Dr. Kevin Churchwell - State of the Enterprise (2023)

Pleasure to introduce our guest speaker today, Dr. Kevin Churchill, who probably needs no introduction. Dr. Churchill is the president and chief executive officer at Boston Children's Hospital since joining. And okay. Here he is. Thank you, Dr. Churchill. Well. We're going to be dispensed with all that crap. You know, please. Well, thanks. This pleasure to be here today. And I've just, you know, I had the usual 40 slides. I was going to show and then the last couple of days and figured I wouldn't show them this year. We'd, I think we're, but decided we'd send them out as a pre read. It really goes through a lot of what's happened and what's, and what we're doing. And I'm happy to take questions as we go forward. But what I wanted to do was spend just a few slides just to talk about. From my standpoint, you know, why we're here and where our opportunity is. And so if you can bear with me, they'll be my talk. And after that, I'm happy to open up for questions. You know, one of the things I wanted to do before I start is just to thank all of you for just the incredible work that you do every day. You know, you guys are the center of the work in Boston Children's, the amount of kids, children, that need our care in the O.R.s and the ICUs just to continue to grow. And the need just at times, I know you feel is endless. But in that, what you do every day just describes what Boston Children's is. I know that sometimes you feel that the hospital is not doing all it can to help and support you. It's not because we're not trying. I've heard the word incompetent sometimes. I've heard the word difficult. But that's not the reason why it's this complex place. And the more we work together, the more we can figure out all the issues that faces. And I'm sure you've noticed that when we do that, we just get it figured out. This is one of the special parts of this place. We just get it figured out. So we'll continue to do it together. And what you do is continues to be just incredibly important. So I just want to thank you for that. So what I wanted to do just to start to kick off by just talking about what's right in front of us today. US news came out. I've been night. And as you probably know, we're not number one this year. We're number two. And it's I think disappointing to most of us, to all of us from that standpoint. But the reality is we never do our work based upon rankings. Rankings do not define us. The work defines us. And in respect to the works that we do, defines our ranking. And so you know every day what you do, it's really defining the best children's hospital in the world. And that's why patients come to us, not just from our neighborhoods, but from the state, from the region, from national and international. And that will continue. That will continue to be who we are. You know, we're going to find out, you know, what happened this year. We'll find out. And what we'll do is continue to examine what it means, what it takes for us to continue to be number one. You know, I got a call from Larry Moss. Larry Moss is the president and CEO of Numerous. Larry's a pediatric student. He's a surgeon. Hold that against him. And we used to wonderful guy. And he called me about two, three months ago to talk about, should we all just drop out of the US news and world for rankings? You know, Harvard Medical School had done it and the law schools have done it, and so on. And at the time I said, you know, Larry, I don't, I don't think so. I think that if we look at the rankings as just. The end all be all then, you know, we kind of get screwed up and thinking by that way. Now, I think I told him that we at Boston Children's just look at it as a sort of a touch talent to understand, where do we need to invest? What do we need to develop to consistently keep our departments and our programs at the top level? Because in doing that, we are providing the best possible care for all the children that come to us. And that's how I talked to him about, you know, what the rankings were and why I thought it was important for all of us to stay in it. That we continue to be engaged with US news to continue to develop it and have it make sense. As opposed to stepping away from it. Reality is US news is a magazine that needs to sell magazines. And in doing that, even if you step away from it, they're still going to rank you. Because the rankings are the only thing that they have now. And it's touch to for many people, parents, children in this country. You know, if you fly into Philadelphia, you just have to fly in it a lot. And then you get on I 95 that corridor really defines how US news is used. For all the hospitals. So in that corridor, you can put billboards up. And so you can you you go less than a mile, you see two or three billboards advertising for health care. And if you get any kind of ranking in US news, it is on that billboard. It doesn't say number one hospital or number two, it just says usually ranked by US news and will report. Or ranked as a top hospital. It's all you have to say. You know, in our announcement today, there was a discussion. Should we put in we are the number one ranked children's hospital in the Northeast. And I said, no way. Because that's not how we think about ourselves. So, you know, this is an opportunity to think about where we are and what we need to do to continue to provide the best possible. And lead pediatric. And so I wanted to talk a little bit about that. How do we get here? You know, I title it is my US news and we're reports important. So just if you could bear with me for a little while, I'll just want to talk a little bit about that. So I want to just frame it in terms of where Boston Children's was in 2000, where we were and where we are in 23. And