 My name is Blake Denison and I'm the Director of Clinical Profusion at the Texas Center for Pediatric and Congenital Heart Disease at the University of Texas. And for the last two years I've been a part of an amazing transformation here at Dell Children's Hospital, for which I helped to start the profusion program. And it's a great honor for me to be able to share that story with you. Austin is a great city to live in these days. The population here is absolutely exploding. And it's not that surprising enough because it's a beautiful place to live. It's got amazing outdoor activities and wildlife. And not to mention a spectacular food and music scene. We even have UT's Minister of Culture keeping the city motto alive and well. Although I've never started a program from scratch before, I believe that this job was a great fit for me, as it was the perfect intersection of chance and opportunity. Because a lot of the skills that I have used to help build this program were not honed in an operating room. They actually started right here, prior to profusion school, when I was a project engineer building the four seasons' residences in the heart of downtown Austin. So where do giant projects like this start? Usually with a need and an idea. And those ideas are translated into iterative sketches. Moving from sketch to reality, it takes extreme planning and coordination. Hundreds of people come in together to deliver the highest quality product that their discipline can provide. You may never stop to consider the fine balance it takes to actually piece together a 32-story luxury condo. Remarkably, the coordination between structural engineers, architects, and project managers, it's not all that different than the relationships between surgeons, anesthesiologists, and perfusionists. Each discipline has a unique skill set, and they cannot execute their duties without the proper tools and equipment. They need to work together in harmony to move towards a common goal safely. But before you ever start building up, you need to have a good foundation below you, and that foundation cannot be laid without an actionable blueprint. Before coming to Austin, I spent six and a half fantastic years at Texas Children's Hospital, absorbing as much as I could. Fostering my career at the number one congenital heart surgery center in the country, it was an absolutely amazing experience for me. Being at Texas Children's, it gave me a 30,000-foot view of how a heart center is supposed to run. But once you're outside the walls of a well-oiled machine like that, you start to realize that you don't necessarily understand all the intricate mechanics to get a new venture off the ground. Being in the plane is definitely not the same as flying it. Historically, Austin had a siloed heart surgery approach with rotating teams of itinerary clinicians. Nurses rotated to different disciplines, the perfusionists rotated between pediatrics and adults, and the surgeons worked in different cities entirely. Children needing more complex heart surgery repairs were typically funneled into larger systems in other cities. And despite people's best intentions, Austin had a low volume and an organizational problem which saw STS mortality rates above the national average. A new paradigm arrived in the form of a partnership between Dell Children's Hospital and the Dell Medical School at the University of Texas. Spearheaded by Dr. Charles Frazier. But excellent surgery starts well before an excellent surgeon walks through the door. Without the proper organization and mindset, a heart program can easily fall flat. A good program requires hard work from an organized team to accomplish amazing things. So if you were brand new and tasked with making meaningful changes like I was, where would you start? Well, I started with the low-hanging fruit, cleaning and organizing the perfusion room. Small changes like this set the tone for larger projects later on. Alongside that, I decided to streamline the bypass circuit to make them safer and more compact. Beyond the design, you have to work closely with the product rep and the purchasing department to make sure the circuits are available in the new quantities that you need them. Everything that you use or receive in the OR requires a process and every system can be changed for the better. You don't simply receive the drugs you need when you need them. To change things like this, it requires thoughtful discussion and coordination with the pharmacy. I say you have to be thoughtful about these things because the ramifications are your decisions. They're a big deal. I ran into major hurdles when trying to procure a custom cardioplegia solution, which Dr. Frazier had used for thousands of surgeries. I was quite literally told it could not be done multiple times. But by heavily involving myself in the process, educating myself and others' stakeholders through research, it helped immensely and we ultimately cleared all the roadblocks. Because at the end of the day, your stamp of approval needs to guarantee that the actions you are seeking safely do the things you say they do. When it came to blood, I adopted a process that frequently resulted in the type and screen sample being sent in the operating room on the day of surgery, which left the perfusion team without blood until late in the morning. I had to steer the relational coordination between multiple disciplines to make sure that the right blood was in the right place at the right time. It's a tall task to make sure the nurse practitioners, OR nurses, and blood bank all work together so that the perfusion and anesthesia team can utilize the blood safely when they need it. You also never want to miss an opportunity to make things easier on yourself. Since it was hit or miss, I had to implement a process