All right. Well, good morning to everyone here and on Zoom. I'd like to, uh, have everyone please join me in welcoming Doctor Elena Bafani from the Department of Anesthesiology to deliver grand rounds today. Doctor Bafani completed medical school training in Bucharest, Romania before moving to New York City to complete her anesthesia residency at Saint Luke's Roosevelt Hospital. She then came to Boston Children's Hospital. For a fellowship training in pediatric anesthesia, is now the Associate Division Chief for Operations and perioperative anesthesia and the clinical director of the Maine OR. Doctor Bfani also provides excellent general and regional anesthesia care to our patients, and whenever she walks into the operating room, you know you are in good hands, so is your patient. So, without further ado, Doctor Bafani. Thank you. Who remembered this? Suddenly I do, and I just earned my 20 year of service PIN, which means I got to experience this for two decades. But luckily we found a better way. It is actually shocking that in the post-COVID era, an organization as big as ours still relied on pen and paper and rudimentary processes to run the operating room, which actually generates 50 to 70% of the hospital revenue. Uh, recently, I have been more involved in operations and more efficiencies, and to learn more about the operational management. Um, I actually enrolled in the Executive MBA at Sloan. Uh, today we're gonna discuss, uh, about 3 things modernizing operations and replacing the pen and paper era with our custom electronic board, uh, the future of integration, what is next for anesthesia, nursing, and surgery, working as one, and governing with data, solving the physician call schedule crisis to transparency and equity. We as anesthesiologists work shoulder to shoulder with you, the surgeons and the nursing team all day, every day in the operating room, running the same machine. But we're actually total strangers when it comes to the process. We really don't know how your schedule constraints are, surgical schedule constraints are, and you guys probably don't really know how complex our scheduling is. And we are not unique. This is CHOP. Shockingly, CHOP is managing the whiteboard manually, tracking cases with magnets on the board. They actually write every single case on a magnet, and they move them around, and the little magnets are the anesthesiologists who if they're pre-call or post-call, they're turn upside down or on the side, and that's how they manage it. And it's very similar to the other 6 places that we visited before we implemented our system. Just to give you an idea how big we are, anesthesia department, we have 77 attendings, 30 CRNAs, 18 fellows, and 25 rotating residents every month. And we are staffing 45 to 47 locations every day, 24 in the main campus, but we have the satellites, the radiology, uh, the GI suite, and we actually staff at, uh, Dana-Farber and the Brigham. So many organizations uh like ours use physical whiteboards, magnet uh boards, and other analog solutions to to facilitate coordination, uh, of the care, but these solutions are very limited. First, they require manual input of data, which is really slow and susceptible to errors. The data is only updated on the anesthesia floor runner is present at the, at the physical, physically present to enter the information, and the process is not instantaneous. Uh, well, information becomes outdated very quickly in such a fast-paced operating room. Uh, so, they're limited to a single physical location, that means everybody who's in the operating room can't see what happens at the front desk and, and the main OR, uh, and they can't access and or input and output the data. Um, so that reduces the transparency of the physical board. So why change the system? Highly inefficient, lack of transparency, no real-time data, and ineffective communications. But the next big hurdle was how to change minds. If you look at the slides about individual attitude about change, as um that is very shocking that only 5% of the population embraces new ideas. So, unsurprisingly, initiative to build an electronic board faced immediate resistance, and you can see from the slides how few people really want to change. But thank thankfully Doctor Cvero supported our idea and Susie Eklund and I, along with our software, uh, genius software engineer Chris Butter who's here in the audience and his team, we're able to digitalize the entire process and we can look at the critical details to see what the new system tracks. So this photo shows the different photos of the of the project. We really started in 2022 and this was the original whiteboard at the old the our desk. Then we went to hell and we couldn't fit the whiteboard, so we actually did papers for a little bit and then we proposed a digital format and we installed the, the digital, the big digital um whiteboard. And the way we did it, we actually asked our software engineers to follow up and to shadow us in the mean while to see and to understand the workflows and how the physical board was used. So they were actually like following us through the day when I was running the floor. And over the course of a few months, our engineering team worked to implement the whiteboard and now for each room, the white board show all the staff assignments, and the procedures, the cases, and we'll, we'll uh look at all the details, um, uh, next. So this is really not just a screen. It's really our uh central command center for the main operating room, and it moved us past the manual tracking. It really gives the floor runner instant reliable information of operation, but also gives every member of the team access from any computer on the mobile device. And you may be wondering why not, why don't you use just Epic? Because EPIC is excellent for medical documentation and the billing, but it is simply not designed for real-time operational scheduling or resource management. It really can give us all the information and that's why the custom whiteboard is essential. It really pulls the information from multiple sources. It gives the cases from, from EPIC. Uh, it, it takes data from, for the call scheduling from our spin fusion system, and I think you guys use the lightning bolt. It shows all the team coverages, uh, from ICU, cardiac nurses, the NPs, the regional, so you can look on the computer and see everyone, uh, whoever you need in the operating room is there on the board. Uh, so by integrating all the sources, uh, this white board became the single reliable source of truth for operation. And it gives us a visibility that no other standard medical record uh system can provide. Here you can quickly see who is responsible for different call assignments. You can see the attendings on call, you can see the fellows, the CRNAs, the residents, the anesthesia techs, ICU who's on call. And next, we can include the surgeons on call with their attached phone numbers. So when we walk to the front desk or when you go, and we have access, you can access it through the EPIC. There is a, a link uh that you can go directly in the Estaff and uh access this. We