then ended by just talking a little bit about where we want to go in 2030 and how we're going to get there. So in 2000, you know, Boston Children's was a different place. You know, Dr Burns and I arrived here in 87 88. And a few of the group was here. Dr. Schemberg was here. Dr. McManus was here. And you were here. And I think we'd all agree it was a bit of a different place than it is today. Dr. Lilah, I was here. And I just point those individuals out because they were all in my mentors. They all basically described how I actually took care of patients. And I just want to thank them for that. And I think that was my attending. And he taught me everything I would know about how to take care of a critical care patient. Also a little bit of my finance too. But you know, what I he taught me I kept to this day. So my thanks. Appreciate that. So, you know, the place in 87 88 and the 90s was a little different. You know, I don't know if you guys realize that prior to 1986, we really did have emerged. We had something that was. It was placed in where we have our primary care program now. And it was staffed by primary care pediatricians, moonliners. And we took care of emergency room patients there in those rooms. Those rooms haven't changed. Those are the same rooms that Dr. Burntman took care of patients during that time. And we have an endless drug, you know, drop off child of patient, etc. And we basically had to manage patients in that in that environment. And so when Gary Flescher came here in the 80s, 86. He came here with a mandate to get us into the 20th century of pediatric emergency departments. And you can see where we are today. It is top tier. In terms of how that's developed. But that's what we, it's where we rely during that time. We were excellent and patient science research. Okay, and we've always been that way and that's always been a touch challenge for Boston children's. In terms that work, but I would describe it that the care and I think that many of us would agree that it was a bit fragmented. There was pockets of excellence. And there were pockets of no one's here to take care of the patient. And those that were here, you know, worked really incredibly hard to fill those gaps. As we took care of patients. Well, we got to about the year 2000. You know, it was a difficult time for Boston children who were losing about 70 million dollars a year. And I didn't do the inflation, but that's probably closer to 200 million in today's dollars. And we were at a significant crossroads. And what was decided was that they had to be a change. And so the change came about by the recruitment of the new CEO Jim Mendel and COO Sandy Fenwood. Along with a new leadership, many in the departments of surgery, medicine, pediatrics, et cetera. That was really important. I want to stress that that was really important because part of the time Boston Children's was really didn't have a direction. Great place to train. Absolutely great place to train. Great place to be educated. Great place to do basic science research. Great place in pockets to provide care. But it didn't really have a cohesive view of what it needed to be about. And so with that did not have the direction that it needed to go into the 2000s. And so there was a lot of work that was produced to actually sort of develop what should Boston Children's be. And what makes the most sense. I'm sure you've seen this slide. And when you see this slide, we see it, and it passes right through our heads, because we show this slide all the time. But I will tell you, this is the most important slide that I will present today. And it's the most important slide because it defines how we develop our mission and our strategy. We made the conscious decision that Boston Children's Hospital will be the leading children's hospital in the world. And we would do that by investing and developing these four pillars. The pillar around care, providing cutting edge innovative care. To be the leader in research, the leader in pediatric research and discovery, a leader in education, educating tomorrow's leaders in child health, and leaders in our community. Transforming the health and the future of children. Now, this is our local community now. But you can realize, I think you understand, that local now, for us, is hard to define. Local used to be the neighborhoods that surround us, right? There's Roxbury, Madapand, Dorchester, Brookline, Newton, those are the neighborhoods, Boston. But our reach has just increased dramatically, right? It is now common with the Massachusetts. You can define it some of our neighborhoods, because we've received kids from all over the commonwealth. We have direct connections and referrals from Bay State, from UMass, Holyoke, South Shore, South Coast. All of those are connected to us, truly connected to us. And that was different. That didn't happen. That didn't just didn't happen. That's happened from intentional standpoint. But even the communities nationally, we receive kids from all 50 states of the union. There's no hospital received states from all 50 states. Receives patients from all 50 states of the union. There's no other hospital. Children's hospital that has that. We see, we receive patients, children, and take care of children from 40 countries around the world. So when I look at think about neighborhoods, and I'm taking more about in our community work, it continues to expand, I mean, as we think about it. But when we look at this slide, it helps define what our mission is. And it's more than that, it helps define what we invest in. Where we take our dollars, where we take our, what are, who are people, and recruitment, and retention, and that development. And you may not notice it, but it kind of happens that we continue to utilize this slide as our