Patient Driven Change; The Collaborative Care Model

So good morning, everyone. Uh, I'm David Wessel, Chief Medical Officer for Hospital and Specialty Services, and I want to add my welcome today uh to Grand Rounds in 2021. It's my pleasure today to introduce as our speaker, Doctor Mark Levitt. Uh, Doctor Levitt is Chief of the Division of Colorectal and Pelvic Reconstruction and professor of Pediatrics and professor of Surgery at the George Washington University Health Sciences. Uh, it's a special pleasure for me to introduce Mark today. Uh, he's a, uh, consummate professional, uh, an outstanding surgeon, a master surgeon, really, and a master teacher as well. He's focused his career on enhancing the care of children with colorectal and pelvic, uh, reconstructive needs. Uh, and I have to say that, uh, I know personally that he's created new innovative procedures, uh, that, uh, have been applied to children here at Children's National as well as many patients that he's cared for before. And it differentiates Children's National Hospital, uh, from others, and it provides hope for children that, uh, have these complex pelvic, uh, GI and GU reconstructive needs. Uh, and he can address these issues in a fashion. That really involves the experts from multiple specialties, uh, from GI, from GU, uh, from GYN, uh, and his special surgical talent, uh, that comes to also just bringing these groups together into a, a collaborative new multidisciplinary kind of focus on these patients. So, Mark has cared for children from all 50 states and 76 different countries. Uh, he's done more than 15,000 pediatric colorectal procedures. He's written 3 textbooks. He's authored more than 300 original scientific articles in this particular subject area. Uh, but he's also, uh, a master teacher. He's educated students, surgeons, other medical colleagues, and nurses, and he's also developed this integrated program in colorectal centers all around the world. So Mark received his undergraduate degree from the University of Pennsylvania, his medical degree from Albert Einstein. He completed his surgical training at Mount Sinai Medical Center, and the colorectal training was at Schneider Children's Hospital. Uh, he then did a pediatric surgery fellowship in, uh, Buffalo, uh, and then really helped build and create new programs in this subspecialty. At Cincinnati Children's Hospital, and he created and led the program at Nationwide Children's Hospital. We were able to recruit Mark thanks to the efforts of Tony Sander and his uh great group in surgery, uh, about a year and a half ago. And Mark has done some wonderful things here at Children's National Hospital. So he currently serves as Chief of the Division of Colorectal and Pelvic Reconstructive Surgery. That's a new division here at Children's Hospital. So I'm going to introduce Mark, but I think my opinion about Mark and his uh master's skill set, uh, is not quite so important as the opinion uh of his patients. I get several letters, uh, over the past few uh months, I've had several letters from patients and families, uh, that Mark and his team have been, uh, involved in their care. And I wanted to read one short, uh, note that came to Mark, uh, and was passed on to me. Uh, dear Doctor Levitt and Doctor Gbari and our, our great GI service and company, Thank you all so much for your help over the past 10 years. And more specifically, thank you for your help over the past 6 months. 1 year ago, I would not have imagined the progress I have seen since my most recent surgery. Accident-free used to seem impossible. But you've made that dream a reality. Therefore, I owe you the most sincere thanks. Your example has also taught me a great bit in recent months. Some people say things and make great promises, but you all do great things. As I am at Purdue, pursuing biomedical engineering with a pre-med emphasis, I will constantly remember the influence you all had on my body and my heart. And in my life ahead, I will strive to do as you all have by loving and serving others through the medical field. So I think that's uh an even better introduction and endorsement of Doctor Levitt and his team. And I uh turn the podium over to Doctor Levitt. Mark, are you there? I'm here. Thank you so much. That was uh lovely and Brought me back to the emotion of that particular patient. So, I hope today to convey what this journey of 25 years has been all about, um, in our attempt to improve the lives of patients with colorectal problems. But the reason why I'm talking about this at this, uh, venue to all of you is to try to convince you that the collaborative care model is applicable to many different types of problems that we face in the healthcare. Uh, field. And to try to explain some of the lessons that I've learned over this time, and how to apply that to other situations. So, let's uh dive right in. What do you think of this picture when you see it? I'm sure many of you see this image every single day as you drive to work. Well, this is a beautiful architectural design, and I suspect that what happened here is a group of people got together and drew a picture, and somehow brought this project to fruition. With a great organization and pre-planning, with all the elements organized in advance. Because otherwise, this never would have happened, because I can assure you had the cement layers come first and done their job, the steel beam people would have been frustrated the next day when the cement had already hardened. Sounds ridiculous, but I can tell you in the complex care of patients, we usually don't coordinate our projects, our patient care in the same way as these architectural designs were organized. And I want to uh make a plea that we ought to do that a little bit better. So, Um, in my journey, I was a medical student, and actually here is a picture of me. Believe it or not, from 1992, when I met Alberto Pena, father of colorectal surgery and children, quite fortuitously on an elective during medical school. And I observed from my vantage point. that he was taking care of all aspects of a very complicated patient. And I felt very um ineffective in being able to do that one day, in large part because I felt in order to take care of this patient, one needed to provide neurologic care and gynecologic care and gastrointestinal care. Medicine was getting more and more complicated, and there was no way this could be done by one individual in a well-coordinated fashion. So, some of you have read this book as I have read it, but I'm sure many of you have not delved into its deep meaning like I have. Because it's