Welcome to today's plenary session, which will be followed by the continue the conversation session. Please welcome Dr. Megan Lane-Fall. Hello. I am Megan Lane-Fall, and it's my pleasure to introduce Dr. Brendan Carr, who will be presenting this year's Peter Saffer Memorial Lecture. Dr. Carr is professor and chair of emergency medicine at the Icahn School of Medicine at Mount Sinai and the Mount Sinai Health System. He is a renowned emergency physician and health policy researcher who has dedicated his career to blending research, policy, and practice to advance acute care delivery. His work has focused on building regional systems of care for emergency care and developing innovative delivery system solutions to create a more distributed and accessible acute care delivery system. Dr. Carr completed medical school at the Temple University School of Medicine, residency in emergency medicine at the University of Pennsylvania, and then fellowships in trauma and surgical critical care, as well as the Robert Wood Johnson Foundation Clinical Scholars Program, also at the University of Pennsylvania. He previously served on the faculty in emergency medicine, surgery, and epidemiology at Penn, as well as Thomas Jefferson University Health System, where he was professor and associate dean for healthcare delivery innovation. He holds master's degrees in clinical psychology and in health policy research, has received research funding from the National Institutes of Health, the Agency for Healthcare Research and Quality, the Centers for Disease Control, and multiple foundations. His research focuses on systems of care for trauma, stroke, cardiac arrest, and sepsis. Dr. Carr has authored more than 150 peer-reviewed publications, received awards both for teaching and for research, and has advised and supported global not-for-profit foundations, the World Health Organization, and the National Academy of Medicine. In addition to his academic portfolio, from 2012 to 2020, Dr. Carr served as the director of the Emergency Care Coordination Center and a senior advisor within the U.S. Department of Health and Human Services. His federal portfolio was focused on improving trauma and emergency care services at the national level. This work included working with the Department of Veterans Affairs and the Department of Defense to integrate military and civilian healthcare response during disasters and public health emergencies. Dr. Carr arrived at Mount Sinai in February of 2020, one month before the first case of COVID-19 in New York City was diagnosed in the Mount Sinai Hospital Emergency Department. He had a central role in coordinating the Sinai Health System's response to the COVID-19 epidemic in New York City, efforts that were recently recognized by Crane's Healthcare. Today, Dr. Carr will present Health System Readiness 2.0. Everyone, please join me in welcoming Dr. Brendan Carr. Thanks so much, Megan, and thanks for the invitation to be here. I'm sorry we are not in person. It is nice to see you again, full disclosure, Megan and I have known each other for a long time at this point. So it's my pleasure to be here today to talk about private sector healthcare and public health threats. My name is Brendan Carr, as you heard, and I am just about two years now into my position as the Chair of Emergency Medicine at Mount Sinai. I want to just take a minute to acknowledge you all and to thank you all for asking me to give this talk. It's not lost on me that Peter was a giant in the field of critical care, and it's also not lost on me that he is famous for saying, don't walk when you can run, years and years before it was stolen by Iron Man, telling us that sometimes you got to run before you can walk. As I was looking through, you know, his career and thinking about what he'd done, you know, as a co-founder of SCCM, but also a co-founder of the World Association for Disaster and Emergency Medicine, it just sort of struck me that it's pretty telling, because I will tell you, I don't consider myself to be a disaster expert. I'm an emergency physician and a policy researcher who ended up sideways in the disaster space at HHS, Department of Health and Human Services, and then especially at the center of the response to COVID in New York City, wave one, we'll talk about a little bit today. So by way of background and disclosures, I was at Penn for a long time for residency for critical care fellowship, for policy research fellowship, and then I was at Thomas Jefferson University. I helped to coordinate their innovation portfolio. I was at HHS for eight years in a couple of different capacities. I ran the emergency care policy office, which we'll talk about a little bit, and then I was a senior advisor in the office of the assistant secretary for preparedness and response. Now, as I said, at Sinai, I still have some research funding left, though it is dwindling and my administrative roles are making me come dangerously close to losing funding for the first time since I finished my fellowship. I listed here some of the work just because I wanted to really highlight the fact that I, like you, think about systems of care and think about the intersection of the disease with the system. That's what intensivists do, and SCCM is the home for people that are at the intersection of trauma or stroke or cardiac arrest or sepsis or whatever it might be. I'll try to weave that in as we talk a little bit about it today. I just wanted to say that we at Sinai are a big enterprise. We are eight emergency departments and six urgent care centers and hundreds of docs and a half a million visits a year, two residency programs, lots of fellowships. We have a very, very close partnership with the Institute for Critical Care Medicine at Mount Sinai. This is both adult and pediatric ICUs, multi-specialty practice, and enormous critical care training grounds. They will have 10 emergency medicine critical