touch known of how we've developed. So let's just think about this, right? Just in terms of care. By the mid 2000s, we had built the Brithume building. We had opened Walton. That evolved to North Dartmouth as a satellite. It evolved to Peabody as a satellite. That's evolved to now, we're broken ground on Needham. And it continues to expand in terms of our care. We look at the main campus. The work that's happened in terms of the hail building. The hail building was just a concept. It's now a reality. The work to actually reconfigure the main building is happening. If you ever get a chance, don't all do it at once, please. But if you ever get a chance to go with facilities and ask them for a tour, ask them for a tour of what's happening on the seventh floor, the eighth floor, the ninth floor, the tenth floor. Of our main building. It's phenomenal. It's going to look just like hail. The whole hours have been gutted. They're being transformed. And so this is a reinvention that Boston Children's continues to invest in and develop because it's important. It puts us at the cutting edge. We view this, we, the collective, we view this as our cutting edge opportunity to lead pediatrics and care. Now, the building is just a building, right? It's the shell. You are the most important part of that. You are Boston Children's. We just need to provide the space for you, the equipment for you, the opportunity for you to do what you do every day. And that's how I think about our investment. Investment is high. You guys know capital dollars are just off the chart in the Northeast. It's almost to the point that it's prohibitive compared to our colleagues across the country. Our great colleagues in the Midwest Cincinnati was number one this year. And in the state of Ohio, they have at least two to three children's hospitals that are really good children's hospital, Cincinnati Children's nationwide being two great examples. Nationwide and Cincinnati are just building buildings left and right. They build a new critical care tower. They built a new behavioral mental health building. Nationwide has cost of the building is about $158 million. So think about that. For us, that's three ICU rooms. Cost of us working and developing our behavioral health plan with Franciscans is north of $500 million. So that's what you think about, right? In terms of what we have to do and what we're investing in. Cost of the refurbishment of the main building. You know, that's that's north of 300 million. Hail was 1.2 billion or something like that to finish it up. So we are committed, right? This is a place that is really hard to that the operative word is never know. The operative word is, well, OK, yes, and how we're going to figure it out. And I think that really sets us apart in terms of care. We're always looking for the best and the brightest, providing them the opportunity to do the best they possibly can to feel their dreams, their opportunities, their ideas. About the next evolution of care. And that excitement continues to be, I think, what sets Boston Children's Republic. Next evolution is Shammy's work. He is pushing us. And my encouragement to Shammy's keep pushing us. It gets us to where we want to be. I didn't say need to be, but want to be in terms of our maternal field care. To be at the forefront of providing the incredible opportunities. That we can provide for our patients and families. So in research, research has always been the connection with care here at Boston Children's. So I mentioned back in 2000, we were great basic science. Always been fabulous. John Enders. Enders building. But the decision was made to how do we make that really strong connection between research and care? How do we create that continuum that the discoveries that occurred basic science get translated to the bedside. And those observations that you can end get translated back for more discovery. Well, you know, that's a part of recruitment, retention of the best and the brightest enthusiastic scientists, but also space. So when you see that we're, you know, investing in new space, that's why we're investing in it because it's part of our strategy, it's part of our mission. We have built our involved with at least three research buildings now filled them to the brim. What we're doing now in terms of attempting to expand our research is I call it, we're playing a Tetris right now. Somebody leaves, we replace them or we find a nook to for another investigator. So it's not a strategy. And so what we've been looking at is the next 10 years, how do we make sure that we've got our research strategy in place because it has been our differentiator. And so when I talk about the new research building, that's what that's all about in terms of our development, in terms of our mission and strategy. In education, we have always been a leader in educating. You know, I had the opportunity to train here for eight years, and then I got kicked out and then went on on my Moses journey for about 15 to 17 years before I returned. And I learned a lot going outside of Boston Children's. I learned that pediatric health care is not the same in that in many places in this country, it was 10 years behind us. A place I went to right after Boston Children's, I spent 15 years there and I spent 15 years working with other colleagues developing that place. But honestly, when I got there, there was no view of high flintric acid ventilation. There was no view of ECMO. There was no view that you could actually place a cardiac patient ECMO. I had to basically stand up the middle of the ICU and say, oh, yeah, you can do that. Oh, we got to take him to the calf lab. No, we can't take him to the calf lab. That's impossible. I said, no, we can do that. We can do that all the time. But that was the environment I was