quite amazing if you think about it that everyone deals with this natural physiologic process, but we really don't think about it. But I can assure you if a patient is born with an anorectal malformation, and the family is told that their child's anus has not properly developed. They're suddenly thinking about it, and they are very, very worried about it. And our mission is to figure out what to do about the sequel to this book. Which is this book, because in some patients, amazingly number of patients in our world, in our medical world. have various problems in exiting stool from their body, both anatomically and physiologically. This is one of my favorite uh pictures. This was a um a project asked of kindergartners to draw a picture of what they thought their mother did for work. And you can look at it for a minute and contemplate what this picture actually conjures up. But I think the reason why this picture is so powerful for me is, is because it illustrates the importance of context. And I was in that scenario. I was such a student looking in, and I needed to understand the context because the truth of this picture is that this child's mother worked at Home Depot, and it was a snowy day, and there was only one shovel left to be sold, and a lot of people wanted it. I'm not sure what you all were thinking she was drawing, but the context obviously mattered. In the context of myself as a medical student, looking at the daunting care required of a complex patient. Knowing how medicine was getting more and more complicated in its various subspecialties. I recognize that the care of colorectal patients required a coordinated model. Because if you think about the anatomy, and this is a fetus at 20 weeks, fetal MRI done for a cystic abdominal mass which shows a cloaca. The most complex of colorectal problems. And here you see illustrated the bladder in the front, the gynecologic system in the middle, and the rectum in the back. And all three of these structures are all filling the pelvis and they are right next to each other. How is it possible that we could have a system where all three of these parts of the body are managed by different specialists who don't talk to each other and don't coordinate their efforts? It's impossible. You must have all 3 of these teams, plus the GI team that deals with the physiology, all talking and planning for the care of this patient. So when one thinks about how you organize a plan to care for complex patients and develop what I call a collaborative care model, I think the first step obviously is to identify the problem that needs to be solved. And for those of you out there representing various specialties and areas of care of medicine, think about that in your own field. I predict many of you represent care of children that need collaborators, that need colleagues in order to get a good job done. So there we are back to that patient centered-based care. The patient is at the center and around that patient, in my world, we need all of these specialties all coordinated. Colorectal, urology, GI motility, and gynecology. Those are the top 4 groups that work almost on a daily basis on almost every patient. I cannot emphasize enough the importance of nursing care, which is the backbone to our program. And likewise, components such as social work and child life are vital to the care of these patients, as well as some of our colleagues in psychology, pathology, radiology, anesthesia, cardiology, orthopedics, and neurosurgery. And I hope all of you can draw a similar diagram. With your patient in the middle and all the specialists around who need to be coordinated in the care of that patient. Because our challenge is quite daunting in colorectal. We need to provide care for that 20 week fetus I showed you with a cloaca until she grows up. Has menstruation. Wants to have a baby herself, conceives such a baby, delivers that baby, and even thereafter, when she has other issues later in life. That's our mission. We have to take care of all of those patients. Well, in colorectal, we are really faced with a daunting challenge because here are some numbers. The ARM, the interectal malformation patients that are born per year in the United States, number 600. For pediatric surgeons in training, they do about 14 such cases in their 2-year experience. And a pediatric surgeon, once they've graduated, might take care of one such patient per year. How is it possible that those individuals will have enough experience and enough exposure to do a good job taking care of these complicated patients? The only solution is a coordinated care and regionalization of care, which has been my mission. So, The impact of this, the moral imperative to solve this is based on the fact that there are significant complications that we face. Fecal incontinence, urinary incontinence, renal dysfunction, sexual dysfunction, and infertility. Lifelong suffering that we could possibly fix if we had a better model of care. And I wanted to show you, I'm not sure if this video plays with some sound, hopefully it does. It does. Watch the video play out. Yeah Yeah Uh. Oh. Uh So if we were live, usually that video gets quite a laugh. And I want you to recognize that those wildebeests are surgeons and many other kinds of doctors that have this concept that no complication could possibly ever happen to them. And I'm here to say that you have to avoid those complications. And the way to avoid those complications is to gain experience. And the way to gain experience is to regionalize the care and bring all the complicated patients to a certain number of centers around the country and around the world to try to avoid these problems. So how do we do that? Let's, let's do it, let's give you a recipe. First, I think no matter what problem you're trying to solve, you need to offer unique skills. Skills that can't be offered at other organizations. You need to take a moment to define the hospital impact. You have to convince the administration that having such a coordinated program actually has value to them, not only in great patient care, which of course is top priority, but also towards the bottom line, towards attracting patients for those problems. I really like this picture a lot because a lot of people think that colorectal care is pretty easy, as demonstrated in the picture on the left, but in fact, it's quite complex and is a heavy lift. There's my dad, very proud of his 40 pound redfish. And a shout out to him and to my mother. I think both might be watching this. And my mom's birthday at 79 was yesterday, and her gift was a vaccine. So