Smilow Cancer Hospital Town Hall | March 22, 2023

Transcript

• 00:00All right. Well, welcome, everyone.
• 00:03I'm just going to go
• 00:05ahead and share my screen.
• 00:08Welcome to our. Just make sure I.
• 00:14For the panelists,
• 00:15is everyone seeing one screen?
• 00:17Hopefully, yes. So thank you.
• 00:19All right. Welcome, everyone,
• 00:21to our Smilo Cancer Hospital town hall.
• 00:26I'm Kim Slesser,
• 00:27vice president of patient services for
• 00:30Smilo and joined by my dyad partner,
• 00:33Doctor Kevin Billingsley.
• 00:34We have a few announcements to
• 00:37go over and a few highlights,
• 00:40but the majority of our town hall today
• 00:42will be our agenda as you see below.
• 00:45So we have with us Doctor Jensen
• 00:48Morris to go over some updates on
• 00:51code policies for the health system
• 00:53and then our program highlight.
• 00:56This evening is our Center for GI
• 00:59cancers and we are very fortunate to
• 01:02have doctors Pamela Kuntz and Manju
• 01:06and Chavier Lord with us this evening.
• 01:10So very excited for them to present.
• 01:13And then hopefully this month we will
• 01:15have time for questions and answers.
• 01:18So start to think about those
• 01:19questions that you might want to ask.
• 01:21We we have been trying to make
• 01:24the agenda a little lighter.
• 01:26So that we have more time for Q&A.
• 01:28So there should be plenty of time to
• 01:30answer any questions that anybody has.
• 01:36So we always like to
• 01:37start out with making sure that we're
• 01:39highlighting things to celebrate and
• 01:41smilo and then the Yale Cancer Center.
• 01:44And so on March 19th of every year
• 01:47that is our day that we celebrate
• 01:50in the nursing profession,
• 01:52Certified Nurses Day.
• 01:53So this is a day where we really
• 01:56recognize our nurses who have
• 01:58achieved specialty certification.
• 02:00So in order to do that,
• 02:01a nurses generally have to work.
• 02:04At least two years in that specialty
• 02:06and then they have to study and
• 02:08sit for an exam that really
• 02:10demonstrates their competence and
• 02:12expertise within that specialty.
• 02:14So 35% of all of our smilo nurses
• 02:18are certified in a specialty.
• 02:20And again, we do have a, you know,
• 02:23a number of new graduate nurses.
• 02:25So our our rate of eligible nurses
• 02:28is even higher than that 35%.
• 02:30But we want to make sure that we
• 02:32recognize all of our certified nurses.
• 02:34Today during this town hall and
• 02:36we're proud of their commitment
• 02:38to nursing excellence.
• 02:39So this was the picture of some
• 02:41of our certified nurses that was
• 02:43on social media over the weekend
• 02:45to celebrate the event.
• 02:46So thank you to all of our certified nurses.
• 02:51And before I go on to the next slide,
• 02:55we don't really have a slide for this,
• 02:57but it just so happened that today
• 02:59was also a day that there was a change
• 03:02in the health system mask use here.
• 03:06So we thought we would just take a
• 03:08minute and go over those changes.
• 03:09So there really are no changes to
• 03:13patients or employees wearing masks
• 03:15and clinical or patient care areas.
• 03:19So we wanted to make sure that everybody.
• 03:21Knew about the the minor changes
• 03:24across the health system.
• 03:25So mass art remain a requirement in
• 03:27all clinical and patient care areas
• 03:30and that are accessible to visitors
• 03:32throughout the health system.
• 03:34So this obviously includes our lobbies,
• 03:37our reception areas and waiting rooms,
• 03:39our hallways and elevators and
• 03:43charting areas.
• 03:44Located in the hallways are cafes
• 03:47and obviously our patient rooms,
• 03:49exam rooms and treatment rooms.
• 03:51So masks are still.
• 03:53Required during all of those
• 03:55activities and environments,
• 03:57but masks are optional now when
• 03:59you are in an area not designated
• 04:01for patient or visitor use.
• 04:04And so in general this can
• 04:06include our auditoriums,
• 04:07our conference rooms and
• 04:09closed door charting rooms.
• 04:11It can also include our lunch or break rooms,
• 04:14office spaces,
• 04:15administrative offices and hospital
• 04:18inter campus and parking shuttles.
• 04:21This was really a change.
• 04:23By the health system due to the decreasing
• 04:26level of COVID-19 transmission in the
• 04:29Community and an increasing level
• 04:31of immunity across the population,
• 04:34we've had mandatory masking
• 04:36with no change since early 2020.
• 04:39And again just these minor changes in
• 04:43non clinical areas and our infection
• 04:46prevention team and infectious disease
• 04:48teams will continue to monitor rates
• 04:50of COVID-19 and if there are significant.
• 04:53Increases then mass may be
• 04:56reinstated in all areas.
• 04:58So we're happy to take any
• 05:00questions later about that.
• 05:02There are some nice FAQ's that are
• 05:07available on the COVID-19 intranet site
• 05:10for anybody that would that needs it
• 05:13for their staff or for their own use.
• 05:17And now I'm going to turn it over to Kevin.
• 05:23Thanks, Kim. You know,
• 05:24as many of you are aware,
• 05:26last week was national Patient
• 05:29Safety Week and I think we would
• 05:32be remiss if we had this gathering
• 05:35today and did not under score
• 05:38the importance of our collective
• 05:40commitment to safety for our patients,
• 05:44not only in our hospital environment,
• 05:46but in all of our care environments.
• 05:50And I just wanted to kind of
• 05:52take a moment to under score the
• 05:54importance of the work that many,
• 05:57many people are doing around the organization
• 05:59to help us make our patients safe every day.
• 06:03First off, I want to just give a really
• 06:08enthusiastic hats off and cheers for
• 06:11our team on NP11 hematologic oncology.
• 06:14As many of you know they have
• 06:18joined the thousand day.
• 06:21Bob, 1000 days without a caudy, so.
• 06:26Incredible work, you know,
• 06:29that's physicians, nurses.
• 06:32ACA's environmental services
• 06:34truly A-Team effort,
• 06:36so thank you very much.
• 06:39I also just want to give a quick shout out to
• 06:42our quality and safety team here in smilow.
• 06:44They work with all of us.
• 06:47They're part of the system,
• 06:49but they are an incredible group of
• 06:52professionals under the leadership
• 06:54of Michelle Kelvey Albert.
• 06:56I don't want to leave anyone off the list,
• 06:58but I do want to say a special
• 07:00thanks to Chloe Shevlin.
• 07:02Tom Collins,
• 07:03Maria Mora and I know there are others,
• 07:06but.
