splints ants and knots for surgeons anesthesiologist and nurses in the OR and then we did a combined study of this. So this was just the OR May 2nd 1980 18 when we were doing the feasibility and you're not going to see all this but this has everything that happens in in in the operating room including pre op huddles sign ends time outs sign outs critical parts of the case. Etc and how did we perform and then the most important part is we all got together and talked about it and listen to each other because there is so much to learn based on the professional expertise in the room and then we scored that everybody in this room if I gave you a subject to go learn and put you in a room your smart you've gotten a's on test you'll figure out how to do that. What we're not so good at is number one understanding that we need other people's helps so teams always outperform individuals and to understand that this doesn't apply to me that this is somebody else's problem and that's how we get into not mitigating the errors is not coming together on this so this was some of the scoring in the first 24. The good news was 100% of the time in the operations that we've observed so far consent match site was seen patient was identified there what we weren't so good at as you worked your way down was lots of things but most importantly contingency planning so between doing all this stuff right and you finish your time out and when you do your own closure stuff happens in the operating the people have to respond to and we weren't so great at trying to figure that out in advance. So our compliance scores were good but there's risk and even a 400% compliant a tool and other people's data tells us that's going to probably mitigate risk about 70% of the time the other 30% comes in communication so communication really matters these were the overall scores but for example one thing and we talk with Paul and Lynn about what the anesthesia takes more of a passive role until the patient gets sick or has a problem in the operating room so this speaking out an issue to have that there's doing has to do with this as well. We realize also in choose in diets were fabulous scrub nurse and surgeon before set up circulator nurse anesthesia with induction surgeon and anesthesia to start the case scrub and circulator during equipment issues scrub and surgeon during the surgeon surgery the surgeon the fell of the PA during planning the triad huddles of everybody coming together was rare and not done very comprehensively when we talk to everybody they are going to get a surgery and they are going to get a surgery. They told us and you know this the OR is a busy place that's at times confusing and stressful that communication is not only desired but necessary and important that nursing and anesthesia will avoid interfering in the surgical task unless there's an at risk problem we got to talk to each other before there's an at risk problem and collaborative with leadership is vital to less than our risk and our stress and have better teams. So we know we give great empathic care you people are fabulous professionals how you handle patients their parents how you do your work is outstanding. We also know that trusting relationships on a professional basis really will make us better at all this and so this is Jeff Cooper's talk at this anesthesia foundation annual lecture. I think I would leave you with is I don't know anybody in the room today who's going to want to go home and have dinner with her family tonight and say you know great day at work today we did the wrong operation we operate on the wrong kid we didn't do it right. You just don't want to and so we have to understand we all are at risk for this orthopedics is most at risk if you look at the data thank you. Thanks Peter and Sean so part one of this we can we're going to deal with the communication part one is we have to have a sign in a timeout I wound closure time out and an end of that procedure that is absolutely done right now the group that's worked in this has been a number of nurses Beth Kingsbury Nicole Hunter Megan Katie Franklin Alicia has been very helpful in this Lynn was from anesthesia. And worked with us in this group Francis Fin Thompson Sean and Peter and we've been working at this over several months and it happened that in the midst of our work on this came these events and the DPH and the CMS thing that this said it has absolutely had to be done and it had to be done a hundred percent and it's rare that you have an opportunity to make a change with the change with such a mandate as we have right now with that I'd like to go into where we are. This is the surgical safety checklist that's changed we have a bunch of stop signs there there for a reason the circulated nurses wanted to take on a major responsibility for ensuring that this be done to explain each of these sections we're going to have our group come forward and Lynn do you want to talk about the beginning. Beth is in India so Lynn's here to do this. Yeah so good morning everybody so the sign in we don't do well we do it inconsistently if we do it at all it's not done in a uniform and consistent fashion so what we plan to implement is a very brief process which actually must be applicable to all case types the shortest case with crying children and awake mothers coming in for quick turnover cases as well as a long involve case that may have an awake young adult so this has to be applicable to all case types so as the patient is walking into the room before the patient is put on the bed the circulator will ask the anesthesiologist to verify the patient name date of birth medical record number weight and allergies and confirm the surgical procedure once that is done the patient will then be placed on the bed there will be a laminated card with this information on it that will be picked up and we're going to do that. That will be picked up it will be verified that it's been done the patient will then be placed on the bed but we know from anesthesia is 30% of our medication errors and adverse airway events occur at the beginning of the induction of anesthesia we're going to ask that once the patient is placed on the bed we have a