care fellows alone next year, and there's been a drastic evolution of our critical care enterprise over the last few years. Six years ago, seven years ago-ish, it didn't exist, and over the last 12 months, 18 months, it has stretched across our system to have a presence in all of our hospitals and all of our ICUs. You see there the critical care services. It's not just the ICUs that they run, but they run a bunch of the different teams that respond across the enterprise, the difficult airway team, rapid response team, et cetera, et cetera. It's run by Rupa Kohli-Seth. Rupa's a close collaborator, and I told her I would advertise for her a little bit today. So I, like you, remember the before days. It was leap years, February 29th, 2020. One of those little guys there is my youngest, and I was at a soccer tournament when I got a phone call from the folks in the emergency department at Mount Sinai Hospital in the Upper East Side telling me, hey, listen, I think we got the real thing here, and you might want to let the president know, and you might want to be on site because it's going to come back from the lab, and the press is going to show up. And then this is the first case in New York City, and then that's the governor off to the edge there, and this is MSNBC telling the world that the first case of coronavirus in New York had been diagnosed in a patient who had traveled to Iran and who had come to the emergency department and had been discharged home. So I don't need to tell you guys all that things changed quite a bit. Our first wave was enormous. It was a rapid peak. There was a plateau at the top that felt like forever. Like many of you, this is wave one. Sadly, this histogram carries out way to the right through all the other waves. In total, we have taken care of 20,000 inpatients across our system. For those of you who have been to Mount Sinai, this is the Upper East Side campus on the bottom left there. That is the fancy atrium with huge, beautiful glass windows that normally has a Starbucks and a grand piano in it. This is mid-construction as we were building temporary rooms in the lobby, and you see the wall of one of our hospital buildings with the windows knocked out and HEPA filters with plywood being put in there to make them as negative pressure as possible. I won't spend a lot of time, just because I know that many of you have been through very, very similar circumstances. It's worth saying that when things were really, really bad in wave one, there were federal assets that were deployed to us. The comfort, obviously, rolling into New York was chilling for most of us, and at the same time, it was really, really welcome. The bottom right there is our convention center, the Javits Center. The comfort ended up caring for 180 patients, and the Javits for 1,100. I wanted to just remind you of the disconnects that were existing at the time. Remember, we were told that the COVID wouldn't take anybody who had COVID, and at the time, everybody had COVID. We had turned off everything. There was no elective surgeries, and our hospitals were full of patients with COVID. I remember someone saying, as they walked into the Javits Center that didn't take medically complicated folks, that they said, this was the quote, they said, why did they build a hurricane shelter? I'll try to come back to that and talk about the fact that we have a playbook in the federal government, and we didn't have a playbook for what happened to us, so we applied the one that we sort of had, which was, it was really built for hurricanes. It was built for people that were displaced with some simple medical needs. So we diagnosed that first patient on my one-month anniversary at Sinai. On my two-month anniversary at Sinai, we opened up a field hospital in Central Park for the first time since the Civil War, and this field hospital ended up taking care of 68 beds. In partnership with Samaritan's Purse, there were 10 ICU beds in the complex, and we treated almost 200 patients a day, treated almost 200 patients. It is a different talk, one I'm happy to give, or one that I'm sure the Chief Medical Officer for Samaritan's Purse, Elliot Tempany, would be happy to give about the partnership that we crafted. They are parked right in front of our hospital, because you can imagine it allowed us to align in so, so many ways from replenishing their pharmacy, that they come with their own, but it's easier to replenish to managing everything from consults and experts that they might not have available to managing decedents. So this is sort of the beginning and the thrust of what I wanted, the question I want to ask in the conversation that I want us to think about today. We all know the triple aim, the Institute for Healthcare Improvement's triple aim in the civilian healthcare system makes us balance population health, the cost of healthcare, and the experience of care. I'm framing this in an intentionally controversial way as a just-in-time system, and I'd like to contrast it with what you see on the right here, which is the military's healthcare system, they do believe in the triple aim, better health, better care, lower cost, but they have a quadruple aim. They have a quadruple aim because they are always prepared for, or always preparing for conflict and for incoming casualties. So they balance their just-in-time with the just-in-case concept of readiness. We spent a lot of time when I was in government, interacting with the military health system and talking with them about this philosophical difference from where we were. So this is my moment to say, I'm not in government and haven't been in some time. And it's pretty freeing to be able to talk about what I think should be done differently. That said, very clearly, I'm not speaking on behalf of anybody other than me and the perspectives that I have. I ran this office inside of ASPR for a while, the Emergency Care Coordination