• 07:06I I just want to recognize the
• 07:09work that all of you do week in
• 07:12and week out with all of our teams
• 07:14to help us make our care safe.
• 07:19I think this slide is an important
• 07:22reminder because really being a high
• 07:25reliability organization is about
• 07:27creating a culture that supports that.
• 07:31And all of us continuing to learn,
• 07:34continuing to learn and our
• 07:36processes and operations,
• 07:38continuously examining,
• 07:39testing and refining,
• 07:42asking questions and then equally
• 07:45important is creating, sustaining.
• 07:47And nurturing a culture of high reliability.
• 07:51And I think this slide from that IHI
• 07:55really highlights the number of the key
• 07:58elements of what HRO culture is about.
• 08:01And I'm going to call out the 1st that I see,
• 08:03which is psychological safety.
• 08:05And that really is about creating an
• 08:09environment where any or all of us
• 08:11feels really good about speaking up or
• 08:14stopping the line when we see or feel
• 08:18something that we're concerned about.
• 08:20And I would encourage all of
• 08:22us to support that environment,
• 08:25whether you're a nurse,
• 08:26a nursing student, Med student,
• 08:28your opinion and your concerns are
• 08:31important and valuable. And please.
• 08:35Help us keep our patients safe.
• 08:40You know,
• 08:40it's a good time just to refresh all of
• 08:44our memory on what our champ behaviors are.
• 08:47You know, our importance,
• 08:50our emphasis on communication.
• 08:53Accurate, clear communication.
• 08:54Usually supported by an S bar.
• 08:58Effective handoffs.
• 08:59Meticulous attention to detail using
• 09:02star moments and star behavior.
• 09:06Mentoring,
• 09:06supporting each other to 200% accountability
• 09:10and that's certainly part of teamwork,
• 09:13communication,
• 09:14psychological safety and last but not least,
• 09:18practicing and accepting a questioning
• 09:21attitude against tying back to a
• 09:24sense of safety and accountability.
• 09:26So again,
• 09:28just a big note of thanks from Kim myself,
• 09:33the other Cancer Center in Smilo leaders.
• 09:36For the work that everyone does to
• 09:39support the safety of our patients.
• 09:42Next slide.
• 09:45So one of the things that I
• 09:47wanted to spend a few moments
• 09:50updating our community on is that.
• 09:54Our system is undergoing growth,
• 09:57change and development and as
• 10:00we adapt towards a specialty
• 10:03driven cancer care enterprise,
• 10:05we're going to have changes in our
• 10:08operations and the way we deploy our
• 10:11providers and our clinicians at different
• 10:13clinical sites around the enterprise.
• 10:16And one of the things that we're
• 10:18trying to do is to make high level
• 10:22expertise accessible to patients and
• 10:24families in a way that is close to home,
• 10:28yet also aggregates the key
• 10:32elements of specialty driven care.
• 10:35And to that end we have,
• 10:38we are we are going to be
• 10:41reconfiguring our smilo center in
• 10:44Orange to provide comprehensive care.
• 10:47For patients with benign
• 10:49hematology needs and diagnosis,
• 10:51this is a complex and growing group of
• 10:54patients and we have found that there
• 10:58are efficiencies as well as benefits
• 11:00and care coordination and expertise
• 11:03in clustering some of those things
• 11:05together in a centrally located site.
• 11:08Doctor Joe Lasala has practiced
• 11:10at this site and done broad based
• 11:13hematology and oncology for many years.
• 11:17We're transition will practice
• 11:19to Guildford on June 12th.
• 11:21Her hematology patients will either stay in
• 11:24orange or follow doctor Lasala to Guilford.
• 11:27Doctor Kelsey Martin will remain in Orange,
• 11:31where she has a predominantly benign
• 11:35or classical hematology practice.
• 11:38And we'll see some of her patients,
• 11:40particularly malignant hematology
• 11:41patients at our site in North Haven.
• 11:45Classical hematology that has
• 11:47previously been in North Haven
• 11:50will transition to orange.
• 11:52So like all change,
• 11:54there is some anxiety and concern.
• 11:58Associated with that,
• 12:00it does mean long established
• 12:02practices will be moving,
• 12:04but this is an enormous opportunity
• 12:07to leverage the collective expertise
• 12:09of our system and our collection of of
• 12:12sites and assets really to deliver the
• 12:14best possible care to our patients.
• 12:16So I would just ask for people to
• 12:19be supportive and understanding
• 12:20as we go through this,
• 12:22which will be probably one of many
• 12:24changes as we evolve to a more
• 12:27specialty driven and integrated.
• 12:28Organization.
• 12:31So a big, big round of enthusiastic
• 12:36congratulations to Doctor Pat Lorusso.
• 12:40As most of you know,
• 12:41Pat is our fearless leader of our
• 12:45phase one clinical trials unit.
• 12:47This is truly one of the resources that makes
• 12:50Smilo and the Yale Cancer Center a leader.
• 12:54This is the center where
• 12:56we bring truly innovative,
• 12:58cutting edge therapies into the clinic.
• 13:01And Pat has been elected to the Presidency of
• 13:05the American Association for Cancer Research.
• 13:08She's the president-elect for 2023 to 2024.
• 13:12The American Association for
• 13:15Cancer Research is probably.
• 13:17One of the most highly regarded international
• 13:21organizations for the oversight and
• 13:25support of cancer care research,
• 13:29it largely focuses on the translation
• 13:32of basic scientific discoveries into
• 13:35therapeutics, an area of which doctor
• 13:38Lorusso is clearly an expert.
• 13:39So it's a big.
• 13:43Endorsement for Pat's leadership
• 13:44in this space and a great feather
• 13:47in the cap for our organization.
• 13:49So well done, Pat.
• 13:54So with those updates out of the way.
• 13:58It gives me great pleasure to kick
• 14:00over to my friend and colleague, Dr.
• 14:03Pam Kunz and her team of GI Oncologists,
• 14:07who will be giving us a program update on
• 14:09the Center for Gastrointestinal cancers.
• 14:12So Pam and team, take it away. Thank you.
• 14:20Thank you, Kevin.
• 14:21And I hope everyone can see
• 14:23this slide to start with.
• 14:24So it's really my pleasure to
• 14:26represent the Center for GI cancers
• 14:28and we're going to focus a little
• 14:30bit on colorectal cancer tonight.
• 14:32But I hope this slide just really shows
• 14:35how the breadth of multidisciplinary
• 14:37care really across across our network.
• 14:39And it's really been,
• 14:41I've been here now about 2 1/2 years and
• 14:43it's been a pleasure to direct this center.
• 14:46So our Center for GI cancers is
• 14:48organized in a leadership cabinet.
