Dr. Kevin B. Churchwell - State of the Enterprise (2022)

All right, good morning, everyone. I think we're going to go ahead and get started. Welcome to, I'm going to take up my mask just introduced. Welcome to Grand Rounds for the Department of Anesthesia and Surgery. It is my great pleasure to introduce our speaker this morning, Dr. Kevin Churchwell, who is the President and Chief Executive Officer at Boston Children's Hospital. Since joining Boston Children's as its Executive Vice President of Health Affairs and Chief Operating Officer in 2013, he has brought to Boston the same passion for enhancing patient and employee safety and the patient family experience that defined his tenure as CEO of both Nemours, Alfred I. DuPont Hospital for Children in Wilmington, Delaware, and Monroe, Corral, Jr. Children's Hospital, which is part of the Vanderbilt University Medical Center in Nashville. An advocate for equity, diversity and inclusivity. Dr. Churchwell has committed to the work required to make Boston Children's a community that's made stronger by our differences and a leader in equity for all. A graduate of MIT and Vanderbilt Medical School in Nashville. Dr. Churchwell completed his pediatric residency and a clinical fellowship in pediatric critical care at Boston Children's Hospital. He is currently an associate professor of pediatric anesthesia at Harvard Medical School. And Dr. Churchwell is the Robert and Dana Smith associate professor of anesthesia at Harvard Medical School. Thank you, Dr. Churchwell. Great. You have great to be here. And my goal today is just to take some time just to talk about what's going on at Boston Children's. It's called the state of the enterprise. But there's a lot going on and actually you are all part of it. And I just want to thank everyone here in the audience and here on Zoom for the work that you do every day. You know, there's work that's happened that here is on 300 Longwood. There's work that happens at Lolltham that you are just so important and part of that continues to make a difference and allows the kids that we are responsible for that we take care of. So I just want to thank everybody for all the work that you do. So, you know, what I wanted to do is just to be able to quick tour and just have some time. If hopefully hopefully they answer questions, if there are questions about what's going on at Boston Children's. This first slide just really tries to define what are goals that what we've tried to create our hospital enterprise goals are for FY 22, what we're concentrating on. And I think appropriately we're concentrating on access. We're looking at, you know, how, how best to do, how continue to prove access for our patients and our families to us. And we're doing it, of course, with our people. We do it with the work and a view on equity, diversity and inclusion. We always do it at Boston Children's in terms of doing it with innovation and discovery. And we do it in a way that continues to be financially sustainable to continue to feed the mission of what we do every day. It's important that our pillars of our mission continue to be at the forefront. Access is important because of what we offer the world, terms of the innovative clinical care that happens every day here. The research that happens, the work that we do in our community and of course our work in terms of education, educating the next generation of pediatric leaders across the board. So I'll start by talking about what's going on with COVID and the hospital capacity. This is now, you know, two and a half plus years of what we've been experiencing. I can't tell you that it's going to go away anytime soon. I can tell you that it continues to evolve. We continue to see what is happening with COVID and its effect on us. You can see, you know that we had a bump in January, a significant bump in terms of infectivity, in terms of the rate of infection, but also it was a little different for us that we saw actually more patients, more kids with COVID than the hospital that we had seen previously prior to that. We had been seeing kids in the numbers of three to four admitted to the hospital, a couple of ICU, etc. I think we peaked out at 50 at some point in January, February. So that was different. And so it was a different type of infection. Subsequently, of course, that's resolved. We've had a bump since then, smaller bump in terms of infection due to the different variants. But as you can see, our infectivity now is down to more than less than 5% by 5.4%. And we continue to track the wastewater and the wastewater shows that things are hidden in the right direction. Now, if you read the paper, there are some concerns around the variants and what they're going to cause. There's a concern that there probably may be a bump sometime this summer. I think the concern was that there's going to be the bump would be more into the southern states, more likely related to the decrease or the less of the decrease in the population that's vaccinated there. And that's always been a problem in terms of the southern states. Here, vaccination rate is almost at 80% and with the vaccine being approved for kids grade and six months of age, I think that's going to be really important to give us to greater than 80% close to 85% vaccinated. These variants continue to cause infection, of course. But we know that if you're vaccinated and boosted, that does protect you from significant disease. And, you know, I'll take that because I just was infected about a month ago and was able just to deal with it. And that was I was thankful for that. So expect a bump, another bump. I think this fall, we expect that to happen in October, November, as it did last year. So our policies around masking and et cetera were adapted based