Center, created in 2009. The federal register is where you announce that you're creating things. And this is when it was created, the ECCC is a new strategic entity located within the office of the Assistant Secretary for Preparedness and Response. And you see down below, HHS recognizes the successful delivery of daily emergency care as a necessary foundation for the nation's emergency preparedness efforts. So there's a connection between what's happening under normal circumstances in our healthcare system and our ability to be ready. And it's that connection that we're supposed to dig into today. I will tell you that I went to Wikipedia to grab that thing on the right and to the original federal register to grab this initial language around this office, because I guess it doesn't exist anymore. I don't, I know that I wasn't replaced, I don't know if things were stood up by the new administration when they came in, but I can't find any reference to the old materials in the old portfolio on the web. There's a couple of things I want to stick front and center for you to think about as we're marching forward. Top left there is an IOM report on hospital-based emergency care, sort of referencing that it was at the breaking point. That is 2000, that is a couple of decades old at this point. Over to the next to the right there is 2015, much more recent, it's a bipartisan blue ribbon panel thinking about biodefense, infectious diseases, and biothreats in particular. More recently, 2018, the National Trauma Care System, most recent IOM report on trauma systems. And then across the bottom there, the National Biodefense Strategy in 2018, the National Health Security Strategy 2019 to 2022, and then something you should never read, which is the Annual Threat Assessment from the Intelligence Committee. This is the most recent one, sort of talking about the things that we should be thinking about and wondering about. I put these here to draw for you a continuum of national health security in the context of biothreats and trauma, because the only backstop for things that may happen to the United States really is the civilian healthcare system. And at the heart of that civilian healthcare system are people like me, I trained in critical care medicine, but don't practice critical care medicine anymore. I practice emergency medicine, and you, the critical care community, because you're the glue that sticks together whatever it might be, you know, high consequence infectious diseases, biologic weapons, trauma, you know, pick your poison. They end up in your ICUs, and we depend upon you to take care of them. Let's jump to the one on the top left for a minute. So this bottom left here is a guy named Bill Schwab, who was the Chief of Trauma at Penn when I was there, ran the program for a very long time. Over his right shoulder here is the guy that ended up being my boss in the federal government years and years and years later. I was at this committee meeting, went with Dr. Schwab when they were rolling out the future of emergency care reporting. He made this, this is a trauma surgeon showing up to talk about the emergency care system, and this is what he talks about. As I walked through the ED, I saw teams of specialists down there, carbs, neurology. The one that really frightened me was an infectious disease specialist. This friend of mine in the infectious disease department is a virologist, a virus expert. And I finished my thoracotomy, walking out to do my paperwork. I thought of all the things I'm afraid of, and what I'm afraid of most is that a virologist was seeing something, a virus, sitting in the middle of our emergency department with all those hundreds of people, and there's just no way that simple solutions are going to fix this. It's going to take a concerted effort. So this is 2007. 2007, he says this. I'm going to flash forward now to 2016. This is the House Energy and Commerce Committee. This is Mr. Pitts from Pennsylvania. And this is the rollout of the trauma report asking for a national trauma system, something to be organized at the national level rather than the patchwork that we have today. And Mr. Pitts says, in the last couple of years, we've seen a lot of destruction as a result of man-made and natural disasters. We've seen, we've responded to threats from infectious diseases such as Ebola and influenza and Zika. And he asks, are we building parallel systems for these? Should we be? Or should we be taking a more strategic look at where the gaps are in the emergency care delivery system and approaching this with a broader perspective? In the same hearing, there is, this is Mr. Cardenas from California saying, why are you talking to Congress about this? This is trauma care. This is health care. Isn't this a free market issue? What does Congress have to do with increasing the capacity of the health care system? Is the free market going to pay for it? Let's be honest. Is the free market going to pay for what you're asking for us to have in the United States? The answer is no. So there's a chess game happening here. And we often, when we're practicing clinical medicine, we are at the bedside. And I'm not sure that we're sort of as thoughtful as we can be when we're thinking with our policy and advocacy hats on about how to build a better system. You know, I think of readiness as a three-legged stool. There's the public health infrastructure. There's the health care infrastructure. And then there is emergency management. On the left and on the right here, CDC and FEMA are pretty well-recognized homes for the public health infrastructure to public sector enterprise that rolls out to state health departments and local county health departments. It's run by grant programs and public dollars. Ditto FEMA, public sector program, the Department of Homeland Security, the Federal Emergency Management Association, and then grant programs that go out to