• 14:51I serve as the director and we've had some
• 14:53evolution over the last couple of years.
• 14:55And again I just want to demonstrate
• 14:58how this really has brought together
• 15:01stakeholders throughout multiple
• 15:02disciplines including medical oncology,
• 15:05surgical oncology,
• 15:07radiation oncology path,
• 15:10digestive diseases,
• 15:11cancer imaging and and you can see
• 15:14some other examples we have a.
• 15:16Mini cabinet that has recently
• 15:18formed that includes myself as
• 15:21the Director of Clinical Research,
• 15:23Mansky as the Director of clinical
• 15:26director for medical oncology,
• 15:28Mandar Muzumdar is our
• 15:30Translational Science director.
• 15:31In current Shiraga is the
• 15:33surgical oncology director.
• 15:35I won't go through all of the names
• 15:37of our ad hoc cabinet members,
• 15:38but really it's a fantastic
• 15:42group of individuals.
• 15:44Since my arrival,
• 15:45we have launched 4 key disease
• 15:47based programs that themselves have
• 15:49steering committees and these were
• 15:51really based on existing expertise.
• 15:54And we are going to focus tonight on
• 15:56the colorectal anal cancer program
• 15:58that is led by doctors Michael Cikini,
• 16:01Chavier your and Anne Manju has
• 16:03newly joined as a Co director
• 16:06representing colorectal surgery.
• 16:08Doctor Chikuni cannot be on tonight,
• 16:10so I am representing medical oncology.
• 16:14So I'll remind everybody that March
• 16:16is colorectal Cancer Awareness Month.
• 16:18These are some pictures from
• 16:20across our network and I think Joe
• 16:22Mendez for a few of these pictures.
• 16:24Dress in Blue Day was March 3rd
• 16:27and this was again a really cross
• 16:30health system effort led by Joe and
• 16:33the folks in digestive diseases and
• 16:36a really fun way to both increase
• 16:40awareness around colorectal cancer screening.
• 16:44I'm going to pass now to Doctor
• 16:46Ann Monjeau to talk a little bit
• 16:49about the national accreditation
• 16:50program for rectal cancer.
• 16:52Hi,
• 16:52thanks Pam.
• 16:54So
• 16:55as part of the ACS,
• 16:56we now have a pathway towards
• 16:58ex seeking excellence in rectal
• 17:00cancer care and that's the NPRC or
• 17:03National accreditation program.
• 17:04What we know is that cancer outcomes
• 17:06are better when patients are managed
• 17:08according to multidisciplinary team care.
• 17:10And in Europe, in fact when they've
• 17:13implemented similar programs,
• 17:14they have seen decreases in
• 17:16the rate of permanent stomas,
• 17:18reduce rates of local recurrence and
• 17:20basically greater delivery of evidence.
• 17:22Face care on the appropriate
• 17:24time scale and so that's sort of
• 17:26the goals of the NPRC program.
• 17:28They
• 17:28have sort of three elements that
• 17:30they look for and that's program
• 17:32management ensuring that you
• 17:34have an appropriately qualified
• 17:35rectal cancer program director.
• 17:37And we have a wonderful director
• 17:38in the our division Chief of Colon
• 17:40and rectal surgery, Doctor Reddy.
• 17:42They look at clinical services to
• 17:44make sure that patients receive,
• 17:46are presented appropriately at
• 17:47multidisciplinary care and also receive
• 17:49their treatments in a timely fashion
• 17:51according to the latest standards.
• 17:53Old standards of treatment for rectal
• 17:55cancer and finally quality improvement
• 17:56using data to improve our efficiency,
• 17:59looking at how we do and continuing to
• 18:01standardize our care and improve our
• 18:02outcomes as we go through the process.
• 18:04We are in the process of applying
• 18:06for any PRC accreditation and that
• 18:08is basically a multidisciplinary
• 18:10team that comes together to do this.
• 18:12And that's not only just surgery
• 18:14or surgical oncology,
• 18:15but that involves our colleagues
• 18:17in pathology, radiation oncology,
• 18:19radiology and medical oncology.
• 18:22It's a pretty large.
• 18:23Commitment and we all work together
• 18:26to create a program where patients
• 18:28have true multidisciplinary care and
• 18:30can progress smoothly through it.
• 18:32So that's
• 18:32just a little bit about the program.
• 18:34I'm going to
• 18:34pass it off now
• 18:35to Doctor Lord.
• 18:47Thank you very much and thank
• 18:48you for having me tonight.
• 18:49So we're going to talk a little bit
• 18:51about the colorectal cancer screening
• 18:53pathway as one of the tools that that
• 18:56that we've helped develop to really ramp
• 19:00up our screening efforts here at Yale.
• 19:04The first thing I wanted to
• 19:05show you is this, we've been,
• 19:07we've become accustomed to seeing this.
• 19:09Graph, that's always been
• 19:11so encouraging since then,
• 19:13um, 1980s, mid 1980s,
• 19:14where we've been seeing this a progressive
• 19:17decrease in both incidents and
• 19:19mortality related to colorectal cancer.
• 19:22So we've been always very happy about that.
• 19:25But the reality is that over
• 19:27the last few years,
• 19:28things have changed a little bit and
• 19:31now the declining incidence rates have
• 19:34become confined to the individuals
• 19:37who are 64 years old and older since.
• 19:40Rematch 2011 and when we look at individuals?
• 19:45Who are aged 50 to 64,
• 19:49these incidence rates have kind
• 19:51of stabilized,
• 19:51but looking at the 50 to 54 year olds,
• 19:54these incidents has started going up
• 19:57and and the more consistent level,
• 20:00the individuals that are younger
• 20:02than 50 have seen an increase
• 20:05of about an average 2% per year.
• 20:07So really worrisome trends here and
• 20:10in fact the diagnosis of people under
• 20:12age of people under age 55 have doubled.
• 20:16From 11% in 1995 to 20% in in 2019
• 20:20and this is very nicely visualized
• 20:22here in this slide from the uh,
• 20:25this uh recent publication from the
• 20:27ACS that looks at individuals by age,
• 20:31cancer diagnosis by age by per per
• 20:34100,000 population and in red the
• 20:37red bars is population between ages
• 20:40between the 1975 and 79 and the green
• 20:43ones between 2015 and 2019 the more recent.
• 20:46As you'll see there's a big difference
• 20:49in in the earlier years we would
• 20:53see this progressive increase in
• 20:55incidence as we are getting older.
• 20:57Yet when we're looking at the
• 20:59more recent studies,
• 21:00more recent population we see is
• 21:02that this is pretty much similar,
• 21:04all these bars are similar.
• 21:05So really seeing this this disproportionate
• 21:08increase among the younger individuals.