upon that. I think at some point, this, it may be this summer that we're able to actually loosen and reduce our utilization of masks outside the hospital. We'll see in terms of where the infectivity rate goes, but we'll just continue to follow the science and the recommendations of our experts as we move forward. This is just a little bit more data that really shows what's happening within the hospital in terms of hospital capacity. You've all felt it. We've all felt it. That's a capacity has been very significant since the beginning of the year. Prior to in 21 and 19, we were busy when our average daily census was in the 38390s. Our capacity, when we tell the state is a bed capacity of 401. We know that we passed that, but we, we, that's what is documented in 401. And so prior to the pandemic prior to COVID, when we were busy, our major capacity numbers were, we'd be in the 385, 392 range, some 90% plus capacity. Ever since January, we've actually been more than 400 on pretty much every day. So it means that, and so are we an outlier compared to our colleagues across the city, and across the state? Well, they are. No, we're not. Because of base state, they've been over about 105% capacity for that period of time. It's an example. And so both our adult colleagues and our pediatric colleagues across the country have experienced the same issues, the issues around COVID, the issues around the regular respiratory and other diseases that actually come to us during that period of time. And then the issues around delayed care and the continued work that you have to deal with every day in terms of scheduling, rescheduling, and putting out time sensitive cases and having to bring them in. All that combination has really, I think, contributed to what we've seen in terms of our capacity. Along with the issues with behavioral health and behavioral health has been that issue of our kids that continues to be a significant problem that we account of every day. It's unclear what is totally the total issues around that. Why are we seeing so many of our kids with behavioral health issues coming to the ED? Certainly it's related to COVID, but I will tell you that we were seeing this prior to COVID. We were seeing an increase in the number of kids coming to us with anxiety, suicide, ideation, depression, coming to the ED. But with COVID, there has been just an explosion. When we were busy prior, we would see kids, the number of kids we would see would be in the 20s. And we were actually stressed as a enterprise to deal with that number. At our peak in May, we were seeing 80 a day. When you get to 80, what do you do? You basically try to get through the day. And we see about two-thirds of the kids in the country. I mean, in the state, two-thirds of the kids in the state with these problems. Our expectation is that with school ending, that this will subside for a period of time. And you can see that's what we're probably seeing. So just looking at June, there's been a gradual drop in the number of kids coming to the ED, the number of kids who have needed to be boarded with behavioral health issues. This is what we see traditionally. But the expectation is that we need to continue to work to get prepared for the fall. And that after Labor Day, after school starts again, there will be an increase because of the stress related to that. And so there's a lot of work that's happening that, you know, how do we get ahead of this? Is an important question that we need to work to answer? How do we utilize our space to have our kids with behavioral health, be it in the right space, with the right care, moving forward? So stay tuned for that. Vinny Chang is our CMO, his Lee and Group, along with our Laura Wood in terms of and really looking through, you know, how best can we do this as we can, as we get prepared. There are some things that are happening that are getting important from that standpoint. There are more spaces, more beds opening up within the system, within the state. Now, that's what the state leadership, with Secretary Sutter, at Health and Human Services, our Secretary of Health and Human Services has done, has worked to provide and to push more and create more beds for both adults and kids with behavioral health issues across the state. How those beds get staffed is going to be the other key issue, right, in terms of the development and the recruitment of the right staff for those beds. But we've certainly seen some progress with that. As you know, we've opened beds in WALFM and we continue to search and our work with Franciscans is, I think, going to be very important in terms of creating that proper space, the proper location and care sites for our kids with these issues. So this is an ongoing piece of work that we'll continue to do. I expect that the issues around delayed care or the backlog that you're experiencing may take a year for us to really deal with that, a year plus. And our adult colleagues are really willing to, are of course also feeling the strain around that and that there's, CMI has increased because of that delayed care. It's directly correlated to that and that delayed care is now related to patients coming to the hospital too late or later, resulting in a longer stays and more critical illness. And I think that that's going to be the case for a standard period of time as we continue to deal with COVID. So we're learning a lot of course in this piece of work and there's a lot to do to continue to figure out how best to do and improve our capacity. Part of that including capacity is actually finding and creating more beds. And I'm happy to announce that we are able and we've moved into the Hale building. And when you think about it, that's about a, that's more than a 15 year planning cycle. So 15 