 Good morning, usually I have somebody introducing what we're here and what we're doing. I don't have a luxury today. Maybe you can tell me what we're doing here and I can make sure I can, hopefully, my presentation meets those needs. So, are all of you first, second, third year residents, no, okay. Make all students, residents, combination of all the above, great. So, one reason why, first of all, I'm Luca. I've been working at the University of Utah for about three years now. Prior to that, I worked at Intermountain Healthcare for another five years. Mainly do these similar things, helping with our cultural transformation into focus on value, implementing efficiency principles, to help us really drive better processes for the stakeholders, all of stakeholders. The providers, the nurses, the MAs, all those individuals that are providing care for the patients, but I didn't have to say that, but at the same time, we're trying to create better processes for our patients so we can ultimately provide better care with the buzzword, higher quality lower cost, blah, blah, yes, we get it. But hopefully, by the end of the day, you'll have a better, by the end of one hour, you'll have a better understanding of what I'm trying to say with that and how we're going to do that. So, one of the things that it has become obvious as I participate in many of these discussions, I focus mostly on the education piece, education and research. That's the stakeholder that I work with. My counterparts are helping, are facilitating discussions and improving hospital and clinic processes. I'm working towards, I'm working to improve the education research processes. And I get, I have the opportunity to work with a graduate education as well as undergraduate education. I work with various colleges, nursing dentistry and so on. And so, one of the things I'm asked occasionally is to participate in the residency QI programs. Again, another buzzword, but it really implies that there is an interest as well as a mandate. I'm going to focus on the interest because it's important for the various residency programs to engage and tap into this workforce, it is the resources that it's you. Because you see the processes, you see what's going on in caring for the patients. So, we can leverage your knowledge and expertise in your time, hopefully without asking too much more of that, in helping improve the way we're caring for the patients as well as the way that I would say we're educating you to become experts in helping others in changing processes. So, I call my presentation, Introduction to Value Engagement because by the time I'm done with this, yes, we'll talk more. Laura Hanson will be reaching out to you as far as next steps. So, is Jeff Petty and Ayanna Warner, Barbara Orozco and so on. I've all been working with them. This presentation is part of my discussions with them. But for now, my goal is to touch on some principles. I hopefully have a conversation. I know it's early in the morning but I feel free to interrupt many times and ask if you have any questions and I may pause as well. But let me get started. So, the main thing that I'm here to talk about is basically that it's this principle of value that you're going to hear at Nounsia within the university, value this, value that. And it's really, we have, it's kind of our branded concept for process improvement. I'm going to use various words interchangeably but for now let's use the word value. And so, focusing on value allows us to ask if our activities are moving us forward in delivering what our customers expect of us. We want to pay attention to what our customers expect from us. Why? Why do you think it's important? Customers meaning patients but I will also add customers meaning any person behind after your processes, after what you do. So they can be the next doctor in line, can be a next nurse in line waiting for you to complete an order or see the patients or exit the room and so on but most importantly the patient that are waiting for you to do something for them. Why it's important that you pay attention to what their needs are? Okay, while you think about your answer, this is a video that Toyota which is kind of one of the main thinker of where we have copied a lot of their principles from back in the 80s that started to consult with a for non-profit for other organizations. One of these organizations is iClinic and hopefully this will get in the right, set the mood for the conversation. Wait, thank you. 15 years from the age of about 17, I was unable to afford medication so I stopped using it for about five years. My eyesight goes blurry and I see flashing lights throughout the edges. I did not know that diabetes would cause this type of damage to my eye. It would be nice to be able to see my family, my surroundings, especially my sister that he is. I just paint energy all over, focusing through when it dreams me. So I feel like I'm not there for them as much. It's hard on me. I try to be the stronger one. Lizette is a great example of our patient population. She's young and she didn't have access to care. We are a county-owned facility and our mission is to serve the underserved. She came in with diabetes that was out of control, high blood pressure in addition, she was bleeding into her eye. We had a surgical waitlist that was hundreds of patients long and to not be able to intervene in a timely fashion was really, really difficult to deal with. Was that a patient's life? Was that who would have to wait for months for surgery and in the process were going blind? Tura was contacted by the Harvard UCLA Medical Center and when I heard that many patients were going blind waiting to get service, I actually could believe it. How can that happen in the United States? People ask all the time, what honor do making cars have to do with hospitals and healthcare? Hospitals and health systems are looking to the Toyota production system to improve and we reached out to them. We really didn't know what was wrong. Sometimes when you