change the global supply problem for hydrocarbons, which has been based upon, call it, a decade of bad policy, and they can't change the price of food. So we're going to see energy and food prices march higher over the next year, and we're going to see the economy cool off. And you already see Fedsland Futures telling you that they're going to have to cut rates sometime in mid-2023, and I agree with that. You know, I just don't see that happening. You had Q1 at minus 1.4. You'd have to average, the next three quarters will have to average over 4% growth to hit the Feds staff's target of 2.8, so that's just not going to happen. So I think that we're in a scenario where we have a stagflationary environment. I think the economy is going to cool off, and we will have a recession by the end of this year or the beginning of next year, and we'll still have rising food prices and rising energy prices. And unfortunately, the Feds monetary policy just can't change that. I believe that the amount that they can raise rates is indicative or kind of anchored in the delta from the base and not necessarily equalizing it with, quote, the neutral rate. So I don't think they're going to get much over 200 basis points and hikes before they have to pause and turn the other way. But again, the tapestry or the characterization of a bear market is when they bounce them on decelerating volume. That's a terrible volume day. And as much as the last bounce day that we had also came on decelerating volume. So again, get ready. So people are like, oh, we're going to rally into month end. Well, okay, we're not. The central case for investors is the Feds going to tighten until they achieve what they want, which is engineering a soft landing. But really what they'd like to see is a demand destruction by either jobs falling or GDP contracting. And I think the thing that is not really priced and very difficult to price is a lot of things could go right. I mean, something as simple as labor market could start to ease because you get rebounders, people coming back to the workforce or the job market weekends. Or we could have a real decline in goods prices now that we've seen it from these retailers. They have too much inventory. That's actually deflationary. Supply chains could come back online better than expected and possibly the war could end. I mean, so I think if you think the cumulative probability of many of these things is much greater than the market's discounting, that means stocks and the Fed could actually be much further along than people realize. A standout in the last couple of weeks is the fact that we declined 16% in less than four months. That's only happened 16 times uniquely since 1940. So it's not, we're in a different mode where I think it's not about fundamental now to technical decline. But the good news is of the 16 instances, 12 out of the 16 times, the market was higher six months later. Average gain is more than double digit. And 15 of the 16 times, the market was higher. 12 months later, average gains 20. So we're in a zone where if the market finds its footing, we're in a world of double digit expected returns. We think unit growth measured correctly is going to surprise hugely on the high side of expectations and that inflation is going to turn down. And we would not be surprised over time to see it go negative once more. Because disruptive innovation is becoming a much bigger base in the economy. Electric vehicles, when we first started ARC, weren't even, they were probably not even 20,000 vehicles. That was 2014. Last year, we were up at 4.8 million units. This year, we think we could be close to 7.5 million units globally as the consumer preference shift accelerates towards electric. And so that's approaching 10% of all auto sales. And I think Nancy's idea of this reshoring, the manufacturing renaissance here in the United States, is going to be a boon for our country. It's going to hurt other countries, but a boon for our country, I think that's one of the reasons the dollar is going up. And I think that our productivity gains are going to be enormous. Because we lost a lot of the industrial world to other countries. Now we can rebuild it here with state-of-the-art technology. And that's very exciting from a productivity point of view. These are my revised stock price estimates. This chart coming up is what the existing share count is now. And I show it under this and the new share count with the looser. This is 2021. I'm not a financial advisor. I'm working out the numbers for the 2025 model year for Ride. And I'm going to play that supporting information, but it's pretty shocking to me. The present value target I have on Ride after the start of production without dilution is $125 a share. OK, so this is the update on that with the full dilution of the shares approved at the shareholder meeting recently. And this is June 2022. That price at the start of production that high, the jump is to $30.50 a share back of the napkin. Not an accountant, not a financial advisor. Don't really like to do the numbers. Can't really do math anymore, but this is my best estimate at this point. You know, production growth, 15% increase. So we should be able to double production growth easily at large time because we're starting at such a low level. We can probably, we can at least double every year from this year or let's just say next year to 2025, no problem. So the average price we're going to get when we do that, we're starting at $125 without dilution. We're going to be at $190. And with dilution, we're going to be at $171. Now, again, here's the 2022 revision on that price target. That revision on the price after we ramp up production is $45.60 a share. And again, this is with the full 150 million share dilution applied to the existing stock. So, you know, this is from the starting point where we are now of $2 a share. So this is the update. This is what I come up with. Now, here's a chart, which isn't very good. But we're starting right here at 6, OK? And then this point here is when we get certified and they roll the truck off the line and we start sending out the product, even if it's five units, whatever it is, that shop. I predict the stock is going to shoot up to this level. And then over the three years, here's the endurance right here, we're going to see this hockey stick. And I believe since we are starting again at such, we're starting at zero, we can double production every year easily. I think these prices are, if you've seen my last few videos, you've seen how I come up with this number, these numbers. So by 2025, if we average these two, you know, it's 180 a share, which is 30x, 30x from present value, something like that. Anyway, this is my evaluation. I just want to go down here. OK, these are forecast numbers I did back in September of last year, based on the Schmidt buildout of the plant. Foxconn may improve this capacity, we don't know. But these were numbers that were carefully thought out and also included in the expected demand. These are some production targets that I've come up with. So we got 15 cars an hour at top production speed, eight hours, 120 per shift, potential 480 a day, 110,000 units a year for