years ago, that's really went that, you know, this thought around creation of our new bit tower started. About five years ago, six years ago, the actual building started in terms of the construction. So it's taken that period of time for us to get the building build. But with that, in this week, we've moved everyone over. And so what we've gotten now is our new neonatal intensive care unit, 30 bed intensive care in it. We've gone from the open bays. And actually, I was a resident when we moved patients over to what we thought was the state of the Arctic you in 1988. To what we have today and those that are our nurses and physicians and everyone else involved in care there, they're incredibly excited. As other parents, we've had parents actually stayed with their babies overnight. It's never happened before. So that's just that's that evolution of care that we were looking for. The heart centers moved over. And so now we've got a, I think we would all say it's really a state of the art heart center in terms of the beds, the rooms from a technology standpoint, from a space standpoint, from a cardiac critical care from the ORs and et cetera. They're incredibly excited about what's happening there. And that evolution in care will continue to grow. There's a lot of work to do. As you can imagine, they've gone from one floor of a cardiac intensive care unit to now two floors. So how do you manage two floors is the work that's that they're dealing with. An example of that is actually Singapore, I believe, in terms of I see use that are more on more than one floor. And so that'll be an evolution of the work from just a procedure standpoint, everything's on one floor in terms of the ORs, cath labs, echo, and et cetera. And that's exciting. That type of continuity and an end in conversation that can occur and care that can occur with that. And so we'll see that evolution as we go forward. We're also opening up the open up the 10th floor, which is our surgical floor for complex kids. We moved 24 patients into 24 beds. And then we had a 25th patient and they were thinking about putting that patient in a treatment room. But I think we got that figured out. So that's where that space is going to be busy, obviously, in terms of care. And then we've got the 10 operating rooms that are going to be opened up. I think there are a couple that still needs to work, especially the MROR. I hope if you haven't had a chance to see it, you'll get a chance to see it and be part of it, obviously. But whenever if you get a chance, as soon as possible, I would recommend going over there. If you haven't had a chance to do that, it's incredible space. And the MRORs is an example of that. Just a quick story. When the teams are planning that space, they would come to me and say, this is what we want to do. And I my only question them is, are you sure you want to do it this way? Because there were two ways to actually build the room, right? There was a space where the MR moved or the patient moved. And initially we decided to build a space where the patient moved and the MR stayed static. And so I said, are you sure you want to do that? And so it was clear at the time that that was the state of the art, which changed dramatically over two year period. Actually, the state of the art became the MR moved and the patient stayed static. And so we'd our start building the building. Okay. And so the reality is in doing that, we actually had to reconstruct the building with steel. The steel that was at it was just amazing to actually make this work because you're adding an MR that's actually going to move. But what they didn't tell me was that we're actually building not just one room, but two rooms. So we could actually take care of two kids. And the MR would move, which is just amazing. So I had a chance to actually go and toured while they were building. And part of the space is that you have to copper line the entire space. So I think we took all the copper in the state of Massachusetts at one point to build it. It was just amazing. You know, I think I think we ought to call it the copper room as opposed to anything else. When you get the chance and it would be part of that, it's just amazing. I think there's a couple other things that need to be done to make the MR work in terms of lighting and stuff, or probably by the next couple of weeks that that room will be active and will be able to take care of patients there. So along with what I've mentioned as moved, that includes SPD. I mentioned 10 South, 7 North, 6 South, radiology, cardiology, outpatient services. They're all moved. SPD is moved. And now our card system is active. And so this is where we're headed in terms of I call it sort of our revolution in care. How do we go from where we were doing, which was really, you know, 1980s, 1990s in terms of our technology, in terms of our equipment and our processes, to try and to work to get into the 21st century in terms of care. And this is just an example of how we're doing that and what we're doing. In pharmacy, we've added robots in terms of the moving drugs and getting drugs to the bedside. Still little kinks to figure out from that standpoint, just in terms of the utilization of those. But I think that's where we need to hit in terms of the utilization of that technology and our people as best we can to provide the care that we want to provide. So we've moved into Hale and said what's next step? Well, the next steps are the evolution, of course, of the Longwood campus. And that all the space that we've moved out of, we will continue, we're going to continue to utilize. Now, there have been some changes, right in terms of the timing of the renovation, because of other work that I'll talk about. But our plan has always been to actually