work in chaos, you don't know how to get out. So what Toyota did for us is they helped us learn to see our own environment and so we did observations. We stood at the clinic and watched the process flow. We just had a table with all the charts lined up, one big mountain full of papers. Doctors were frustrated, nurses were frustrated. So with the color of the system, now we know red is laser. It's so much easier for everyone. Physicians were spending more time in the hallway than they were in the clinic and the reason why is that they didn't have the spies they needed close by and it sounds like a very simple solution and it turned out to be we asked them what do you need at the clinic side? Part of Toyota's message is that this is our hospital. They're not going to be here to tell us how to do things. They're going to come here and teach us how we can identify ways to make ourselves better. It's changing our culture. It's transforming us as an organization. We're not the same organization we were a year ago. We're taking some of the lessons that we learned from the eye clinic and are spreading the change throughout the hospital. Open both, that's right. We did really, really well. Over the past two years, we've taken a surgical bath club and that was hundreds of patients long and we eliminated it. It's five o'clock and all the patients have been seen. This is the best project that I have ever had. Dude, work. We actually helped people. I never would have thought that implementing the Toyota production system would help save lives or through people from going blind. But it has. You make it on your fingers a little bit. She just wanted to, at least on the left, insist that she is going to have good vision. She has many, many years ahead of her. Being able to see my family. Focus on patient. There is a reason why I started it ahead and there's a reason why I showed this video. It's because by the time I'm done showing you a few more slides and I talk about value, and if you can substitute the concept of value improvement work or value methodology to the Toyota production system, what we're trying to do is the same. We just rebranded it. Is that what we're doing is for the patients. So instead of having a backlog of 100 or 10 patients a day, you don't have one. That you can always find what you need at the bedside or that everything works clockwork in a way that makes sense so you can take care of the patients. And so when we talk about the concept of value added, so, okay, backtrack for a moment. What's value in your mind? What are some of your thoughts? When I say the word value or value to the patient, what comes to mind? Time, health, okay? Anything else? Patient comes to us for two reasons. Information about their health and care provision. Anything besides that is non-value added. They don't make the rule, but I just say where it is. And so an activity is value added when it builds on patient's information or is directly involved in patient's care. Therefore, if what we're doing has to move us closer to delivering what customers are expecting from us, that step in the process should be eliminated. Now, so there are three things you've got to remember. Value added activity, seeing the patient, talking with them, yes, value added. Writing an order, probably value added. Chartering is getting the ability to add. If it's add to the knowledge, sure, it's value added. Physician having to walk away from the OR because they're looking for some supplies. What is that? Non-value added. Having to chart for government purposes. What is that? It's non-value added, but necessary. And unfortunately, this box here will always stay there, but our goal is to minimize the impact of the system so that we can focus on these steps while we're reducing those two steps there. So if we can, we want to eliminate steps. If we can't, we've got to live with them, and at the same time, help us keep the process moving forward. Any thoughts, questions? That's a big slide. In the concept of... Well, that's kind of cool. How do I do that? Actually, what's supposed to happen? In the concept of non-value added activities, there is the... We categorize, if you want. This is just a list. There are these activities, these steps, these things that take place within our work environment that we consider waste. It is not impersonal. Our work is not wasteful, although we may feel like it sometimes. I'm not picking on anybody. Maybe I'm picking on myself, perhaps. Most of what I do is maybe consider non-value added to the patient, the reality, and yet they're paying for me. But I'm non-value added. But in my little part, if I can help people be more effective and efficient in what they're doing, then I'm impacting a tiny bit of the healthcare provision as well. So, seven ways. When you're going out and taking care of the patient, try to think about these. When you notice them, you know that you have spotted a non-value added activity. And your light bulb should go up, and you should say, I found one. And then there are steps to remove them or address them another time. But that's what I'm hoping. As you go out there, you start thinking, oh, these two men look the same. They shouldn't be looking the same. I have no idea what they are. Why are they looking the same? I'm going to confuse myself for others. Or, oh, I operated on the patient with the wrong eye. That used to happen a lot more. Now it doesn't because we learn. Errors or defects shouldn't have been happening. Inventory. We should have loved that one here in hospitals because we'd never find blanks. Ten years ago, we couldn't find blanks. So we're going to hoard all of them. Or we're going to stock all these supplies because we get a discount by our vendors. So we're going to buy 200 more than we ever need. But, you know, we got space in the hospital, so no big deal. So inventory takes space, costs money, and we want to eliminate it. Over-processing. I was trying to think how you would put that. This is an academic medical center. Within