the first year. 65,000, a present plant capacity as we have it aligned right now is 174,800 units. OK, with this projection, we're going to be running at that capacity. We're going to have to increase plant capacity year two and year three. By 2025, the plant maximum capacity is going to have to be expanded by 280,000 units a year. So we're looking at, I don't know what these total sales are, 300, 380, 400. OK, we're talking about, let's say, half a million units in sales. This is what I'm projecting. So you're going to have to build a new plant elsewhere or they have 70% of open space at the present plant. So the point is, someone mentioned in comments Schmidt, the president, he said, shouldn't we get an executive in there instead of having a production guy? No, we should not. We're going to have explosive growth. According to these projects, these numbers I've worked out, you can do your own numbers, you can work them out. I'm going to go over what this scenario is in a minute. But the point is, we're going to have to expand the plant twice to meet demand, OK? And we have room there and Schmidt's the guy to do it. And now this is a rosy scenario. I'm not a financial advisor. We still got a 34% chance of a black swan, OK? We got this new virus coming around. Who knows what's going to happen? Many things could happen, recalls and so forth. Failure, OK? But these numbers and that stock price means that we sell all units made. And I think they'll do that. They'll sell every unit they make. Just by the forward lightning demand right now, they're going to sell every unit they make. There's only one model, the endurance, OK? So these numbers are based on selling every endurance they can build over that time period to 2025. And by the way, these are, I believe, achievable PEs and everything else at those stock prices. If you get into speculating, they can go above those prices. And on the stock price, I think that the change is coming. The tipping point has been hit with EVs. I think this stock price, if you saw my latest video about Ford, the Osborn effect, I think this stock price certainly can be speculated up and invested up. I think there's a lot of room to grow. This is a conservative estimate. But the top end is unlimited, I think, depending on the rebound in the macro economy and so forth. There's a van coming. We've already got the high top van coming. They said next year in one of the calls. We don't know if that would be a secondary product. They also have an SUV planned the following year in 2023, big sellers. So these production numbers could double with any success with these other products. So I'm just talking about one product. And also, now, what we can assume fleet sales, but at some point, they're going to break out into public sales. So we're just talking gross sales, OK? Now, again, they're going to have to expand the capacity just to meet the needs of my opinion. Now.


Yes. Well, welcome to this first Zoom session of the Harvard Medical School Center for Bioethics Organizational Ethics Consortium. I'm Jim Saban of the Harvard Pilgrim Institute, and I'll be moderating our exciting event today. This is the 30th session of the Organizational Ethics Consortium, which began in 2014 with the objective of creating a learning community around the issue of organizational ethics in health care. Health system organizational ethics has been underattended to as a crucial area of the ethical quality of our system, and we're very happy to welcome a large group from the kind of national audience that Zoom allows to this session. We'll be listening to our panel, our distinguished panel, and you can raise questions and make comments on the chat function while that's happening. Kelsey Berry will monitor the chat and help us draw on it for questions and comments after the presentation. Once the presentation's over, I'll say more about the technology of how to communicate. But our aim, as I said, is to build a learning community and Zoom gives us the opportunity to do that in a more extensive way. So today, we have an event that embodies the goal that we set when we started this. We have the leaders of three ethics programs. Anita Wagner, who leads the program at Harvard Pilgrim Health Care. Jonathan Harland, who leads the ethics program at Atreus Health and Lachlan Faro, who has been the leader of the ethics program at the Beth Israel Deaconess Hospital. So three sites, which are often at loggerheads with each other, as types, as representatives of types of places, sharing a common inquiry into how we can improve the ethical quality of our health system. So we'll be hearing from them. And I think at this point, we can invite you to take it away. So good afternoon, everyone. And welcome to Building Bridges for Better Health. Our opening presentation will be by Anita Wagner from Harvard Pilgrim Health Care, Lachlan Faro from Beth Israel Deaconess Medical Center, and by myself, Jonathan Harland from Atreus Health. And we will be asking the question, can inter-organizational ethics contribute to better health care? Next, Kelsey. So today's discussion will have three parts. First, we will give an introduction to our three institutions and the ethics programs that reside within them. We'll also be talking a little bit about how we started thinking together and what brought us to today's discussion. Then for part two, Anita Wagner will provide us with an illustration from oncology care. And we'll see that we have a fragmented system. Competing forces determine the actions of hospitals, ambulatory care practices, and insurance companies. And we're hoping to keep parts one and two to less than 30 minutes so that we have plenty of time for part three, about an hour. And that will involve all of you in a conversation. We'd like to hear your feedback. And we'd like to hear your suggestions. We'll be asking many questions, wrestling with many questions. One of them will be, how could inter-organizational ethics promote progress towards a more equitable health and social system? Next, Kelsey. All right, so let's begin with our three organizations. What are our three organizations? So Harvard Pilgrim Health Care is a nonprofit health services company with innovative teaching and research. It's an insurance company. However, it's unique due to a number of qualities it being nonprofit. Also, it's very population health-oriented. And in addition, it has a tremendous academic infrastructure. Then we have Beth Israel Deaconess Medical Center, which is a nonprofit academic medical center, and is now part of Beth Israel Leahy Health during 2019, Beth Israel Leahy merged into a larger hospital-based organization in the Boston area. And finally, we have Atreus Health, which is a nonprofit primary care practice treating about 750,000 patients in Eastern Massachusetts. Now, it's a multi-specialty primary care practice. So it has both primary care and a variety of medical-surgical specialties. And about 30 clinics in the Boston area. So we try to bring care closer to where people live. And we don't have a hospital. We partner with many hospitals. But that makes us very different from, say, Beth Israel. One other thing I'd like to mention is