49da0dc7-e046-42f2-9180-fcdca458e228/5-0
00:00:03.208 --> 00:00:07.596
The Medical Director of Utilization
Management in the Office of Clinical

49da0dc7-e046-42f2-9180-fcdca458e228/5-1
00:00:07.596 --> 00:00:12.164
Services and Population Health at New
York City Health and Hospitals. Josh,

49da0dc7-e046-42f2-9180-fcdca458e228/5-2
00:00:12.164 --> 00:00:14.328
thanks so much for joining us today.

49da0dc7-e046-42f2-9180-fcdca458e228/6-0
00:00:13.928 --> 00:00:16.568
Thank you for having me, Jordan.
I appreciate it.

49da0dc7-e046-42f2-9180-fcdca458e228/8-0
00:00:16.448 --> 00:00:19.349
Yeah. So for those who don't know,
NYCH&

49da0dc7-e046-42f2-9180-fcdca458e228/8-1
00:00:19.349 --> 00:00:23.024
H is a 5000 bed health system
headquartered in New York,

49da0dc7-e046-42f2-9180-fcdca458e228/8-2
00:00:23.024 --> 00:00:26.119
NY with 8500 providers supporting 14
hospitals.

49da0dc7-e046-42f2-9180-fcdca458e228/8-3
00:00:26.119 --> 00:00:31.341
Now today we're going to be discussing 2
projects in particular at New York City

49da0dc7-e046-42f2-9180-fcdca458e228/8-4
00:00:31.341 --> 00:00:35.338
Health and Hospitals.
One will be both within the utilization

49da0dc7-e046-42f2-9180-fcdca458e228/8-5
00:00:35.338 --> 00:00:36.048
management.

49da0dc7-e046-42f2-9180-fcdca458e228/9-0
00:00:36.168 --> 00:00:38.657
Sphere.
One will be centralized emergency

49da0dc7-e046-42f2-9180-fcdca458e228/9-1
00:00:38.657 --> 00:00:43.281
department utilization review and the
second will be a centralized process of

49da0dc7-e046-42f2-9180-fcdca458e228/9-2
00:00:43.281 --> 00:00:46.541
writing appeal letters for the health
system. So Josh,

49da0dc7-e046-42f2-9180-fcdca458e228/9-3
00:00:46.541 --> 00:00:49.802
thanks for joining us and take us through
the journey.

49da0dc7-e046-42f2-9180-fcdca458e228/9-4
00:00:49.802 --> 00:00:54.248
What's what led to the decision to move
towards a centralized EDUR system?

49da0dc7-e046-42f2-9180-fcdca458e228/11-0
00:00:54.888 --> 00:00:58.102
Yeah. So, you know,
we're the largest public health system in

49da0dc7-e046-42f2-9180-fcdca458e228/11-1
00:00:58.102 --> 00:01:00.643
the country.
So we have some challenges that are

49da0dc7-e046-42f2-9180-fcdca458e228/10-0
00:00:58.488 --> 00:00:58.968
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/11-2
00:01:00.643 --> 00:01:03.495
unique to us and also not unique to to
others as well.

49da0dc7-e046-42f2-9180-fcdca458e228/11-3
00:01:03.495 --> 00:01:07.643
We are a safety net facility taking care
of a lot of New York City's residents.

49da0dc7-e046-42f2-9180-fcdca458e228/11-4
00:01:07.643 --> 00:01:10.599
And so we had to try to think outside the
box. You know,

49da0dc7-e046-42f2-9180-fcdca458e228/11-5
00:01:10.599 --> 00:01:14.073
we're very limited resources,
so much so than other facilities and

49da0dc7-e046-42f2-9180-fcdca458e228/11-6
00:01:14.073 --> 00:01:14.488
systems.

49da0dc7-e046-42f2-9180-fcdca458e228/13-0
00:01:14.488 --> 00:01:18.010
And so how can we be better,
smarter and more effective and efficient

49da0dc7-e046-42f2-9180-fcdca458e228/13-1
00:01:18.010 --> 00:01:20.426
with it?
And one of the things we noticed with,

49da0dc7-e046-42f2-9180-fcdca458e228/13-2
00:01:20.426 --> 00:01:24.351
you know, with ED utilization review,
emergency department utilization review

49da0dc7-e046-42f2-9180-fcdca458e228/13-3
00:01:24.351 --> 00:01:27.068
is that between the 11 acute care
facilities we have,

49da0dc7-e046-42f2-9180-fcdca458e228/13-4
00:01:27.068 --> 00:01:30.993
everyone was sort of doing it a little
bit differently. Some were doing 24/7,

49da0dc7-e046-42f2-9180-fcdca458e228/13-5
00:01:30.993 --> 00:01:31.648
some weren't.

49da0dc7-e046-42f2-9180-fcdca458e228/14-0
00:01:32.168 --> 00:01:36.280
Some had the nurses doing multiple tasks
like care management tasks with the EDUR

49da0dc7-e046-42f2-9180-fcdca458e228/14-1
00:01:36.280 --> 00:01:40.142
tasks and it really was setting up a
system where it wasn't as efficient and

49da0dc7-e046-42f2-9180-fcdca458e228/14-2
00:01:40.142 --> 00:01:43.301
effective as it could be.
And so we said what can we do that's

49da0dc7-e046-42f2-9180-fcdca458e228/14-3
00:01:43.301 --> 00:01:45.909
different?
And we looked at it and really the skill

49da0dc7-e046-42f2-9180-fcdca458e228/14-4
00:01:45.909 --> 00:01:49.821
set and the roles of EDUR while having a
lot of overlap with CM is distinctly

49da0dc7-e046-42f2-9180-fcdca458e228/14-5
00:01:49.821 --> 00:01:51.928
different and to do both at the same time.

49da0dc7-e046-42f2-9180-fcdca458e228/15-0
00:01:51.928 --> 00:01:55.604
Is very distracting and so that let's
carve out the EDUR piece and let's

49da0dc7-e046-42f2-9180-fcdca458e228/15-1
00:01:55.604 --> 00:01:59.129
systematize and centralize it,
especially because we are live on Epic

49da0dc7-e046-42f2-9180-fcdca458e228/15-2
00:01:59.129 --> 00:02:02.906
now for for many years and we have a
system we can communicate with people

49da0dc7-e046-42f2-9180-fcdca458e228/15-3
00:02:02.906 --> 00:02:05.374
electronically.
Why not centralize that process,

49da0dc7-e046-42f2-9180-fcdca458e228/15-4
00:02:05.374 --> 00:02:08.596
build it up, develop it,
invest in it and make the best quality

49da0dc7-e046-42f2-9180-fcdca458e228/15-5
00:02:08.596 --> 00:02:11.568
candidates working on it as possible to
be most efficient?