a scenario, you've got students, all kinds of students, nurses, MA, nurses, doctor, all in the room, all working on one poor patient when they're in there. So I just imagined a room full of people doing lots of work. Over-processing is not just that. Over-processing doing something is doing more than you need to. Again, we're trying to provide information or provide care. Anything that is overdoing that is a waste. Also over-production. That one reflects well to the numerous tests, exams, x-rays that we do that are not necessary. The perfect example is when I listen to a process improvement project, and one of them identifies that when a patient comes to an ED for a specific procedure, for a diagnosis, I can't remember what it is. It doesn't matter for the purpose of this conversation. But they used to get an x-ray. Then they used to scale up to a CT and eventually they would move to an MRI. But they already knew that we were going to get an MRI. Why are we doing the x-ray and the CT as well? That is an over-production and over-processing kind of waste. This whole precision diagnostic medicine is really addressing the concept of stop ordering so many x-rays when you go or stop doing too much ED treatments and so on. Motion. That's still very much important. It's how much do you go from one point to the other. Already they had to do with ergonomics, human ergonomics, how much are you bending, moving, straining, hurting yourself, doing things that you should have been doing. Transportation. Again we see a lot of that one. What you need from motion and transportation really takes care of these principles. What you need should be next to your work environment. If it's not, you're going to walk and you're going to have to find it and the patient is waiting. He was working with the OR a while back and they were explaining to me when surgeons and nurses had to leave the OR because the supplies weren't there, there is an impact to the patient. The patient is under anesthesia for longer than it needed to be. Now the impact is... So that is a big deal. So we had to figure out a way to reduce motion and transportation and inventory. And then everybody's favorite, it's waiting. It is kind of... People imply that when they come to see the doctor they have to wait. And I beg to ask the question of who. We are redefining that. The university is trying to make the processes... When we say processes patients centered, we are trying to create this paradigm shift that says how can we make it easier for the patients to come here and then go home and move on with their life. At the same time, the reason why I chose that picture because I would never forget the discussion with this orthopedic surgeon, very busy, and I was observing his processes and he everywhere is sitting in the OR just me and him. He was flipping, he was twisting his finger. The other side of the pole turns around. Look, I'm waiting. Where is my patient? Where is my patient? And the patient had to go to the bathroom. So the patient was terminus late. And we do not want to keep the highest paid person waiting in the room, which is you. And because you also drive... The doctor also drives the process forward. So eliminating non-value added. So any questions yet? Did I answer why we want to eliminate non-value added activities? Okay, so when you go out, look all the waste, stop thinking this is the waste of a presentation. It's not. I'm getting somewhere with that. Okay, so when you go out, look for all those waste. If you catch one, ha! Write it down and make it known. One of the nice things about this the Moran Institute is that you actually have a very engaged faculty and leadership. So that really helps. They're very... They're working on many projects to improve patient care, but also the processes that benefit you as well. So when I start thinking about how do you improve, how do you eliminate non-value added activities and how do you streamline the non-value added by business necessary? These are two principles that come to mind. Effectiveness and efficiency. Standard work, you're going to see a lot of it. We're not trying to create robots or automate everything that happens in a hospital's life, but the degree to which something is successful producing the results should be standardized. And then once you identify ways to do something better, then we can create a better flow. And all those wastes that we talked about before the defect of a processing of a production, motion and so on, those create rocks in the river of flow, in the flow river, and you want to eliminate them. So standard work is a principle, but it's often time we've seen in the form of a document, a checklist, something that pops up in Epic that tells you, are you sure you want to do this? It's something that is embedded in our work life that we are accountable for. Hopefully, I prefer to imply it is a written something that people understand that when you go in, when you are seeing a patient, this is what you do because this makes sense and is the most efficient way to do it, but really it's a common sense. It's the one way to do something that everyone or mostly everybody agrees is the best way to do it. If everybody agrees that the easiest way for the patient to be brought into the room is that the patient checks in, then the MA comes and get him or her and takes them to the room and the MA takes the vital, then that's everybody does that. There is no need to reinvent it. We don't need to have the doctor going in, taking the patient back in the room because I gotta do it. Or the nurse to do it. And yes, I've seen it. There's a nurse taking the patient back in the room. Why is it a nurse doing nursing duty? So standard work helps create an environment where clear expectations reduce variation. Variation is the enemy of efficiency. So we're trying to reduce that. We're trying to understand what makes the system flow. Now, with that being said, I did not say the standard work is perfect. I'm not going to imply that by the time you