distraction free zone for the induction of anesthesia much like the nurses have on the floors when they draw medications all non essential conversation should be taken out of the room and all the patients are in the room. And all of the attention should be placed on the anesthesiologist the patient and the induction of anesthesia so that we are not distracted we don't make mistakes and we don't have medication errors and I think it should help us with our compliance and improvement. For the time out we have Megan and Nicole. Hi, group. So for the time out portion these are the updates that we decided to incorporate in the new time out so circulating nurse will initiate and lead time out. We initiate and prompt the surgeons and the whole team and ask questions as we go along the time out time out will be a hard stop for all team members so we're going to stop what we're doing give undivided attention and make sure we do the time out correctly. At the beginning of the time out the team members will all introduce themselves by name and role we do this variate in variances either in the beginning and the middle we forget so we want to make sure the team is established in the beginning. So the circulator is going to lead the checklist questions and we want this to be a conversation we're really trying to engage all of our surgical colleagues are nursing colleagues are anesthesia colleagues in a conversation this is a communication tool it's not that we're just going to run down the things that we have to do that are regulated. We want to have a conversation and start that conversation and close the loop so we're going to have the nurses ask the questions and each individual participant is going to respond to those using active communication and close the loop. We're going to have an intentional discussion of high risk situations so if you're worried about something from anesthesia perspective from nursing perspective from surgeon perspective we want those things to not live in your mind we want those things to be out in the open. We want to have a conversation and we want to have a conversation and we want to have a conversation and we want to have a conversation and close the loop so we can all worry about them and all points out when we're off track. We want to have verbal agreement before moving forward we want to know if you're worried about something we should all be worried about that and let's not move forward until we've rectified it. We want to have that secondary timeout. We just want to run through this with you what the changes are. This is what the new timeout checklist is going to look like. You see at the very beginning it says the hard stop of foreign decision and then that secondary timeout like Megan said in the last slide is up there so that we make sure we run through this again if another surgeon joins the case or if there's a new consent added to the case. The circulator is going to say ready for the timeout let's begin introductions and everyone around the room will introduce themselves by name and role. We'll do the confirm patients name date of birth. I'm around weight and allergies like the sign in and then we'll be speaking to the surgeons and the team members and asking what's your detailed procedure today what are we doing and we expect them to feed back to us with active communication about what we're definitely going to be doing what they're going to need. We have everything confirm the site marking and visualized especially laterality in the field. Well there be any specimens what's the number what's the source so we're not losing anything so we know what to expect. And the circulator is to confirm that the consent matches and we hope that the surgeon asked that question back to us and that we continue the conversation. As we talk about closing the loop to the circulating nurse is going to close the loop and confirm that the equipment needs and settings are available that the implant is here so if you have a plan for what your implant is that the implant is here we want to confirm implant name size type and expiration date as we're as we're able to do and confirm medication that are on the field and labeled. We have other pieces we want to talk about the anesthetic plan so the anesthesia will talk about their plan and we management blood loss talk about antibiotics if they're indicated and go over the fire risk assessment I think we can all agree that we don't do a great job at fire risk assessment and that is regulated we need to do that for every single case that we have a concern. And then this is the high risk piece so all team members are going to discuss the things that we're worried about right I think we can all look in the room have a time where we were really worried about something and this is where we want to make it psychologically safe to bring those concerns out and let's talk about them so we can make sure that we're all on the same page so is there a high risk for wrong site or wrong procedure. Are there high risk safety concerns for this procedure and then we want all team members to verbally confirm just like they introduce themselves to verbally confirm that we were going to proceed so some of the common high risk situations are multiple operative sites prone position and laterality with non visible pathology we're also going to seek feedback from you to make this better so this is a start and we're going to have areas where there are going to be other things that we need to discuss so we're going to also seek your feedback so thank you for giving us the opportunity. Francis and Katie we'll go over the one closure time out and the sign out and then we're going to have time for some discussion of this and wrap it up. The one closure time out was specifically designed for the attention of meeting the needs of all surgeries there's a best difference between an EAK and an EO2 placement and we wanted to capture the one closure time out and the sign out to be applicable to both. I understand this is good for small wounds as large wounds as well as even some cases that don't have wounds. We have had cases where packing and bite blocks have been almost left in in cases so it's important