I really am uh very happy to have them and their inspiration. All right. Here's a list for colorectal of what the hospital impact might mean. And you can make a similar list for your own centers, surgical cases, both colorectal and collaborative, non-surgical cases such as the bowel management program, the lifeblood of which is our nursing program. Other outpatient visits, other consultations, radiology, pathology, urodynamics, and motility studies. These are all created by the patient that is encouraged to come here for collaborative care. And I think it's vital to track your success. I think it's important to recognize the metrics by which you are saying that you're doing a good job. Inquiry of patients wanting to come to intake. Did they actually fill out their paperwork to clinic visit? Did they actually show up? We tracked these on a weekly basis. We track our collaborative OR cases, cases that involve colorectal plus urology, plus gynecology. We do this almost daily that we have these kinds of cases. We track our downstream impact. What is the patient who was brought here for the collaborative program do for the benefit of the hospital from a financial perspective. Patients coming from outside of the network. Are we attracting patients from outside of our region, from the rest of the country, from other countries. So far we've had patients from, from I think 25 states and 25 countries here at Children's in the last year. And I think we have to demonstrate our deliverables. We need to document our outcomes. Are we doing a good job? Quality improvement projects. Are the patients satisfied? And are this is the staff satisfied? Are they enjoying working in this program? Here's a graph from um where I was previously. Where we track the different components of care each year, where the patient has their impact. And as you see such a program steadily grows as the patient volume increases, as your successes increase. Well, you need to gather personnel and needed resources. And here really the devil is in the details. And the details really matter in development of such a gladly program. And I was reminded of this important uh message when a number of years ago I was at my daughter's high school and I saw this poster, which said, let's eat grandpa. Let's eat, comma, grandpa. Proper punctuation saves lives. So where are those commas? Where are those T's being crossed and those I's dotted really make a difference? And I can tell you all of that, and this is mainly for the administrators on this call, is affected by the personnel. Who is tasked with staffing this challenge? What is the infrastructure? Where is the support? You obviously need certain surgeons in our cases and medical providers. You also need a coordinator, program managers, nurses in the OR and technicians, outpatient nurses, advanced practice prac advanced practitioners. Operating room staff, inpatient nursing units and their care, OR schedulers, pre-certification experts, social workers, and child life. All of these people need to be in place, taking care of these patients in order to do a good job. And here is a photo of our, of our group. When we just got started, which I love. Julie Schweke, our program manager, organized this picture that we were in, in progress, program in progress. But now I can confidently say we have launched. Well, one of the main administrative challenges is this. Here we have 4 groups of doctors, colorectal surgeons, urologists, gastroenterologists, and gynecologists, all working together, let's say on one complex case. 10-hour surgery. Who gets the credit? Is that my surgery? No. I couldn't have done that case by myself. I couldn't have attracted that patient by myself without a collaborative model. But what if urology only did 2 hours of that case, and gynecology did 1 hour of that case. Who gets credit? Does everyone get credit for 10 hours? That's the challenge. And we have had some intricate. Analysis done to try to demonstrate the activity of each patient to prove that the collaborative model is effective, and all the people needed for the collaborative model are essential. Another key step. How do you let everybody know? The marketing team and and PR team here have been absolutely outstanding. They have gotten the message out. Otherwise, the patients have no idea that we are here. And we need to convince them that we are the place for them to come for care. And it reminds me of this New York Times Magazine uh ad of a cardiac center. Hail to the Victor's Valiant from Michigan. Now, this patient is quite proud of his scar related to his heart transplant. But I can tell you, we're very proud of our incisions as well, but we can't put those incisions in the New York Times Magazine ad. So our marketing team needs to be that much more creative to explain that we are the center that helps children with colorectal problems. But it's not something a lot of families really want to talk about. Next challenge, can we go regional? Can we go global? How do we get the patients from outside of the network? Well, here are some key things that are required. I think it's important to contribute to the literature because clinicians out there and parents are reading those articles and they're reading about you and what you wrote and whether you are an expert in this particular field. We need to help the patients find us with a web presence. We need to help the patients get here like a welcome center. Particularly places like the global program. How do we make them feel welcome when they're traveling from far away? I think it's important to go forth. Obviously in the days before and then upcoming after COVID, we need to get out there to outreach, teach, and in our case, sometimes even help other teams learn how to do complex surgery and training. We need to bring surgeons and medical professionals and nurses here. Who then learn our routines and then go back. To their places wherever they are in the world and help those patients and then they actually become a referral source for future complex patients. And I really think as part of our mission, it has been to bring complex care to the entire world, even places that can never send a patient here, the developing world and bring their trainees here and have mechanisms for their trainees to come here. Because really our mission is to help patients all over. Well, what can you achieve when you collaborate? Amazing things, and I would I wanna go over is just a few examples of what I believe has been accomplished in this field, because of the collaborative model. Here we have prenatal diagnosis. We