just in terms of the three of us getting together, our very brief history is that we all have ethics programs at our organizations. And so we've interacted with each other. And we decided to kind of informally meet. And we got together on one of the balconies at the old Sears-Robuck building at Landmark Center, which is where the Department of Population Medicine is located. And the three of us, Anita, Locke, and I would kind of sit up there on the balcony and begin to brainstorm, what could we do together as three organizations that perhaps we couldn't do individually? OK, next. So we began to discuss ethics in health systems. And here we have the classic iceberg analogy. In this case, the tip of the iceberg is traditional medical ethics. Now, for many years, hospitals had ethics committees. And when a doctor had a challenging ethical issue, perhaps with an individual patient, they might call an ethics consult. And the committee would address that particular case. This has been part of the history of medicine. And it remains an important function in medicine. So these committees are very valuable and should continue. However, when you think of ethics more broadly, these individual cases can be thought of as just the tip of the iceberg. Underneath that is organizational ethics. And this is the ethics that applies to organizations, policies, processes, procedures. In fact, Anita, Lockwood, and I are a part of ethics committees that address organizational issues. And then deeper still, you have an even broader area, which you could call societal ethics. And these are the kinds of issues that you may hear about in politics or on the news. And certainly, many of these issues have come up during the pandemic this year. Next. OK. And at each of these levels, we have various decision support questions. Now, this particular framework on this slide was created by our dear friend and colleague, Jim Saban. And Dr. Saban ran an ethics advisory group at Harvard Pilgrim for many, many years and designed this structure to kind of describe what they do and give them some guidance. So first is identification. What is the ethical issue at hand? Then after some discussion, we attempt to arrive at a decision. What's the right thing to do, given diverse values? Then implementation. What's the most ethical way to do it? And while we're doing this, we're always looking forward and looking backward. Forward is anticipation. What ethical challenges are coming? Backward is retrospection. What can we learn from actions in the past? Next. OK. So now let's take a look at the organizational missions of the three organizations that we represent. We'll start with Beth Israel Deaconess Medical Center. Their mission is to provide extraordinary care where the patient comes first, supported by world-class education and research. Then Harvard Pilgrim Health Care to improve the quality and value of health care for the people and communities we serve. And finally, Atreus Health, we provide the right care with kindness and compassion every day for every person we serve. So if you think about these three missions, they seem pretty compatible to me. There's slight differences. Beth Israel, perhaps, emphasizes academics. Harvard Pilgrim may have an orientation towards population health. And Atreus Health is perhaps more focused on individual health care. But overall, these are very positive missions. And I would say they're very compatible with one another. So in theory, these three organizations should be able to work together very well to improve care for an individual patient. Next. Okay, so here we're continuing with the building bridges metaphor. This particular bridge is in Toledo, Spain. And what I'd like to do next is talk about our three ethics programs. And we'll divide that up and we'll each talk about our own programs at our institution. So we'll begin with Atreus Health. Next. Okay. So the Atreus Health Bioethics Program has a mission to provide an organizational framework for the thoughtful analysis and practical discussion of ethics. And here are a few components of our program. The core is the Ethics Advisory Committee. And the committee has about a dozen core members, but it's actually open to the practice. So our discussions are open. Anyone can join, anyone can contribute. And we address organizational topics. Then we also have what we call amplifying empathy forums and I facilitate these during our new clinician orientation. So it's actually built into part of the structure of our orientation. And what we do is we encourage conversations about how to communicate with patients in a more empathetic manner right from the beginning. Then there's Schwartz Rounds. Atreus Health is a member of the Schwartz Center for Compassionate Healthcare. And we have Schwartz Rounds going at a couple of our sites, the Watertown site and the Braintree site. And then finally, there's the Atreus Health Academic Institute, which is based at the Harvard Vanguard Kenmore practice in Kenmore Square. And we have four academic centers, education, informatics, research and innovation. The Atreus Health Bioethics Program is housed at the Center for Education. So that's Atreus's program. And I think we'll switch over now to Beth Israel Deaconess Medical Center. Laughlin, would you like to open up that discussion? Yes, I'll be brief. I think people can read this slide. So I don't need to read every word, but Beth Israel has a very interesting, history in terms of ethics, because it was a pioneer before I was involved in a lot of things. 1972, the first statement of patient rights of any hospital in the country, I think the world. In 1976, published in the Williamson Journal, a new kind of hospital policy about DNR orders. Both of those replicated other places. But until the mid-90s, it was one of the few academic medical centers that never had an ethics committee because Dr. Rabkin, our leader, didn't believe in ethics by committee. He really believed ethics is everybody's responsibility. And you could page the rabbi, you could page Dr. Farah. We didn't have anything systematic. But I went to him in the mid-1990s and said, we do need some things that are more systematic than that. And then fast forwarding, the core themes really are thinking about the iceberg that Jonathan showed you are really anchored in the culture out of which individual ethics cases may come. And the culture that we've tried to foster is, ethics is everyone, it's not the ethics people. Ethics should be the basis of everything. Anytime you ask why you're doing something and then why is that important, you should end up with the mission and core values. You see different core components of things that we do. And then summarize the criteria of success. Every staff member goes home at the end of their day or night justifiably proud of their work. And every patient and family member arrives feeling completely welcomed and leaves feeling justifiably grateful. And if either of those is ever not true, we think there are values or ethics issues that we need to be thinking about. What I'll just observe and then stop here is that when you look at this, the staff members being proud of us, being proud of our