• 21:10So definitely that's been that
• 21:12is being a concern and that again
• 21:15has changed the narrative.
• 21:17That we the the very optimistic
• 21:19narrative that we had been seeing
• 21:21over the last 30 years or so.
• 21:23And on top of that we've also seen an
• 21:26increase on the percentage of cancers
• 21:29that are regional or distant we've come.
• 21:32We've moved from 52% in the mid
• 21:352000s to a 60% in 2019 and that's
• 21:39mostly due to these in individuals
• 21:43ages 20 to 49 and the 50 to 64.
• 21:47So again,
• 21:48more on that worrisome trend
• 21:50of younger individuals and more
• 21:52advanced stages at diagnosis.
• 21:54So with some of these data that we've
• 21:57been seeing for a while already,
• 21:59the the American Cancer Society
• 22:02Commission Modeling Group to really
• 22:05try to figure out if that would warrant
• 22:08to increase to start colorectal
• 22:11cancer screening at an earlier age
• 22:13and the through the modeling they
• 22:16really have concluded that actually.
• 22:18Screening or average risk persons between
• 22:20the ages of 45 and 75 would reduce
• 22:23mortality from colorectal cancer with
• 22:25an acceptable risk as measured by number
• 22:28of colonoscopies for life years gained.
• 22:30So that kind of like that was the
• 22:33first group that really positioned
• 22:35themselves to really move the screening
• 22:38for average risk individuals to a 45,
• 22:41the USPSTF Commission that pretty much
• 22:43the same modeling and again it's it's the
• 22:46modeling that they've used in the past.
• 22:48But what they did is they updated the
• 22:51information on the recent trends of the
• 22:53earlier onset colorectal cancer and
• 22:55they came up with the same conclusion.
• 22:57And in 2021, May 2021,
• 23:00they came up with this great B
• 23:02recommendation of starting screening
• 23:05rate screening for average average
• 23:08risk individuals at 45.
• 23:10And all other societies have
• 23:13really endorsed these.
• 23:14And I think that we're all pretty
• 23:16much on the same page regarding this.
• 23:18Move to a earlier screening age.
• 23:22So where are we standing in terms
• 23:24of screening?
• 23:24This is national data and I'm
• 23:27going to show our own data here and
• 23:30basically looking at the national
• 23:31data by 2021 what we had is.
• 23:34That.
• 23:3758% of the population ages 45 to 75 are
• 23:42up-to-date with colorectal cancer screening.
• 23:45Only 20% are up to date on the
• 23:4845 to 49 age group, which is not
• 23:50surprising provided that we basically,
• 23:52it's been only a couple of years since
• 23:55this has been widely recommended.
• 23:58But what's really should be a little bit
• 24:01more surprising and not so nice to say is
• 24:03that only 50% and that's pretty consistent.
• 24:06Only 50% of the 50 to 54 are up to
• 24:09date with screening and this has been a
• 24:12recommendation for the last 30 years, so.
• 24:15That for 30 years we've
• 24:16recommended to start at 50,
• 24:18but we are not able to to really get
• 24:21to those levels in this population.
• 24:24And probably there's been a lot of
• 24:27wondering about what the fact is.
• 24:29But there's this described like if effect
• 24:31which is that we start talking to people
• 24:34at age 50 and by the time they really
• 24:36make the the decision getting screened,
• 24:39we're getting already too
• 24:41old and older than 50 to 54.
• 24:44And as we've seen by that time,
• 24:47many of those patients may have already
• 24:50have developed colorectal cancer.
• 24:51So we really have to make a push here.
• 24:53When we look at our own data,
• 24:55not extremely different.
• 24:56This is data from February 28th,
• 24:583 day, several days ago.
• 25:0158.4 of our patients are up
• 25:03to date with screening.
• 25:04And among the youngest individuals,
• 25:0833% among among the 45 to 49
• 25:12and 51.8% among the 50 to 54.
• 25:15So certainly a lot of work to
• 25:18be done particularly with this
• 25:19worrisome trend and and our very
• 25:22still very low levels of screening
• 25:24among the younger individuals.
• 25:26And beyond these younger individuals
• 25:30there are other groups that are have
• 25:32screening rates that are less than 50%,
• 25:34particularly Asians and Hispanics,
• 25:36people with less than high school
• 25:39diploma education levels are very
• 25:42well related to screening rates,
• 25:44Medicaid and uninsured patients.
• 25:45Have the lowest levels of screening
• 25:48to individuals who migrated to the US
• 25:50less than 10 years ago and individuals
• 25:52with lower income levels in general.
• 25:54Those all have levels that are below
• 25:5750% and those will really require our.
• 26:01Special efforts to really try to
• 26:04get them to a more palatable level.
• 26:07And as we've seen with with the need,
• 26:11the growing need for more colorectal
• 26:14cancer screening,
• 26:15here I'm just showing up the newly
• 26:18eligible population 45 to 4049 and
• 26:20what that would represent if we were
• 26:22to do colonoscopies for all of them,
• 26:24that would increase that to close
• 26:26to 18 million extra colonoscopies.
• 26:29So certainly it's extremely doubtful.
• 26:31The US is prepared to handle screening
• 26:35in the way that we've been handling
• 26:37it which which is through colonoscopy.
• 26:39And so I think we all realize about
• 26:42that and on top of that data is strong
• 26:45enough that there are other options
• 26:47that are being endorsed that do have a
• 26:50good data regarding their effectiveness.
• 26:53And beyond colonoscopy we have
• 26:55CT colonography we and we
• 26:57have stool based test speed and and multi
• 27:00target stool DNA and we also know that.
• 27:02Multiple screening options,
• 27:04having the possibility to have more
• 27:07options does increase the screening rates,
• 27:10but at the end of the day we'll really
• 27:12what we really have to learn is to
• 27:14figure out how we manage all these
• 27:17possibilities with these options for
• 27:19screening and how we better utilize
• 27:21our resources and so how do we
• 27:24choose among these different options.
• 27:26And and how do we make those shared decision,
• 27:29shared decision making with our patients.
• 27:33I think that's going to be critical
• 27:35and and part of that will rely
• 27:37also on risk stratification.
• 27:39And I think we are all in agreement
• 27:41that we would really make sure
• 27:43that screening happens among the
• 27:44highest risk through colonoscopy.
• 27:46But then we do have options for
• 27:49the other tests that have also been
• 27:51shown to be a very useful test.
• 27:53So I'm going to stop here and and.
• 27:55Yeah.
• 27:56We'll run the short 2 minute video
• 27:58that kind of summarizes the colorectal
• 28:01cancer screening pathway that's been
• 28:03built along with primary care providers
• 28:05and and a lot of different people.