are now diagnosing patients with colorectal problems in utero, and a collaboration with the fetal program is vital. We then may have a patient with a newborn complex problem and we need that baby in our great NICU to take care of that patient and coordinate that patient's care. That has been dramatically affected by the collaborative model. I cannot say enough about our collaboration with urology and gynecology. Many patients with colorectal problems were not even known to have urology or gynecologic problems until we forced them to have an evaluation by all these teams at upfront. This is not my patient. This is our patient. This patient by design gets a urologist and a gynecologist automatically because they have an anorectal malformation and they might have a problem in one of these areas. Our collaborative model has helped us define the anatomy. Surgeons are talking in the same language now. This is a, a, um, Rodin statue that I in fact saw a bladder when I saw this statue and helped define the types of interectal malformations that one can have bladder neck, prosthetic, and vulbar level. And now across the world, all surgeons are using these terms and they are using them correctly. Well, what if we prospectively collected our data using the electronic medical record, use validated tools to measure our outcomes, and had real-time rapid feedback. This is now possible. Just like the airline industry knows how many flights were delayed out of a certain city yesterday, we ought to know what is our wound infection rate, what is our continence rate? When a patient becomes of the age of potty training. And we can calculate this by putting in the information during our normal pro progress note when we're taking care of the patient, taking the data out of our note, and then tracking our outcomes. Vitally important to see how we're doing. And the long-term functional outcomes include. Fecal continence, urinary incontinence, sexual function, fertility, renal health, and pelvic floor. We can make an enormous impact on healthcare of these patients if we track our results and change our, our, our treatment plans based on our outcomes. The collaborative model has allowed us to calculate whether a patient who's born will be continent or not based on their type of malformation, the quality of the sacrum, and the quality of the spine. Imagine the impact on the family's peace of mind. If you can have a conversation with that baby in the NICU and tell them everything's gonna be OK when your child is at potty training age, we expect them to have voluntary bowel movements. The collaborative model has helped us learn how to best care for patients with a cloaca like the field picture that I showed you. We've learned the importance of the urethra length and the common channel length. The collaborative care model helped do this. Our colostomy closure rate, surgical site infection was high, it was 22%. And we got all together and we implemented a bundle, a GI bundle of care, and we dropped it to 7.9% over the course of several years. And then we changed the antibiotic that we were using, we dropped the rate again and our stoma closure rate is now 2.2%. This never would have happened without the collaborative model and good collection of data. Our redo population, there are many patients out there who have not had successful surgery. The moral imperative that I talked about. And these are all the indications of why we have to do re-operative surgery. Well, that has actually successfully translated into patients who are now continent. Even in patients who have in this lower group, poor potential for bowel control, we have now allowed them to achieve their potential by getting their anatomy right. And that has impacted their continence scores, and that has impacted their successful improvement in their quality of life. A lot of the families that we take care of the patients have problems with fecal incontinence. And there's a problem somewhere. The sphincters, their anal canal sensation, or their motility. And these are our four patient groups that we care for anorectal malformations, Hirschberg's disease, those with spinal problems, and functional constipation. And in order to care for these patients with continence issues, you need colorectal surgery, you need GI with motility, and you need a deep team of nurses. And I wanna hire this young boy who on his science test, filled out these answers. Name a solid, name a liquid, and name a gas. This is a future colorectal surgeon, I believe. Well, the GI motility and colorectal surgery collaboration has been incredible. I used to operate on patients in isolation in a vacuum without the impact, without the influence of what was happening physiologically and bonding with our gastroenterologists over why certain colons don't work has been life-changing. We've changed our protocols quite dramatically. Our gastroenterologists assessed the sphincters using an anorectal manometry probe. They assess the colon's movement using a colonic manometry. And based on these results, we come up with the best surgical plan which could involve a flush of the colon through the appendix which we situate into the belly button. Believe it or not, connect the appendix to the belly button and you can give the patient a flush through there and get them clean and essentially overcome the fact that they are fecally incontinent with a mechanical program. Sometimes these patients need their large colon segments that aren't working manometrically removed. We would never know that and never treat the patient properly without the GI collaboration. And we have published our long-term results. These are results based on the bowel management program run by our nurses, nurse practitioners, and PAs that get the patient clean. And successfully get them clean with a medical program. And one might say, why is a colorectal surgeon doing medical care? Well, first of all, I think it's our obligation to get the patient clean and in normal underwear. But in addition, from an administrative point of view, Believe it or not, 35% of patients that come to us with soiling that need the bowel management program, ultimately need some surgical intervention down the road. So from an administrative point of view, it is a driver of surgical volume. The collaborative model in addition to the GI collaboration that with colorectal urology and gynecology has dramatically improved the care of patients. So for example, how would we handle a one year old with a cloaca needing urologic, gynecologic, and colorectal reconstruction before And after the