work, we're proud of our work that we do in the hospital, but not necessarily completely aligned with what effects we may be having when we discharge a patient and then atreus has to deal with those things or even we know that in hospitals, sometimes the way people express pride is blaming the insurance company and oh, the problems your insurance company, which creates problems for the patient, even if we're proud of how great we are. I'll stop here. Thank you, Lachlan. I think it's over to me. Thank you, Kelsey. Thank you everybody for this great start of our conversation and for the opportunity to join you all. So I have stepped into the very big shoes of Dr. Saban to lead the Harvard program ethics program that Jen founded and led for 23 out of its 24 years. This is a unique program at a commercial health insurer, which was created in the times of managed care and we can separately discuss the history. Suffice it to say that the goals of the program have not changed over all these years. It is to support the health plan in the management of the value dimensions of its work recognizing that by definition, the decisions that have to be made at the health plan level have inherent questions about value and those values may differ according to the health plan and the constituents which include the members, the contracted clinicians, the employers, the brokers and the staff within. So the goals are several fold, namely internally focused to increase the internal awareness of the value conflicts that might exist in many decisions and then externally to share that we are thinking about those really deliberately and trying to proactively address things that will by definition come with value conflicts because the world around us is changing. And I think we still may remain one of the few commercial health plans that has a program like this. And the key aspect of its functioning is an ethics advisory group that combines these different constituents now virtually quarterly for a discussion that is brought to it by the leaders of the organization but neither the program nor the results from such discussion have any kind of legal or mandatory aspect to them which may be part of why this program that Jim created has been so long in existence. Thank you very much. Kelsey, would you please go to the next slide? So Jonathan, Lachlan and I were thinking about what example could be used to start a discussion where we hear from many of you as you've heard our sort of ethics on the balcony, Troika as Jim likes to call us is fairly recent and we've been brainstorming recently and we would love input in this big questions that we hope to raise in the next couple of slides and we'll hang them off this on quality care example illustrating competing forces in our healthcare system today. So there's a lot of unmet clinical and I go quickly through these bullets to not go into depth in any one of them but to just illustrate the issues and how they are legitimately competing and could be viewed legitimately different from different perspectives. So there is unmet clinical need for cancer patients there has been enormous scientific progress since the human genome decoding and that scientific progress has obviously been very public and there is a lot of demand in part created by patient groups and clinicians and the whole system to meet this unmet clinical need and that demand results in a demand for rapid access to innovations which makes FDA approve new treatments relatively more rapidly than it used to be the case in the past most of those rapidly approved treatments are oncology treatments and they come to market with limited evidence of the clinical benefits or sometimes with evidence of limited benefit because we advertise widely in this country we are one of two countries that allows advertisement direct to consumers that's happening largely for oncology medicines with millions or to the tune of 500 million spent on some of the drugs per year creating hope of course but also sometimes hype and because we have no regulations of prices of goods for medicines these drugs can come to the market and do come to the market at whatever the market can bear at very high and increasing prices for injectable oncology medicines there is a what's called a buy and bill mechanism meaning that providers oncologists who administer injectable drugs can buy them at wholesale prices and build the insured retail prices and that margin supports the operations of oncology practices at a level of some 50% for some so there is an incentive to use these medicines the insurer is limited in its negotiations with the manufacturer because in all states we have reimbursement mandates for price for coverage for insurance coverage of oncology medicines they differ but they exist in all states that limits of course price negotiations between an insurer and the manufacturer so then the insurer can put in management tools that qualify a patient for a particular drug at a particular time in the trajectory that has been resulting of course in administrative person burden for everybody involved this is on a per drug per patient basis this prior authorization the few highlights that I presented here contribute from my perspective to potentially contribute to three of the six major categories of waste in health spending in the US those have been, there are six categories that have been defined administration is the biggest one pricing is the second biggest one that's about $250 billion per year pricing failures because of non-working markets and low value care if we assume that not all of these medicines provide clinical value to everyone who gets it so in the big picture what can an insurer do? So with increasing drug spending which is what we see we see the increasing drug spending that increases healthcare spending in the country and drug spending is increasing most rapidly of all growth categories of healthcare spending and most of that drug spending comes from pharmaceutical spending and most of that pharmaceutical spending increase comes from specialty pharmaceuticals most of which are oncology medicine so we have although not maybe as clearly viewed a link between increased spending on pharmaceuticals oncology medicines and increased healthcare spending so if we have increased healthcare spending as a payer the payer has two options the increase in pharmaceutical spending can in part be transferred to the member who needs to the patient who needs the drug so that increases cost sharing I think that is probably not what we desire it leads to financial toxicity or it can spread it to the population which leads to increased premiums potentially which leads to increased under insurance then for patients and on the employer side employers have to decide if they spent more on premiums or if they spent more on salaries in the public sector where budgets need to be balanced increased spending on healthcare means taking money out of other common goods occupation housing and all of these are social determinants of health so one could argue that increased healthcare spending in part driven by increased pharmaceuticals spending worsens population health and increases in equity next