create these kind of documents, then there is not a set standard, a set model for standard work. You create your own or a system creates one for you and you just adopt it. Or because it's not perfect, you improve it. I hate that... I hate... I'm not... When a organization comes from the top down and say, implement this, that is not standard work. That's a mandate, but it's not standard work. Standard work implies a common sense that you, the people doing the work, have been brought into a process and say that, yep, we have learned, because we studied the process, we do it, and we collected some data, and we know that if we do these steps, we follow this checklist, but the standard work doesn't have to be a checklist. It can be that. This is the standard work for restocking a room. And it is a protocol that if you follow these guidelines, it takes you to an optimal outcome, but basically if you're saying that if we do this, yep, we're going to get good outcomes. And after you do that, after you set these standards in place, now you can focus on always improving them. Now you can look at the system and say, okay, now we're all doing the same thing. We're trying to reduce variation and, wow, that patient is still waiting 60 minutes. Or I still can find my supplies, or I can still schedule, or I'm working 70 hours a week. Sorry, I forget, you've worked way more than that already. I'm working 200 hours a week, I don't even know if it's possible. But so the way you do it is by problem solving and waste elimination. And of course, visual management, 5S and 4S functions. So out of all the most important things that I said today, and I'm not done yet. So if there is a, besides a value non-value added and non-value added by a necessary component, this piece to me it's important. Because out of all the methodology for improvement, out of all the things we talk about, there are some steps. So you're going to go out there. So the whole principle, the whole purpose of process improvement is this, that you have a problem, you discover it, we have a backlog, like in a video, they had a backlog of 100 patients. And people were losing their sight because they couldn't come and see the doctor. I said, that's a pretty important problem. Not everything is so dramatic, but we do see those. And so you form a team. This is important because, remember, you may be the expert of one piece of your process, but you may not know all of the other stakeholders, so you need other experts to come and help you to see the whole picture. So you bring other experts and you go and see. Remember they stood and they walked and they watched the process happening, they observed it. That's what I'm talking about in there. You want to observe what is happening. Sometimes you see it, sometimes you don't. And so you want to go and walk the process. Then you want to understand it. Oftentimes, we want to ask questions. We want to map out. There is some power in mapping, visually, physically mapping out the process with those sticky notes or on the whiteboard, writing down what you're seeing happens and then realizing that, wow, that's not how I imagined it. Especially when you bring in the other stakeholders and now you're all putting this visual in front of you and you're like, what is the mess? We've got to fix it. And then you collect some data and you realize, oh, yeah, this problem we thought was always happening, but it actually happened only once, so it's not a problem, but this one here happens all the time and delays us by this much, so we want to address that one. So when you go to the app that you collected some data, you check with the customer making sure it is actually a problem worth addressing. Remember, we were trying to create value for the customer, for the patient. And then you work towards a solution by creating, by doing a pilot. Well, now we've not solved anything yet because perhaps what you're trying to, what you implement first, what your intervention will not solve anything. But we want to test it anyway. Plan, do, study, act. There's a cycle that happens and we want to look at it. This is our methodology. Plan, do, study, act. We discover the problem. We address it to observation and data analysis. We test it and then we assess. And that's important that I mentioned this because oftentimes, no, well, there are two things that I see a lot happening. Problem, I got a solution. So let's implement that because I am the boss and just do what I say. Or even better, I got a solution, I need a problem. Come on, I want to implement this so let's think about what can it solve. Oh, yeah, that. Oh, yeah, my solution is going to cost me $100 million. So I'm going to solve it. I'm going to implement that. So, value engineers, can you give me a problem? Yes, it does happen. We can. Define the power to change. Define power to change that. Thank you. I like that. And I appreciate that. Yes, I have to address that. Don't let me leave the room before I finish before I address that. This slide is just me acknowledging that with all this observation type discussion implies that when you're going out and looking at the process, don't just look at averages, look at the confidence intervals, and instead of just looking at one data point, instead of addressing a problem or, yeah, or doing an intervention because you see a point falling off too high or too low, look at the control charts, they will give a better picture making sure you understand that, make sure you see that this is actually a normal pattern. But so, we'll have more of these discussions where we'll get more into details into these matters, but control charts, confidence intervals, data analysis really feeds into visual management that is our efforts to capture it and more timely base the work, what is going on daily, what is going on. And what should we be addressing. We are starting to work towards scorecards, your department has quite a few of them, but the goal of this visual management is really to help us identify what's normal versus