that would require the height and the weight to be updated prior to each surgery. Seems simple, but with accurate data, you can easily create a flow card in Excel that spits out programmatic goals in a matter of seconds. Once in the operating room, how are you measuring lab values? Do you settle for lengthy wait times, or do you insist on having real-time data at your fingertips? In our first few surgeries, we were waiting upwards of 10 minutes to receive blood gas data. We had to convince the point of care lab to buy new equipment, which ultimately moved the entire hospital to a new lab collection device. And then once you can run those gases, how do you make sure that the information you create ends up in the right place? If you ever want to improve your quality, you're going to want to revisit the aggregate data at some point in the future. For data collection, you can simply start like we did with an Excel sheet or a red cap database. But hand charting, it leaves large unrecorded gaps in the care spectrum. So we bought a real-time data collection system, which talks to multiple devices around the operating room. Between implementing this and the point of care testing changes, it has resulted in dozens of meetings with information services. And I swear all the jargon that they use, it sometimes makes me feel like I'm living in the matrix. Remember that everything you do, though, will be checked by watchdogs. The point of care testing lab will want validation of the blood gases and ACTs. Infection control, they'll want to see the documentation of heater and heater cooler maintenance. In the Joint Commission, they could walk in at any time asking questions. Everything must be done by the book. You're also going to want to protocolize your methods through research and best practices. All that documentation and all those guidelines can create mounds of paperwork. But there are some things that are truly unique. I was fortunate enough to be heavily involved with developing the architectural plans for our two new operating rooms. It really makes you think about workflows and the future needs of the program. And at the end of it all, it's really cool because you get to see the fruits of your labor. All these process improvements and all these growth opportunities, they translate into countless hours of meetings and discussions. And sometimes it truly does feel like projects stand still. One of my favorite things of this whole transition has been designing a premier bypass system. When you purchase brand new pumps, they really can feel like a blank slate. And it's not just bypass machines either. It's all that extra equipment that allows you to do your job. But don't forget that these things cost money. And how much money? Well, lots of it. And these figures, they don't include any of the salaries. Or they don't include any of the ECMO equipment growing in parallel to the operating room. You take the durable equipment, disposables, and a VAD starter pack like we did, and you're well into the seven figures. How and who do you convince that all this was necessary? Well, more meetings with the administration and the capital purchasing department. Those slides don't really do it justice, but I spent roughly two months getting things ready before any surgery actually occurred. Just working on the foundation to start pumping cases. And yeah, you might be thinking, yeah, so what? Every profusion team has to do stuff like that. Well, I like to think that as a program, we have chosen to be different. Programmatic changes start by conveying your vision to create a truly integrated practice unit. We created a culture of measurement and transparency. We get energized by getting better. Failure is I and praise is we. We aligned our growth with a philosophy. And we created a multidisciplinary team that shares decision making, a team that embraces the checks and balances. We include all the stakeholders and we don't dismiss any of their comments. And if you're going to do it right, you better get it right from the start. So we held multiple surgery simulations before we ever touched the patient. And that quickly translated into our very first surgery. I'm sure that Dr. Frazier would agree with this, but it turns out that building is not the hard part. It's gaining the momentum, which is hard. In the book, Good to Great, Jim Collins talks about the flywheel effect. The initial movement of a giant 2000 pound flywheel is extremely hard from a dead stop. And it takes a lot of hard work. But as you start to add more energy to it, it becomes easier to rotate. And adding Dr. Carlos Mary fed that flywheel for us. By the time Dr. Ziv Beckerman came into the picture, he rounded out an all start surgical team. The next major push for us was the addition of Dr. Aaron Gottlieb as our chief of anesthesia. She is an incredibly talented clinician and leader. In time, she started building her own handpicked and dedicated team of nurse anesthetists. Which made way for Dr. Tony Sabata. Our perfusion team was right there pushing that flywheel too. Richard Owens has been my co-pilot and has been extremely helpful throughout, especially with the VAD and ECMO program. And despite what you think, people aren't your best asset. It's the right people who are your best asset. And we were fortunate enough to make some great hiring decisions. We look for people with the right attitude, communication skills, and mindset to be a part of something bigger than them. Kellan Rostin and Tiffany Robb really bought into our ethos as a system. And as a team, you've got to check your ego at the door and be humble enough to continually learn. And never miss an opportunity to absorb something new because there's plenty of chances to do it. But as you go along, don't forget where you started before