slide please and another click please Kelsey thank you so if we map these big headlines that I just went through to a system view and I chose if you would please please click one more time if we take the socio-ecological model and use it for this purpose it wasn't designed for this purpose use it for this purpose we see that many of these system factors that happen at the bigger realm of policy and then trickle down to the organizational the community, the interpersonal the individual MEM patient and the individual clinician-patient relationship we see that all of these facts that the system characteristics lead to potentially non-optimal situations and that can be happening at the level of the quality of care if some of these medicines aren't really doing what they are hoped for to do at an individual level patient and if we think about social determinants of health they might affect the population community health so another click please Kelsey so if we turn the iceberg around and liken it to the system diagram we see that what might be happening at the medical ethics decision making clinical decision making level is really the tip or the bottom of the iceberg and a lot of system structures influence influence what's happening there but also influence the broader societal crisis I think that we're facing so next click please so that means that we should all think about the bigger picture and that's what the three of us have been embarking on trying to do as individuals not as representatives of our organizations but as individuals thinking about ethics from the perspectives of our organizations next slide please so we came up with a set of questions which will come up again later but I'll just highlight the fact that we really look forward to learning from you on a set of questions on whether at all thinking from ethics perspectives of different types of organizations we can move the needle in terms of a more ethical health and social system but before we go to these questions we would love to hear from your experiences in potentially also fragmented system let's go further next slide please Kelsey yeah so the reason for why we are doing all of this obviously is because we all as you have heard from the missions of the organizations and I'm sure all of us on the webinar are caring for the well-being of people in this country and across the world so next slide please so we live in fragmented system but our expert Dr. Sharon Levine lives in an integrated system and has practiced ethics there for a long time and so I hand it over back to Jim and Sharon to continue the conversation thank you so thank you to the panel and thank you to Sharon for joining us across the country Sharon Levine is a pediatrician who has been a leader in the Kaiser Permanente organization I'm just I'm trying to make myself visible Ashley I don't know if you can do that for the moment I'm not able to okay Sharon has been a leader in the Kaiser Permanente organization for four decades she's been in the widest range of leadership positions and through all that time has had an enduring involvement with an interest in ethics it was a privilege for us to have Sharon on our distribution list for the Harvard Pilgrim Ethics Advisory Groups and we received comments from her recurrently Kaiser embodies what the panel has been working to explore how do we bring disparate elements together in a way that our health system often militates against so we invite Sharon to help us look at the issues raised by the panel from the perspective of an organization that has built them in a unique way for decades thank you Sharon thanks thanks so much Jim and I really appreciate the opportunity to participate in this I have enjoyed reading the materials from the Harvard Pilgrim Ethics Advisory Group for years but one of the benefits of the pandemic is I actually have gotten to participate in the two meetings that have occurred since the shelter in place has taken place so thank you to all of you and in many ways one of the things I think that we have all realized is that all decisions made in healthcare systems contain ethical dimensions there's an ethical dimension to almost every decision that's made whether it's at the bedside in the exam room or in the committee that designs benefits as Jim said, Kaiser Permanente is an integrated delivery system with a monogamous relationship if you will, a mutually exclusive monogamous relationship between the payer the providers, both institutional providers the hospitals and the physicians and other clinicians who care for patients within the hospital and the ambulatory sites and it provides what ought to be in many ways an ideal environment for an integrated approach to thinking about the trade-offs and implications of the decisions we make and how they impact the communities we serve and as well as the individual patients and the extent, I mean, the one area that and given all that, this is not easy this work happens every day and there needs to be on a daily and recurring basis a recommitment to ensuring that aligned incentives and shared values actually translate into the best decisions possible for the institution for our patients and for the broader communities and I was interested actually in seeing the three mission statements for your three organizations each of them refers to care that is health care or health care services and yet for all of you, for each of these institutions your aspirations really go beyond health care and extend to health, to improving the health of the population and the communities from which those populations come and wonder if you ought to include that in your vision statements, that's an aside but coming from an outside observer that in one of the ways that Kaiser Permanente has approached ensuring that we take full advantage of the opportunities provided by aligned incentives and a mutually exclusive relationship is to ensure that the notion of stewardship stewardship of our patients health of our members health, community health and of financial resources is a critical element of the orientation and onboarding of everyone who works for the organization and to ensure that our professional training and as clinicians and or as administrators or insurance executives doesn't get in the way of understanding that no matter where you sit or where you stand or from in which department you operate it isn't an either or proposition it is a both and proposition we have responsibility as clinicians with every decision we make to ensure that we are stewards of our patients health as well as ensuring that the decisions that we make the health of the patient, the health of the family and also the financial solvency and for many years people have argued or complained if you will but that expectation, that dual responsibility is a conflict is an unresolvable conflict in that physicians should be responsible for quality and let somebody else worry about the cost of healthcare and in many ways, I think decades of that kind of mindset has led us to many of the dilemmas we face today and Kaiser Permanente has worked very hard to ensure that carrying out that dual responsibility is never experienced as a mandate