renovate the main campus where it needs to be renovated, to create, to remove all the double space rooms, to get them single space, to build spaces that are very much new and renovated and in the spirit of what we've done in terms of Hale. We had started to have a goal to finish about 2025. As you can see, that we're now going to finish about 2029 in terms of all the projects, in terms of all the phases. We could probably spend two hours to talk about all the phases. Some of the phases include creating more green space and issues around that. But as we go through this, my hope is that we'll hopefully be able to accelerate the phases and the work so that as we move forward. But our goal is, of course, to renovate the existing inpatient floors. We're going to renovate our operating rooms. As I mentioned, our goal is to eliminate the double inpatient rooms and to add green spaces, we move forward. So the construction will continue on our main campus. So with that, that's where we are in terms of 300 longwood, in terms of the work that's happening here within the clinical enterprise. There's also work, of course, happening in our satellites in terms of the clinical enterprise and our development. Specifically, we have put a plan in place and if it's made of this plan to the state for approval, our Rema satellites, where we are investing and developing WALFM more, WAMF and NETM. In WALFM, as you know, we need to continue to modernize that facility. We need to continue to add clinics, expand what we're doing, expand, for example, the creation and expansion of an infusion unit, adding a sleep program there, and expanding the radiology program are examples of what we're doing in WALFM. In WAMF, we're actually going to work with a developer to build a building. The current building that we utilize is an old building. It's a building, it's a wood building. And I think from my standpoint, there are safety concerns that really need to be addressed when that's standpoint. And also, we run out of space. We continue to space that area can easily be truly a hotbed on terms of need. And so, our plan is to build a new building, close to the South Shore Hospital, that will include all the physician services that are currently at WAMF in terms of the physician clinics. We are going to include other opportunities, including cardiac testing, radiology, and an MRI, which actually doesn't exist there now, audiology, physical therapy, to make it more of a comprehensive site for that area of the state. So, the third part of our strategy in planning for satellites is need them. And that's a green field. And what I mean by that is that we took time to try to appreciate and understand where else did we need to build the next satellite, ambulatory surgical clinic site, knowing that we were basically out of Woon at Lotham. Lotham is getting very close to being a 24-7, 365-day operation, as they move forward, as we move forward in terms of care. And even then, there is just the continued recruitment that is occurring within our surgical subspecialists, and the need for for more space and more for our time and et cetera. And recognizing that, we recognize that we needed to build a new ambulatory site. We looked at multiple areas, okay, we went as far as framing ham as an example, to find the right site, and actually found it, we believe, that need them and need them. It's a site that where the trip advisor building is, I try to give that. And so, the beauty of that site is that, you know, there is, there are, the exit has already been built, right? And so, there's a easy exit on and off from 128.95. So, you can get to us from the north from the south, east and west, and so kids can get to us. So, it's a really a gateway site for our communities, whether it's at need them or Canton or Brockton or North. That's an opportunity. So, where are we? We've had a public hearing, and importantly, in a public hearing, we give our case, and those that oppose this can give their case. No one was opposed us doing that public. So, we were, it was, it was one of the most positive public hearings I've ever been part of in this date, compared to the proud issue that was a really positive, to be honest. And so, we've gotten through that part of it. There is a cost analysis and independent cost analysis that is occurring. We're expecting the report back that will be reviewed by the state. We expect that, I expect that to be positive, and I am expecting that that will not in hinder us to get approval so we can start building. But stay tuned, right? This is the state of Massachusetts. So, nothing's sure until it's sure. And then you've got to double check again after you get it approved. But that's where we're headed and we're excited about that. You can see that our goal continues to be to have this work done by 2026. And we haven't had an obstacle that has changed that. So, we'll continue to give you the update about where we are in terms of that piece of work. So, that's the clinical enterprise in terms of the work that's happening and what we're moving forward in terms of building. Now, I also want to make sure you know that we're actually looking and developing our plans around our research enterprise. It's been recognized that we've basically very close have run out of research space. Space for our investigators, space for recruitment of the next generation of investigators. And what we've done is work to find space outside of the envelope that is long what happened there, right? And so, we actually are releasing space in the new building that is in Finway for at least one or two of our research groups as an example. The concern that our investigators have is not getting too far away from Boston Children's Hospital. And that part of our secret