state. And we all sort of know what these entities do. That other leg, health care, is sort of, we know what it is when we're talking about scheduled care. I don't think we really have our arms around what it is when we're talking about unscheduled surges. And when I was in government, to think about the different things that came across our desk, to think about a mass shooting, think about Las Vegas, just to take you back there in the times before COVID, to think about different bombings that have happened in the United States, and to think about the degree to which the health care system was or wasn't a part of the infrastructure and the response to that. Do we create capacity when there's going to be a large mass gathering in our communities? Just in case. We certainly get the public systems spun up. There's all kinds of EMS activity, and there's emergency management activity. There's lots of planning around that space. There's public health thoughts around it. But the private sector health care system in general is doing its thing. It is managing the patients that are scheduled to come get managed that day. So who, this health care sector that I haven't read down there, is a private sector that is based on a reimbursement model. Who's in charge of it? Is it ASPR? The Assistant Secretary of Preparedness and Response, which is in the Office of the Secretary of Health and Human Services. That's where I work. Is it CMS? They control the most money. Is it, I put United in an anthem not to call them out, but because they're two of the big ones. Is it the insurance industry? I guess, you know, I would say that it doesn't really, there's no answer to the question. And the reason that we got caught the way that we did over the course of this last two years is, I think, because we don't have a unifying strategy. You heard it being asked by Dr. Schwab when he was talking about the future emergency care report. You heard it being asked by Mr. Pitts when he was talking about the National Trauma System report. There's not an overarching, there's not a macro strategy. And when that strategy breaks down, there are human lives impacted. There are really compelling stories that make us wonder whether or not we can do better. I would encourage you, I have absolutely no COI here. This is the Daily Podcast. And just stick this in your feed for your next walk to work or your Peloton or your drive home, just to think about the mistakes that New York made as the way that it was framed. Because it highlights some of what I'm trying to talk about here. Highlights some of the disconnect between public sector, private sector, some of the disconnect between public health and health care in ways that I think we owe it to the public to improve upon. I wanted to just briefly, this is a wildly incomplete list, but these are some of the big programs that it's worth knowing the names of. In ASPR, the Hospital Preparedness Program is a very big program. This is, to misnomer a little bit, the money doesn't go to hospitals, it goes to health departments and it's distributed to hospitals along with other entities that are parts of things called health care coalitions, teams, community-based teams of all the people that respond together. I put the dollars here just to remind you of how modest the investment is in readiness. The National Disaster Medical System is, these are the most well-recognized piece of this are the deployable teams. Those deployable teams can go out and set up field hospitals and help should there be a response. Pediatric disaster care was developed just a couple years ago. I'm not going to go through each of these. The Medical Reserve Corps, volunteers that can go out and help, and then a bundle of them that are all sort of under one umbrella, the National Emerging Special Pathogens Training and Education Center, the Regional Ebola and Other Special Pathogens Treatment Centers, and then the Regional Disaster Health Response Demonstration Grants. I want to come back to those and talk about those just a little bit because this is the evolution of ASPR trying to build a regional solution. And then at the CDC, there's a partner program to HPP, although it's much, much bigger, which goes to the health departments. And instead of going to the health care sector, stays with the health departments in general, stays in the public sector. And just as a matter of reference here, these programs totaling up to within ASPR, maybe $300 million, $400 million, and at CDC, $600 million. You just have to remember how big CMS's budget is and how big health care is. They're a $4 trillion industry. And I will sort of throw my longtime partner in crime at HHS under the bus here and sort of say, Dave Marcozzi told us all the time that we're never, ever, ever going to be able to grant our way to readiness. There's not enough money. There's not enough grant money. We need a different strategy. And he's right. He was right then. He's right now. This is active legislation. This is the Senate's version. The Senate HELP Committee circulated just a couple weeks ago, the Prepare for and Respond to Existing Viruses, Emerging New Threats and Pandemics Act, the Prevent Pandemics Act. And I searched it for you so that you didn't have to, to demonstrate the degree to which these now almost 15, 20 years of asking the federal government in one way or another through the Institute of Medicine and through committee hearings to think about what our priorities are. And you see public health is in here 218 times. Medicare, that's a search for CMS, Center for Medicare and Medicaid Services, not at all. Trauma makes its way with 24. And then down the right-hand side here, hospital and health care also not in there. Critical care, intensive care, emergency care. This is a bill that is a public health-focused bill. And that is, at least through my lens on things, is a problem. Not because public health isn't