collaborative approach, or before, we might have a colorectal surgeon dealing with the rectum only and not worrying about the fact that there are gynecologic and neurologic procedures that are required. We might have a urologist managing the bladder and not really understanding the impact. Of the colon on that bladder's ability to function. Now, all three teams have coordinated their efforts. We meet the family together, we examine the patient together, and we operate together, saving the patient's surgery and anesthetics, and a lot of morbidity down the road. Well, what's in the future? I think some of the future will be some research in basic science. Ultimately, I believe tissue engineering could dramatically change our reconstructive plan. For example, if we need a new bladder, uh, what happens if the patient doesn't have enough bladder? What if we could grow their own bladder and sew that bladder in and genetics to try to get to the bottom of why some of these things are happening and maybe even prevent the disease from happening at all. Another big emphasis has been for me to develop colorectal centers. In 2005, the first such center was launched with the recruitment of myself and Alberto Pena to Cincinnati. We had a small center functioning in New York before then, but this was the first moment where an institution really said, let's take colorectal surgery to the next level. And then I worked very hard to develop other centers. In this case, in Columbus, for example. And in debt in uh in Seattle and in Salt Lake City, and then over time. We have centers now that we are collaborating with all over the country and now all over the world. Under the PCPLC, the International Consortium that represents all of these centers. We are all tracking data together in an organized way with the same data points, feeding them into a master system and then able to do multi-institutional studies and really improve care. Well, for the administrators in the room or on the call, does this sound like a good business model? All we're doing is building up our competition. And I've been asked that question time and time again. Well, first of all, what's right for kids? That's the right thing to do anyway. But from a business point of view, actually, I think it makes a lot of sense. First of all, a lot of these patients cannot travel for insurance reasons or social reasons, and they, they deserve good care too. Why not have their care somewhat standardized in these regional centers that are all working together and improving care together. But in addition, from a business point of view, Those become the gatekeepers for those regions. And when the patient has a very complicated problem, they may then refer those patients to potentially to us here because the case is too complicated for them. So I actually think developing these relationships have been extremely beneficial both from a patient care point of view, but also even from a business point of view. Because As Sir Dennis Brown, one of the famous pediatric surgeons in the UK once said, the aim of pediatric surgery is to set a standard, not to seek a monopoly, and I think that's really vitally important. Well, let's talk about Children's National a bit. Um, Doctor Wessel said, I've been here for a year and a half years, and it's been a fantastic launch and really a wonderful experience. It's not all sunshine and roses, but a good amount of it is. But let's talk about some of the challenges that we have had. I drew this picture once on one of our administrators' boards, as a as a funny cartoon, that there are all these patients that are trying to get in, and they can't get in, because we need to recognize that access to care is so important, not just demand. Imagine if you had a restaurant that only had a few tables. Remember the days when we had restaurants and we went out to dinner? Imagine if you had a restaurant with only a few tables and you had a line of people out the door. What's gonna happen to those people? Well, they're gonna go to a different restaurant. But if you expanded your restaurant and added more tables, you could serve more customers. We have the same challenges here, and that is capacity. And our capacity depends on staffing. Administrative support. I call those individuals the directors of first impressions. They're the ones on the phone. They're the ones that are making the families feel good about their choice to come here. The pre-authorization team and getting insurance clearance is so incredibly challenging. And that team has been amazing to try to work out all the different ways of getting a patient officially into the system from an insurance point of view. And that's not just domestic. It's also international, which is quite challenging. And the whole coordination by global services, as I mentioned, scheduling is daunting. How do you get a patient here that has all the radiology, all the uh consultations with the appropriate clinicians and their surgery all on one visit. That's the game changer for collaborative care. Because in the past those people would have seen A different clinician, several weeks apart, had diagnostic tests on different days. Imagine the impact on a family of having to go to all these different appointments. We now can schedule them to have 3 days of testing, consultation, and surgery, all with one unified itinerary. That requires a lot of very devoted people that get that problem solved. Diagnostic testing slots are important. How many MRIs are available could impact the success of your program. Radiology has been nothing but incredible in helping us get this problem solved with the volume of patients that we have been asked to see. Clinic space, as all of you know, an enormous challenge here. Literally getting the patient in a clinic room then facilitates them from having surgery. OR time, getting them into an operating room. All of these things are influencers on whether or not we can take care of that number of patients that are being asked to get their care here. Inpatient beds and of course office space. We need a place to put the people that are doing all this work. Well, let's review some successes thus far. I cannot say enough about our colleagues in surgery and and medicine thus far that have stepped up to the plate to bond and join us in this mission. Everyone has been incredibly welcoming, excited about this new initiative and wanting to be a part of it. The nursing component has been absolutely marvelous in three areas, outpatient, inpatient, and OR. Patients cannot get the same level of care without superb nursing. The