• 28:08The basically what he's trying
• 28:10to do is really help people walk
• 28:12through the process on who,
• 28:14who better qualifies for the
• 28:16different tests and what,
• 28:17who's better suited for everyone.
• 28:19And also from there the capability to
• 28:22really place the orders and have all
• 28:24the information from the pathway directly.
• 28:27Without having to go to anything,
• 28:28any other places to really go
• 28:30through that whole process.
• 28:31So it will show you the video
• 28:33and then we can talk about it.
• 28:41The care signature colorectal cancer
• 28:43screening pathways were created by
• 28:45Yale New Haven Health system experts
• 28:47in alignment with the most recently
• 28:49released guidelines and evidence
• 28:51to provide a resource tool for
• 28:54providing best practice care while
• 28:56discussing screening with patients.
• 28:58You can find the care signature
• 29:01pathways by going to the pathways tab
• 29:04while within a patient's encounter.
• 29:06To get to the colorectal cancer
• 29:09screening pathways,
• 29:09you can scroll or simply type in
• 29:12a ski search term including CRC or
• 29:14colorectal to find the pathways.
• 29:23The initial screening pathway
• 29:25is for patients who have not
• 29:27had colorectal cancer screening
• 29:30previously and identifies patients
• 29:32who should be offered screening.
• 29:35And those who should not
• 29:37be offered screening,
• 29:39and also populations where screening
• 29:40should include a discussion
• 29:42of the risks and benefits.
• 29:47Patients who are at high risk for
• 29:49colorectal cancer are identified and
• 29:51specific screening guidance is provided.
• 30:01For average risk patients,
• 30:03the focus is on a shared decision
• 30:05making model where the best
• 30:07screening test for that patient is
• 30:09the one that they will complete.
• 30:11Advantages and disadvantages are noted.
• 30:18As well as sensitivity and
• 30:20specificity of the available tests.
• 30:25A smart phrase has also been created
• 30:27that can be used to document your
• 30:30shared decision making conversation.
• 30:32There are also some various educational
• 30:34tools available to provide to patients
• 30:36which may aid in your discussion
• 30:38and in their decision making.
• 30:46Once a shared decision has been made.
• 30:49Simply click on the link for
• 30:51the preferred test to place the
• 30:53order for that test in Epic.
• 31:00You'll notice that some of the
• 31:02information has been prefilled to
• 31:04aid and efficiency whenever possible.
• 31:15We have also created pathways to help
• 31:17with clinical decision making for
• 31:19patients who had who have had previous
• 31:21negative colorectal cancer screening.
• 31:31And also a pathway to help guide and
• 31:35set expectations and next steps for
• 31:37patients who have had abnormal screening.
• 31:52If you have feedback about these pathways,
• 31:54including suggestions on how to improve them,
• 31:57click the feedback button and
• 31:58send you to send your suggestions
• 32:00directly to the care signature team.
• 32:03All feedback is appreciated.
• 32:17So Pam and team, thank you for this
• 32:21overview of what is really one of our
• 32:26our outstanding programs and it is,
• 32:28it's terrific to see the disciplines
• 32:31coming together to deliver these services
• 32:33and I know that this presentation
• 32:36just barely scratched the surface.
• 32:39I think we will see if there are any
• 32:43questions from from our our virtual
• 32:46audience before we go on to doctor
• 32:49Morris's update on code status and
• 32:52while we're waiting for some to come in.
• 32:55I'm going to take a little bit of
• 32:58moderators privilege and kind of kind
• 33:00of ask this question and and it's
• 33:03it's not an easy question so I I don't
• 33:06expect a straightforward answer but.
• 33:09And maybe I'm Javier.
• 33:11This is probably mainly for you,
• 33:13but I I'm struck by the fact that.
• 33:18Colonoscopy remains a uniquely
• 33:21effective and significant tool because
• 33:25it is not only early detection,
• 33:29but it is a powerful prevention modality.
• 33:34And as much as I would love to see deeper
• 33:38penetration of the other screening
• 33:41tools because I think they will be
• 33:44more accessible and they are probably
• 33:47our pathway forward in terms of.
• 33:49Broadening the access for early detection,
• 33:53how do we,
• 33:54how do we as clinicians reconcile
• 33:57what I think is a is a as is a bit
• 33:59of a disparity in the benefit that
• 34:02patients get colonoscopy versus
• 34:04other screening modalities.
• 34:06Does that make sense?
• 34:08Yeah, yeah, I think we all
• 34:11struggle with this concept.
• 34:12I think that at the end of the day where
• 34:15we have to go to back to is the data and
• 34:17the data has been very consistent that.
• 34:19We've decreased mortality with all
• 34:21these other options and that's
• 34:23why they are being endorsed.
• 34:25So and and there are a lot, a lot of aspects.
• 34:29Some people just don't want to go
• 34:31for a colonoscopy and we've been
• 34:33for the longest time ignoring them.
• 34:35It's like you're due for colonoscopy,
• 34:36boom ordered and then they don't show
• 34:39up because some people have fear,
• 34:41some people think this is
• 34:42way too overwhelming.
• 34:43So having none.
• 34:46Says that are not colonoscopy
• 34:48based is really able to just get
• 34:51a population to to to really get
• 34:53tested otherwise they would not
• 34:55be getting getting that tested.
• 34:58It's no small thing also to identify
• 35:00early lesions versus more advanced
• 35:02lesions and stool based tests and
• 35:05and cynical and ography have shown
• 35:07capacity to the to do that to again I
• 35:10think that it's when we take things
• 35:14to a population level that's when
• 35:16you really see the role of all these.
• 35:18Things,
• 35:19but I think it's also honest to say
• 35:22that we have to look at resources
• 35:24and colonoscopy is not an infinite
• 35:27resource in our environment.
• 35:29And with this new huge amount
• 35:31of new patients who are going to
• 35:34be eligible for screening,
• 35:36there's been no way that with our
• 35:38current environment will be able to
• 35:40screen everyone through colonoscopy,
• 35:41even if they were enthusiastic,
• 35:44all of them enthusiastic about
• 35:45having colonoscopies.
• 35:46So I think it's just looking at
• 35:48reality having a population.
• 35:50Have that level based approach
• 35:51and we really have to like try to
• 35:54reconcile all these thoughts that
• 35:56I think we're all sharing.
• 36:00Kevin, can I add just one thing that
• 36:02sort of ties if some of this together.
• 36:05I'll just mention that there are broad
• 36:07coordinated efforts to try to educate both
• 36:11our physician community and our patients.
• 36:13And we've done a number of those
• 36:16this month through CME one,
• 36:18I know CHAVIER has been participating in
• 36:21many of them, but through partnership
• 36:23with our primary care physicians,
• 36:25I participated in one of those and
• 36:28in addition with kind of a patient.