important, but because public health and health care are different. We do different things for people that need help. What do we do about that? Absent a line item, absent a bill that's going to suddenly generate the kind of resources that we would need to get things done. I want to just highlight, this happened a couple of years, shortly before I left, actually, government. There was this question that was circulating long before COVID. How do we get the private sector involved in readiness? Why are hospitals and the health care system so disinterested, and what can we do to change that? So these two gentlemen sitting here are Ken Schein and Don Berwick. Going right to left, Don Berwick. Many in this audience will know him from the Institute for Health Care Improvement. Don really created, helped us all to think about how we make quality and safety central to the implementation of it, central to what we do in the health care space. On the left there is Ken Schein, who was the chief architect of Two Errors Human, the IOM report that really put quality and safety and medical errors on all of our radar. We went to them and said, you guys built quality safety into the health care system without a line item. You didn't have a giant budget to do this, but somehow you figured it out. Can you help us to think through, to strategize how to do this for readiness? This is a JAMA piece, and I summarized it a little bit here. This is what they said. They said, look, you need regional cooperation for readiness, and that is a hard thing to do. I'll explain why in a moment. You need concrete regional projects to focus on. You need metrics because you have none right now. You don't know if you're ready or if you're not ready. Then you've got to identify training needs. Then they said this really interesting thing, which is you need a partnership. You have a public sector need and a private sector delivery system. You need to figure out how to create a public-private partnership to get us to where we need to be. Everybody talks about regions, communities, and yet our health care, just to really belabor it one more time, doesn't think like that. Health care systems divide up people based on where they get their care. Insurance companies do the same thing. You're referred to somebody inside of your network. You see these little cartoons helping us to think through this. It isn't how mass casualty events happen. It isn't how floods happen, how tornadoes happen, how things that end up impacting the need for health care. It certainly is not from a super dense city that got hit really hard the way that COVID happened. The one on the right is the way public health thinks. The other two are how health care thinks. We have different denominators. It would be an incomplete conversation to not just remind everybody that these communities often, if they're under-resourced, if they're poor communities, or if they're communities that are patients that are more likely to be Black or Brown or underserved in other ways, they have worse health outcomes. This is just the Kaiser Family Foundation reminding us that Hispanic, Black, and American Indian, Alaskan Natives are twice as likely to die from COVID as whites if you age adjust. It should just be a reminder and a sobering reminder of how much work we have left to do. So I mentioned this program before, the Regional Disaster Health Response System. This is a program, this is one of the last programs that ASPR, one of the most recent ones rather, that ASPR launched. They are pilot programs. They're playing with figuring out how to create a regional framework around things. There were two originally, one in Nebraska and one at Mass General. Two years ago, they awarded one to Denver. And then last year, they awarded one to Emory. So this is the country broken up into the regions that HHS uses. And the goal of these programs, it's a much longer conversation, but it really is to start to understand the players in those regions and to build expertise in those regions because that's how response is going to happen at the macro scale. It's obviously too much to go into depth. It's a great story with a lot of promise, I think. But it is $3 million per site. This is a $12 million investment on a $4 trillion industry. We're not exactly, I think, where we need to be. Another key thing that I want you to think about as we start to think about this, remember the question here, the playbook that we wanted from Berwick and Shine was how to do it without a mandate, how to do it without a budget line. And so this is recent work. This is just out, I don't know, three months, four months, somewhere thereabouts, about attribution for critical illness and injury. When you're thinking about attribution, it's about finding an accountable unit. And most of the time, that means my primary care practice, my number of central line infections in my ICU. It means some measurable accountable unit. And this is a framework that is building regions and patient populations as the accountable unit because that is how unscheduled care happens. That is how unscheduled critical illness happens. That is how pandemics happen, how mass casualties happen, all the things that require the glue of the critical care infrastructure. This is a worthwhile read, and if it can be actualized, it can be transformative because you know what happens once you start measuring, then you tether reimbursements and public performance reporting to this. And then some other key players in here just to sort of round it out. Top left here, this is the Healthcare Leadership Council giving us a template for a public-private partnership. This is a playbook in response to the requests that are happening. On the bottom here is a very active group, the National Special Pathogen System of Care that has articulated a clear path forward to organize critical illness around special pathogens, around