also have a color-coded system to help us identify who's on call, who's priority to leave, and needs to go home, uh, early, uh, the CRNAs and SRNAs and all, uh, the people who are in the main operating room, and we have to manage them daily. Um, although the OR nursing staff has a separate similar whiteboard, the changes to the nursing staff is integrated with anesthesia display, so we can actually see who's circulating in the room and who's the, the scrub, and who's the tech. Uh, and if you hover over any name, you can see the phone numbers, so you can actually access them right away, uh, and that communicates, uh, that facilitates communications, um, and we're just working to integrate the nurses' phone numbers in the system. And every OR is is started at children's by uh by an anesthesiologist, and this is unique at Children's uh at in Boston, uh, because most of the places they have staggered cases for 7:30 starts, but we believe that it's really difficult to start to, to start an anesthesiologist to start the cases in the morning. But I'm actually sure that when you show up in the morning to do your cases, you have no idea who's starting your case. So it's always kind of like this idea, who starting my case and it, it's always was a little chaotic. So now everybody has access to it. It's at the front desk. You can see who starts, and our physicians, we have a system where the um uh non-clinical uh physicians, the PACU attending, the board runner will start uh the day uh aiming to start on time, and emphasis on aiming. Um, so, and we can manage the break because let's be honest, we all know how much we as anesthesiologists love our breaks. So the sys the new system, it's really just knows that, uh, uh, and makes sure that we get them. Because actually the anesthesiologists have their highest focus during the induction of emer emergence of anesthesia while surgeons concentrate more during the actual procedures. So we manage our, uh, day on the opposite schedule from the surgical team. And being the busiest, uh, during the, at the beginning, at the end, and during the cases when we have to pre-op the patients and we have to pre-med and set up the rooms and everything else. So, uh, people get breaks after the cases start. Um, what we, uh, did nowadays, nowadays, the system actually lunch, uh, the lunch breaks are automatically listed. So if the attendant is solo in a room or it's covering two rooms, uh, they, they come automatically, we can add them manually, and this helps reduce the phone, the number of phone calls and allow easier communication between staff and the bull runner. And if you are in the OR and you can request a break from your, uh, mobile device or from the computer. So this is the mobile view. We all use cellphones for everything nowadays. So we have a mobile view on the phone. You can see who is assigned to the room, so you can just pull the app, you can see who's assigned to the room, you can see who's on call and what kind of call the person is, or if we need to like access the pit nurse or who is doing uh different uh jobs uh during the day, and you can also see the breaks and you can request the break. This is real-time availability, which is really somewhat hard to track, um, but now we have tools to track the late rooms and see how late our staff stays. And this is extremely important in the summer when we run so many late rooms. So this way, if somebody, uh, stays late, we can actually see next day they come on the whiteboard that's green. So we try to make sure that if you are really busy and you stay really late in the OR one day, next day, we'll try to, uh, prioritize you for relief. Um, but this is all data that we can use to analyze how we run the operating room, where do we have holes, and when are we running too many late rooms. And, uh, we're really looking at building predictive schedule, uh, and looking how late the operating rooms are, uh, are running. This is another tool that was very important to us, uh, to create. What happens when you have a physical whiteboard, a room would finish and you would know, you have no idea, and we all know the drill. Once the room is finished, everybody disappears. You go in the room and you really can't find anyone, so you would really have to literally hand them down like the nurses. The anesthesiologist, if we put an ad-on in the room and, and look for them. So now we can see exactly who is available and the time they finish in the specific OR. So for example, if you look at the board, you can see Walid was came probably on call at, at 3 o'clock. Uh, Patsy was done in her room at 3:45. So once the. This ends in an epic, it drops down the whiteboard, but then we have this little box that says available staff. So if you can click on it, you can see who is not in the water at a particular time, and you can see you can dismiss them or you can actually call them and say, I have a case for you. So you have a bucket where you actually can see who is available. How many times have you talked about an ad on the Floor runner just to call later in the evening or the next day and people say, I don't know what you're talking about, you know, I don't know about this case. I never heard of it because information transmitting the information, it's really uh tricky, especially when it's so busy, uh, especially when you don't have an electronic schedule or, or an electronic way to actually document stuff, uh, things just get lost. So to address this now, the, we, we, we added on the board, the electronic handoff. So, for example, if I'm running the floor today and Doctor Fishman called for a CDH and the CDH is not ready but needs an echo, you can write it down and the next person who comes and talks about what cases were done or why the issues are in the OR, uh, they can see it and you can see all the reports, the recent reports, uh, so you can actually go back and see, um, the, see the information about the cases. We also edit messages. So anyone with access to the whiteboards, and by that means every single uh physicians in our anesthesia department have access to the whiteboard. Then you can send messages from the computer through the system to relay the information to the to the front desk. Now, we, our floor runner is busy helping studying cases, coordinating the day, talking to the nurses. So sometimes getting through the phone, uh, to the, uh, getting to them through a phone call, it's really difficult. So if it's something that we really don't need to relay the information right away. We can really send a message and we use it for example, if I'm in MRI and now the MRI is going to run late and it's really hard to track, I can actually send a message to the bull runner or the bull runner can send a message to me and says, you know, they have to add on the estimated end time is 6 p.m. The moment the the floor runner saw the message and pressed the check, the message disappears, so we all know that they know it, they've seen it, it's gone. Uh, or let's say Doctor Fishman is asking for a second room in room 301, and it doesn't really need to go to the boron right away, but then he puts