sauce in terms of the research enterprise or the basic science, translational and clinical research is that integration is that communication that our physician scientists have, our scientists have, our clinical researchers have working together and distance is a concern. And so with that, we're looking at building the next building basically in that envelope of 300 longwood. Back in the mid-2000s, we purchased what we call the Philberg garage that was part of Beth Israel. And so it's been sitting there. We actually got it approved for a research building. And so now we're actively working in terms of the planning exercise to decide what we're going to build, thinking and working to get it in the next year to year and a half started. There's a lot of work that has to happen for that to occur. But that's an active piece of work with our facilities, with our researchers and et cetera, in terms of planning and execution. So I'm going to apologize to you right now because it's going to disrupt traffic. But we have what we do. We always disrupt traffic for a period of time. But it's going to be, it's going to make a real difference. It's going to be, I think the next, again, the next evolution of where we are and what we need to be in terms of our research enterprise. So stay tuned. We'll continue to provide you information about where that is and the work that we've had it. Goal is to have that building up by, the building will, that building will be up before 2029. But it's a piece of the puzzle in that when we build that building, we're also thinking about what to do with this building and how to renovate this building. Enders, right? Enders is of 1960s. And honestly, tearing this building down, we're not probably not being our best interest because if you tear it down, then the state says you can't build on the same on-block. So it would be a smaller building, pushback and etc., etc. As opposed to, can we take this building and do renovation? Just thinking about the research enterprise thinking about the clinical enterprise in terms of how to best utilize Enders. So that's also part of the discussion as we move forward. That's why the dates 2029, because so we would build the research building, move research programs over and come back and renovate this building. And that would take that, so the envelope of time you're seeing is part of that envelope so we move forward. So I've covered a covered the space, work around the clinical enterprise and the research enterprise. I want to give you just an update on where we are with a couple of opportunities that actually sort of spring up over the past year and that's Franciscans and Tufts. So Franciscan Children's Hospital is a hospital that's about a mile and a half away from us in Brighton and Austin. We've had a relationship with that hospital for 40 years in that it is a hospital that concentrates on kids with complex issues, rehabilitation issues. And so we populate about 75 to 80 percent of their beds in terms of our kids that we send over for care. Franciscan also has a robust behavioral health program, kid for adolescents and children. They work with McLean Hospital in that regard. And in the past two years, as I've mentioned, the work around behavioral health has been has been churnally at the forefront for us. How do we continue to work and manage our kids with these issues? Approximately a year plus ago, we found out, I found out that Franciscans was going to build a new building, a building that on their campus to actually support their kids with behavioral health issues. So the first question I asked leadership there was what could we add to your building? Could we add two floors? We'd add two floors that would actually help consolidate our kids care and give us more room. Well, it's more complicated than that. The further the more discussion we had, the more complicated became about just adding two floors. And so we took a step back and said, well, was there something more important that we should talk to them about? And so we came back to Franciscans with the idea how we think that it's time for us to actually to affiliate, to come together, to become under the same umbrella in terms of our campuses, in terms of our planning, in terms of our strategy, in terms of our care. And so the invitation to Franciscans was to bring Franciscans and children's hospital under our umbrella. We said all of us sit under the children's hospital medical center umbrella, right? The hospital does, the foundations do, etc. And we all report up to the same border trustees, etc. I say that just in doing that in that recommendation, what that would I always do with Franciscans would be to plan together to actually provide capital, to actually create a campus for our kids with behavioral health and rehabilitation needs at Warren Street. It took us about a nine months or so to really get that agreed upon. Both boards had to agree upon it. We had to get agreement from their oversight, which ultimately is the Vatican. Right now, it's the Franciscans missions of mission that they report to. And so it's kind of a big deal, right? That ultimately what will happen is that Franciscans' children's hospital comes under and is comes affiliated with Boston Children's Hospital, separate from their affiliation now. So there are state requirements for that. There are Vatican requirements for that. We're almost, we're working through the state requirements. We're working through both. We expect that by sometime this fall that will have gotten through the state requirements in terms of approvals of the transfer of ownership. And then we expect by some early next year that will work through the others in terms of the canon law requirements. But ultimately, we're on the track to actually