infectious diseases. And then the top right, I've listed a couple others. Trauma centers are already in this mix. Burn centers very actively in this mix. The Radiation Injury Treatment Network, long-standing engagement in this space, those small, and now lots and lots of conversations happening around medical operations coordinating cells. All of these things require regional responses. We don't yet have the home for that regional response, and we certainly don't have the finances to make it work given the way that healthcare is paid for now. But it is the beginnings of a really important conversation. This is from the group that put together the National Special Pathogen Systems of Care. And in full disclosure, I worked in close partnership with them thinking about this. And I want to just highlight, I used the word matrix before, and I just want to highlight that absent a giant budget, there needs to be a mechanism to get it done. And so you'll see a couple of different mechanisms here. How can you change the bond ratings or create preferred loans for hospitals or healthcare systems? How can you leverage tax benefits to make it easier for them if they invest in readiness as a key component of their community? Donations and trust. What is the corporate lens on this? New York City has a partnership called the Pandemic Response Institute because corporate America is willing to pay dollars to never turn off the economy again. And they want the healthcare system and the public health system to help them to make sure that it's backstopped. And then I won't belabor them all, but you can imagine there are obviously traditional things like reimbursement and things of that nature here, but there are also alternative pay models here. There's a whole matrix of things that might allow us to get to where we need to be, which is to say many different payers rather than a single robust budget item, which I think is probably unrealistic given the magnitude of the healthcare system. And I think that so this conversation is ongoing. This is our Center for Healthcare Readiness at Sinai. We put stuff in modern healthcare in the Hill. We went to the Aspen Ideas Festival. You see in the bottom right there, that's a health affairs piece that is talking about a national special pathogen system of care, how to fund it, and where to begin because we have to start this conversation. And I'll just end by saying that I showed you this before, this Prevent Pandemics Act. That was the first draft. They got a lot of feedback from a lot of people. And 2.0 will be coming. This is the time. This is the time for SCCM and for your voices to influence the future direction of this. So I look forward to a conversation. I'm sorry to be the policy wonk in the room, but it turns out that I think that form follows finance and that it's our job, given that we understand what it's like on the front line, to influence those who can help us to build a much more robust and much more ready healthcare system. Thanks for letting me be here today. Brendan, thank you for an amazing talk. And you mentioned that we've known each other for a very long time, and that's true. I want to say I was a resident when you were a fellow. That's probably falsifiable. I don't remember. But the other little tidbit is that your wife was my children's pediatrician, and she still remembers them after all these years. So it's such a pleasure to be able to chat with you and to hear about your work because, you know, sometimes we work with folks and we don't get to hear all the knowledge and the wisdom that they've accumulated over the years, which you certainly have. So we're in our continue the conversation mode. We have questions for you from the audience that branch off of the concepts that you discussed already. So I'll launch in. The first one is that the COVID-19 pandemic demonstrated communication breakdowns when frontline clinicians and system-wide leaders received different information and made different plans in response as the information evolved. How do you think healthcare systems should avoid these communication missteps and these treatment treatment missteps that are related to sort of crossed paths in communication? It's a great one. Thanks. You know, so I think there's two big factors at play here. One is never going to change, which is to say there's incomplete information as things are evolving. And that I think it's important to think about our communication structure a little bit separately from the fact that we don't have all the information at the beginning. So pushing that one aside, there are really thoughtful ways to think about what it looks like to create a command center, what it looks like to create an orderly and organized portfolio of subdomain experts and a communication strategy that pushes things out. But that central to sort of getting the job done is creating trust amongst your employees so that they believe you're shooting them straight, so that they aren't generating their own realities based on what they're seeing in front of them. And the last piece of there is that that trust needs to be bi-directional. There needs to be an organized structure. There needs to be communication down. And then there needs to be sort of communication up and both have to sort of be solving for the same problem, which is to say finding the truth and finding the best path forward. There, you know, I guess I would point people if you are interested that the Tracy Technical Resource Assistance Center, I'm losing it, T-R-A-C-I-E at HHS at ASPR is really a nice place where people collate and collect best practices around creating command structure and transmission of information. But the trust piece is the hardest piece of all, making sure that people believe that you're really solving for the same thing that they're solving for. You don't get to cheat on that one. You got to shoot people straight, even when