it on, on our radar. One of the biggest challenges we used to have was the pre-op uh of the uh the workup for uh sick add-on inpatients. So if you call for an inpatient in the, in the afternoon, it used to be the residents on call, they wouldn't get to see the patient until 8:00 p.m. of the previous night, and sometimes they will be in, you know, in a violation of the hours of the records. They really need to leave by 8:00 p.m. So a lot of these add-ons were really. Uh, left because no one, no, the patients weren't clearly assigned and really no one was responsible for them, so we inevitably call for the patient and find out they're missing important tests like an echo or something was not done or we don't have consent. So now, that's all gone. All the add-ons are automatically added to the digital board, and our NPs are fully responsible for pre-ops and consent, and we can track exactly what was done when right up until the patient reaches the OR. So they can click and you can see, they see the PAF, the consent, what was done and what was not done. And you know, they, they can add consent and they can see exactly where the patient is going. Uh, and that really improved our process quite a bit and made our life easier. The final proof of success, we surveyed the staff and the survey, and the response was clear. If there is a glitch in the system for more than 5 minutes, there is a general crisis in the OR. The system has moved from being a useful tool to being absolutely essential for our workflow. And here you can see how much the system is used and it was loaded at least 1000 times per week in the month of October. So everybody can load it in their office, at their computer, at their, uh, if you walk in the OR at the anesthesia computer, pretty much everyone has the board up there. So this summer, we extended the white board to nursing, and unfortunately, it was a big transition. We worked with uh Chris and Eileen to actually uh deploy the system and they retired just before it was uh it was deployed. So that was a little bit of a challenge and the, the new um nurse managers are working on it. But, uh, since the nursing are such an integral part of our work. Floor in the OR we really and we're working with them side by side. We felt that we actually, they would benefit greatly because this is how the OR nursing white board, the Children's Hospital, Boston in July 2025 looks. All the operating room and every single case is written manually and the nurses and the shifts, so you can imagine how efficient that is. Um, So this is how it looks now. In August, we deployed the new system. The nurses schedule is really complex too. It's as complex as ours. They have all different shifts. They have circulators, they have scrubs, they have short calls, they have breaks. So now, each room displays who the nurses are in the room, uh, what shifts they are, and we're working on linking their phone numbers. All the information from the nursing whiteboard, they have their separate whiteboards, so a, a, a, a different website. But the information for the nurses when they come to the room, uh, it comes, uh, on, on our anesthesia whiteboard, so we would know who the nurse in the room is, uh, and we can uh talk to them. Fortunately, this is going great. We're fine tuning the operation, working on the breaks assignment, the shifts availability, and learning a little bit more about their schedule. In summary, we already implemented the systems for anesthesia and nursing, but there is a big opportunity to expand these efficiencies by including the surgeons. And if we integrate you in the system, you'd be able to see the live case updates and assignments, and we can all work together for better operational efficiencies. So If you guys are interesting or have any ideas how to um use this, the system for uh integrating the surgery, uh, let us know. Uh, and we really think that by increasing the operational efficiencies, you can reduce the turnover time and align all the three teams in one lifetime line. Let's talk about, let's talk now about anesthesia scheduling assignments, and this may be of interest to you as the assignment can really truly make or break your day. Uh, and we spend a big part of our life at work and who do we work with makes a big difference in our work life. And maybe some of you think there's no method, method to the madness, but believe, believe it or not, there is a very systematic review behind, behind how we make these assignments, and there are a lot of subtleties uh related to the daily schedules. We know that better teams lead to better outcomes, and as we review our system, we really wanna hear your ideas about how we can make it even better and one factor, what factors are important from the surgical team's point of view. This is, uh, so we, we build an electronic ward schedule to replace the pen and paper, and this is Rebecca Brennan, who many of you probably email for case requests, and we would go in this room and it would take us 2 to 3 hours to actually make the, make the schedule. We'd count the cases manually and how many residents and how many attendings, and you would put people in the room and you would delete them and you forget who was assigned already and it was just a mess. So, in 2023, after we deployed the whiteboard, we, the next, our next projects are anesthesia scheduling. Uh, so this screenshot on the slide shows a partially built schedule. On the left hand, you have the attendings in blue, you have the fellows, you have the residents, and you have the CRNAs. Uh, on the other side, on the right side, you have all the rooms in the OR and you can Uh, collapse or expand to see every single case. And on this side in the middle, you can see every single attending of family anesthesia, the previous assignments, and where, where, um, what are their costs, where they are on the call schedule or what the assignments they have. Uh, so this new schedule, uh, led to more optimal case, team pairings and higher staff satisfaction. So the scheduling system takes data from all the sources, from EPIC, from spin fusion for a call schedule, but pulls only available physicians. So if you are on vacation or lab days or non-clinical time, you're not appearing on the system. Um, we can, uh, the, the, the system can automatically pre-assign positions like late call assignments, or if you are regional or if you're floor runner on case and patient request. Patients are also flagged by the MP based on the data and the EPIC. So when you see, uh, every single patient, uh, if, if they have information that would be significant for our scheduling, that would be, uh, you, you can see, uh, on the schedule. And that's very useful for, for us because for example, if there's a complicated case in a room, let's say at 9:00 a.m., we really want to make sure that if that attendant covers two rooms, the second room they're covering has healthier patients. And would assign a more experienced CRNA uh based on the difficulty of the cases or who to assign for fellows, uh, or residents. The system also shows for every attending the historical assignment. So every