abnormal and have, of course, a clear action plan to respond. I'm going to throw this in there now. This quickly, this identifying and addressing, that's the leader's role. So, when I hear, yes, we find problems, we present them, but nobody does something about it. That's the leader's problem and it's to be addressed. Remember, the cultural transformation is not over yet, we're all working towards that, but it is important that we are aware of it. Yeah, I'm just throwing more examples of things that have helped improving processes. When you can't find something, you just make it easy to find. The 5S is a really very simple, one of the very first places. So, when you finish your residency here, you go to another clinic or other hospital, you're probably going to start, so even here, you're going to start seeing tools all labeled up, everything as a place. They just, this is one of the very first things that hospitals do when they try to embrace the Toyota production system. They just try to make things easy to find. It doesn't always work, but then again, we have to be able to we have to create a culture where we can speak up and improve things. Is that it? And another one is forcing function. When I suggested there are ways that Epic can prompt you to do something or stop you before you go to the next steps, that's the forcing function. We're starting to build a lot more electronically, but a lot of them in the past used to be oxygen, plugs or power cords are all examples. Basically to do something, you can only do it one way. Or before you go to the next step, there is a reminder or a warning. This is just my, me trying to give examples of the kind of tools and principles and methods that people are using to eliminate or reduce wastes. Some of these examples have been applied within the university system. When I said these are examples, that's what I want to talk about now. For example, envisioning the process where the patient is a center mammography used to take, used for basic mammogram screens. A patient used to get, used to come for their appointment for their mammogram and they used to get the results after six or seven days in the mail for the normal patients. If you had the potential for cancer they would call you back within a couple of days but the normal patients would get the result back within six to ten days. The doctor said it's unacceptable. Patients are concerned, they want to know the results right away. So they implemented a process where within their means without adding costs or resources they were able to provide what is called results. And now you're going for a mammogram and you get your results within 15 minutes while you're standing there. That's putting patients first because initially the clinic and the other doctors were like I don't want to talk to the patient. I got screenings to read but they reviewed the process and they made it work and now everybody realized this is great for us and for the patients. Make the work visible so at the workplace we're spending a great amount of time training, coaching nurses but also going around and using that five s things that I showed you before. Improving the reliability of the inventory management systems within the surgery department we're working just on doing that making it easier for them to replenish the supplies when they're running out. One of the big initiatives that we've been working on is being to improve the flow of the doctors within the clinic. We call it clinic flow projects but basically the goal in there is benefiting the doctors where they used to go home spending 10 hours on the weekend reading, reviewing and answering messages through my charts through some tweaking in the processes we're trying to take that 10 hours or two or something like that improving the doctor's technology I love technology we're finally getting some of it in healthcare too I feel like sometimes we're so behind the times but we when I use technology in a way that it helps improve processes not slow them down where do we work so when I said before we have a solution give us a problem kiosk to me seem to address a problem nobody asked but we're going to invest into them we're going to spend a bunch of money and we're not going to use them improvement project eventually turned out to be that we could use them more efficiently and it helped patients experience as well our cycle and then simplify their revenue cycle as well what's next is a lot of mumbo jumbo we talked a lot about value non-value added, waste standard work, why do we need it we talked about the problem solving methodology what you should be doing and examples of how these tools are being used within the system and then you said yes but we find problems and we bring them up to knowledge and we don't know what to do with it well there is a mandate and you are requested to work on improvement projects so my question is have you guys been assigned an improvement project yet you choose your own that's kind of nice actually and once you choose your own do you have how are resources to help you with that project are located for resources I mean people that know the data people that can pull the know the data or team members to help you that's part of also why I'm here I'm learning so in my mind I keep having this how do we make the perfect learning environment for the residents given your limited amount of time and the fact that really experiential learning is the best way to pick up something I could go through one of my projects but it's much easier for me if we talk about your projects and then I help you go through the steps that's how you learn best so I think you guys and Laura have to discuss what projects Laura Henson or Jeff P.D. I have to discuss what projects you're picking up for next few months a year or so whatever takes and then we can discuss what are the next steps my goal and my hope is of course that this project are well defined enough to find those resources that can help you improve something I know I'm very