the news is not great. Otherwise, you lose faith very, very rapidly. That makes a lot of sense. And I appreciate the references for folks to look into for more information. I'm going to transition to asking the big city doctor a question about rural areas. So one of the areas that struggled the most in health care are the institutions that serve small towns in rural areas. They were already struggling before the pandemic. So what's the best approach for these smaller institutions to take so that they can take care of the often underserved patients in their communities? Well, so, I mean, you and I have clearly have a lot of expertise in this. You practice in Philadelphia, I practice in New York City. This is, I think, squarely in our wheelhouse. You know, it's obviously, I think that we can't do any of this unless we have partnerships. And you heard me talk a couple of times about what these regional structures look like. We generally think about our partnership as being within our health care system. Your hospital, your large academic medical center has partnerships with community hospitals. So does mine. We don't, in general, you know, in these large academic urban places have connections to small rural hospitals. But some of the structures that I've been talking, some health care systems do. But some of the structures that I've been talking about have created or trying to create a home for that sort of conversation. And I referenced again that it's just a worthwhile listen on that podcast. This isn't just a rural problem. This is a smaller under-resourced hospital problem. It's augmented, of course, when you're out far distances from folks. But even when you're nearby, the idea that there's not visibility of who's got capacity and how you level load that capacity. And there's not an agreed upon partnership about how that will happen. And there are really, really, really ugly economic disincentives to being transparent about that and doing that. Many of those hospitals you're talking about in rural areas, many of the hospitals that I'm talking about in New York City are hospitals that have a payer mix that makes it really hard to create a business case around accepting a transfer of those patients. We have to be explicit about those problems or we'll never get to solving them. That's great. So another question from the audience is that as the pandemic has progressed, our major limiting factor in supporting health systems has changed from stuff like ventilators, CRRT circuits, and PPE, and space like physical beds in a traditional ICU or for you in an emergency department. We've transitioned from that to challenges with staff with burnout increasing and many clinicians actually leaving the profession altogether. So what are some strategies that health systems can take to reduce the challenges with people and staffing? Well, I mean, I'm just really grateful that you've stuck only with the softball questions. Indeed. Yeah. So this, I mean, this is the existential one and it would be foolish to tell you that I have anything intelligent to say. There is, but like many things, I guess I would say that if we look at how stretched those rural hospitals were beforehand, if we look at how stretched the healthcare system is on any given Friday or Saturday, you know, with respect to capacity, and then we look to see how stretched our workforce is psychologically, emotionally, and certainly, you know, just with respect to the rural numbers of people that we have available to us, none of us should be surprised. This is, it's a just in time mindset, you know, and I sort of said early on that just in time and just in case aren't the same thing. People didn't have any gas in their tank. We asked more of them than we ever could have or should have. They responded and it had real human consequences. So the, you know, I, you know, the answer to your question, I guess, is an established pipeline, some understanding of who's coming next. It's about a distributed healthcare, distributed responsibilities in the healthcare system, letting other people into the mix, diversifying so that we have, you know, not just a strict reliance on docs, but on all kinds of providers and not just on nurses, but on all kinds of staff that can help to take care of patients. But this is a question without an answer, as you know, at least a concise one. But I think we've learned a lot about the ownership and the responsibility that we have to our staff, and we have to think differently. We have to think differently about the degree to which we take care of them during the blue skies so that when we need them during the worst times imaginable that they're available to us. A little bit, I think maybe we deserve to acknowledge that there are plans in place on some level to shift folks around. Had this not been the scale that it had been, I don't think we should lose hope entirely because we couldn't under these circumstances make it happen. When it is smaller than this, it's different, you know, and people can be shifted. We should build those pathways in the day-to-day, rotating people out to get rest because most events are not going to be what COVID has been over the last two years. That's true. So I'm curious, as a sort of follow-on to that question with your chair hat on, how have you shown your staff that you value them? And how do you do that in a way that's received well and not seen as, you know, some sort of not realistic, not sort of genuine statement of appreciation? Yeah, I mean, I guess I will leave it to them to sort of to tell you whether or not I've succeeded and whether or not I get a pass even when the hospital or the healthcare system or the school of medicine are doing something that they disagree with. I guess, you know, I mean, I guess I would say on some level you're asking a leadership question and I spend a lot of time worried about whatever it is that I might do