bring Franciscans to us. And with that, we're planning, we have a Master Facilities Plan for the campus in terms of the rehabilitation of that campus new building for that campus in terms of our kids with behavioral and mental health issues, behavioral health issues, complex care. Creating a campus that really provides care, both inpatient outpatient, provides a campus for education. Because right now we do not have enough psychiatrists, psychologists, nurse practitioners, social workers in this regard in terms of behavioral health and rehabilitation. And also research in terms of what's the next evolution of research for our care for our kids with these issues. It's exciting. It's deciding with both groups, with both leaderships about where we're headed. And we're doing it in a stepwise fashion from that standpoint. I say that I'll take responsibility that that was my idea. Next one wasn't my idea. So I want to give you an update around Tufts. And this is important. And so I have a couple of slides about this. Tufts came to, Tufts leadership came to see me and Peter Lawson about August of last year. And they basically came to say we have been really looking at our president future and have made a decision. And basically the decision they made was that they needed to close their inpatient pediatric hospital. And reopen it for the care of their adult population. Because what was happening is that through COVID and through their investments in their adult programs, transplant, cardiovascular, they had created an environment where there was a need. Adult patients were coming to them and were overloading their capacity to the point that they were turning patients away 30 patients a day, 300 patients a month, adult patients. In an environment where in their pediatric hospital, 40 beds, they were utilizing 20. But they were isolated beds that couldn't utilize them for anything else. Understanding that Boston Children's Hospital was approximately a mile and a half away. So it made more sense of them to actually partner with us for their pediatric care and then repurpose their pediatric beds for adult beds. And that's where the discussion started. It took us about six months of quiet discussion to understand was this possible because there are a lot of implications, right? There are patient implications, there are faculty implications, there are staff implications, there are education implications, residents, medical students. And we've had to work through all of those to see, can we given this hurdle, can we solve before this hurdle, can we solve for this problem? So we felt by January, yes, we had to solve for this problem and that's when it was announced. And during the next six months, we really worked through okay, the the mechanics, the recruitment of staff, nursing staff, which has gone well in terms of creating that transition of toughs nursing to Boston Children's Nursing. The creation of a faculty that supports toughs pediatrics, their knee nail intensive care unit, their outpatient services, that faculty is coming over to Boston Children's and an employment vehicle, we're calling it the BCH Foundation and then they will that faculty will be responsible for a toughs, the toughs, our toughs patients. I say our become they become they become they are becoming our patients and in a collaborative way. And so we've had over 70 physicians now come over into this new environment, not everyone came over okay. The surgical subspecialists for the most part did not come over. And that evolution will continue whether it's otolaryngology, whether it's pediatric surgery for two examples. Pediatrics of specialties, some have come over. There's a portion that did not and our faculty are are will be managing those patients as we continue to recruit into this this vehicle as we move forward to support the ambulatory practice that we are absorbing. The plan is for toughs Children's Hospital inpatient to close July 1st. We're headed in that direction, right? And that and that is going to occur. And then we will continue to move forward as we continue to populate the ambulatory sites and etc and continue to work through that. This is kind of important, right? Because it's a signal that we're seeing. We're seeing it boss the childrens and our colleagues are seeing around the country. In terms of you know we've been talking about re-servization of care pediatric care for about 15, 20 years that it's going to happen for multiple reasons, right? The lack of the specialists, the need for centers of excellence in pediatrics and how that referral should happen. Did I do that? Well anyway and with that, we're seeing that I believe we're seeing that in Massachusetts and that toughs is an example of that in terms of creating a that collaboration with us. I believe that as we move forward there will be other collaborations probably not in the way that we have we work with toughs but other types of collaborations that will continue to evolve in terms of this regionalization of care where kids come to us, especially kids with complex critical illness that it's not the portal for a run of the meal type of care that will be more and more centralized for us to take care of. So let's see I've got a few more slides. So stay tuned. My goal is to continue to give you an update about where that's headed and where the opportunities are. So there are a couple more things I just want to cover and I just want to give you an update on where we are outside of our work outside of 300 longwood that is continue to occur. What I mean by that is that you know we are doing a lot of work in terms of what you've just seen in terms of our space here in terms of recruitment development within Boston Children's proper, our satellites and etc. But there's