49da0dc7-e046-42f2-9180-fcdca458e228/16-0
00:02:11.848 --> 00:02:13.448
Infected in that universe.

49da0dc7-e046-42f2-9180-fcdca458e228/17-0
00:02:13.728 --> 00:02:18.268
And just for our listeners benefit,
can you outline some of the key

49da0dc7-e046-42f2-9180-fcdca458e228/17-1
00:02:18.268 --> 00:02:23.008
stakeholders involved in the decision to
move ahead with this process?

49da0dc7-e046-42f2-9180-fcdca458e228/19-0
00:02:23.208 --> 00:02:27.386
Yeah, it was a system wide conversation.
It was system wide between nursing

49da0dc7-e046-42f2-9180-fcdca458e228/19-1
00:02:27.386 --> 00:02:31.290
leadership, physician leadership,
care management leadership, finance.

49da0dc7-e046-42f2-9180-fcdca458e228/19-2
00:02:31.290 --> 00:02:35.634
It's really EDUR touches every point of
the healthcare journey on an inpatient

49da0dc7-e046-42f2-9180-fcdca458e228/19-3
00:02:35.634 --> 00:02:38.273
side and so really quite a big global
strategy.

49da0dc7-e046-42f2-9180-fcdca458e228/18-0
00:02:35.968 --> 00:02:36.688
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/19-4
00:02:38.273 --> 00:02:40.968
It was not a short or quick undertaking,
it was.

49da0dc7-e046-42f2-9180-fcdca458e228/21-0
00:02:40.968 --> 00:02:44.252
Months to years in the making,
we officially went live with a

49da0dc7-e046-42f2-9180-fcdca458e228/21-1
00:02:44.252 --> 00:02:46.741
centralized EDUR team as a one year.
Actually,

49da0dc7-e046-42f2-9180-fcdca458e228/21-2
00:02:46.741 --> 00:02:51.031
our one year anniversary was this month
and so now live and active for one year.

49da0dc7-e046-42f2-9180-fcdca458e228/20-0
00:02:48.688 --> 00:02:49.528
Mm-hmm.

49da0dc7-e046-42f2-9180-fcdca458e228/21-3
00:02:51.031 --> 00:02:55.269
But the process to build up the tools and
the resources you can get there were,

49da0dc7-e046-42f2-9180-fcdca458e228/21-4
00:02:55.269 --> 00:02:57.970
you know,
many months to years prior to the launch

49da0dc7-e046-42f2-9180-fcdca458e228/21-5
00:02:57.970 --> 00:02:58.288
of it.

49da0dc7-e046-42f2-9180-fcdca458e228/22-0
00:02:58.848 --> 00:03:03.086
So I'd like, you know,
a lot of times at Healthy Data podcast,

49da0dc7-e046-42f2-9180-fcdca458e228/22-1
00:03:03.086 --> 00:03:08.603
our listeners are are listening to this
episode and we'd like to make the stories

49da0dc7-e046-42f2-9180-fcdca458e228/22-2
00:03:08.603 --> 00:03:12.169
real to them.
Can you walk us through an example of,

49da0dc7-e046-42f2-9180-fcdca458e228/22-3
00:03:12.169 --> 00:03:15.600
I guess,
how the new centralized EDUR is impacting

49da0dc7-e046-42f2-9180-fcdca458e228/22-4
00:03:15.600 --> 00:03:17.888
some sort of end user's life, how?

49da0dc7-e046-42f2-9180-fcdca458e228/23-0
00:03:17.968 --> 00:03:21.608
Data is different and what the impact of
this change has been.

49da0dc7-e046-42f2-9180-fcdca458e228/25-0
00:03:21.888 --> 00:03:25.651
Yeah. So the impact is, is really great.
So #1 is we're doing the reviews in in

49da0dc7-e046-42f2-9180-fcdca458e228/25-1
00:03:25.651 --> 00:03:28.943
real time as possible, right.
We're really hitting the reviews within

49da0dc7-e046-42f2-9180-fcdca458e228/24-0
00:03:27.488 --> 00:03:27.848
Hmm.

49da0dc7-e046-42f2-9180-fcdca458e228/25-2
00:03:28.943 --> 00:03:31.295
an hour or two of being admitted to the
facility.

49da0dc7-e046-42f2-9180-fcdca458e228/25-3
00:03:31.295 --> 00:03:34.823
So it's really allowing real-time
conversations between clinicians and the

49da0dc7-e046-42f2-9180-fcdca458e228/25-4
00:03:34.823 --> 00:03:37.786
nurses doing their reviews.
And so in the world of billing and

49da0dc7-e046-42f2-9180-fcdca458e228/25-5
00:03:37.786 --> 00:03:40.984
reimbursements, you know,
unfortunately the medical record is still

49da0dc7-e046-42f2-9180-fcdca458e228/25-6
00:03:40.984 --> 00:03:41.408
that Ave.

49da0dc7-e046-42f2-9180-fcdca458e228/27-0
00:03:41.648 --> 00:03:43.947
Conduit.
And if it's not in the medical record in

49da0dc7-e046-42f2-9180-fcdca458e228/27-1
00:03:43.947 --> 00:03:46.707
a form of medical decision-making or a
form of a diagnosis,

49da0dc7-e046-42f2-9180-fcdca458e228/27-2
00:03:46.707 --> 00:03:49.329
you're not going to be able to get those
costs provided.

49da0dc7-e046-42f2-9180-fcdca458e228/27-3
00:03:49.329 --> 00:03:53.008
And so these nurses are reaching out to
physicians in real time and ask them to

49da0dc7-e046-42f2-9180-fcdca458e228/26-0
00:03:49.888 --> 00:03:50.408
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/27-4
00:03:53.008 --> 00:03:56.228
help upgrade the documentation,
upgrade the quality of their level of

49da0dc7-e046-42f2-9180-fcdca458e228/27-5
00:03:56.228 --> 00:03:57.608
care or upgrade the diagnosis.

49da0dc7-e046-42f2-9180-fcdca458e228/28-0
00:03:57.608 --> 00:04:00.411
Example,
a physician admits a patient for leg pain.