marketing team, which I've mentioned, which have got, who have gotten the message out there. And then the, the, the intangible, the mission and the culture of the organization. I think all of you on the call probably feel this on a regular basis. This institution warmly welcomed this program. The leaders really said, let's dive in. Let's get this done. This is right for kids. And everyone has been Incredibly welcoming. That I have rarely heard no. Usually it's, let's see, how do we make this possible? That's a great idea. That is based on mission and culture. So to review, We talked about how to develop a center. First is to offer unique skills. Second is to define the impact on the hospital, and whether and to determine with the administration, whether the organization wants to approach this particular problem and put the necessary resources behind it to solve the problems that are being faced. Track your successes. I think it's vital to document what you have done. And your outcomes to prove over and over again that collaborative model provides better care. Gather the appropriate personnel. This includes the need for dramatic infrastructure support, market the idea, commit to learning from your patients, and then over time build capacity. So I just want to end with this little story. A six year old girl came in with daily soiling, wearing a diaper, was teased at school for our bowel management program. So I said, in a week, you will be clean and in normal underwear. And she's thinking, and she gave me that quizzical look that I made, many of you have already seen in six year olds, you are an adult with no clue. And guess what? A week later, she comes in and says, Doctor Levitt. You make good promises. And what we did by this collaborative model is we delivered for this child. This is what she wanted, and this is what she got. And the only way we achieved that was the collaborative model working on all cylinders, getting the goal solved for this particular patient. So I really thank you very much for your warm welcome to this organization. It's been a real pleasure. It's been a wild ride so far and we have lots more to do, and I would be thrilled to take any of your questions. Mark, thank you very much uh for that talk. Uh, it's uh really inspiring to hear you as a surgeon talk about the care delivery models, uh, and the organizational aspects of, uh, new and vital programs that have such meaning to our patient populations. We just see many examples. I see many notes of patients who struggled with the fecal and urinary incontinence. Uh, they spend time with your team, and their lives are truly transformed. So, uh, there are some, uh, questions in the Q&A section that I like to go over, but I also think there is, uh, on, in the audience here, uh, another, uh, senior surgeon who was very instrumental in your arrival here, Mark, and that's, uh, our CEO, uh, Doctor Kurt Newman. Uh, Kurt, do you have some, uh, remarks you'd like to add to this? Uh, uh, sure. Uh, thank you, David. I, I don't know if I am on screen. You are, uh, at, at this point. Uh, well, thank you for the opportunity. Uh, it's, uh, terrific to hear just such a, uh, an amazing, uh, discussion and so comprehensive about a topic that has, uh, bedeviled, uh, pediatric surgeons, pediatricians. And most of all, parents and families and, and children, uh, over many, many decades and having a master surgeon and master teacher, uh, like Doctor Levitt, uh, be on our team, uh, and guide us to, uh, this next level of, uh, of care and excellence is, uh, you know, just, uh, inspiring, inspiring because I know, um, as a pediatric surgeon, I, I trained. Uh, here at Children's National. And, uh, it was not uncommon where we would have a very difficult, uh, uh, cases. And there was a paucity of uh expertise in the world. And Doctor Levitt, as you heard from the introduction and his discussion was one of the first, uh, what I'd say, young contemporary surgeons that embraced the concept and trained with the world, uh, leader. And I saw firsthand because I, in fact, had an extremely difficult patient that I knew was on my expertise. And I contacted his mentor, Doctor Pena, and I met Doctor Levitt, who was a young surgeon, uh working uh with uh Doctor Pena. Even at an early age, he had, uh, decided that this was gonna be his life's calling, and he helped me take care of this family and this child. What I wanna tell you is, uh, uh, Mark just described his career. Uh, to me, it was almost like a homecoming. And uh the, uh, I, I don't even wanna, I don't wanna use the word irony. But it, this family, uh, still here in the Washington area had talked to me, uh, as I was uh uh a surgical leader, chief of surgery, and then became CEO. And they would talk to me every 6 months to a year when I'd see their, their daughter, about when are we gonna, you know, get into this world-class. Not that we didn't have world-class surgeons or world-class uh pediatric uh gynecologists like Doctor Gomez Lobo or pediatric urologists. Um, Uh, uh, like Doctor Rushton, uh, or radio, we had all the pieces, but we'd never really, uh, uh, put it together and, and, and, and Mark mentioned, I think, a, a big one, motility and Doctor Darbari. Uh, but we needed, uh, that leader, and I would always have to kind of make, uh, uh, excuses and Doctor Sandler and I had been trying for, for years to, uh, build this program and we found, uh, the right leader. So, I was just thrilled a year and a half ago when I could tell, uh, this family that we had really moved, uh, uh, forward. Now, Mark mentioned Uh, about the interaction between, uh, clinical care and, uh, and finances. And I, I just, uh, I think his philosophy is correct. Great patient care leads to great healthcare finance. Um, some people think it's the other way around, uh, but I think Children's National and our trajectory over the last 10 years has proved that. And so, Mark, uh, I wanna thank you for, for, uh, uh, joining Children's National, uh, and building this collaborative team. And, uh, you know, it's, uh, the sky is the limit here. Uh, but I think it's, uh, the mark of the maturation of Children's National that we have programs like yours and, and so many others, uh, around the organization, uh, that are working together. Uh, to really, uh, uh, make this such a destination for the most complex care. So, uh, thank you again for, uh, sharing your, uh, uh, wisdom, uh, and inspiration with us. Yes, and I wanna in turn thank you and Tony Sandler because I can assure you I would not be here today. And I would add David Wessel to that list if the three