• 36:31Related SMILO shares so I think some
• 36:33of this is getting the message out
• 36:35about all of these different screening
• 36:38modalities and my a disclosure my
• 36:40husband's a gastroenterologist so I
• 36:42sort of drink the kool-aid and and he
• 36:44says you know any screening is better
• 36:47than no screening and and I think
• 36:49that that's really the take away as
• 36:51we try to really advocate for them.
• 36:58So Doctor Manju,
• 37:00you were a gifted communicator.
• 37:03Do you have any tips for this audience,
• 37:06who all have families, friends,
• 37:09loved ones and community contacts?
• 37:13Any talking points to help
• 37:15get people in for screening,
• 37:17particularly as we know younger
• 37:19people are at more risk than
• 37:21we ever think and that can
• 37:23be a hard audience to reach.
• 37:25How do we get over the ick factor?
• 37:29And your and
• 37:29you're asking the colorectal surgeon
• 37:31who chose this as a profession?
• 37:37I mean I think one of the things I I talked
• 37:39to my own patients about is that I have
• 37:42done a colonoscopy and it's not awful.
• 37:44And you know I think one of the things
• 37:46that we do need to highlight before
• 37:48people in their head think about their
• 37:50parents and that four leader thing
• 37:52of go lightly which is horrible and
• 37:54we have so many alternatives to prep now,
• 37:58some that are tablets, some that are
• 38:00so much better than anything we had
• 38:02before and I think actually telling
• 38:03them that you know. Helps a lot,
• 38:06but also saying we lead by example as
• 38:08physicians ourselves that we have gotten
• 38:11age appropriate screening and that
• 38:13you know we have information for them
• 38:15about alternatives to colonoscopy.
• 38:18Just so again any screening and I
• 38:19think that's the most important thing.
• 38:21If that's the foot in the door
• 38:23that they are scared and we know
• 38:24that we have a lot of patients
• 38:26who are scared and they don't,
• 38:27they'd rather look the other way
• 38:29because they're worried about something
• 38:30rather than get invasive tests while
• 38:31this might be a foot in the door.
• 38:32And so I always say try to get
• 38:34them to do something.
• 38:35If we start with fit or Cologuard
• 38:36just to get them tested so we can
• 38:38maybe catch something that was
• 38:40already quite large in a young patient
• 38:42that no one would have screened.
• 38:43You know that 37 year old or 27 year old
• 38:46medical student who's having some bleeding,
• 38:48you know,
• 38:48we might be able to catch something
• 38:50there when no one would be looking
• 38:51for something and we have all
• 38:53seen that patient before.
• 38:57Thank you, doctor Manchu.
• 39:01I think why don't I,
• 39:03I think I'm going to have us go on
• 39:06to doctor Morris's presentation and
• 39:08then we'll have a bit of a Q&A at
• 39:11the end that will be broad based.
• 39:14Doctor Morris needs no further introduction.
• 39:16She's our esteemed director of
• 39:19our Smilo hospitalist service and
• 39:21our go to person for all updates
• 39:24related to inpatient policy,
• 39:26procedure and clinical management.
• 39:28So thank you, Doctor Morris.
• 39:31Thanks, Kevin. You guys can hear me
• 39:34and see slides, OK, getting the nod.
• 39:36That was such impressive
• 39:38work from the GI Group.
• 39:40I learned a lot in that short presentation.
• 39:42Thank you. I am going to speak briefly
• 39:45about the new code status order set.
• 39:49This all went live yesterday.
• 39:53This is critically important,
• 39:54not just for our inpatient clinicians,
• 39:57but our outpatient staff as well,
• 39:59because we know that a lot of advanced
• 40:02care planning happens on the outpatient
• 40:05side and we do need it to translate
• 40:08into the inpatient side and vice versa.
• 40:11The reason we are we changed code status
• 40:15orders is that every hospital in the Yale
• 40:19New Haven system until yesterday had a
• 40:22different way of documenting code status.
• 40:25And as all of you know,
• 40:27we frequently accept transfers
• 40:29from other hospitals within our
• 40:32system and there can be confusion.
• 40:34And unfortunately, there have been
• 40:37errors in providing the wrong code.
• 40:40Treatment ACLS,
• 40:41treatment for patients based on some
• 40:43of the differences in how we document.
• 40:46So this is a standardization.
• 40:49Now, there are essentially
• 40:512 important code statuses.
• 40:53There is no longer a menu of choices.
• 40:56You can be full code or you can be no code.
• 41:01You may remember if you've worked
• 41:03on the inpatient service before,
• 41:04that it used to come up with a menu.
• 41:07You could have pressors,
• 41:08you could be intubated or not intubated.
• 41:11You could go to the ICU or not.
• 41:12You could have Bipap or CPAP or not.
• 41:16And it was not only confusing.
• 41:19But impractical and unsafe,
• 41:21you can now be full code or no code.
• 41:25Now this is really important.
• 41:27When you go into the code status order,
• 41:28there is a code status that
• 41:31says Defibrillation only.
• 41:32This only applies to the Cath
• 41:35lab and the cardiac ICU.
• 41:37These are for patients who have
• 41:39essentially frequent runs of Vt and they
• 41:42actually are getting shocked frequently.
• 41:44And they might choose to be Defibrillation
• 41:46only for the rest of the hospital,
• 41:48which means all of us.
• 41:50It's full code or no code.
• 41:53And this code status comes into effect the
• 41:56moment you are in cardio pulmonary arrest.
• 41:59So the moment your patient is pulseless,
• 42:02this code status is either full or no code.
• 42:06So this is what the order now looks like.
• 42:09You you can choose full code,
• 42:12discussed with the patient,
• 42:14verified with the attending,
• 42:16and you would accept that.
• 42:18You'll see there's no menu, simply full code.
• 42:22No code.
• 42:24Same thing.
• 42:25With whom was this discussed?
• 42:27Umm, code, status verified,
• 42:30full documentation and medical record.
• 42:32Again, no choices.
• 42:34Full code or no code except enter.
• 42:38Defibrillation only as I mentioned,
• 42:41only in bright red you will
• 42:44see Cath lab or cardiac ICU.
• 42:46In fact there if you are a resident at Yale,
• 42:50New Haven Hospital or when other
• 42:53hospitals within our system,
• 42:54you cannot even enter this order.
• 42:56This can only be ordered by an
• 42:59attending or designated APRN.
• 43:01So truly I bring this to your
• 43:03attention for awareness.
• 43:04You will never use it.
• 43:07Here are code status indicators.
• 43:09This is a change.
• 43:11So as of yesterday on the patient storyboard,
• 43:14that's the left side of your epic screen.