49da0dc7-e046-42f2-9180-fcdca458e228/28-1
00:04:00.411 --> 00:04:03.161
That's really not a great diagnosis.
In real time,

49da0dc7-e046-42f2-9180-fcdca458e228/28-2
00:04:03.161 --> 00:04:07.204
they can look into the chart and
recognize the MDM is pretty much in there

49da0dc7-e046-42f2-9180-fcdca458e228/28-3
00:04:07.204 --> 00:04:11.409
talking about this is a gangrenous foot
that's going to go to the OR and it's

49da0dc7-e046-42f2-9180-fcdca458e228/28-4
00:04:11.409 --> 00:04:14.644
really an acute emergency.
And so by communicating with the

49da0dc7-e046-42f2-9180-fcdca458e228/28-5
00:04:14.644 --> 00:04:17.448
physician in real time,
we can show data where the.

49da0dc7-e046-42f2-9180-fcdca458e228/29-0
00:04:17.568 --> 00:04:20.805
Diagnosis are increasing,
the level of severity of illness is

49da0dc7-e046-42f2-9180-fcdca458e228/29-1
00:04:20.805 --> 00:04:24.408
increasing and being more reflective of
actually the care providing.

49da0dc7-e046-42f2-9180-fcdca458e228/30-0
00:04:24.208 --> 00:04:27.542
I appreciate that.
I think that probably allows for greater

49da0dc7-e046-42f2-9180-fcdca458e228/30-1
00:04:27.542 --> 00:04:30.488
revenue capture for the organization.
Is that right?

49da0dc7-e046-42f2-9180-fcdca458e228/31-0
00:04:30.568 --> 00:04:33.349
Absolutely.
And also denial mitigation as a result.

49da0dc7-e046-42f2-9180-fcdca458e228/31-1
00:04:33.349 --> 00:04:37.841
So we're watching our denial rate go down,
revenue go up and also trying to improve

49da0dc7-e046-42f2-9180-fcdca458e228/31-2
00:04:37.841 --> 00:04:41.852
the the severity of illness of our
patients and the CMI of our patients by

49da0dc7-e046-42f2-9180-fcdca458e228/31-3
00:04:41.852 --> 00:04:45.328
more accurately capturing the information
on the medical record.

49da0dc7-e046-42f2-9180-fcdca458e228/32-0
00:04:45.328 --> 00:04:48.457
I got it.
And so in terms of and so it improves,

49da0dc7-e046-42f2-9180-fcdca458e228/32-1
00:04:48.457 --> 00:04:52.928
is it primarily improving documentation
that leads to those outcomes?

49da0dc7-e046-42f2-9180-fcdca458e228/34-0
00:04:54.088 --> 00:04:57.047
It's a combination.
So #1 is the documentation on the front

49da0dc7-e046-42f2-9180-fcdca458e228/34-1
00:04:57.047 --> 00:05:00.351
of the physician, right?
So the ED physician is that first contact

49da0dc7-e046-42f2-9180-fcdca458e228/34-2
00:05:00.351 --> 00:05:02.619
point to the process of where denial
happens.

49da0dc7-e046-42f2-9180-fcdca458e228/33-0
00:05:02.408 --> 00:05:03.008
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/34-3
00:05:02.619 --> 00:05:04.888
It also goes through the inpatient care
stay,

49da0dc7-e046-42f2-9180-fcdca458e228/34-4
00:05:04.888 --> 00:05:08.389
but the EDUR nurse manager also is
responsible for taking that initial

49da0dc7-e046-42f2-9180-fcdca458e228/34-5
00:05:08.389 --> 00:05:12.039
documentation and packaging of arrival
letter and saying to the insurance

49da0dc7-e046-42f2-9180-fcdca458e228/34-6
00:05:12.039 --> 00:05:13.568
company explaining why they're.

49da0dc7-e046-42f2-9180-fcdca458e228/37-0
00:05:14.328 --> 00:05:16.404
Being admitted to the hospital.
And so you know,

49da0dc7-e046-42f2-9180-fcdca458e228/37-1
00:05:16.404 --> 00:05:19.668
if the physician documentation is not
written in a manner that's reflective,

49da0dc7-e046-42f2-9180-fcdca458e228/37-2
00:05:19.668 --> 00:05:21.999
for example,
syncope as a case that gets denied a lot,

49da0dc7-e046-42f2-9180-fcdca458e228/37-3
00:05:21.999 --> 00:05:23.949
this is syncope and they send it another
way.

49da0dc7-e046-42f2-9180-fcdca458e228/37-4
00:05:23.949 --> 00:05:27.000
The care manager's massaging out the
details and saying, wait a minute,

49da0dc7-e046-42f2-9180-fcdca458e228/37-5
00:05:27.000 --> 00:05:29.925
you're describing heart failure in your,
describing a kidney injury,

49da0dc7-e046-42f2-9180-fcdca458e228/37-6
00:05:29.925 --> 00:05:33.061
describing a head injury in there.
I could see by your thought process by

49da0dc7-e046-42f2-9180-fcdca458e228/37-7
00:05:33.061 --> 00:05:34.248
what you're ordering that's.

49da0dc7-e046-42f2-9180-fcdca458e228/38-0
00:05:34.328 --> 00:05:36.965
You're thinking, but it's not reflecting.
Let's do that.

49da0dc7-e046-42f2-9180-fcdca458e228/36-0
00:05:35.248 --> 00:05:35.768
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/38-1
00:05:36.965 --> 00:05:39.788
And the care managers getting better at
writing that letter,

49da0dc7-e046-42f2-9180-fcdca458e228/38-2
00:05:39.788 --> 00:05:43.444
applying the criteria that a lot of the
insurers use to judge an admission and

49da0dc7-e046-42f2-9180-fcdca458e228/38-3
00:05:43.444 --> 00:05:46.915
then sending it off to the insurer.
And so that only not only improves our

49da0dc7-e046-42f2-9180-fcdca458e228/38-4
00:05:46.915 --> 00:05:49.877
initial upfront payment,
but also our initial upfront length of

49da0dc7-e046-42f2-9180-fcdca458e228/38-5
00:05:49.877 --> 00:05:52.977
stay needs for the patient.
You put a week diagnosis like syncope,

49da0dc7-e046-42f2-9180-fcdca458e228/38-6
00:05:52.977 --> 00:05:54.088
you get a day out of it.