in. There was no human dialysis of the pediatric patient at the institution I was at. There was no human dialysis. There was just perinel dialysis. So I was trying to dialize a patient with hemolytic uremic syndrome by perinel dialysis. I learned a lot. And that institution grew. But I also would always look and say, OK, what's Boston children's doing? And that became the conversation in terms of that education across the board. If it's OK, if it's important, if it's new, the question came up, well, is Boston children's doing it? And if they're doing it, it's OK. Because that's the trust that we have indended across this nation in terms of our colleagues and other children's hospitals. From the standpoint of education, you go to any place in this nation. You will find our DNA in leadership. Either the individuals did their internship or residency here. They did a fellowship here. They did a traveling fellowship here. They were on staff here. But you will find those connections across this country. And then you will find those connections around the world. Now I was in South Korea about six years ago at their major children's hospital in Seoul. And got a tour of their transplant unit, bomber transplant unit, their cardiac unit, et cetera. And all they wanted to talk about were their connections to the educators here and children's. And the time they spent here and how important it was for them in terms of their development. And so that's part of our DNA. And that's part of how we need to continue and want to and need to continue to invest in terms of creating that environment for educating the next leaders in pediatric health care. And I mentioned our work in the community and how that needs to continue to evolve and we need to invest in it. Because it's part of our strategy. It's part of leading in pediatrics. And there's a lot of opportunity there for us as we continue to grow and reach out to our communities. And understand what does it truly take to provide the best future for our children in terms of health. And how Boston children's needs to lead that conversation. We can't fix it. We're one institution. But given where we are, given who listens to us, we have this great opportunity to lead from that standpoint. So that's what I've used, Sandy and Jim and Craig and Bob and the rest of leadership here thought about and developed from afar. That's what we were seeing. That's what I was seeing. The terms of the, I call them the go-go 2000s for Boston children's. It gets us to Boston children's 2023. And you can see where we are today. A leader in pediatrics around the world. And then I've asked myself, you know, what is it going to take for us to remain there? And it's, and I think that's a good question. Question that we should continue to ask ourselves. Because if you stay in one place, you just stay in one place. And if our goal is to lead, we should continue to move the discipline of pediatrics forward. We should continue to ask ourselves, do we have the right structure? Are we working together with our departments and foundations in the right way? Are we looking around the opportunity for recruitment and retention and development of our people? Because our people is the, is the classic secret sauce, right? It's the classic secret sauce of why we are the way we are. Been very successful. Picture shows the hill building. And it's opportunities. But the question is, you know, do we stay pet or what else do we need to do moving forward? Well, I think that's our challenge. You know, I think that our challenge is. How do we get to 2030? You define it many ways. I think that marking communication is not going to like it. That I call it Boston Children's Health 2030. But you know, good stop. It's a good start. Right. D in terms of looking at it. I don't think we change our mission and our strategy. I think it has been incredibly successful. But more than just successful, it is truly defined us. It has been consistent in terms of its evolution. And we've been around more than 150 years. And if you talk to the leaders that are a bit older than us, they talk about how Boston Children's evolved also. And how one of the key individuals that changed us was a guy named Charlie Janeway. Was the physician and chief about, you know, upwards of 30 plus years, the 1940s to the 1970s. Janeway was not pediatrician. They internal medicine dog in the Brigham. I became in and created a different kind of view of pediatrics. Dr. Nathan describes that he came in and created a discipline. Around excellence. And doing that created environment where departments could develop. Now, if you go to most children's hospitals. I only like four departments. Okay, there's the apartment surgery. There's apartment pediatrics department, anesthesia. And sometimes there's cardiovascular. Sometimes before the most part, everything else is with a division. Right, so in the party, the actually had the division of neurology division of cardiology, etc. That's not the way it is here. And that's really important for us to recognize that we are all that you are all part of departments. And we have been given the opportunity to grow and develop. Outside of the division view. I think that's really just fascinating and kind of genius. It's not been replicated really across the country. Because it takes a bit of a discipline, but also it takes the view that it's okay. It's okay. And we allow groups and others to grow and develop. And try to be the best they possibly can. So that's how we've developed all of our departments for more like an adult hospital from the standpoint of looking at academic medical center where they have a department of medicine and neurology and etc. And you look at that. And I think that's Jane ways. Evolution from that standpoint. And that's just