to do something that is in conflict with one's values as a professional and a lot of that has to do with the way those things are executed it is all about implementation so that as a clinician you are at the bedside or in the exam room your obligation is to the patient in front of you but as a participant in an organization with a commitment to population health to community health, each of us has an obligation outside of the exam room and outside of the away from the bedside to participate in the kind of work that ensures that the collective decisions we make as oncologists, as pediatricians, as cardiologists are informed by the best evidence and provide guidance, not handcuffs but guidance to every clinician who then has as much autonomy as is literally possible in this current world to make decisions in the exam room at the bedside that are in the best interest of the patients and in many ways, it requires understanding that there is, we operate both with a covenant and with a set of contractual obligations and it is where the covenant that those of us who trained as clinicians have sworn to uphold has to exist within the context of the contract, social contract and the contract that the carrier that the health plan executes with payers, individual payers, public payers and commercial employers to provide all the care and services that are required to care for patients. And as clinicians, we have an ethical obligation, a moral obligation to understand the constraints of the contract and to understand our obligation to live within the constraints of that contract at the same time never backing away from our covenantal obligations, if you will to advocate on behalf of each of our patients. And the extent to which physicians understand this, clinicians understand this and actually participate as members of the community in these collective decision bodies whether it's benefit design or pharmacy of therapeutics committees, utilization management committees, it's in those environments where the competing values if you will need to be articulated where the potentially ethical and business differences need to be identified where decisions are made and the extent to which there is widespread participation in those environments, there is better understanding of the world in which we operate. And at least within an organizational context, our ability to carry out our mission which Kaiser Permanente's mission is to provide high quality affordable health care services and to improve the health of our members and the communities we serve. And as I said, this isn't easy. This isn't a slam dunk. It requires active engagement participation. And I really applaud and endorse what I think it was Lachlan said, which is the goal is that never, never should a clinician feel compromised in any way about what the organization is compromised in terms of his or her values, in terms of what the organization expects to be done. And that requires vigilance. It requires constant vigilance because we live in a very difficult world. And the very important imperative of identifying preventive ethics and learning from the decisions we've made and where they've been the right decisions and where we've gone astray is a critical part of this. And for me, my introduction to the world of ethics was really through understanding how professionalism and ethics in many ways are overlapping and urgent concerns for the profession and that the extent to which we as organizations, every part of our organization understand what is required to behave in a trustworthy way towards one another across the silos that exist in every organization and with our patients. It enables us, I think, to be assured that at least we are doing the best we can to carry out our ethical obligations to our colleagues, to the institutions, to the stakeholders who are entrusting us with both their health and their financial resources and to the communities we serve. So I think I've used my five minutes at least and we'll turn it back to you. Thank you, Sharon. Ashley, if you could turn my video on, I'd appreciate that. Thank you, Sharon. Thank you, panelists. We should underline what's happening today because I think it's quite important. This consortium began with a focus on intra, inside of organization, ethical issues. From the recognition that organizations, as well as individuals face significant challenges around identifying and implementing values, the panel and Kaiser Permanente take us to the level of inter-organizational ethics. Kaiser Permanente for 75 years has brought together the disparate pieces of the health system into one organization. That's part of the genius of the structure that they've created. And our panelists who have been meeting on a balcony have been exploring how can this process be carried out by entities that are ordinarily siloed in a way that Kaiser Permanente has undone. At this point, we invite everyone to raise your hand, use the hand-raising function in the chat area. And I will monitor that looking for hands, recognizing that it will be challenging to keep to an orderly way of doing this. And if we miss someone, we apologize in advance. And also the chat function where Kelsey will be monitoring that and bringing up issues that have come through the chat. We're eager, I can already see that the chat function takes us a step towards communal exchange across the geographical distance that we're at. So I'm gonna quickly look to see if there are any, I'm not seeing any hands up yet. So I will begin by noting that Sharon described how Kaiser Permanente by bringing the elements of stewardship of individual patient health, stewardship of community health and financial solidity into one family. How over the course of 75 years, that organization has developed ways of bringing these disparate values, all of which deserve respect into constructive conversation. And we might start by asking our panel, what have you learned from your initial exploration on the balcony among participants who often are speaking at cross purposes rather than at collaborative purposes? What have you discovered about the impediments to communication and the opportunities and facilitators of collaborative communication? Thank you, Jim. I'll jump in here. So one thing that I've discovered at Atreus Health and in my communications with people from other organizations is that it's actually hard to engage people in general in ethics conversations. And I don't think it's because people are less interested in ethics. In fact, quite the opposite. I think it's a strong interest. It's very much on people's minds in general. But healthcare is such a stressed system right now. There are so many financial stressors, operational stressors and medical stressors that people are overwhelmed. They're actually very focused on their individual jobs. And much of this is, I would say, very positive and mission oriented. They're interested in taking care of patients or working on systems to back up providers who are taking care of patients. But they're basically overwhelmed due to bigger issues. And because of that, ethics is often on the back burner. And it's been a challenge engaging people in a way