49da0dc7-e046-42f2-9180-fcdca458e228/39-0
00:05:54.248 --> 00:05:56.567
You put a cute heart failure on chronic
heart failure,

49da0dc7-e046-42f2-9180-fcdca458e228/39-1
00:05:56.567 --> 00:05:59.899
acute kidney injury and a head injury.
You're talking about a couple more days

49da0dc7-e046-42f2-9180-fcdca458e228/39-2
00:05:59.899 --> 00:06:02.008
of hospital stay automatically approved
up front.

49da0dc7-e046-42f2-9180-fcdca458e228/40-0
00:06:02.128 --> 00:06:08.026
So it sounds like there's a lot of back
and forth between the payer arm and the

49da0dc7-e046-42f2-9180-fcdca458e228/40-1
00:06:08.026 --> 00:06:14.219
clinical arm when it comes to utilization
review. I'm wondering if any agentic Gen.

49da0dc7-e046-42f2-9180-fcdca458e228/40-2
00:06:14.219 --> 00:06:19.822
AI tools are in the roadmap for being
leveraged in order to facilitate this

49da0dc7-e046-42f2-9180-fcdca458e228/40-3
00:06:19.822 --> 00:06:20.928
back and forth.

49da0dc7-e046-42f2-9180-fcdca458e228/41-0
00:06:22.328 --> 00:06:22.528
Work.

49da0dc7-e046-42f2-9180-fcdca458e228/44-0
00:06:22.768 --> 00:06:24.586
Yeah,
we're actually looking into some A I

49da0dc7-e046-42f2-9180-fcdca458e228/44-1
00:06:24.586 --> 00:06:26.532
stuff,
not necessarily for the back and forth

49da0dc7-e046-42f2-9180-fcdca458e228/44-2
00:06:26.532 --> 00:06:28.816
piece of it,
but actually reviewing the documentation

49da0dc7-e046-42f2-9180-fcdca458e228/44-3
00:06:28.816 --> 00:06:31.481
to improve the quality.
Like are there better diagnosises that

49da0dc7-e046-42f2-9180-fcdca458e228/42-0
00:06:29.608 --> 00:06:30.088
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/44-4
00:06:31.481 --> 00:06:33.977
can be captured?
Can we be more accurate and more specific

49da0dc7-e046-42f2-9180-fcdca458e228/44-5
00:06:33.977 --> 00:06:36.176
in the ICD 10 codes when you're on there?
You know,

49da0dc7-e046-42f2-9180-fcdca458e228/44-6
00:06:36.176 --> 00:06:39.391
you talk about in the past issue this CK
day, you talk about the API today,

49da0dc7-e046-42f2-9180-fcdca458e228/44-7
00:06:39.391 --> 00:06:42.648
but you don't put the two words together
and you choose the wrong diagnosis.

49da0dc7-e046-42f2-9180-fcdca458e228/46-0
00:06:42.728 --> 00:06:45.678
This is on the IC10 list that's going to
lower your index.

49da0dc7-e046-42f2-9180-fcdca458e228/43-0
00:06:44.128 --> 00:06:44.688
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/46-1
00:06:45.678 --> 00:06:48.928
So from a data perspective,
we're using this to improve the CMI,

49da0dc7-e046-42f2-9180-fcdca458e228/46-2
00:06:48.928 --> 00:06:52.128
improve the data capture,
improve the quantity diagnosed in the

49da0dc7-e046-42f2-9180-fcdca458e228/46-3
00:06:52.128 --> 00:06:55.528
chart to be more accurate or popular with
the care we're providing.

49da0dc7-e046-42f2-9180-fcdca458e228/45-0
00:06:53.608 --> 00:06:54.088
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/47-0
00:06:55.328 --> 00:06:58.405
So Josh,
I think many of our listeners might be

49da0dc7-e046-42f2-9180-fcdca458e228/47-1
00:06:58.405 --> 00:07:02.893
interested in a few things.
The first of which would be what are some

49da0dc7-e046-42f2-9180-fcdca458e228/47-2
00:07:02.893 --> 00:07:08.150
of the data challenges of going through a
years long process of centralizing this

49da0dc7-e046-42f2-9180-fcdca458e228/47-3
00:07:08.150 --> 00:07:09.048
EDUR overhaul?

49da0dc7-e046-42f2-9180-fcdca458e228/50-0
00:07:09.288 --> 00:07:13.196
Yeah, so that's a great question.
That's bad data makes for bad output,

49da0dc7-e046-42f2-9180-fcdca458e228/50-1
00:07:13.196 --> 00:07:15.638
right? We know this garbage in,
garbage out.

49da0dc7-e046-42f2-9180-fcdca458e228/48-0
00:07:14.848 --> 00:07:15.528
Yeah.

49da0dc7-e046-42f2-9180-fcdca458e228/50-2
00:07:15.638 --> 00:07:19.546
And so prior to launching this,
we spent a good year fixing the quality

49da0dc7-e046-42f2-9180-fcdca458e228/50-3
00:07:19.546 --> 00:07:23.183
of the data capture on the physician and
the user. So for example,

49da0dc7-e046-42f2-9180-fcdca458e228/49-0
00:07:21.048 --> 00:07:21.288
Yeah.

49da0dc7-e046-42f2-9180-fcdca458e228/50-4
00:07:23.183 --> 00:07:27.471
we created a standard system-wide note
that helps with medical decision-making

49da0dc7-e046-42f2-9180-fcdca458e228/50-5
00:07:27.471 --> 00:07:29.208
when you're admitting a patient.

49da0dc7-e046-42f2-9180-fcdca458e228/51-0
00:07:29.768 --> 00:07:33.191
And we automate it so that if you choose
a disposition admission and you open this

49da0dc7-e046-42f2-9180-fcdca458e228/51-1
00:07:33.191 --> 00:07:35.088
note,
it automatically pre-populates with the

49da0dc7-e046-42f2-9180-fcdca458e228/51-2
00:07:35.088 --> 00:07:38.140
questions that we know you're thinking
about, we know you need to answer.

49da0dc7-e046-42f2-9180-fcdca458e228/51-3
00:07:38.140 --> 00:07:40.903
Why are you admitting this patient?
Because the labs are abnormal,

49da0dc7-e046-42f2-9180-fcdca458e228/51-4
00:07:40.903 --> 00:07:42.842
the imaging is abnormal,
they're at high risk.

49da0dc7-e046-42f2-9180-fcdca458e228/51-5
00:07:42.842 --> 00:07:44.368
So it captures all those data points.