a straight line in terms of our mission and strategy when you think about it. From anesthesia and critical care standpoint, if you really think about how we revolve from that standpoint, it's with the incredible leaders that really take, really take a chance. When others just wouldn't do it. Bob Gross is viewed as one of the art of our Godfathers in terms of surgery. Well, the is the first, you know, cardiovascular operation he did. We and lad didn't want him to do it. Lad was the head of pediatric surgery, the lab procedure, right. Gross presented to him. I can do this. We've done it lab. You know, we can take care of this PDA. And let's say no, it's too risky. Don't do it. Then lab one of vacation. I think report they keep caught or something like that. And then gross causes a group together and does the operation. It's good. It was successful. The patient is she's still alive. She helped me throw them all out of Fenway about three years ago. But it kicked off of you. Of what surgery is here. And it's critical care at a steegee. You know, we don't have the pictures of either. Writing either like any of our colleagues do. But we think about how the evolution of pediatric anesthesia and critical care developed. The night is one of the major night is this was Boston Children's. This one was sophistication stand. And I was thinking about what's the next evolution in care in the OR. What's the next evolution of care in the ICUs. You probably know, ECMO, you know, did a start as a pediatric entity. ECMO started as a total. Major trials were done in adults. And they failed. So it was discarded. To work in Michigan and here. Then we thought about in terms of the pediatric and the neonate. But Boston Children's did was take it and say, okay, we can do it in the units. How about pediatric patients. But how about cardiac patients. About, you know, Longfay or patients. How about oncology patients. Things that for other groups just wouldn't think about say no, we can't do it. And that's not been our view. The word no is not something that music goes in context of Boston Children's. So how do we keep that view and that idea as we move forward to 2030. Well, I think it's, we have to have a great discussion about structure. We're structured. You know, we have a lot of comfort being on 300 long with. I call it 300 long with the place where currently are. And so, you know, we have the opportunity to have much more reach. In fact, more lives. Because of who we are, because what we do. Because of what we can provide. And so, you know, we're actively thinking about how does that work. How we should be part of it. How you should be part of it. And so, what we're going to do is, you know, we're going to have a great discussion about how we should be part of that. Is how do we stay on 300 long with, but move and expand and have our tentacles reach out of 300 long wood. Outside the state of Massachusetts. Where will Boston Children's look like in terms of 2030. Will be elsewhere from a national standpoint. Will be elsewhere from an international standpoint. Are the opportunities that are presenting themselves to us. We have to actively think about how to do that. Well, who should be involved in it. And how it represents us. You know, Cleveland Clinic, you know, has done a really good job. If you really talk with their teams, their leadership and thinking about that. It took them about 15 to 20 years. Think this through. In terms of a national expansion and an international part of that Cleveland Clinic is just Cleveland Clinic. And they made a determination of just not being that, but to be excellent. Excellent, specifically in adult cardiovascular care. Recognizing, you know, that that's when the leasing issues, of course, in the adult populations. And they have really sort of doubled down on that. And they have done it. It's taken time, energy, people. Grit. And perseverance. But what you see that they've done from a national standpoint in terms of expanding outside of Cleveland, outside of Ohio. What you've seen what they've done internationally in terms of Cleveland Clinic, Abu Dhabi. It's fascinating. I've had a chance to see it a couple of times. I personally would have done it that way. I don't know Dr Burns, if you feel the same way. But they are very much committed to it. In terms of their people in terms of care that they are providing to that region. And so as we get to 2030, I'm asking all of us and seeing our leadership to think about. And so how do we define Boston Children's work in that regard in terms of our reach. By 2030, we want to continue to expand our connections in terms of our mission. And on the right, you see the research building, right? And that's just a drawing. But that's the next evolution. We built inters. And that was about 1960s, 1960 early 70s. So inters was our first research building. The next building was carp. In the mid 2000s. And then we're leasing space in the next building called CLS and leasing space elsewhere. But the reality is we have not built a research building since the mid 2000s. And research has changed dramatically since the mid 2000 in terms of space utilization, what happens and et cetera. And so this opportunity that we have here in terms of our next research building is right in front of us. We have thought about our next opportunity being. And we have a plan we own at the what we call the Philber garage site. That space that is right between 333 and the B.I. Shapiro building. They're clinic building. That that garage site. And it started plans to work on how that building would look and the cost of it. And that's the cost got to two billion. We just started let's just stop. Just in terms of the site itself. It's one of those sites where it appears you have to build down as you build