all that momentum was built. You have to be willing to help wherever you can for the greater good. Over time, we were able to balance the load by introducing surgical fellows like Dr. Sarah Mendoza and Dr. Lok Sinha. After you transition to a team approach, it's basically a bunch of new people working together in a new system, which could be a recipe for disaster. So how do you assure high-quality surgery while reducing preventable errors? Well, you set your sights on reducing variation in fostering a new culture. Outcomes measurement is key to quality assurance, but truly meaningful measurement is very difficult when variation exists. Luckily, variation can be whittled away through refinement to make this baseline uniformity in order to move forward as a group. To reduce variation as a perfusion team, are you willing to spend 8 to 12 months training new perfusionists? Well, we are. We know that things run very smoothly when you limit the unexpected, when you plan and train for any scenario. Air traffic controllers can quickly utilize all the tools at their disposal to coordinate a fast pace and complex web of planes. They must be multiple steps ahead of every detail in order to make sure each pilot lands safely. That's why we designed our bypass machine to look similar to a control tower. I can see where the surgeon is going long before we get there. I can access every tool I need to do my job quickly and safely. When it comes to pediatric perfusion, turning knobs and pressing buttons just doesn't cut it. We focus on those micro details because there is no compromising with the physiology of a fragile 2.8 kilogram baby. Our prime gasses and patient gasses are aligned to the best of our abilities, and they're maintained throughout the bypass run so that we can stay on bypass for many, many hours if we need to. We optimize the patients during the bypass run so that the post-operative course runs as smoothly as possible. Every single aspect of our setup is placed for a reason. The physiologic monitor is placed directly in our liner site right next to our custom venus occluder. That way we can wean the smallest patients off bypass over many minutes if we need to, safely and ergonomically. We also hold all of each other accountable to the patient. Any discipline is capable of calling a full stop at any time if we see something out of the ordinary. We have given ourselves the tools to use that same philosophy retrospectively with sickbay. I can pull up any patient under our care and their monitoring devices to see how they are doing. The amazing thing about this capability is that you can optimize the future by looking into the past. In this example you can see the saturation drop as a heart rate went down earlier in the day. Now our communication is the point of pride for us. At times we sound almost robotic, but articulating just the facts through challenge and response delivery, it completes a succinct triangle of trust. Braided into our culture is the encouragement of innovation. We want to be at the forefront of advancing our field. It could be as simple as that custom venus occluder or a new bypass machine bracket. If you find something that intrinsically motivates you, don't be afraid to tap into the available resources and you can truly make any idea come to life. And sometimes you literally get the opportunity to stick your nose where it doesn't belong and do some amazing things. There are not many partnerships we could have picked better than the one we have at the Valley Institute for Health and Care. Who better to help embrace the transformation than the people who literally wrote the book on value-based care? When it all boils down this job is hard and it's unforgiving at times. Cases can be long and we do much more than just punch a clock. Even though it's a rather silly annual trophy, you have to find ways to motivate around the negative aspects. So again, you might be saying, cool, you did all the things. What does it mean? Well now you have a high-performing team all working together centered around the only thing that matters. The patient. We are constantly refining our practice not only to make the routine aspects run smoothly but to save lives during those rare occurrences. Nearly two years into the program and we are doing higher volume and higher acuity cases than ever before in Austin. We have been able to provide our patients from around the world mortality rates well below the national average. We are transparent with our successes and failures. Each team member is well aware of the patients we failed. But as much fun as it is to look back, you have to continually look forward and ask yourself how can we grow even more? Austin is now home to the first dedicated pediatric cardiac care unit in central Texas. The 24-bed unit officially opened today at Dell Children's Medical Center to treat children as young as infants with the most serious heart conditions by using state-of-the-art technology. Within a short amount of time, we went from a clean slate to mock surgeries to ventricular assist devices and we were quickly approaching the ability to our first heart transplant. I truly wish I had more time to discuss all the exciting changes we have implemented because I just scratched the surface. But our programmatic growth has not gone unnoticed and it's very exciting to see what the future holds at Dell Children's Hospital in the University of Texas. Thank you for your time and before I conclude, I wanted to share some words with the profusing students from the Little Book of Wisdom which might be good to remember as you start your careers. Should always do your best. Don't make assumptions. Listen with slight skepticism. Be impeccable with your word and don't think things personally. And oh yeah, we're hiring. Thank you.