49da0dc7-e046-42f2-9180-fcdca458e228/53-0
00:07:44.888 --> 00:07:48.700
That are relevant to the admission and
put it on a piece of paper right there.

49da0dc7-e046-42f2-9180-fcdca458e228/53-1
00:07:48.700 --> 00:07:52.465
That will then automatically pull in to
the Ed care manager's note as they're

49da0dc7-e046-42f2-9180-fcdca458e228/53-2
00:07:52.465 --> 00:07:55.264
writing the note.
So a lot of data is being pulled in all

49da0dc7-e046-42f2-9180-fcdca458e228/53-3
00:07:55.264 --> 00:07:58.015
the Admiral vitals,
the Admiral labs are being pulled in

49da0dc7-e046-42f2-9180-fcdca458e228/53-4
00:07:58.015 --> 00:08:01.008
automatically now to make their time
effective and efficient.

49da0dc7-e046-42f2-9180-fcdca458e228/52-0
00:07:58.168 --> 00:07:59.168
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/54-0
00:08:01.048 --> 00:08:03.802
On the next point,
we've now standardized the inpatient

49da0dc7-e046-42f2-9180-fcdca458e228/54-1
00:08:03.802 --> 00:08:07.835
documentation across our health system.
So all inpatient medical documentation is

49da0dc7-e046-42f2-9180-fcdca458e228/54-2
00:08:07.835 --> 00:08:11.769
problem-based charting now and it pulls
in all the data on the chart and allows

49da0dc7-e046-42f2-9180-fcdca458e228/54-3
00:08:11.769 --> 00:08:14.474
you to update it in real time.
So when the physicians,

49da0dc7-e046-42f2-9180-fcdca458e228/54-4
00:08:14.474 --> 00:08:16.688
especially the residents,
are writing notes.

49da0dc7-e046-42f2-9180-fcdca458e228/55-0
00:08:16.808 --> 00:08:20.344
They can update the course throughout the
entire hospital state to make their time

49da0dc7-e046-42f2-9180-fcdca458e228/55-1
00:08:20.344 --> 00:08:22.688
more effective and efficient and more
reflective care.

49da0dc7-e046-42f2-9180-fcdca458e228/56-0
00:08:23.248 --> 00:08:26.480
OK.
So it sounds like there were a lot of

49da0dc7-e046-42f2-9180-fcdca458e228/56-1
00:08:26.480 --> 00:08:32.559
efforts before implementing to fix the
quality of the data and the big path to

49da0dc7-e046-42f2-9180-fcdca458e228/56-2
00:08:32.559 --> 00:08:37.408
to do that was to standardize
documentation. Is that accurate?

49da0dc7-e046-42f2-9180-fcdca458e228/57-0
00:08:38.248 --> 00:08:41.677
That a huge lift of ours,
a huge foundational improvement to get to

49da0dc7-e046-42f2-9180-fcdca458e228/57-1
00:08:41.677 --> 00:08:42.888
the point we're at, yes.

49da0dc7-e046-42f2-9180-fcdca458e228/58-0
00:08:42.208 --> 00:08:44.780
OK.
And then from there you were able to

49da0dc7-e046-42f2-9180-fcdca458e228/58-1
00:08:44.780 --> 00:08:49.862
automate some of this note documentation
to facilitate greater time to admission

49da0dc7-e046-42f2-9180-fcdca458e228/58-2
00:08:49.862 --> 00:08:54.944
and greater throughput and efficiency,
which you mentioned the very beginning is

49da0dc7-e046-42f2-9180-fcdca458e228/58-3
00:08:54.944 --> 00:08:57.328
all pointing back to the need to make.

49da0dc7-e046-42f2-9180-fcdca458e228/59-0
00:08:57.408 --> 00:09:01.425
More happened with less as a public
safety net health care delivery system,

49da0dc7-e046-42f2-9180-fcdca458e228/61-0
00:09:01.128 --> 00:09:03.462
Absolutely.
And we're finding the quantity of reviews.

49da0dc7-e046-42f2-9180-fcdca458e228/59-1
00:09:01.425 --> 00:09:01.848
correct?

49da0dc7-e046-42f2-9180-fcdca458e228/61-1
00:09:03.462 --> 00:09:06.602
So when we measure the Edu activity,
we're measuring first the quality of

49da0dc7-e046-42f2-9180-fcdca458e228/61-2
00:09:06.602 --> 00:09:08.808
their views,
making sure their reviews are reaching

49da0dc7-e046-42f2-9180-fcdca458e228/60-0
00:09:08.008 --> 00:09:08.488
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/61-3
00:09:08.808 --> 00:09:12.033
the quality expectations we have.
We have 5 standard points we look through

49da0dc7-e046-42f2-9180-fcdca458e228/61-4
00:09:12.033 --> 00:09:14.240
as far as the quality,
are these in the right data,

49da0dc7-e046-42f2-9180-fcdca458e228/61-5
00:09:14.240 --> 00:09:17.762
the right care sets, the right etcetera.
And we look through the quality and watch

49da0dc7-e046-42f2-9180-fcdca458e228/61-6
00:09:17.762 --> 00:09:20.648
that improve over time and then the
second stage is to improve the.

49da0dc7-e046-42f2-9180-fcdca458e228/62-0
00:09:20.728 --> 00:09:23.357
The output of there,
how many reviews are they able to do per

49da0dc7-e046-42f2-9180-fcdca458e228/62-1
00:09:23.357 --> 00:09:26.411
hour? Are they able to, you know,
do a certain amount of cases per day?

49da0dc7-e046-42f2-9180-fcdca458e228/62-2
00:09:26.411 --> 00:09:28.914
How many touch points are they having
with the physicians?

49da0dc7-e046-42f2-9180-fcdca458e228/62-3
00:09:28.914 --> 00:09:32.265
And so we're measuring that and we're
watching their quality and quantity both

49da0dc7-e046-42f2-9180-fcdca458e228/62-4
00:09:32.265 --> 00:09:33.368
increase at the same time.

49da0dc7-e046-42f2-9180-fcdca458e228/63-0
00:09:33.568 --> 00:09:36.532
Well,
I think many of our listeners would love

49da0dc7-e046-42f2-9180-fcdca458e228/63-1
00:09:36.532 --> 00:09:41.576
to implement something like that that
increases the quality and the revenue for

49da0dc7-e046-42f2-9180-fcdca458e228/63-2
00:09:41.576 --> 00:09:45.171
the organization while while improving
patient outcomes.