time we assign a person in the OR, uh, we can see what they did for the last two weeks. So if someone was very busy or I was on vacation, we can manage, uh, their clinical load, uh, since we really work 5 days a week and 44 to 5 days in the week in the OR. Um, the system has color-coded on the screen, so we can actually see, uh, who, since we have so many trainees and so many rotating people, you can see who you're paired with, if you are with a fellow, if it's a resident, or if it's a CRNA, um. The electronic schedule also allows multiple people to work on creating the schedule from different locations at the same time. I can go and work on it from my office. I can work in the morning before the schedule is released and put some um Uh, we can put some, uh, assignments in place. Uh, our fellowship director can make provisional assignments for the fellows and make sure that they all, uh, meet the ACGME requirements, and we actually track on the system and see for every resident, let's say they're required to do 5 neonates before they, they leave the rotations and Uh, 100 patients between 2 years old and 10 years old. So the system actually tracked the data and we can see uh how many cases they have done and when they get to the end of rotation, if they do not have enough neonates, the system will show us pink, uh, like a pink sign, a flag that tells us that we have to assign these residents because they are graduating and they really can't graduate without the number of the cases that they need to do. Um, also, if one of you make a request for a speci for a specific anesthesiologist or for a specific case, let's say Tom Mancuso is requested for a CDH on Friday. We can actually put in the system and that follows it until the schedule is done. Uh, and there used to be a lot of phone calls, a lot of, you know, uh, uh, paper written and notes in the book. Uh, so now everything is integrated. And as we get bigger, it's really hard to keep track of assignments. The whole system had no memory, so we never knew if you were assigned in the same location, let's say in IR for 5 days in a row, and that would make people very unhappy. Um. Before the schedule is released, the system flex potential issues. So we have a, uh, like we added some rules in the system and we build them in the system, so there are no mistakes on the schedule is released. Because believe it or not, our staff is less flexible than you think, and they really don't like changing assignments. So, once the schedule is released, it's very important to get it right the first time. Once the schedule is released and you make changes, people become very unhappy. Um, once the schedule is finalized in the electronics, uh, schedule is transferred to the white board for the following day, and the PDF copy, uh, copy on Excel spreadsheet is generated and sent to the department by email. Uh, and since the electronic system helps send the, the OR schedule much earlier, now the clinical times have more time to check their cases, identify issues, talk to the surgeons, uh, just much, much earlier in the day. This is the tagging system for the nurse practitioner. They review each patient chart in the pre-op or the, the, uh, main OR nurse practitioner, and they flag manually, uh, they add flags manually to alert the anesthesia team of the comorbidities, and that is. Really important when we make the schedule because if I know a patient's going to ICU or for example you have a difficult intubation, we'll try to match that with a fellow or with someone who is uh more expert in particular areas. Uh, the system also automatically suggests pairing of trainees with advisor. We have 25 residents every month. Uh, new residents. So really, they, they are, uh, paired with an advisor, so we really have to make sure that actually they work with their advisor, so they get their, uh, you know, the teaching, the feedback, and all, all, all they need. Case minimum required by ACGME are shown to the scheduler so we can make sure that everybody gets their cases. And finally, the physician requests and personal preferences are stored and shown. And sometimes, you know, we can satisfy uh the personal preferences, and sometimes we can't. But for example, we have physicians who really like to go to Waltham, but they don't really like to go to Lexington, or they really like MRI but they don't like GPU. And while we don't guarantee everyone the place that they have to go or they need to go, we can actually take that in consideration. Um, and sometimes it really helps us, uh, avoid pairing teams who have a conflict, so we can put notes in the system and we can actually try to avoid that. So I really wanna uh highlight specifically what this electronic system can mean for you. Because we know that you guys, uh, the head of the table, uh, your life is influenced by who is the anesthesiologist or the nurse. So, a big improvement was the earlier schedule release. We used to release the schedule at 3 p.m. and now we aim for 120. It takes much shorter, much less time to do the schedule with, with less mistakes, so we have improved accuracies. Um. We have time to, to look at the patients early in the day, so hopefully, every, if there are cancellations, there's enough time in the day to replace the cases or new cases. Um, we know the preferences and the specific needs for certain cases, but they're all documented in the track, so we can actually look back if people complain or people have some, um, uh, you know, concerns about cases, and we can also pre-assign cases to ensure the right fit. And what's really important for us and maybe for you guys is the faster handoffs. Between 3 and 5 p.m. in the afternoon when there is a change in shift for anesthesiologists and nursing. The front desk used to be chaotic. Like, you know, it, it took a long time to write all the cases on the boards and where wherever everyone was. Now everything is online, it's updated live, so really the handoff at the end of the day is happening much faster. This is the ward nursing. We just deployed the ward nursing scheduling app in August. They're loving it. There's still a lot of work to do, but now we will have a combined schedule with anesthesia and nursing assignments released by the end of the day and emailed to the whole OR. And this is how it's gonna look. Um, we get this by email just with the anesthesia assignments, uh, but now we're just building up that we can actually, when the schedule is released, you can also see who the nurses in the OR are. And this is one of the things that we really uh were thinking about for a while. We know the communication in OR it's really difficult, and we, I was part of the water efficiency Committee a few years ago, and one of their big ideas was to do the in-person huddle, and we all know how that went. The, the moment, uh, the health building opened up, that actually like stopped. So, you know, getting people in the OR at 7 a.m. to do an in-person huddle was almost impossible. So we're we're thinking about new ideas, how to improve this cross-departmental uh communication. And this is designed to replace the in-person