up, which I don't understand. But that's what they were trying to explain it to me in terms of what we would have to do. Actually make that side work. And so, you know, there was an opportunity look for other opportunities and other sites. There was a community ed lab forum to go think that it's being called the sort that the heavy mail process was going to launch on June 16 fifth. And so, this is going to beango 202 a summer and it will just be another thing that I have a government impeachment. Back when I said, And that building, this research building will be stayed the art in terms of the next 10, 20 years for Boston Children's. Our ability to recruit and develop the next evolution of care is that opportunity. So we're working diligently on this and by 2038 will be a reality. So there's a lot of work to do. There's a lot of exciting work to do as we get to 2030. And I'd like to do is invite all of you to be part of that. Bring your ideas to the table. Bring your thoughts to the table to bring your grip enthusiasm to the table as we move forward. I'm going to stop there and have to take questions. Hope there are a few questions. Yeah. As we continue to expand the clinical mission, I think one of the challenges for us, especially in anesthesia, is we can't invest as much in the academic missions. And I'm thinking long term, how do you think about that as an organization, especially when many of our people come to places like Boston Children's really for that, for that tripartite missions. I think that's a great question. And of course, I have all the answers to that. But what I do have, I do have a perspective on that. And my perspective is that the solution set is within us. To solve for that next. You know, that next opportunity. And the reality is if we continue to do things the way we're doing now, we're not going to solve it. We continue to have the expectation of how we provide education and support the way we did it five years ago, where we were doing it now, or the way we did it 10 years ago. It's not going to work. Right, because the clinical mission is not staying still. It's continuing to continue to develop. It's all your fault, by the way, because of the incredible work that you do. And the need for parents to come to us. You know, when I was at the other institutions, the biggest issue that I identified. That was a problem, and I thought was a real problem, was that at some point in those other institutions, you run on a road. You run out of clinical road, you run out of things you can do, we think you know how to do. And what you do is then you go to the family and you tell them, hey, well, I'm sorry there's nothing else we can do. That's one thing you can say to them. And you, you would be surprised how often that occurs. There's nothing else we could do. You should take your child home. That conversation still occurs in 2023. The comment that's made is there's nothing we can, you know, we don't really know how to take care of this, but we have some ideas and we want to try this. So that's the other one that. What doesn't occur as often is the comment we don't know how to take care of your child. The Boston children's does and we're going to send them the Boston children. And so as that third option becomes the first option, we're still you're going to have you're going to see more we're going to see more and more patients. But the issue and the opportunity I see is that it should not just track from the educational academic mission. It should feed that. It should help us grow that. It's only going to do that if we work together and figure out what's the next evolution of that academic and educational mission and how to do that well. How do we utilize technology? How do we utilize our people? How do we utilize the environment for that to happen? I think that's the challenge we face all of our colleagues all our I come our brother and sister institutions they face it to. But again, we have the opportunity to lead to figure out how to do that well. That's how I do that. Thanks so much for coming and thanks for your comments. I guess I would just love to hear you comment on the idea that our structure is part of our success. And so clearly as part of the challenge for us and that we have these very independent foundations departments and hospital entity aligning all of us for the things that we want to do is possibly more challenging here than it is in entities that are more generally governed. And somebody thinks of a program that has implications for not only themselves say in a pediatric division of the department. But also impacts anesthesia impacts surgery has space requirements and support requirements from the hospital. I guess I'm wondering do you have thought about how we can do better in a challenging environment going forward in terms of lining all the things we need to align to be successful. You know, I think that's one of the key questions. And I think it's that alignment is part of the challenge for the opportunity. What I see. And I've been part of when I've been part of is the development of we call them silos. And in many respects, we're proud of our silos because they have really helped develop just incredible programs. And they're incredible opportunities. And their silos across the board, right? It's not just the department's flash foundations. It is the silo of finance or the silo of the C suite or the silo of patient care operations or the silo of HR. You go there, you know, it's almost like you've got to have the secret code to get into the room, no matter where you go in our institution. And it's work for period of time. It's worked. Like you can't argue that it hasn't worked. But you know, with anything is it going to be long lasting? Is it going to get us to where we need to be in 2030? I