that doesn't take up too much of their time. And I bring up this issue first, perhaps, because it's often not discussed. And it's a real practical impediment of the progress that we're hoping to make. So, Jim, this is Sanita, and can I just add? Thank you, Jonathan. Yeah, so I think Jonathan, your point is very well taken about everybody and the whole entire system in all aspects is enormously stressed at this time. But I think the issues that we are facing are a long standing and a long time in the making. And since I come from a different continent and country, it strikes me that COVID-19 has brought out how the structures of the system have really been stretched to the limit here. They also are being stretched in other countries, of course, but the separation that we make between individual focus and medical care versus public health and population and community health and put those sort of onto different sides of a ruler or spectrum in terms of focus, in terms of conversation, in terms of investment, I think that's problematic because as we try to lay out in this little case example, it's all connected. But legitimately, a provider who can make more, can recover funds for operations from margins on procedures or margins on drugs. And so we have set up a system that incentivizes not necessarily what would be beneficial to population health. And so I wonder if in an, I wonder, I have two questions and I hope that the audience and Sharon can help us. One, in an integrated system like yours, Sharon, you can have the population health goal front and center and construct contracts and negotiations and all that around that. But it's my understanding that most of us in the US live in fragmented systems, where it's very legitimate for a clinical system, a hospital, an ambulatory practice to survive, they need to make margins to pay operating costs even when they are non-profit. And that takes away resources from things that might benefit the whole population, but then they are responsible to their patients first. So does that mean responsible to patients first that population community from where these patients come is second or can this be combined? And how do we need to change our mindset towards that combination? Can I crack your sound? Go ahead. Yeah, so you pointed out a very important issue and it's the issue of payment schemes and how the way organizations and individuals get paid are often the biggest obstacle to carrying out or either to rationalizing, optimizing behavior and behaving in a way that actually serves the higher good. And I think it is the biggest challenge we have in the United States at this point today which is how do we migrate from a payment scheme that is largely based on what we do, how much of it and how high the margin on each individual encounter is to one in which the shorthand is paid for value, value obviously is in the eye of the beholder. And in many, many ways, this single, I think the single genius that Henry Kaiser and Sidney Garfield used when they first constructed the framework for Kaiser Permanente was to set up a scheme whereby the payment to the plan which insurance plans are essentially prospectively paid through premiums was also reflected downstream in terms of the hospitals and the doctors. And so our medical groups are prospectively paid. They essentially have a population health payment. Physicians are salary, there's no fee for service component. And so the alignment of incentives around the fact that we haven't easily identifiable finite pot of money and that any decision that's made by an individual or a group of individuals to expend money, to expend resources, it doesn't deliver a dollar's worth of health for every dollar expended is money that won't be in the system for other higher uses. And that notion and that sort of understanding of how we get paid and how that is linked to what we do is both has been a very strong reinforcer of this notion of stewardship. It's also as many men, most of you on the call understand is the source of great concern at times on the part of consumers and patients that somehow prospective payment, population health payment will lead to rationing. And again, vigilance and trustworthiness and ensuring that there are no inappropriate pressures on clinicians to withhold care. And then in fact, there are no financial incentives, no financial benefit to clinicians for not doing the right thing is the only way that that can work. There is no payment scheme that doesn't have the potential for perverse incentives. No matter what scheme you put in place, I think one of the challenges and you're describing is cross organizational collaboration becomes a challenge when the payment to the different organizations creates different incentives for different behavior. Thank you, Sharon. I am starting to see hands now. So I'm, Charlie Munitz, are you, can you? Yes, can you hear me? Yes, so yes. I'm Charlie Munitz. I've been a long time member of the Ethics Committee at Cambridge Health Alliance in Boston playing off of what Anita was talking about. I'm curious in a very down to earth way whether some of you can talk about the PPE crisis that occurred and how communications among organizations are helping to address the sort of conflict between self-interest in organizations and providing for their particular patients and what seems like a kind of trans organizational concern with distributive justice. Thank you, Charlie. Do we have a response about the question that Charlie raised? Let me just add, Charlie, thanks for the question and the PPE, I almost have PTSD, just remembering what there was like and hope that we're not gonna have that again. I'm gonna use that as a kind of segue to a broader sense of how lots of conversations and decisions in the whole COVID area have happened. I've been deeply, was deeply involved with the state crisis standards of care, but just sticking to PPE. One of the real challenges for us at Beth Israel Beaconess with the limited PPE was that that was part of the reasoning process and having to be really, really restrictive about families being able to visit even dying patients because we had limited PPE and we prioritized staff. I'm not saying that was the wrong decision, but the conversations were not involving patients and families and their voices and staff and balancing all of those. And so there was a sense that the staff are deciding and the staff would give themselves priority. And even if that was the right decision, the process of getting there left a bunch of people feeling like they didn't matter and left out. I think you can take the same phenomenon and look at all kinds of things in the medical center more broadly about ethics today. And linking Jonathan's comment about, it's hard to get people to talk about ethics and what Sharon said about systems and supporting all your frontline doctors so they're doing things as well as they can. I think a fundamental challenge to all of us today is even at my medical center, and I'm proud of it, we'll compare it favorably to almost anyone. Even at my medical center, way too often when a staff person is in moral distress or worried about something, they do not instantly