huddle. Um, so we're really planning for our system to send a single automatic email every day at 4 p.m. to every OR stakeholder, the surgeon, the anesthesiologist, and the nurses. And this email will allow the surgeons, the anesthesiologists, and the nurses in a particular room to communicate their needs for the next day plans directly and efficiently. So you can reply all and you're really just talking to the people in your room. So, this is um a sample email. This is how it's gonna look, and it says, dear ORP you have this schedule, these are the surgeons, this is who you're gonna start the cases, um, and uh you can discuss what you need. So if the surgeon needs some instruments or the anesthesiologist has an issue with the case, or the pre-ops or the pre-meds or whatever we have, or the nursing. Uh, it could be contained to that particular operating room. So, it really is a way to replace the uh, in-person had-on. And what's next? We're really exploring artificial intelligence for scheduling automation, and we really plan to investigate how AI can move us beyond our rule-based system into a true predictive scheduling and automatically optimizing assignments, making everything as much smoother, and really, Kind of give us a little bit more time in our day as anesthesiologist, uh, while the system does everything electronic. Uh, we would like to improve the mobile experience and the handoffs. Um, there are ways when we're building the interfaces, uh, to streamline the patients' handoffs and to takeover and they're really reducing the communication errors, and we're investing in improving the mobile user experience, uh, to increase the adoption across all staff in the OR. And the last, uh, point I want to talk to you about is the call schedule. It seems that you guys are also facing some challenges when it comes to the call schedules, and I really do believe that we can learn from each other because let's just face it, calls are painful. No one likes them, and they're exhausting physically and emotionally, but they're really not going anywhere, and we just have to figure out a way to organize them to make them less painful. We used to face a massive problem with our call schedule, and the bigger we got, the, the harder it was. We generated constant complaints. Because on the surface, the schedule is just a spreadsheet, but it's, it's names in boxes, but the perception is um important and the reality is that the schedule is the framework for our professional life. And first of all, it's control. The national data tells us that autonomy over one schedule is the top 3 driver of job satisfaction. If you can't predict your day, you can't run your life. And the second is well-being. We know that not having control of our schedule is the fastest route to burnout. As time is our scarcest, uh, scarcest resource, when we get the schedule right, everything else works better. So we realized the solution wasn't just a software, it was also governance about the core principles which are in the culture of our department and our intervention was built for two, on two principles, transparency and equity. So, this is how the, the call schedule looks, uh, uh, uh, we, we do it every, um, uh, for every 1 month, 3 months in advance, and we made the system completely transparent. Every physician and anesthesia department now knows exactly how many calls they need to take, and they're really uh prorated based on their, uh, uh, full-time employee, either they're full-time or they're part-time. And this simple act means the physicians take ownership of the schedule rather than feeling victimized by it. And we uh we ensure equity and flexibility. We ensure that all calls are equally distributed and, um, uh, we created a mechanism for the staff to submit requests for a specific call dates or to block out the specific, uh, periods and we build the final schedule around honoring those. Preferences so you can see at the end of the um the month everyone can see uh live uh how many calls they've done we make sure the Saturday night calls which are really painful, you don't get everybody has one of them and um make sure that at the end of the year people are very uh clear about how many they have to do. And flexibility, it, it is a double-edged sword because it creates a lot of work for the person who makes the schedule. But that allows for work-life balance, which is very uncommon in our profession specialty since we don't really have service weeks and we're mostly clinically full-time. Uh, so this is a huge value add for our department and it's worth the extra hassle for the gen for the schedulers. This is how the physicians request calls or no calls. So, if somebody requests a call, they put where they, which calls they want and when they request no call, uh, they put them in the system and the system can gene generates uh a call sys uh a call schedule based on those requests. And when someone these days cannot do a call, there's no more, uh, there's, it used to be so difficult to find someone to replace the call, but now everybody knows that if you give up your call and you take a call for someone else, it will count, it will be part of your quota. So it's actually, uh, you don't really do an extra call for someone else. And the result is we eliminated the problem. We really no longer have constant complaints because the system is perceived as fair and it respects the physicians needs of for control over their life. So the lesson on decision making, this this success taught us a key lesson about uh executive decision making. Uh, you must listen to the majority and just not the loudest voice. We actually start with town halls and meetings, and they're useful for bringing specific issues to the surface, but the single, single strongest voice can often dominate the conversation, leading to solutions that don't satisfy the need. Uh, and we do, we did learn that there are many ways to skin a cat, but you need to choose one way for our department. So the approach is use the town hall for discussions but always follow up with the structure surveys or the data collection to see what the majority wants. And when the majority decides on the process, no one can be blamed if they blamed if they don't like the outcome. And then, uh, we achieve lasting compliance. Holiday call schedule used to be our single biggest administrative headaches and the, the source of the most dramatic complaints because the stakes are personal. No one wants to be on call for Christmas or Thanksgiving, and that personal sacrifice quickly turns into resentment when the schedule feels unfair. And we knew that this wasn't a problem that we could just assign away. We had to fix it by using objective data-driven fairness. So, We built this electronic platform for the holidays, uh, call schedule, and the principle was like objective fairness. Everyone submit the ranked list and you can see the rank list on the side, they submit it in the, in the system and the system selects the lowest ranked holiday, uh, and maximize the individual satisfaction by ensuring that the person, um, who least wants to work a specific