showing up in social media as some tokenism or some, you know, something that's less than what I want it to be. But the answer to your question, I guess I would say, is that it's about authenticity. I mean, I think being present, really taking it in, asking people to problem solve with you, being willing to be in the fight with folks and trying really hard to educate them about what the limitations are. There were times, you know, I mean, it was crystal clear that our response, our game plan, let's be clear, our game plan was to go bankrupt. We're going to spend money that we know that we have to spend, even though we know that we're not going to be able to recover from this as the healthcare system unless there is a bailout. That's crazy. And that makes it really hard and the right thing to do. It's crazy and the right thing to do. But it makes it really hard to thank people in the ways that people deserve to be thanked, which is to say with extra time off and with extra money and with extra, you know, fill in the blank of the real things people deserve. There's a real conversation. There's a healthy conversation happening now around what these things are because giant piles of money solve lots of problems, but there are things that are just short of giant piles of money, like the things that make life go around, childcare, you know, food services at home, laundry services, rides to work, hotels. You know, I mean, these things, they really do matter. And, you know, I don't know. Sometimes I'm sure they feel token when it's not enough childcare, when it's not enough, you know, food delivery. But these are the conversations that if we're authentically having them that we're going to sort of, I think, arrive at something that feels like a reasonable balance. And as a final extension to that, with a nod to the multidisciplinary membership of SCCM, I imagine you have to work with leaders in other parts of the hospital, with nursing leadership, with respiratory therapy leadership. How do you work across those disciplinary professional sort of silos to think about a team-based approach to supporting the staff? Yeah, you know, I'll add one last piece there, which is, you know, for me, so I'm just, you know, just two years into a different environment. And I had never interacted with the, because our system is so big, with so many different types of employees. So, employees of the School of Medicine, employees of one hospital versus another, all with their own separate rules, members of one union versus another, all with their separate rules. The answer is, you know, it's obviously extraordinarily difficult, but I think the answer sort of comes down to the same, it comes down to sort of the same principle, which is that you have to be genuine in trying to arrive at the solution, sitting down with the key stakeholders, having them talk with their, the people that they're representing, and then talking and then talking through what the issues are and trying to arrive at it. It's just, it's really, really, people's needs are really, really different. And when sometimes, you know, to go meals for people's families as they were leaving meant everything, and other times hotel rooms meant everything, and other times we got it wrong, and people didn't want what we were offering them because it just didn't, it just didn't meet their expectations. They didn't want it, they felt like it was too paternalistic for us to tell them what you need is, you know, housing or food or laundry services or child care, when what they wanted was money. You know, that's, that sometimes, sometimes there aren't answers that are, that are acceptable, and those are the most difficult circumstances when you have to have a conversation around why it's not possible and how unfair that seems. Boy, is there, is there a softball somewhere in here? No. I'm, I don't know. I'm going to end with something that's, that may be a softball. We've got just a couple of minutes left, and you know, you've talked about some big hairy systems level issues that we're going to have to grapple with as a country that might require legislation, policy changes, and I'm curious for the individual who's watching you, who's listened to your comments, who's listening to you now, what can an individual do now or in the near term to, to help make steps toward readiness or, you know, making sure that our system is a little bit more equipped? What's, what's sort of one small step? I think I'm going to double down on where I just ended, which is local relationships. I mean, I think that, you know, that gets you to a place where you can have a candid conversation and that gets you to a place where you can solve for the problem. So if you meant in the workplace, and I think you did, I think it is about making sure that you, that you trust the people, that you communicate honestly with the people that are leading you and that when they're not being authentic, that they hear about it because there's not a shortcut to sort of, to sort of being present and doing what's right for the folks that are relying on you during those moments. Thank you. We have continued the conversation. It's been amazing to chat with you, to catch up with you and to hear about all the amazing work that you've been doing in New York and the insight that you've given us on readiness at a, at a national level. So please accept my thanks on behalf of the Society of Critical Care Medicine. And if we were in person, you would have thunderous applause. I'm sure it's happening virtually, but thank you so much. You're very kind. And it's great to see you. Thank you once again for the invitation. Thank you, Peter, for the named lecture and allowing me to be here.

health system readiness

acute care delivery system

COVID-19 pandemic

regional systems of care

comprehensive approach to emergency care

public health

communication breakdowns

staffing shortages