that the wound closure occurs even in the cases without wounds. It is a hard stop before closing suture. The nurse will ask is the wound exploration complete. They will have the opportunity to go over specimens and ask has specimen have the specimens been reconciled. This is also an opportunity for the closing counts to be discussed. Also recognizing that the length of every case is a little bit different. We wanted to make the wound closure and sign out applicable to all of them. For longer cases you have the opportunity to do the one closure time out right at the time the closing suture right before that is given. On some of the shorter cases you have the opportunity to do the wound closure time out and then jump directly into the sign out. We wanted to make it flexible and applicable to all cases. The last but not least is the sign out portion of the new time out. I think we all agree that whether the case takes 10 minutes or whether it's a 10 hour case that the sign out is probably the last part of the procedure when the entire team is together and it's really the part of the case where there's the final opportunity to dedicate important components of the case. Like the previous components of the time out this will again be a hard stock before the surgeon leaves the surgical field before this is about. It will again be prompted by the circulator to confirm the procedure with procedures that were performed. This is particularly true if this is a multi disciplinary combo case and there are multiple components and multiple different procedures that have been performed. That was actually intended to be done is all being completed. This is also another opportunity to confirm the final count is correct and if there's any discrepancy before the surgeon leaves the operating room it's an opportunity to deducate. You know what that count is and come up with any mitigation plans in case the count is off such as getting a chest actually in the operating room with the needle count is off or come up with a plan how to follow up on that. And then again it's one final opportunity for all the team members prompted by the circulator to speak up if they have any specific and property concerns related to that case. Any equipment concerns this is again something that the data has shown that the particularly recurring equipment concerns equipment not being available equipment not working have been repeated events. So these are an opportunity to flag those and entire teams you'll be able to speak up and make make that an important part of this. And last but not least I think it's important for the surgeon and then as these are all just as well as a nursing staff to be able to speak up and specify any specific concerns they have for the patient either concerns that have a reason preoperatively or during the case and have impact on the patient's management after the case has concluded. And so I think that this will then segue into the sign up that happens in either the recovery room and I see you. So the plan for this process change remember the circulator will initiate these process in each of these seconds. There will be a hard stop at each point. The box is on this form that you saw will be checked so we'll make sure that they're done. And as part of our plan of correction there will be this continuous audit that we have to get to 100% utilization of this tool in a very short time. We're going to start this trial tomorrow so that when you go to the OR you will see there will be a group of papers for this checklist and the circulator will be working on this Andrew has taken this on. He says he can do it. No problem. Thank you Andrew. That's quite a job. We'd have to have 100% compliance. Now I'm going to take this opportunity to show you some of my extensive research and sight marking. This is my arm. This is my arm and if you look at it I on the left hand side is the marker and a beta-dine prep and on the right hand side of each of these is that sight marker with an alcohol prep. And it wasn't long ago that we decided we had to be using chloroprep for all of these. Well what the heck happens you use chloroprep it takes off the sight marker. And if you look at different markers one of them this one let's see this is one that we had in the for a sight marker if this appeared totally here's another one that disappears and we've gone to this the WP of the end this is a good one. This is called medline prep resistant MTR you can see it totally disappears. So we've gone to the WP which is the right site plus sight marker. This will stand up the chloroprep and some of those wrong site surgeries were because we thought we were doing the right thing and moving the chloroprep and what did we do we took off sight marking. Well then you get to the OR and if the sight marking is not visible what do you do so oh yeah we marked it we marked it well we marked it but it's gone and as part of that that time out you got to see the sight marking and the sight marking isn't smiley faces it's not yes and no it's not somebody else's name it's your initials where you're making that incision or it can be the alternative sight marking things so you're not marking lips with these indelible markers. I won't show you my arm looks a little like a tattoo with the WP but it will stand up so I think we'll now have questions but you can see the need for a change in our timeout process from sign in timeout and you're not going to get your sutures until you do this wound closure timeout I mean you're going to send them back with open wounds unless you do this right and at the time of the sign out make the plan for post-operative care go over the problems that are there and when implants come into the OR how can we have outdated implants that's an inventory problem but it's also a problem for us in the OR so let's get rid of these problems time for questions anyone. Yeah Rustic. I think this is awesome. I would encourage it to expand it a little bit because it's very common that I look up in the table and there's a new scrub there who really hasn't been thoroughly introduced or the circulator has changed or the anesthesiologist has changed and I didn't know. At seven o'clock we