holiday is protected. It allows everyone to rank their preferences and gives physician autonomy. Um, and the system includes historical data for the three major holidays. So this is really crucial to prevent that any single person will be perpetually given the most, the, the least desirable, uh, the, the least desirable, the most desirable holiday and ensure, uh, true fairness over the long term. And you can imagine people would come to me all the time and they would say like, oh my God, I want, I want Christmas like 3 times in a row. And then you look at the schedule and first of all, it wasn't true, and second of all, now I don't even have to tell it. Look in the system, it's there. So the result, uh, the result was the schedule is produced as a fast derive uh derived from data and it's not a negotiation. It's highly resistant to complaints and reduces the administrative burden significantly. This is the electronic uh rank. Everybody ranks their holidays, and we really aim to have every member of the division take one of their 33 choices for holiday calls. When someone had a low ranked choice one year, we have the data for prior years to ensure that it doesn't happen. Uh, for 2 years in a row. And we also try to double up the shifts for the holidays weekends, so the weekends, even if they're busy, overall, the people liked it better because uh they minimize the number of holidays when they have to work. So when we get a schedule right, everything else works better, the workflow, our teams, and our well-being. So if I have to choose one single thing that made our system better, uh, better and transformed our operations and our culture, it's without doubt the data. Data became the most powerful tool because it delivered 3 critical wins. It killed the complaints, and that is huge. When you bring data to the table, the arguments stop. You simply can't argue with the numbers and the data objectively shows who's where, who's due for a break, and that the schedule is fair. And it replaces the subjective. Feelings with an objective fact. It protects our culture by enforcing transparency and equity through data. We're actively fighting burnout and protecting our team. It respects autonomy and time with the family, and it sends a clear message. The old sacrifice everything mentality is gone. We care about fairness and we prove it with data. And it made my job easier because data transformed my role from a constant mediator of a complaint, uh, and a detective trying to track people down into a strategic manager. The systems handle the grant work and we can uh focus on, um, on future development. So, Anesthesia nurses are now digitized, but we really can't stop here. To integrate our system, the next piece of the puzzle is you, the surgeons, because ultimately, we need to start managing the OR like 3 separate departments and start, start managing it. It's like the high performance engine it's meant to be. Thanks. Who has the first question? Well, I wanna start with a comment, um, I think so much of what you. Showed us resonated with so many. First On a personal level Um, nobody knows what each of the rest of us do all day long, and I'll bet a lot of people didn't know how much time and effort these guys have put into this, um. But surgeons, who you're speaking to mostly here. We have our own way of knowing how our day is gonna go, right? It starts with the schedule comes out the day before, and we look at the far-right column, and we see who our anesthesia staff is gonna be. OK? And then sometimes you say, Oh And then sometimes they say, mm, I'm gonna get in early cause I know my patients can be in the room. Before 7:30, and I know that I'm not gonna have time for lunch because my term is gonna go fast. And when people see Bafani on the schedule, right? They put the running shoes on, right? And they're happy because it's gonna be efficient. And the patient's gonna be safe and it's gonna be pleasant, right? And there's uh you're just one of those people now. What's more rare is somebody like that who's a great doctor, great colleague, very efficient, who decides to become a system engineer to make it better, not for just the people in that room that day, but for everybody, um, because we surgeons are great at complaining about the system or about them or them or them. The room's not clean, can't find anesthesia, they're like, you know, slow, uh, no consent, all right. It is all about all of us working together and uh this is an incredible effort that's going on. I know that I look at. What I call your board. Rather than the snap board, if I wanna know what's going on in the OR, um, I look at this, uh, it's really an incredible effort, um, and I know, um, full, full credit, um, to, to the technicians, uh, uh, not, not, not just, yeah, right, uh, and so there's always, there's always, uh, um, uh, a, a different kind of talent that, that goes behind the people who sometimes get, get the, the, um, the full view, um. One would hope That when you spend hundreds of millions of dollars on a system, that it would take care of these things, something as basic as the things you're describing. But Epic doesn't do it. Serner certainly didn't do it, right? Uh, and so, at the same time that we were doing that, you were developing something knowing that we weren't gonna have this function. The institution was in a, we're getting rid of all the homegrown stuff, all the boltdowns, all the custom apps. But you persisted on this with us knowing, having seen that it wasn't gonna work, and some of us gave up some. I spent, I was you in a prior life and developed a, uh, uh, uh, database that end up being, uh, the, the way that most physicians build in the hospital with QCC and we said, all right, we'll throw it out. Um, there's been some complaints about the fact that we don't have that anymore. We built surgical procedure scheduling which. We threw out, right? because we put faith in the system we're trying to make the system we bought better one day, right? The epics of the world will wanna buy this, um, because it should be available for every hospital, but it's really complicated because what we do is complicated and the end point for this audience is, is my patient gonna get good care. And am I gonna get in the OR and take care of my patients and get the next one urgent or not urgent in the room and get home. Because when people look at the schedule, surgical views are, well, I see all those names on the schedule. But there's only one name. That is for certain gonna be there at the end of the day or night. Regardless of how slow things go, and it's the surgeon who the patient. Schedule their case with because they didn't schedule it with a particular nurse with a particular anesthesiologist. The surgeons know. That that team is essential. But we can't leave because the patient's counting on us because we have that relationship, so for us, for our life. You're making the system better and I know everybody's saying yeah, but turnover time isn't better yet pretty much true. um, everything is still not perfect, certainly true. But I can tell you it would be worse. If it wasn't