also work that's happening outside of the state of Massachusetts where the Boston Children's are brand and also our work is reaching out. Now part of that work is you want to come up or part of that work is work that brings patients to us right. It's that classic work of referral to Boston Children's from the state of New York kids from the state of New York or net kids nationally or kids internationally and you know you've been part of that work and you see our kids that come from those areas come to us and that continues to grow and develop. Thank you. Great. That continues to develop and there are specific areas that we have concentrated on whether it's the state of New York in terms of that work you know we get over 300 kids up a year that come out of the state of New York to us as an example. And then we get and we also have a significant international referral and so that work continues around how do we actually stabilize and continue to work to strengthen those referrals. And we're also then thinking about what are the right relationships that we need to have as we move forward of the next five 10 15 years because it's important to note that as we continue to support and develop our mission around research, clinical care, education and our community but dollars that we produce to invest in that need to continue to flow and need to continue to grow for us to do it the way we want to do it and believe is the right way to do. So I believe that in order for us to truly do that we have to really provide dollars outside of this state for that mission and part of that are these types of dollars this clinical enterprise work in terms of expanding who we are as Boston childrens. And so that's I call it creating a pediatric and example creating a pediatric consortium a consortium of entities that understand what we bring to the table in terms of care and refer kids to us because of that. What I mean by that is that outside of us those that take care of kids in pediatric hospitals do the best job they possibly can. They are working just like we are 24 7 365 but in those entities you do reach a ceiling in terms of the care that can be provided right this child this particular child has this disorder has this disease has a stagnosis and we do not have the expertise for care this happens a lot this happens more than I think all of us really realize and what happens in that regard is that the families present it with three options first option is I'm sorry we can't do anything for you. Second option is we actually don't have any expertise in the care of what your child has we can try this now you'd be surprised how often the first two points are made as opposed to the third point we don't have the expertise to take care of our child we have a relationship with Boston childrens and we'll we want to send your child to Boston childrens and we believe and I believe that that third option now should become the first option in creating this type of consortium like money institutions that understand what we bring to the table and that we work with in terms of that type of referral so we're working through what are those like money institutions that we can have a true relationship with and so it's a win-win for both institutions from an education standpoint from a consultation standpoint you know we work to keep kids local when kids can stay local when when kids need to come to see us we're there for the kids to come to us an example of that is our work with Joe Dimascio children's hospital in Florida that leadership of that hospital reached out to us and said we realize that we can do this amount of work this amount of care but there is a complexity of care that is here that we don't have and we want you to we want you to be our partner in that care so this relationship has evolved over the past three years and I expect that it will continue to evolve in terms of that type of work and what we're doing is reaching out and and looking for other partners like that for example there are other partners in the state of Florida that we believe fit this criteria fit this example and so we're looking at this this slide just describes why Florida would be a great example of that it's a large and growing pH populations fragment of pH care and there are look there are collaborative relationships that we can build upon Joe Dimascio is one example of that and there are others that we're actually sourcing within the state another example is a adult entity that takes care of kids that is national in scope or if you like that one trawl example that is hospital corporation of America HCA HCA has they have hospitals here and actually in London but naturally they have hospitals that take care of children and they are committed to the care of their children they take care of children with complex issues for example they have a relatively moderate size congenital heart program in Dallas at their hospital in Dallas as an example and in Denver and what they've done so far with us is ask us can you evaluate those entities what are we doing right what are we doing wrong how can we improve and can you be our partner in doing that and so that's been part of our evolution in our discussions with them I think an opportunity for us is to be their referral HCA's referral nationally for kids with complex issues that don't fit care in the hospitals that they currently are managing and developing so that's an ongoing discussion that we're having with HCA hospital corporation of America as an example that Boston children from a national standpoint will be could be that referral pattern and then the work that we're doing internationally you know as you know our patients come from everywhere this slide just shows that example but as you can see that