49da0dc7-e046-42f2-9180-fcdca458e228/63-3
00:09:45.171 --> 00:09:50.090
I think you also work on a process of
centralizing writing appeal letters for

49da0dc7-e046-42f2-9180-fcdca458e228/63-4
00:09:50.090 --> 00:09:51.288
your health system.

49da0dc7-e046-42f2-9180-fcdca458e228/64-0
00:09:51.648 --> 00:09:55.048
Can you delve into what that process
looked like?

49da0dc7-e046-42f2-9180-fcdca458e228/65-0
00:09:55.208 --> 00:09:57.386
Yeah,
that's still in its early stages right

49da0dc7-e046-42f2-9180-fcdca458e228/65-1
00:09:57.386 --> 00:09:59.565
now.
We're at the point where we're about to

49da0dc7-e046-42f2-9180-fcdca458e228/65-2
00:09:59.565 --> 00:10:03.292
pilot a lot of that requiring to kind of
in the background organize flow and

49da0dc7-e046-42f2-9180-fcdca458e228/65-3
00:10:03.292 --> 00:10:07.262
throughput and outcomes in Epic to allow
us to streamline work through processes.

49da0dc7-e046-42f2-9180-fcdca458e228/65-4
00:10:07.262 --> 00:10:11.183
And so we're looking to take the appeals
writing that was being done locally the

49da0dc7-e046-42f2-9180-fcdca458e228/65-5
00:10:11.183 --> 00:10:15.008
sites in various different formats,
a lot of outside Epic formats on Excel or.

49da0dc7-e046-42f2-9180-fcdca458e228/66-0
00:10:15.048 --> 00:10:19.156
Or Word documents or an e-mail really
trying to bring it in-house so everything

49da0dc7-e046-42f2-9180-fcdca458e228/66-1
00:10:19.156 --> 00:10:21.416
is searchable,
quantifiable and reviewable.

49da0dc7-e046-42f2-9180-fcdca458e228/66-2
00:10:21.416 --> 00:10:25.421
And so in this process creating work
queues and work lists that will feed the

49da0dc7-e046-42f2-9180-fcdca458e228/66-3
00:10:25.421 --> 00:10:29.221
information along the the conveyor belt
of data that needs to go through.

49da0dc7-e046-42f2-9180-fcdca458e228/66-4
00:10:29.221 --> 00:10:33.227
But then also as the physicians are
writing their appeals quantifying the the

49da0dc7-e046-42f2-9180-fcdca458e228/66-5
00:10:33.227 --> 00:10:34.768
defensibility, this is a high.

49da0dc7-e046-42f2-9180-fcdca458e228/68-0
00:10:34.888 --> 00:10:37.686
Defensible case.
This is a less defensible case.

49da0dc7-e046-42f2-9180-fcdca458e228/68-1
00:10:37.686 --> 00:10:42.196
So then we can then kind of go back and
measure the data and say where are our

49da0dc7-e046-42f2-9180-fcdca458e228/68-2
00:10:42.196 --> 00:10:44.652
problems?
Where are cases that are clearly

49da0dc7-e046-42f2-9180-fcdca458e228/68-3
00:10:44.652 --> 00:10:49.277
appropriately being admitted and treated
for but not being paid by the insurers?

49da0dc7-e046-42f2-9180-fcdca458e228/68-4
00:10:49.277 --> 00:10:49.848
Are these?

49da0dc7-e046-42f2-9180-fcdca458e228/69-0
00:10:50.008 --> 00:10:54.013
Inappropriate denials are these, you know,
these regious denials should be going

49da0dc7-e046-42f2-9180-fcdca458e228/69-1
00:10:54.013 --> 00:10:57.969
after the insurers in these cases where
they're not providing the reimbursement

49da0dc7-e046-42f2-9180-fcdca458e228/69-2
00:10:57.969 --> 00:11:01.826
for the care provided versus these are
cases that are less weak, less strong.

49da0dc7-e046-42f2-9180-fcdca458e228/69-3
00:11:01.826 --> 00:11:05.287
It's just a part of our patient
demographics and population and their

49da0dc7-e046-42f2-9180-fcdca458e228/69-4
00:11:05.287 --> 00:11:08.699
healthcare needs and it just became more
complicated and part of our

49da0dc7-e046-42f2-9180-fcdca458e228/69-5
00:11:08.699 --> 00:11:09.688
mission-driven care.

49da0dc7-e046-42f2-9180-fcdca458e228/70-0
00:11:09.568 --> 00:11:16.146
What are the data sources and data
destinations for this centralized process

49da0dc7-e046-42f2-9180-fcdca458e228/70-1
00:11:16.146 --> 00:11:18.368
of writing appeal letters?

49da0dc7-e046-42f2-9180-fcdca458e228/71-0
00:11:17.448 --> 00:11:20.158
So when the appeals are received at a
local facility,

49da0dc7-e046-42f2-9180-fcdca458e228/71-1
00:11:20.158 --> 00:11:23.421
they're injected into the system and then
fed into a work queue,

49da0dc7-e046-42f2-9180-fcdca458e228/71-2
00:11:23.421 --> 00:11:26.131
which is then routed to a global group of
physicians.

49da0dc7-e046-42f2-9180-fcdca458e228/71-3
00:11:26.131 --> 00:11:30.046
What we're working on right now is to
have a global group of physicians ready

49da0dc7-e046-42f2-9180-fcdca458e228/71-4
00:11:30.046 --> 00:11:33.309
to write these appeals,
which will then kind of route it back to

49da0dc7-e046-42f2-9180-fcdca458e228/71-5
00:11:33.309 --> 00:11:35.568
local facility to finish off the process
of.

49da0dc7-e046-42f2-9180-fcdca458e228/74-0
00:11:35.728 --> 00:11:39.057
Sending back to the payer for appeals,
that's kind of the 30,

49da0dc7-e046-42f2-9180-fcdca458e228/74-1
00:11:39.057 --> 00:11:43.460
000 foot view over there process of the
position right appeal and they're looking

49da0dc7-e046-42f2-9180-fcdca458e228/72-0
00:11:40.688 --> 00:11:41.288
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/74-2
00:11:43.460 --> 00:11:46.414
through the charts.
They are as they're processing it,

49da0dc7-e046-42f2-9180-fcdca458e228/74-3
00:11:46.414 --> 00:11:50.656
they're giving their opinions on the
level of quality of the case and you know

49da0dc7-e046-42f2-9180-fcdca458e228/74-4
00:11:50.656 --> 00:11:53.341
whether it meets criteria,
doesn't meet criteria,

49da0dc7-e046-42f2-9180-fcdca458e228/74-5
00:11:53.341 --> 00:11:55.328
whether it follows clinical guidance.