then get random teams we get the orthopedic circulator we get the ENT doctor whatever it is the TNT scrub and that hurts that everything slows down everything is more difficult. Rustic thank you very much for the comment I'd like to really get back to what Peter Waters said that if you do a good time out and you do this you'll take care of 70% but that communication within the OR is going to take care of the other set of problems. Young Joe. I think the times that I've gotten to trouble in the past was when I did not listen to the nurses. And I can quote some I can recall some of the events but I think I think the process change is important but probably more importantly is the culture change and I think anybody in the room whether it be the anesthesiologist or nurses to feel free to stop the virus. I think the other case and voice their concerns in a lot of times we have a lot of visitors, a lot of noise, a lot of music. I think there are times when there are a lot of distractions and I think anybody should feel free to stop and say what they feel concerned about. Thank you, Joe Kevin. Well, Jim asked me to come to Grand Rounds this morning and in the usual Jim Kasterway said you know we're just going to talk about some things we're going to do in the OR and we'd like you to be there. I didn't know you're going to change the world yet. And Julie, what you're doing is just incredible. This journey we've been on in high reliability is one that you never ever get to the end. But the whole opportunity is for us to get it embedded in our own bones about what we believe we have to believe that it's important. And this presentation is just phenomenal. This just tells me that we have crossed, I like to say, crossed the Rubicon that it's not, I don't know if you guys remember when we started it, it was, you know, you come and present and you'd have to like bring your flat jacket because it was all about it. You didn't know what you were talking about. We're perfect and et cetera, et cetera. And the transparency that was presented here, the data, the opportunity that's being described and the commitment to getting to zero, it's just phenomenal. And so I just want to thank you for this and know that we're all committed to help you do this to be part of this. What Patty presented this morning in terms of the recruitment and development of nursing. Listen, I just want to apologize in that we tried to listen, we tried to listen and we weren't listening correctly. And it was our idea to bring price water south in to actually say, okay, guys, you go and ask them, you asked them what's going on. Let's actually find out and you told us. Now, it's our responsibility to support what needs to happen in terms of that change. So please know that we're committed to that. We're committed to everything that you're doing because this is top of the class. This is, this puts us at a level that most places just are hoping or it and some are specifying thinking about getting to. So thank you for everything that you're doing. So I want to connect a couple dots and at the risk of repeating what other people have said thoughtfully, I just want to punctuate it again when you saw those statistics. Not just in the OR, but throughout Boston Children's. I really believe that the key differentiator in our outcomes have to do with the continuity of nursing and patient care team members. And I would say it goes beyond that. But the fact that we have retention of nurses that is the envy of the country in all clinical specialties has been huge. Patty has proven that time and again in critical care. We have a critical care environment that looks very different than the rest of the United States and the rest of the world. And so those numbers put us at average with the country that's 17% that's the average turnover in the United States. And so some people would say, well, that's not a crisis. But we knew that that wasn't good enough and that that has to change. And so we are rebuilding in a very systematic way. And I think many of you have said to us, we know you can't flip a switch on this. But we are going to be extremely deliberate and focused on building this experienced workforce again and rest to your point. You can't look around and see a see a stranger. You have to be working side by side elbow to elbow with people whose skill sets you understand and where that trust and teamwork has been developed. That is our focus. Thanks very much. Again, I'm going to thank everyone for these tremendous efforts to make this positive these positive changes. Just just a suggestion regarding the main timeout in the operating room, which we do prior to incision. Could you think about doing that before we do the prep and drape this allows the surgeon to access the medical records and their own personal checklist. We can run through the important points that we may have templated up front. We do this in other hospitals as well. And when the way we do it here, you have to do it by memory, the surgeons trying to remember all the important things. So I would suggest to be perhaps do that before doing the prep and drape. Thank you very much. What we're going to do is ask for your responses over a period of a month where we're doing this. This isn't really a pilot. We're going to change to a new timeout sign in and sign out. We're going to collect feedback and we're going to collect these forms all the time. This same group is going to be working on this and by February 15th, we want to be 100% compliant. And then we're going to make decisions about whether we'd laminate this card and we put it in your kit, whether it just hangs on the wall, whether we move to make it computer-based. We will get this right. And we want your feedback. What I'm going to do is that we finished on time. We're going to wrap this up. And where we began was thinking about that first time that you came into children's and you saw surgery and it was miraculous. Out of the last five years, 150,000 cases that were done here and almost all of them had that feeling and occasionally it doesn't. And we want to make it so that there's 30,000 cases done each year are done perfectly. So thanks for your help. Thank you.