do not think that that's going to be the case. I think that our alignment is around how do we break down the silo. And work and actively collaborate and actively communicate around the work. How do we work to actively integrate the work intentionally is the opportunity. And that's the challenge. But that's the challenge that I am very willing to be part of and I know you are to. Because it helps define the next evolution of pediatrics. You know, this is not again, this is one of those. This is not just us. I would be honest with you. This is a conversation that many of the CEOs of the larger children's hospitals are having. Larger children's hospitals are having because our success is predicated on what we just described. But you know, you're seeing the landscape. Some of it's practical. Right. Just just how we get paid. Who pays us. How much they pay us. It's not going to get. It's not going to get. I'll take it's not going to get better. And it's going to continue to change. And we can be frustrated by it or we can adapt and figure out how to get ahead of it. And doing that. I think collaboration and integration is going to be even more important from that standpoint. And that's the question that you know, the major students hospitals, children's hospital, they'll feel. Boston Children's Cincinnati. We're all having. Because we're all facing these issues. We all want to continue and know the importance of our mission. You know, I was in. Philadelphia, like four weeks ago and the sea and I were talking. And I think we use the word mission maybe ten times in the conversation. And we're going to have a commitment to it. And how do we figure out how do we move that mission forward? So you know, that's the conversation that we have to have. We have to start it now. And it has to be a. You know, engaged. Important collaborative conversation for us to continue to figure out how do we evolve to create a success for ourselves. Thank you, Kevin. This is picking up on Joe's question. You've been talking about Cleveland Clinic and you've had a chance to study Cleveland Clinic for a long time. And there are arguably a good example of as you noted, moving out of a relatively small city in Ohio. And somehow maintaining the excellence to expand across the United States and across the world. When I think back 20 years ago, the benefit of being smaller is that somehow we all knew each other. So there was kind of a circulating, forgive the term DNA, about what we were doing. Not because we were talking strategy every time we saw each other. But there was kind of a shared vision that somehow got spread throughout the organization. How what is what is the secret sauce of the Cleveland Clinic? How have they maintained a common sense of mission? Of excellence while at the same time scaling and expanding? Obviously some of us got to be in their structure, their institute driven, but some of us got to be something else. What are they doing? Well, I, you know, I think they're if you sit down with their leadership, it's like talking to all the individuals in this room. In terms of how they view health care and, you know, what they view is important. It's never, you know, it's never about the dollars in the sense. It's about what's what's our impact? And how we're committed to that. And when you talk with their leadership, that's, that's the conversation. And it, you know, it does, you know, it works to permeate their, those that work there. And so, as it does here in terms of that. And so I think we've got that part, right? From that standpoint. There are those that, you know, sort of don't, don't gleam up to that. And have a tendency to step away. We look at our institutions and you could describe that in terms of do you gleam? Are you really going to bond to what happens at Boston Children's? You know, you know, you're not really appreciated. That happens at Mayo Clinic that happens at Cleveland, it happens at chop. But I think finding that the individuals that really believe in what is what they're doing. And what they are accomplishing. And it's impact. I think it's one of the most important things that I see there and I see here also. And thank you for being here today. The Chief Fulness Officer for the Department. One zero three. And my question is, you know, as we talk about how much Boston Children's has changed and how much medicine has changed. Society has changed significantly as well. The family structure has significantly changed over the last 50, 60 years. The structure of the professional has changed. The generational expectations for work, life, integration has changed. And after the pandemic, we've had a tremendous loss. In the health care workforce and any data set you look at, including ones that I've done on a national scale. Show a frightening number of people intending to retire within the next few years. And as the cost of living increases in Boston, what are we doing? What is the executive strategy for enhancing the sense of support within the workplace for all health care workers, not just clinicians. But all health care workers within this within this enterprise. And increasing the sense of valuation and essentially increasing retention and recruitment of the workers within this, this endeavor. Yeah, that's another great question. And it's another question that has parts of a solution, but I really think the solution is more of how do we come together to. Understand what are the significant issues, what are the significant solutions to that? You know, if you throw dollars to something, you think that that's going to work, and I never think the dollars ultimately are the solution, right? It's a more understanding of what the change is and what really affects from a positive standpoint. And then how do we communicate that