for what you and your team have been doing, um, and it's, and it's, um, it's selfless, um, and it's thankless because people just complain, they don't think. So, on behalf of the whole circle community, I just wanna start by saying, Thank you, um, and open up the questions for, for everybody. I'm sure there's lots of thoughts. Um, this is really great, and I've come after it, so I didn't realize, um what things were like before. I think having just been at Larry Children's, they had a, um, notable, uh, epic shutdown for a month, um, due to hacking and things like that, and it affected Everything electronic, um. Is this, like, are you able to do it manually if Things get shut down, um. Electronically or we, we had to like go drop that for a period of time. The system uh connects to Epic in real time, but if Epic were down, uh, it does allow the staff to do manual overrides on almost all of the fields on the whiteboard. So, um, if we lose connection to Epic or our other scheduling systems, they can input data onto the whiteboard manually. Yeah. We can also, uh, because they come from multiple systems, you know, the call schedule is still there, so maybe you wouldn't see the, the epic case, but for all the, um, the things that we have there, they actually added, um, a, a way to manually input like breaks, rooms, we can add a room, we can take a. So we can always have ways to like put it manually. Obviously we don't want that, but, uh, and not all the systems usually fall at the same time. Here and there we'll have a spin fusion, so call schedule wouldn't come up, but usually it's fixed pretty, pretty fast. We really did not have glitches in the system for more than 5 minutes uh from what I know. Elaine and Peter Lawson, um, thank you. This is tremendous. I really appreciate all of the work that you and your team have put into this. I can see applications beyond the operating room, um, across all clinical areas, so building on this further is, uh, should be a priority. I will make one point, Steve, um. We have not tried to, we've tried to limit the number of bolt-ons that were developed for specific minor areas, if you like. Um, but across the hospital, it's clear that EPIC is just a source of data, it's not an intelligence platform. And it won't, will never be in this organization to start with, but second, um, It's local solutions come from this type of work, and yes, getting data from EPIC is one component, but there's other data sources that we need to build in, and I can see the relevance of the enterprise resource platform, for instance, that is an objective in the next 2 years to bring that in, so we have much better ideas around staffing, around finance, around supply chain management, and so forth. You can see how it all can connect in. But we have to start somewhere and to start here gives us a really good opportunity, so thank you, I wanted to. Well, the question I had was relating this to performance. So the performance at Time Star. Changeover, that's, those are important aspects, but then there are other Teams sync in certain ways, um, whether it would be anesthesia, surgery, nursing. Uh, and that can affect the performance outcome for a patient potentially. Is there a way to connect this type of data to both patient outcome and team outcomes? I think, uh, first of all, we have to start somewhere, as you said, and it's small, but every single day we add things. So, what we actually added, and I think it does make a difference, it's really hard to quantify as, like at this time, but I think that is my hope that we can. Um, what this help us the most is managing our team and our workflow for anesthesia, and that's where we want the whole team to be part of it. Uh, for our, uh, operations, for example, um, just putting the data out there without doing any other, um, any other uh kind of intervention. Because the people see when they fall off the board and they know that the data is available, all of a sudden, we don't have this like, oh, my kids didn't finish, or where did the, uh where did people go? Or when we have the inpatient pre-ops, nobody saw the inpatient pre-ops, you can see who saw them. You have this, you know, the direct ways to see. Who did it? Why it was not done, is in the computer. I'm not making, I'm not accusing anyone. It's real data that shows you got out of the OR, you know, you didn't miscommunicate. You know, I was here last night until with, with Bern and we had 3 hours in the OR waiting for a patient who was said that um the pre-op was supposed to call for the patient. Who's Priya? Nobody knows. There's no, there's, you can't track anything. So, unless you have data that you can track and you can go to a person and make them responsible, well, who did the inpatient pre-ops? Now, I know exactly every single patient was pre-op. If that wasn't well pre-op, I can go to the nurse practitioner and say, this is a problem. We don't have consent. How are we fixing that? So, just by having the data there, that will improve the process. Uh, we used to be at 55 p.m. people would say, you know, we get paid after 5 p.m. if you stay hourly. So. People would put their name on the board like randomly I would say like 5:15, 5:20, and then the moment you put the data out there, that stopped. I didn't have to do anything. Just putting my data out there, nobody would come and put their name on the board because it was clear somebody can check it. So I think it's, it's, it'll be slow for sure. It's a big organization. We really can manage. It's unbelievable that even the nursing in the operating room, they, they did it by paper. They still actually, because they're not quite transitioned yet, the nursing are. The, all the managers are brand new and they just died in August. So, uh, it's a huge transition, and I think really, it's very uh difficult for, I, I think the nurse experience in the OR right now is 3 years old. That, that, that, that's the average experience. And it's really the system is getting so big. The, the, the loss of information or even when you're on the floor, you get 100 phone calls. Like you can't really track them. You can't really even follow up with any of them. So I think as we build a bigger system and showing the data and making it available, we could improve patient care. Uh, we can, now we have the data. So Chris, actually, I would say, how many rooms do I have late today and why, and what are the holes? So by building the data, but just doing it through Epic, it's not gonna work. We, we're too complex and too many, uh, too many things that we have to take in consideration. And I think we can't really do it without the surgeon. We can't improve it unless we get the surgeons on board for here and say, what do you wanna see? How, what do you wanna track? What's important for your schedule? I'm in my schedule. I have no idea what Doctor Fishman wants. I never talked to you about your cases. So we kind of like have this like one person having the brain of the operations, and we thought that having one person knowing the operations is not useful. Actually, we have to to transform it into a system. I'm