49da0dc7-e046-42f2-9180-fcdca458e228/75-0
00:11:55.448 --> 00:11:59.968
Versus one of these more specific systems
of of pair guidelines.

49da0dc7-e046-42f2-9180-fcdca458e228/73-0
00:11:55.728 --> 00:11:55.968
Yeah.

49da0dc7-e046-42f2-9180-fcdca458e228/76-0
00:12:01.368 --> 00:12:06.940
A lot of times I ask guests on the show
to quantify the costs of implementing new

49da0dc7-e046-42f2-9180-fcdca458e228/76-1
00:12:06.940 --> 00:12:10.202
programs,
and the cost could be financial or it

49da0dc7-e046-42f2-9180-fcdca458e228/76-2
00:12:10.202 --> 00:12:13.396
could be cultural.
It could be getting buy-in.

49da0dc7-e046-42f2-9180-fcdca458e228/76-3
00:12:13.396 --> 00:12:18.085
And the idea is to help evaluate the
return on investment of of such

49da0dc7-e046-42f2-9180-fcdca458e228/76-4
00:12:18.085 --> 00:12:19.648
interventions, however.

49da0dc7-e046-42f2-9180-fcdca458e228/78-0
00:12:20.968 --> 00:12:28.151
It seems like both of these centralized
process of processes of centralizing Ed

49da0dc7-e046-42f2-9180-fcdca458e228/78-1
00:12:28.151 --> 00:12:35.065
utilization review and writing appeal
letters is increasing revenue with the

49da0dc7-e046-42f2-9180-fcdca458e228/78-2
00:12:35.065 --> 00:12:38.208
accurate charge decreasing denials.

49da0dc7-e046-42f2-9180-fcdca458e228/79-0
00:12:38.408 --> 00:12:43.829
Of claims and then leading to greater
capturing of claims that have been

49da0dc7-e046-42f2-9180-fcdca458e228/79-1
00:12:43.829 --> 00:12:49.696
submitted and denied and identifying
which are egregious and may be able to be

49da0dc7-e046-42f2-9180-fcdca458e228/79-2
00:12:49.696 --> 00:12:53.483
reversed.
So it sounds like the financial case for

49da0dc7-e046-42f2-9180-fcdca458e228/79-3
00:12:53.483 --> 00:12:58.088
both of these interventions is is
conspicuous, is that right?

49da0dc7-e046-42f2-9180-fcdca458e228/81-0
00:12:58.368 --> 00:13:00.685
Yeah,
I would say the one thing that you didn't

49da0dc7-e046-42f2-9180-fcdca458e228/81-1
00:13:00.685 --> 00:13:03.340
capture on there is also the free of
resources, right.

49da0dc7-e046-42f2-9180-fcdca458e228/81-2
00:13:03.340 --> 00:13:06.912
So we don't capture very well is when you
get a denial and how much time,

49da0dc7-e046-42f2-9180-fcdca458e228/81-3
00:13:06.912 --> 00:13:10.049
staff and energy is wasted on chasing it,
right. So it comes in,

49da0dc7-e046-42f2-9180-fcdca458e228/80-0
00:13:09.088 --> 00:13:09.568
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/81-4
00:13:10.049 --> 00:13:14.008
the local person opens up the envelope,
they process it, they they file it, they.

49da0dc7-e046-42f2-9180-fcdca458e228/83-0
00:13:14.128 --> 00:13:16.383
Notify someone, someone as a researcher,
look into it,

49da0dc7-e046-42f2-9180-fcdca458e228/83-1
00:13:16.383 --> 00:13:18.597
decide they're gonna act on it.
If they do act on it,

49da0dc7-e046-42f2-9180-fcdca458e228/83-2
00:13:18.597 --> 00:13:21.304
you gotta write it up.
And the whole process of doing this, this,

49da0dc7-e046-42f2-9180-fcdca458e228/83-3
00:13:21.304 --> 00:13:24.010
this whole workflow here.
And it's it's hard to quantify how many

49da0dc7-e046-42f2-9180-fcdca458e228/83-4
00:13:24.010 --> 00:13:26.594
touch points I have.
It depends on where you're talking about.

49da0dc7-e046-42f2-9180-fcdca458e228/83-5
00:13:26.594 --> 00:13:29.013
Some institutions,
I think a denial will forge written off

49da0dc7-e046-42f2-9180-fcdca458e228/83-6
00:13:29.013 --> 00:13:31.637
makes its way all the way to CF O's desk
to say, you know what,

49da0dc7-e046-42f2-9180-fcdca458e228/83-7
00:13:31.637 --> 00:13:33.688
we're not gonna chase this anymore.
Write it off.

49da0dc7-e046-42f2-9180-fcdca458e228/82-0
00:13:33.768 --> 00:13:34.368
Mhm.

49da0dc7-e046-42f2-9180-fcdca458e228/84-0
00:13:33.888 --> 00:13:36.804
And so how much is that person's time
worth, right?

49da0dc7-e046-42f2-9180-fcdca458e228/84-1
00:13:36.804 --> 00:13:39.832
So we think about all the touch points
along the way.

49da0dc7-e046-42f2-9180-fcdca458e228/84-2
00:13:39.832 --> 00:13:44.093
Every denial saved also frees up staff to
spend their time on more valuable

49da0dc7-e046-42f2-9180-fcdca458e228/84-3
00:13:44.093 --> 00:13:45.888
activities than chasing denials.

49da0dc7-e046-42f2-9180-fcdca458e228/85-0
00:13:45.768 --> 00:13:50.895
So are there any other avenue,
any other areas of the organization where

49da0dc7-e046-42f2-9180-fcdca458e228/85-1
00:13:50.895 --> 00:13:54.617
centralization is going to benefit the
organization?

49da0dc7-e046-42f2-9180-fcdca458e228/85-2
00:13:54.617 --> 00:13:59.955
Or an alternate question would be,
are there any downsides to centralizing?

49da0dc7-e046-42f2-9180-fcdca458e228/85-3
00:13:59.955 --> 00:14:03.608
Because it sounds like there's a lot of
value here.

49da0dc7-e046-42f2-9180-fcdca458e228/86-0
00:14:03.928 --> 00:14:04.168
And.