• 43:17Green bar, full code purple bar,
• 43:21no code pink bar, defib only.
• 43:25No bracelet. Full code.
• 43:29Purple bracelet, no code.
• 43:31Striped bracelet.
• 43:32That's sort of stripe that think
• 43:34of all the Vt that's happening.
• 43:36That's defib only.
• 43:37We will never see that.
• 43:39So it's either no bracelet or purple
• 43:42bracelet for your code status indicators.
• 43:45Alright, now you say,
• 43:47but what about the patient who
• 43:50does have some preferences?
• 43:52So this is so important for
• 43:56everyone to understand.
• 43:58You can be full code or no code
• 44:01and that is when your heart stops.
• 44:03You can have a CLS or no ACL S we
• 44:06know that if you have any version of
• 44:09modified AC LS you will not survive.
• 44:12You need to have full ACL S for
• 44:14your best chance of survival.
• 44:16So that is all we are offering
• 44:18full ACL or no ACS.
• 44:19However we know that there
• 44:22are critical conditions,
• 44:24urgent non cardiac arrest conditions.
• 44:26This is your typical RT situation.
• 44:29Where there are actually some advanced
• 44:32care planning decisions patients
• 44:34might want to have on their record.
• 44:36For example,
• 44:37if they have been intubated and they
• 44:39would like to say no I would not,
• 44:40I do not want to be re intubated or I
• 44:44do not want to be intubated primarily.
• 44:48I will accept cardioversion,
• 44:50but not Defibrillation,
• 44:52vasoactive medications, IV fluids,
• 44:54blood products, etcetera.
• 44:55Please note that if a patient
• 44:58agrees to blood products,
• 45:01they still need a formal consent
• 45:03even though they've already agreed
• 45:04in their code status order,
• 45:06we still consent them just as always now.
• 45:09If a patient says I do not want
• 45:12to be intubated,
• 45:14they cannot on their record have a full code.
• 45:17It will not allow you to make this
• 45:20person full code if they've have
• 45:22a ACL S if they have an urgent
• 45:25non cardiac arrest treatment
• 45:26preferences says no intubation,
• 45:28so epic will not allow a full
• 45:31code in that situation.
• 45:33Note that the code status order.
• 45:36Is a unique order in and of
• 45:38itself the urgent non cardiac
• 45:41arrest treatment preferences.
• 45:43Is a separate order and you would
• 45:45just type in urgent or non cardiac
• 45:48arrest and that would populate.
• 45:50Umm.
• 45:52And so here in your epic storyboard,
• 45:54you're here on the left of
• 45:56your patients chart.
• 45:57You're hovering over,
• 45:58you see full code,
• 45:59but then you also see this yellow banner
• 46:01that says that there's an advanced care plan.
• 46:04You hover over it and you can see what the
• 46:06patient has put in their advanced care plan.
• 46:08Patients do not need to have an
• 46:11advanced care plan.
• 46:12They need to have a code status
• 46:14if they're hospitalized.
• 46:15If my colleagues in the outpatient
• 46:17setting do an advanced care plan,
• 46:20they enter it into Epic and they
• 46:21put in a code status,
• 46:23what will populate when the
• 46:24patient arrives in the Ed
• 46:26is it will say code,
• 46:28it'll say review prior,
• 46:29which will tell me that
• 46:31somebody has already entered it.
• 46:33I need to review it, review it with
• 46:36the patient and agree to it and it'll
• 46:38then populate on the inpatient side.
• 46:41If it says no prior,
• 46:43then I need to establish a code status de
• 46:45Novo when they arrive here in the hospital.
• 46:49This has been done with really
• 46:51careful thought with multidisciplinary
• 46:53committee led by ethics.
• 46:56I am really pleased to see that
• 46:59we have simplified this and in
• 47:01all my conversations as I walked
• 47:03the hospital yesterday,
• 47:05sort of helping people to
• 47:07understand the new process.
• 47:09Universally,
• 47:10people are thrilled to see the
• 47:12menu go away and to see it.
• 47:14Very simple, full code or no code,
• 47:17and I'm happy to answer questions because
• 47:19it I know this could be complicated,
• 47:21I'm going to stop sharing.
• 47:33So, John, so thank you very much
• 47:36for this really important overview.
• 47:43Can you give us any?
• 47:46Early feedback on and maybe it's too,
• 47:49too early for these conversations, but.
• 47:54Um, how have patients and
• 47:57families been responding to this?
• 48:01Do do do we have any early read on this?
• 48:05So it is too early the the first step
• 48:08yesterday morning was all the code statuses
• 48:10in the hospital had to be re entered so
• 48:13all the old code statuses disappeared.
• 48:15We had to re enter all of the code statuses.
• 48:21I do not think it will change the
• 48:24discussions that are experienced
• 48:26clinicians are having with patients,
• 48:28are experienced clinicians talk about
• 48:31goals of care in a much more global way.
• 48:36Let's talk about your disease,
• 48:37your prognosis. How do you see?
• 48:41How would you best?
• 48:42See your life going forward
• 48:44in a much more global way.
• 48:46Our very junior providers had a
• 48:48habit of walking into the room
• 48:51and saying when your heart stops,
• 48:53Missus Jones, what would you like done?
• 48:56Which clearly is not the right approach,
• 48:58but many of our trainees approach
• 49:01code status in that way.
• 49:03And I'm sure you've all witnessed it.
• 49:06What would happen is our trainees would
• 49:08get bogged down in the details of,
• 49:10well, we have CPAP and we have
• 49:13Bipap and we have pressers.
• 49:15And it's lovely to remove all
• 49:17of that from the conversation
• 49:19because it was never an appropriate
• 49:21conversation to start with.
• 49:22And I think those who have these
• 49:25conversations in a skillful manner
• 49:26probably address code status at
• 49:28the very end of the conversation
• 49:30almost as an afterthought after
• 49:32we have established patients,
• 49:34true goals, what they really want.
• 49:42Thank you.
• 49:51We just want to remind people
• 49:52that if you have any questions
• 49:55about the code order changes or
• 49:58any of the topics that we brought
• 50:00up today during the town hall,
• 50:02please put it in the chat so
• 50:03we can answer them.
• 50:14Well, we're waiting.
• 50:16I'll just make make the comment
• 50:19that and and amplify a bit on
• 50:24your point chansa which is.
• 50:26Well, there are really two points.
• 50:28One is that I think this underscores
• 50:32the importance of all of us.
• 50:34Who are caring for patients throughout
• 50:36the spectrum of the disease?
• 50:38Including surgeons such as myself
• 50:42to begin to have conversations
• 50:46early and often about framing.
• 50:49Goals of care choices.
• 50:52Options and helping patients and families
• 50:57identify the limitations of these
• 51:01heroic end of life interventions and the.