and how do we advocate for it? Now, is that a meeting of the, with the mayor. And it was with other leaders within the education hospital community, Harvard, B.U. or the Eastern. And the thing they wanted to point out to the mayor is that affordable housing. It's not an issue that is that should be defined to a particular neighborhoods. But affordable housing is a construct for the growth and development of an economic, academic future development of the city of Boston. Because affordable housing is across the board. You know, you've got the educational institutions where the kids can't afford this to live here. I made the point of the mayor. We can't recruit. We're having the tough time recruiting folks and folks staying because they can't afford to live in the city. They can't afford to live near the hospital. And we're pricing ourselves out. And the point. This is all confidential conversation. But the point I wanted to make to the mayor was that there are groups in the city that believe the success of Boston is based upon what they've done. I either business community. She go to a business community conference meeting. The view is, you know, the success of Boston is based upon what they've done. And the point I wanted to make to the mayor is there's success is not based upon that. The first success is based upon the meal you're Boston. Space upon the academic institutions. It's a base upon the hospitals. Space upon the incredible drive and the recruitment and the development of individuals. That then feed the business community. And the conversation needs to be everybody together to figure out how to make this a better environment for folks to live and to work. And the other thing is one example of that. The other examples, you know, I think the conversation is a conversation that I am open to. What are the solutions that said folks want to bring forward in terms of those. What would make this a better environment? A more supportive environment for for Boston childrens. I've been told that my sometimes my presentation doesn't help, right? I'm actually saying that everybody's a martyr, right? That I thank you for all you're doing. Thank you for, you know, the incredible work and thank you for staying in the breach. And you say that over time and folks are saying, well, gosh, how many times are you going to say that? What else are you going to do to help me help me actually survive and develop in this environment? And I personally want to get out of that. I personally want to have a conversation that describes, OK, given the changes. And given where society is headed, how do we get ahead of this in terms of well being? We're not ahead of it now. OK, it is just run over us like rhinos. Like a elephant stampede right now. And so how do we work to get ahead of it in terms of space, what we offer in terms of how it's constructed? I think that's where we need to go that that's the opportunity. And I'm happy to say if there's a group that wants to really focus on it, not just within anesthesia and critical care, but across the board across the enterprise. I think that would be incredibly helpful to bring forward those ideas and plans as we move forward. Dr. Trot, thank you for being with us today. Very nice presentation. I have two questions. The first is that in the past decade, there's been a major institutional push and support for development of multidisciplinary programs, often dealing with very complex pediatric care. And my question is, what is the institution doing to support those efforts going forward? The second question is now in the post COVID era, what is the prognosis, I guess, for a return of the international patients that we've seen in the past, often coming again for very complex care. Right. So the first from the multidisciplinary programs, I think that's been an incredible initiative and opportunity for Boston Children. And the idea is that we want to continue to support and encourage that evolution. And doing it by the development of space for those programs, development for recruitment and retention for those programs. The, you know, as you pop, you know, the biggest issue is that as we move forward, how do we continue to find the dollars for it? It's going to be one of the key issues. I think that working together, you know, I don't think that's a dead end. I think that's another opportunity. But it is an important opportunity for us to continue to develop and invest in the next evolution of care sits right at those multidisciplinary programs. From the international standpoint, you know, I think we probably peaked in 2019. And I'm saying that because I think that those countries that are sending us patients will continue to send us patients, but they're continuing to look forward and in country opportunity for development of their health care system. The opportunity for us to be part of that development. For, for those patients that makes the most sense for them to stay in country. As we move forward. So I think that that's probably where we are when we talk with them. That's what they want to do. Are there other, depending on the country, there's more, more emphasis on it. Our major discussions have been with the UAE in terms of how they view the next 10 to 15 years. In terms of their evolution and pediatric health care. And the idea from our standpoint is that we should be part of that evolution. Determining and helping determine which patients should come to Boston Children's, which patients should stay in country for care. And how those patients in country and care should be supported. And that's been the discussion active active discussion that we've had with them in terms of the international patient. It's 803. So I guess I better stop, but I appreciate everyone taking the time and staying. Thank you.