hopeful but what's next is I just give you a taste of what's out there of the methodology on the website I will send you the link for it on the value summary portal it's found in polls you can click in there what is value training there are some videos they will teach you what is value what's waste how to do a process map how to do a data analysis how to do a operator chart how to do all those things those 10 minute videos you can watch in there are quite good and that just gives you additional tools and knowledge of when you do have your project where do you get started when you start thinking about what project you want to work on to be successful we have learned that projects that are successful usually have four components they take into consideration vision, team, patient and measure so under vision you want to really think through of why do we want to pick this project now why what's the patient benefit what's in it for me why do we want to work on it right away why is it important now often times resources are difficult to allocate because vision is not right my the main reason why some of my projects have fell off the radar is because the priority has changed so again when I make sure that what we're working on it's feasible but also has the right vision and then the team do you have the right people in there if you involve all the roles, all the stakeholders do you have all the experts to the work both upstream and downstream and the reasons why projects lose interest is because or because or your implementation never gets implemented your suggestion never gets implemented is because you have not consulted you meaning we have not consulted the right all the stakeholders and then the patient maybe kind of cheesy what we have in here but it is true what we are implementing our solution does it help to make the process more convenient for the patient coordinate care better makes the process more reliable or does help us be more empathetic to our patients it just ties back to that initial goal of focus on the patient and then measure that's important too because I'm going to implement this I have no idea if it made an impact or not I think that people are more willing to listen and acknowledge the need for a solution if we can provide some data and have some measures to demonstrate our success we're trying to be more transparent as well with our efforts to improve things but there it is when you are going out there and you're picking your own project and you're looking at things those documents that I passed out is this it's a worksheet and it helps you think through is this really what I want to be working on and when you do that then please go to another part of the value summary portal and enter what we call a value summary it is eventually looks like this but before that it looks like a bunch of fields you have to enter information if you get lost well there is a video that shows you how to enter one but also let me know I can help you work with that but the value summary is two things it's a mental reminder and exercise of the improvement methodology that is oh I got to create my team then I have to state I have a problem I create my team but I got to identify my problem I got to make it measurable I got to set a goal so I know what I'm trying to do and then I'm going to do a based on analysis I'm going to find out what is going on collect some data map my process and so on then I'm going to create my intervention my improvement plan I'm going to test it out I'm going to monitor it and then I'm going to measure the impact so that's my methodology but also it's the system-wide resource where managers leaders are looking for at the projects so when the question comes is leadership engaged this is my question is leadership engaged in the work we're doing the answer is they're getting there we're not there yet but we do have the top leaders in organizations they do look at the value summaries they think it has been placed and so more and more leaders faculty and administrative have paid notice and they are engaged in process improvement using this language so when somebody asks you do you have a value summary for this it remains two things are you following the methodology but have you created one I would say that it would really help if you have working a project you don't want to have a summary retroactively enter it and I say that for two things one you also get the recognition for it but two it's there for other people to see the work that you have been doing this is my introduction I again I try to cover and give you exposure and talk about the concept of value added non-value added why is it important why do we when you go out there start looking start thinking in terms of waste and how do we eliminate them and we eliminate them through standard work and improving the flows by problem solving various other methodologies like 5s forcing functions and so on and then the next steps my mind are if you have any further questions Jeff and Laura are available too but there are training videos in there select your project and enter a value summary any thoughts questions comments just to thank you Luca for the med students this is essentially something that you will I mean it's an incredible benefit to you to be personed in this just more or less your own lives this is something that many of us do intuitively already identify problems but this is a framework to put it into that allows you to actually measure it so often we can feel good about changes that we made and that we are recognizing that they actually had the impact that we wanted and then again for your residencies these are now required projects actually you're going into the job market if you're someone who understands this and can do it all ready then just for the residents just make sure pass along to your co-residents either a continuation of your previous QI projects or new QI projects will be presented in the year but we do need to get value summaries on anyone so thank you Luca thank you