• 51:05Are limited abilities to return people
• 51:09to a good quality of life if they
• 51:13have a significant cardiorespiratory
• 51:16event in the hospital setting.
• 51:19So lots of ongoing work to do and a lot of
• 51:26need for us as professionals to continue to.
• 51:31Develop our own skills,
• 51:32and I think you alluded to this,
• 51:35is something that requires
• 51:37learning and coaching.
• 51:39These are not straightforward conversations
• 51:42and I think those of us who have.
• 51:46Have.
• 51:47Some years of experience in this arena do
• 51:51have an obligation to mentor and share.
• 51:55Some of our lived experience in this regard.
• 52:02There's a question.
• 52:05Thank you, bill. And the question is,
• 52:07is there any concern that the
• 52:09language no code sounds like the
• 52:11patient does not have a code status?
• 52:16Folks on there? Yeah.
• 52:21I I suppose it could be misinterpreted.
• 52:28Yeah, so full code means we do full ACL S
• 52:32and no code means no ACL SI suppose that
• 52:36is why we need to get this message out.
• 52:42I think it is a great point.
• 52:45Maybe it's even something we could
• 52:47bring back to that to our code.
• 52:50You know that that multidisciplinary
• 52:51code team just to because they
• 52:54might have discussed this jensa,
• 52:55right and there might be.
• 52:58This might have been something.
• 53:00So I think we could bring that back
• 53:02to them just for feedback to see.
• 53:03I know sometimes we'll make
• 53:05when something new comes out in
• 53:06Epic and we get some feedback,
• 53:08sometimes we'll change some of
• 53:09the language based on feedback.
• 53:11It's very interesting.
• 53:12I mean it's so new, it just yesterday,
• 53:15right, just like the master today,
• 53:17so very new.
• 53:19So I think I can tell you the reason why
• 53:23is that different patient populations
• 53:25have different code protocols,
• 53:27so we couldn't simply say no.
• 53:29ACS because it turns out that Pediatrics
• 53:33does something called pals and then
• 53:36neonatal has something different.
• 53:38And so I think that is why they instead
• 53:41of saying no ALS, they simply said
• 53:44no code to simplify that language.
• 53:46But. Yes, I will let our director,
• 53:50Ben Tulchin know that this was brought up.
• 53:52Thank you.
• 53:57Evan, can I ask Jensa question?
• 54:01So, umm, jensa, you mentioned trainees.
• 54:04I'm wondering if you can speak
• 54:06to kind of efforts around kind
• 54:09of educating our trainees across
• 54:11the system about this and perhaps
• 54:14using it as an opportunity to do
• 54:16some additional teaching around
• 54:17how to talk about code status?
• 54:23Such a great question.
• 54:26So yes, the trainees have been presented
• 54:30with the new code status changes.
• 54:34Umm, I am meeting with Mark Siegel,
• 54:38who you know only has a small oversight.
• 54:41He has just internal medicine,
• 54:44but I think I could bring that up
• 54:46with him just to ask about what
• 54:49their training is, because I'm not.
• 54:51I don't know what process they go through.
• 54:54Most of the feedback we get
• 54:56is that on oncology is where
• 54:58they learn that they haven't.
• 54:59It isn't something they learn on geriatrics.
• 55:02It isn't something that
• 55:03you learn on the other.
• 55:04Rotations.
• 55:05It's really on oncology that that is.
• 55:09When they learn
• 55:10about goals of care conversations.
• 55:14What are your thoughts, Pam,
• 55:15in terms of how we can do a better job
• 55:17when we're on service with the trainees?
• 55:20Because if, if the primary place
• 55:22they're learning is on oncology,
• 55:24then how can we do a better job?
• 55:28I mean it's, it's a great question
• 55:30and I think they're really trainees
• 55:32across multiple specialties.
• 55:33I think as Kevin was alluding to earlier,
• 55:37really surgical oncology,
• 55:38radiation oncology,
• 55:39madong internal medicine that I think could,
• 55:43I think this is a really great opportunity.
• 55:45Anytime you change something,
• 55:46I think it's a nice time to
• 55:48really highlight best practices.
• 55:50I think partnering with our palliative care
• 55:53teams and Tara Sanft and Communication,
• 55:55I think this is like a really
• 55:58great opportunity.
• 55:59So I I don't the the logistics in
• 56:01terms of speaking to leaders across
• 56:03some of these programs I think is a
• 56:07step but then taking advantage of we
• 56:09have great expertise in the Cancer
• 56:11Center and and in palliative care.
• 56:14I'm going to follow up on that.
• 56:16I I like this is a great opportunity.
• 56:18Change is a great opportunity.
• 56:20I'm going to write that down.
• 56:27Right. Well, I don't see any other questions.
• 56:29And it's 2 minutes to the top of the hour.
• 56:32So I think we could close
• 56:34for the evening unless Kevin,
• 56:36do you have any other words?
• 56:38I, I do want to remind before I turn
• 56:40it over to you for final words that if
• 56:43you have topics that you want to see in
• 56:45town halls or if you have questions that
• 56:48you want us to discuss during a town hall,
• 56:52please send your questions
• 56:54to cancer answers at Yale.
• 56:55Edu whether it's a topic you
• 56:57want to see come here,
• 56:59whether it's a question you want
• 57:00addressed in a town hall, please do so.
• 57:03And I also want to remind people that
• 57:06our distribution lists are always,
• 57:08ever changing.
• 57:08So if you get an invitation to a town
• 57:11hall and you know your colleague or
• 57:14your staff have not gotten that,
• 57:16please feel free to forward those
• 57:19on it is it is so difficult to make
• 57:21sure that we're reaching everyone
• 57:23about our town hall, so.
• 57:25Please ask your ask your colleague
• 57:28that you that you talked to every
• 57:32day talk to your staff,
• 57:33make sure that if they are not getting
• 57:35these communications about our town
• 57:37hall like Kevin or myself or Renee know,
• 57:40we can make sure they get added
• 57:41to the list and then always feel
• 57:43free to forward them.
• 57:45So Kevin,
• 57:45I'll turn it over to you for any last
• 57:47words. Thank you.
• 57:49Thanks to all of our presenters.
• 57:52Really appreciate the work that
• 57:54Pam and her team have done.
• 57:56I know that this was just a narrow.
• 58:00Tidbit of the very impressive work
• 58:03that you're doing when all of across
• 58:06all of our missions and I I I can't
• 58:11emphasize enough, as I said early,
• 58:14the importance of bringing.
• 58:16All of ourselves to our patient
• 58:19safety work and thank you to
• 58:21our leaders there and Jensen,
• 58:23really appreciate your update.
• 58:24So everyone have a great evening.