of you didn't say, let's, let's go for it. Um, because I detected your inspiration, uh, Kurt and Tony. Tony and I have been talking about this for years. Um, and, uh, it was, it was a very, very good choice. And I, and I'm, I'm here to tell you that a year and a half into it, it was a really, really good choice. I really think we've done a really good job. There are a lot of patients that have benefited from the collaborative model. And I cannot thank enough the people that you've mentioned, uh, Doctor Pole in urology. Doctor Gomez Lobu in gynecology, um, and, uh, Doctor, um, Uh, Doctor Badil, my partner in, uh, in, in colorectal surgery, uh, as well. It's been that, that, that part of that part of the mission has been incredible. You mentioned Doctor Garbari as well in uh in GI. The 4 teams working together and now we have 3 members on each of these 4 teams. So there are 12 people on a group text. Um, really do all the, the hard, heavy lifting and the nursing component here. And the mission of the nursing component here has really made all the difference. So I really wanna thank you very much. Thank you, Dr. Newman and Doctor Levitt. Uh, we have, uh, uh, 5 or 6 minutes left, and there are several questions in the Q&A, uh, part of the presentation here that I'd like to move quickly through. Uh, Doctor Levitt, the first question comes from Margarita Ottojave Wessel, uh, in the telemedicine group, who says, have you been able to take advantage of our institution's standardized technology to follow up patients via telemedicine during the past year? Yes, that's a really great question. I, um, and, and you and I, um, um, the questioner, um, spoke about this before COVID. And it was a big, big goal for me is to try to help patients remotely as I had been seen, as I had seen done during my recruitment in cardiology. And then COVID hit. And we all became experts at this. And I can tell you it's changed the dynamic quite dramatically in colorectal care. Because we can take care of a lot. We can do a lot better taking care of patients remotely. The long-term follow-up is by Zoom. Um, and we're keeping track of our patients in a much better way because of the technology that you helped create. And I really appreciate you asking that question because I think for distance care for patients that are coming out of the outside of the region. It's really uh been, been life-changing. Those patients I think used to be lost to follow up or they never would have come because they didn't feel they can keep coming back for follow-up. And now we can see them fairly regularly just by putting on, putting, putting them on a computer screen. So yes, we have taken advantage of it. I wanna take that to the next level. Like you've done in cardiology. I have some plans to join some of the clinics around the world and literally sit in on the clinic and help provide some care to what some of our partners. And we're gonna use some of the technology to do that as well. Great. Thank you, Mark. Uh, the next question comes from Doctor Charlie Bulle, who's chief of the, of cardiology here. Uh, he says, congratulations on your successes so far. What expectations should senior executives, uh, at an institution have regarding the time, uh, on return on investment? In other words, how many years of patience with a C and patience with IENTS. Uh, until multidisciplinary programs like this become profitable. Yeah, that's a really good question. And I think it very much depends on the clinical scenario. I think from a practical point of view, my advice would be to take the clinical problem and document what is the current impact of the hospital of those diagnoses and activities related to those patients. And then, Do all the things that we talked about during this talk to build infrastructure and skill set, etc. and then track your results. And I think you will start to see, you should start to see dramatic effect even within a year of your own patients. Patients that have been taken care of by the system. That now come out of the woodwork because they have new offerings. Patients that have, for example, in my field, have been suffering with fecal incontinence, but now have a bowel management program that might help them. They may have been cared for here. And now they step up and join a clinic. So, You'll see effect within a year of your own patients. And then it will should continue to grow from there. So I think you should see incremental growth as soon as you launch a, a sophisticated care provided you have partnership, of course with marketing to get the word out. I think the administration should expect within a year to see some impact and then each year to show show increasing impact. And again, a lot of it depends on the calculation. You need to track when the patient comes into the system, whose patient is that? Is that a programmatically driven patient? If so, tag it in some way, so the administrators know that that patient was facilitated because they launched the program. I think those are, those are really good points, uh, Mark. Sometimes in our pro forma, uh, we don't really anticipate, uh, a, a break-even point until we get into, into year 3. But I think with good tracking, we can uh see early returns uh on the initial investment. Uh, Rahul Shah, our Chief Quality and Safety Officer, says, awesome talk. How do you consider technology and medical devices uh integrated with care coordination? What's the intersection of these three areas, Technology, medical devices, care coordination in the future growth of this work? Yeah, another great question. I think each of our fields have their own interface with technology. In my field, there are some surgical equipment. There's some surgical equipment that we need. There's the whole audiovisual connectivity, uh, piece. And I think we all need to say how can technology improve our patient care. And then it's worth bonding with these organizations and these, these companies and trying to get them to do what we need. As a very recent example. We needed um a type of device that fit into what's called a Malone appendicostomy. I showed you a picture to patients that can give an enema through their appendix. Well, the appendix is relatively thin, and the only devices available were for the stomach for a G tube. They were 14 French. And I had uh worked with those companies to try to create a 10 French device, which now exists. A lot of work. It requires FDA approval and support and why you need to do that, etc. But I think the more bonding we do with industry, the more creativity will come out of those ideas. And