getting a uh I'm getting a question online through my text, um. Um, yeah, a lot of this, as you, you point out, equity, transparency, and I would say that builds accountability and, um, gratification. You make a point about wellness, um. I've been commenting in lots of. Um, places, including yesterday, the board of trustees, we can't do more cases in more rooms without anesthesiologists, and there was a period of time not too long ago where you couldn't hire an anesthesiologist to work in this hospital, and now we are seeing a, a, a, a very beautiful expansion of the faculty. Um, part of that is the culture that the people that are being trained here. See the experience of the faculty and they're not miserable the way they were perceived in the past and so people wanna join and be part of that and I give Joe Cro credit all the time for that and Nina Deutsch, but in fact it's they're empowering of people like you, some of whom have been here for a while, I'm not gonna say a long time, but a while, um, you already gave your dates, uh, that, um, uh, spreads that throughout to allow people to, to, to improve for everybody. So the online question here is uh dealing with, uh, 11 of the things you, you hit on a little bit of in terms of, of, um, holidays. How do you, how do you do, um, Um, summer vacation weeks, how many holidays, um, and, and, and you, you explain the priorities like they get to rank the holidays. Summary, as you pointed out, is like the busiest time in the OR. How do you decide who gets how many weeks or days off in the OR? Is it the senior people don't have to work and they get to go to Nantucket, uh, or, uh, and the junior people do all of it? Or, uh, how does that equity and transparency work? Um, So it's very interesting because I grew up under Doctor Coca who was very, um, you know, believe very strongly that the young people do the hard work and the senior people will do less as they get more senior. And I, as I get more senior, I kind of feel that I lost that train. Because we don't have that anymore. Uh, like, it's, the system is too big, it generated so many complaints, make people so unhappy, so we could, we can't do anymore. If you're young, you get more, more uh, you know, grant work and then if you're older. So you pretty much distribute equally. Uh, everybody knows for the summer they can only get 2 weeks off. They can put the request in and they're really out. They can look by themselves in the, in the, and they see. So actually like when I, when I put the staffing on, um, in July, we started this, um, new system where everybody can see how many people I have in a particular day and then. They say how many people I need and how many people I have. So if you ask for a vacation on that day, and I'm short, I don't even have to say no, you can look at the system, or you can ask someone else to work for you. So you can do that. So just by putting that out there, you, you get all the schedule, all the hardest, uh, all the summer vacations. Everybody can have two weeks. And we put first the request in and then if some weeks are heavily requested, we try to shift and say, who can switch where and this is the data. This is what I need. I have to make the world work. So, it's nothing personal. So, and people, because they know that I, we make all the efforts to give their time off and everything else. I really don't have issues with that. If they know that, if they have a personal problem or I will work to ensure that they can have, that they can get the time off, I almost never have issues uh with changing their, their stuff. That's new. Thanks a lot, Alina. Um, just, uh, it seems to me, and you touched upon this, uh, a little bit, um, there part of the, um, disadvantage of having so much data is you can get lost in it and it's hard to know what to do with it all. Um, for example, we can't drill down on every single one of the 20 of 24 rooms that is running behind every single day and figure out why that is, um. And you pointed out that we are essentially 3 different entities. We're nursing, we're anesthesia, we're surgery. It seems to me like we need to Pick little pilot projects to do or something like that to figure out how to use the data. Um, would you agree with that, or do you have any of your own ideas about how to use the data, and is there anything, um, that's being, um, touted or pushed at present? Yeah, so, I think the way we actually like started the system very quietly and very small, uh, because we knew people were gonna just explode if, uh, if everything gets there. So, That's what we did. Like the white board didn't come all full with all the information. We would do something and then I'll go to Chris. I said, Chris, can you get, can we have some notes? Uh, I have an issue with the handoffs. We have an issue with the pre-ops. Not all of them came at the same time. So now, um, Chris is just talking to, um, uh, his team about how to get the AI and really AI is huge. I mean, we really function in the last century here. Uh, the, the, the, they can analyze the data and they can speak, speak to the data. So, the most, the, but in order to implement AI you need data that AI can analyze it and understand. So, now we have pretty much 2 years of data that is already in the system, and now we can actually use the system uh to actually like learn it and tell us what the issues are. I think one of the issues with surgeons and anesthesiologists and nursing, anesthesia nurses, they, we work in a different schedule than the surgeons, right? Different incentives, different time schedule, the way you do cases. So unless we, everybody kind of gets in the same system and understand the systems, I think it's going to be a little bit of a breakdown. Um, and incentives are hard, and I've been looking at them quite a bit because, you know, the carrot and the sticks that they don't really work all the time, and people will say financial incentives are the only thing that works, and really, Um, it doesn't. Uh, so this is a very complicated one, question, but I do believe by having the data and starting small and say, let's look at evenings and what are the holes, or let's look at when do we not have the anesthesiologist. And for me, we have the data now. So I think the next, next step is using AI on specific projects and, and move, move with that. I think you could see there's a lot of um excitement, enthusiasm for what you're doing, uh, obviously affects all of us, um, not least of which the patients we're out of time. I just wanna um say again thank you for, um, on behalf of the, the entire surgical community and per-operative community, um, not only for, um, of this, um, sort of, um, uh, data-driven approach to making. Um, it all better, making it all work, uh, more efficiently, improving, uh, job gratification and satisfaction, um, but also the incredible, incredible partnership you've given to so many of us, um, in the room taking care of a sick patient, uh, and, uh, and, uh, we don't get to say thank you very often publicly, so I think on behalf of all us we say thank you. Yeah.
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