the Middle East we 597 bedded discharge that's a lot and we're working to understand what's the next evolution of that given what is happening there in the Middle East specifically in the UAE or Kuwait and how can we should we be part of that evolution in terms of our work over the next five 10 15 years so stay tuned for that piece of work in terms of that development so I've got a few more slides and I just want to just mention a couple of things to update you on one is the work around our departmental searches there are three searches going on currently with a one that will be probably started in the fall so the third searches that are ongoing including our search for our department chiefs like kaitri our department chief of pediatrics and our department chief of radiology will be kicked off our department chief for clinical labs will also be kicked off sometime this fall also you can see that we've identified our chair person and we're working on they're all in different stages on terms of interviews and recruitment there will be executive searches that are ongoing that we will bring up and move forward in terms of the fall as there's a lot of work that's happening and we're thinking through what is the infrastructure the board of trustees has asked me specifically and it's deep was there actually two you know what is our infrastructure for the work that we're doing and how should we develop that and so that's a piece of work that we're thinking through in terms of who else we in what groups we need to actually search for and develop moving forward. So finally I just want to mention and bring up the work around faculty support and that this is an ongoing piece of work that we're concentrating on and that we believe is important for our faculty and there are at least there are multiple areas that we're working on but these are three that we think are really important of course and that's the office of clinician support that's a place that has been developed over the past 15 years that our clinicians can come to with their concerns with issues that that they need help and dealing with we continue to add support to that office and I personally and Peter Lawson I personally work with Dave Dimasso in terms of really working to identify what needs to happen and what we need to do to continue make that office very robust for our clinicians. Recently a system has been set up in terms of the doctors offering coping support or docs a peer support program that we want to make sure that everyone knows is there and is there for support for our physicians and researchers who are experiencing distress and most recently we've created an Amzboff office that's available for anyone within Boston Children's faculty staff etc for a confidential impartial and informal discussion around the issues that you or groups feel needs should be addressed and not being addressed it helps really define where the next steps how do we how should we address it's all very confidential and and informal and has been utilized really well so far and I'm very much excited to the point that we actually added a sick and Amzboff person because of the work. Also want to mention and faculty development the Fenwick Fellows Leadership Development Program that it's available to apply for a two-year leadership development and career advanced program for our EDI work that folks interested in EDI work we want to there are dollars that we've set aside and we want to encourage those that are interested to apply and then there are other opportunities within our office of faculty development you know that annual meeting I would just stress and recommend that's an opportunity to meet with Gene Emons and Carla Kim to develop and see where you are in your faculty development process there are fellowships available fellowships concentrating for women faculty career development of Boston Children's and a basic science career development initiative also that's available so I'll stop there and I think we've got maybe a minute or two for questions so have to take any questions that you might have. You hear me thank you so much Dr. Churchwell I'm just going to announce over the microphone so that our Zoom attendees can hear if they have any questions they are welcome to enter them into the chat and we can bring those up anyone here have any questions yeah bring them over to you. Thanks a lot it was a great presentation one question that I have is HCA by default had a 10% of entire delivery in United States have you ever had any discussion regarding the fetal anomaly with the HCA and those pregnancies? Oh that's we have not you know the the nascent discussions have been sifted around in general heart so far but you know I expect that if we're successful that will be part of the evolution of the discussion right in terms of all that aspects that are the opportunities from that standpoint that's great question. Regarding outreach to Florida there are many children seeking gender affirming care here because planets are closing the Florida how will that in play of what is allowed here and what is allowed and what allowed their work. Good question don't have the answer to that I know that we are continue to be a referral entity for our kids with those issues across the country. There are other children's hospitals that have reached out to us to ask us to be their partner given where they are located and the issues that they are encountering. We believe that's important we are developing and continue to develop our work and our space and our plans around that expecting that to occur. I've not heard an issue with Florida per se but we'll follow up from that standpoint. All right thank you I think that might be thank you thank you thank you so much one more time thank you