the, you know, the collaboration and the link there between the uh Surgical Center of Excellence and our Sheikhzayed Institute for Surgical Innovation is uh a clear opportunity for us to Uh, to utilize the expertise of the Shinxite Institute to bring devices to, uh, the, the care of children, uh, and even in this field and, and other related fields. Uh, the next is an anonymous attendee says, how is follow-up care managed? Uh, for patients that came from another state or country. I, I think that's the biggest challenge of a, of its program that uh brings patients from far away. It's actually gotten a lot easier now with the um uh technology type phone calls that we can do, the follow-ups that we can do. I think the key is to bond with the local provider, either the pediatrician or the surgeon. Have a good relationship with them. They recognize that they sent you some patient that was too complicated. But in large part, they can handle much of the follow-up with good communication. So those families go back, we check in with them on tech calls at certain intervals. We interact with their surgeon or pediatrician with what needs to be done. Um, and, uh, uh, that's the way to do it. Um, because the truth of the matter is they're, not every city can offer that care. So they need to travel, but then they can't keep traveling back and forth. So, um, I think that's the answer to your question. I think that has dramatically improved. That's 11 silver lining in the whole COVID model is our ability to keep in touch with patients and to do a better job coordinating with their, the local provider so that we're partners in this, in this process. So we've got 2 more questions and then we'll wrap up. Uh, Doctor Ellie Hamburger, who's, uh, one of the leaders in our clinically integrated network, the PHN says a wonderful talk. Thank you. Is there a role for collaboration with referring PCPs in ongoing post-operative management and or pre-referral management? So, how does your multidisciplinary program here reach out to the primary care physicians and primary care pediatricians, uh, both in our, uh, hospital, in our network, and in the region? Yeah, that's a very good, very good point. I think, um, well, we've tried to communicate with the local uh PCPs just to let them know that the program exists and what patients ought to be referred. Obviously, connection with them on various lecture opportunities to educate them on what opportunities are available. We try very hard to make sure they get a letter after we've seen such a patient. We've actually taken that a step up and try to coordinate um to have patients that are seen in their PCP's office that the PCP can be coordinator of some of their care with our guidance. Bowel management is an obvious example. There are patients that don't need to actually physically come here. But we can do some manipulation of their laxative dose, etc. through the PCP. So I have a lot of those ideas. We're working hard to do that. I think the uh interaction with the local provider, the patient's doctor, get our expertise added to that care I think is a vital part of the program. Great. Uh, Doctor Aisha Barber is a leader in our GME program and says thank you to Doctor Sandler, Doctor Levitt, Levitt, and Doctor Gomez Lobo for your care of my daughter. She's doing wonderfully. What is your approach to embedding this concept of collaborative care into the curriculum for trainees? Another vital point. I think it needs to become part of the fabric of our, of our care. I think focusing as a clinician in a silo is very old fashioned at this point. Well, the only way I can do that is to contribute in my own way. We have a training program in pediatric colorectal, one of the, one of the only kind in the world. Um, and the collaborative model is vitally important for that trainee. That person spends time in gynecology, urology, and GI and experiences the collaborative model every single day. Our collaborative meeting every single week. Um, with all 4 of those teams on the call, um, every single week. Uh, in addition, anesthesia is on that call to learn about what's coming up in the OR for the upcoming week. So, I think it's a culture thing. I think the leaders need to convey the importance of the collaborative model in each of these fields and the infrastructure needs to support that so that the fellows just simply, it makes it part of their routine. OK. And the last question, cause we're just coming up to 9 o'clock right now. Uh, I give to Doctor Elizabeth Wells, who's president of our medical staff. Uh, and she says, Doctor Levitt, can directors of developing collaborative programs at Children's National approach you for mentoring? And hello and thanks to your neurologist parent, Beth Wells. Nothing would make me happier. You know, my dad is a neurologist, and I hope, uh, some of you have read his, his book, Lessons he's learned from his patients. I was a 4th-year medical student on neurology with him, and he told me, and he told the grand rounds when he was the chairman that I had chosen a non-cognitive specialty because neurologists didn't think surgeons knew how to think. But the truth is, I think I've convinced him after 25 years that I am cognitive. But you're, you're, you're, you're quite right, and I really appreciate, I really appreciate your comment. Great. OK. So that really wraps up our questions. I see a comment from, uh, Kalali Eskanian, uh, our Sheikhzayat Institute, uh, saying that indeed they've got some GTube solutions and other things that are ongoing work there in the Sheikhzayed Institute. Craig Futterman is asking more about how technology is integrated into your program, uh, and others make valuable comments as well. Uh, regarding the, uh, leveraging our PHN, uh, and the PR and marketing aspects of, uh, these new programs. So thank you very much, Doctor Levitt. Great talk. We really appreciate your work, and we're especially grateful for the way you've integrated other members of the CARE team, and really the operations too. I noted that you have a, uh, a recent publication describes Program building and you included your, your center of excellence, surgical Center's, uh, executive director Susan Callicott is a coau important co-author on that, and it really demonstrates your commitment to collaboration and building multidisciplinary models, including your very special partnership with the nursing staff. So thank you for the Ground Rounds presentation. We look forward to seeing more great things coming out of this program. Uh, thank you to everyone who attended today's meeting. Thank you.