49da0dc7-e046-42f2-9180-fcdca458e228/87-0
00:14:04.608 --> 00:14:07.313
Yeah, I mean,
it's a big culture change and could

49da0dc7-e046-42f2-9180-fcdca458e228/87-1
00:14:07.313 --> 00:14:10.343
culture shift, right?
So one of the hardest parts is 11

49da0dc7-e046-42f2-9180-fcdca458e228/87-2
00:14:10.343 --> 00:14:14.239
facilities do things 11 different ways.
And so how do you get people to

49da0dc7-e046-42f2-9180-fcdca458e228/87-3
00:14:14.239 --> 00:14:17.432
participate and be a part of it is a big
challenge, right?

49da0dc7-e046-42f2-9180-fcdca458e228/87-4
00:14:17.432 --> 00:14:19.488
I think the opportunities are greater.

49da0dc7-e046-42f2-9180-fcdca458e228/88-0
00:14:19.928 --> 00:14:22.806
Once you kind of get people rallying
behind your side,

49da0dc7-e046-42f2-9180-fcdca458e228/88-1
00:14:22.806 --> 00:14:26.051
a big part of this role is the change
management piece of it.

49da0dc7-e046-42f2-9180-fcdca458e228/88-2
00:14:26.051 --> 00:14:30.132
But I think we've demonstrated that we
can do more with less by being smarter

49da0dc7-e046-42f2-9180-fcdca458e228/88-3
00:14:30.132 --> 00:14:32.958
and more organized about how we approach
the problem.

49da0dc7-e046-42f2-9180-fcdca458e228/88-4
00:14:32.958 --> 00:14:36.779
I think this will lead to the next
logical steps that might be improving

49da0dc7-e046-42f2-9180-fcdca458e228/88-5
00:14:36.779 --> 00:14:39.448
documentation for billing inpatient
documentation.

49da0dc7-e046-42f2-9180-fcdca458e228/89-0
00:14:39.488 --> 00:14:42.226
Documentation on other services besides
medical services.

49da0dc7-e046-42f2-9180-fcdca458e228/89-1
00:14:42.226 --> 00:14:45.530
I think standardizing the data capture
will be helpful for, you know,

49da0dc7-e046-42f2-9180-fcdca458e228/89-2
00:14:45.530 --> 00:14:48.882
look at trauma as an example.
Trauma's got a very specific expectation

49da0dc7-e046-42f2-9180-fcdca458e228/89-3
00:14:48.882 --> 00:14:52.612
from the American College of Surgeons of
what they want on their documentation

49da0dc7-e046-42f2-9180-fcdca458e228/89-4
00:14:52.612 --> 00:14:55.067
standards.
I think this is their right for the next

49da0dc7-e046-42f2-9180-fcdca458e228/89-5
00:14:55.067 --> 00:14:55.728
opportunities.

49da0dc7-e046-42f2-9180-fcdca458e228/90-0
00:14:56.008 --> 00:14:58.411
To then help with the data capture local
facilities,

49da0dc7-e046-42f2-9180-fcdca458e228/90-1
00:14:58.411 --> 00:15:01.904
there's a lot of trauma centers in our
health system and they spend a lot of

49da0dc7-e046-42f2-9180-fcdca458e228/90-2
00:15:01.904 --> 00:15:03.899
resources on that data capture for the
ACS.

49da0dc7-e046-42f2-9180-fcdca458e228/90-3
00:15:03.899 --> 00:15:07.573
So I think this will help them be more
effective in their role and more accurate

49da0dc7-e046-42f2-9180-fcdca458e228/90-4
00:15:07.573 --> 00:15:08.208
in their role.

49da0dc7-e046-42f2-9180-fcdca458e228/91-0
00:15:08.328 --> 00:15:10.924
As we approach the end of this podcast
episode, Josh,

49da0dc7-e046-42f2-9180-fcdca458e228/91-1
00:15:10.924 --> 00:15:14.723
I'd like to ask you to reflect on the
last few years of implementing these two

49da0dc7-e046-42f2-9180-fcdca458e228/91-2
00:15:14.723 --> 00:15:17.656
centralized processes.
And for the benefit of our listeners,

49da0dc7-e046-42f2-9180-fcdca458e228/91-3
00:15:17.656 --> 00:15:21.503
do you have any advice that you would
have given to your that you could give to

49da0dc7-e046-42f2-9180-fcdca458e228/91-4
00:15:21.503 --> 00:15:25.398
yourself if you had the opportunity to
speak to yourself before you went through

49da0dc7-e046-42f2-9180-fcdca458e228/91-5
00:15:25.398 --> 00:15:26.168
these processes?

49da0dc7-e046-42f2-9180-fcdca458e228/93-0
00:15:26.688 --> 00:15:29.389
Yeah, you know,
I think patience is really important for

49da0dc7-e046-42f2-9180-fcdca458e228/93-1
00:15:29.389 --> 00:15:33.037
this whole process and I think any
expectations you have how quick something

49da0dc7-e046-42f2-9180-fcdca458e228/93-2
00:15:33.037 --> 00:15:35.265
can go,
you really need to slow that down even

49da0dc7-e046-42f2-9180-fcdca458e228/93-3
00:15:35.265 --> 00:15:37.492
further.
You may think it takes you six weeks,

49da0dc7-e046-42f2-9180-fcdca458e228/93-4
00:15:37.492 --> 00:15:40.809
you make a bunch of 12 weeks,
but you really want to give yourself 24

49da0dc7-e046-42f2-9180-fcdca458e228/93-5
00:15:40.809 --> 00:15:42.941
weeks.
It's really with that very tongue and

49da0dc7-e046-42f2-9180-fcdca458e228/92-0
00:15:41.568 --> 00:15:41.648
Uh.

49da0dc7-e046-42f2-9180-fcdca458e228/93-6
00:15:42.941 --> 00:15:45.737
cheekly, but you know,
the reality is you have to be slow,

49da0dc7-e046-42f2-9180-fcdca458e228/93-7
00:15:45.737 --> 00:15:46.448
purposeful and.

49da0dc7-e046-42f2-9180-fcdca458e228/94-0
00:15:46.648 --> 00:15:49.802
Make sure that you're sensitive to
everyone's needs to really make this kind

49da0dc7-e046-42f2-9180-fcdca458e228/94-1
00:15:49.802 --> 00:15:51.728
of level of change that we're working on
here.