think, oh, they're gonna call a supervisor manager or the boss because those people are there to help me because most of us experience the managers, the bosses as worried about our RVUs, our finances, a generation and don't experience them as being on our side, providing moral support, not just rhetorically, but saying, oh, you've got a problem, we're here to help you. And until we get more into that, I think we're gonna continue to have the burnout and other issues and that's just within organizations, not just the people in these organizations then angry at the providers before the hospital who actually should have taken care of the problems or the people outside the hospital, we can't discharge the patients. And I just think there needs to be conversation at every level, including about things like PPE so that we've reached fair decisions. Thank you, Lachlan. Maria Lourdes, you had your hand up before, I don't know if you've lowered it or if you'd like to speak to the issue, so I've unmuted you. If you could introduce yourself. Tim, while we're waiting, can I make just one added comment on the PPE issue? I think it's an extraordinary example of how there are some ethical issues that go beyond institutions and organizations. And it has been such a glaring reminder of the consequences of the lack of a robust public health infrastructure at the state and federal level that should have been in a position to rapidly support individuals, institutions, and communities in assuring access to appropriate protective equipment, personal protective equipment and turning the machinery of this economy over to ensuring that that happened. And so what we got instead was chaos. And actually, if I can just one query quickly, I was stunned and then it was obvious when I heard early on from Ashish Jha, one of the main experts at Harvard School of Public Health, all that needed to happen was at the first instant of worry in late January that there might be a pandemic is that the federal government announced that anybody who produces lots of PPE, if it turns out it's not needed, we will buy it from you at cost. And then everybody would have ramped up it turns out that they would have sold all of their product very well. And so that one simple announcement and we would not have had preventive ethics, we would not have had almost any of the nightmares that we had in all the repercussions. I've heard from my colleague Charlotte Harrison of questions that are raised or comments that are raised on the chat. Charlotte, could you please ask Ashley to unmute the people you've identified? Thank you, Jim. And actually I think Kelsey is gonna bring those questions forward. Yeah, there have been a few themes coming in the chat. And I think one of the questions that has risen is each one of the panelists today are in organizations that have the benefit and have had put hard work into developing these mature organizational ethics programs. And at this point they are now changing or incorporating into their perspective these system level questions as well. So in some sense moving from focusing on the organization and the ethics that exist within it and shifting perspective a little bit. But what about those individuals who in their own settings are trying to introduce a new organizational ethics focus or trying to institute ethics practices in their own settings? Do you have any thoughts about how that might go? And in particular pulling on the theme of today's presentation, are there any ways in which generating a robust organizational ethics process focused on the organization itself might limit the ability to work at a system level or shift perspective? So should that perspective, the system perspective be part of the first steps towards a robust single organizational ethics process? This is Lachlan, I'll try to be just really brief. I actually mean, thanks for the question. My own experience having done this for a long time is that the starting point is almost always best and actually some of that caught the ending point with individual clinicians or patients and families and what is causing them moral distress. And then the responsibility of leadership is to listen to that actually proactively elicit that. And then once that conversation is happening all kinds of other things can happen. But if it doesn't start and end with that then I really worry. Councilor, thank you for the question. This is Anita. I think we need to refer people to Jim Saban's article that many years ago, why to start an ethics program in an organization and why not or not getting the title right. But one of the points I think, Jim and you may speak much more to that is that it needs to be really supported by leaders in the leadership in the organization. And Jim has often told us that if the chief executive officer isn't also the chief ethics office in the sense of really taking seriously the inquiry into and making explicit values of decision making then an organizational ethics program might not be welcome or successful. I do think that we live in a much more explicitly complicated world. There's struggles that we are facing right now in the country, the economic, political, social, racial and all other structural inequities are so much more upfront but they have been there for all the existence of I guess of the US. So I think the impetus to think about an organization's place in this complex system and how it can contribute to making a dent in inequities. I wonder if it's ethically just absolutely not permissible to not start to think about that. So I would think that the current situation might facilitate these explorations within organizations but then with the caveats that Lachlan Lachlan just put up Jim's wonderful article that really are practical points of a program to succeed. Thank you Anita and Lachlan. Please check out Jim's article. I read it before I started the ethics program at Atrius Health and it was very helpful. Certainly you need support from leadership and I was fortunate at Atrius. Our leadership was very supportive of the idea of an ethics advisory committee and program. Begin with conversations with leadership. You want to express to them that you're there to represent everyone in the organization that you're open to lots of different kinds of opinions. You probably also want to communicate that the committee is not there to create a revolution or try to overthrow leadership. Most organizations do not have ethics committees in part I think because of this concern. As long as you come across I think is reasonable and well balanced that will serve you well in the creation of a new ethics program and absolutely check out Jim Saban's articles on the subject. If I could draw attention to the questions that I hope are on the screen for participants I'd ask question three, what role if any could inter-organizational ethics deliberations play? That's the question that this panel has raised and that Kaiser has built into its structure but we'd be very much welcome thoughts that you have any member of our group on what role inter-organizational ethics deliberations can play because that's essentially a theme right for exploration that our balcony group is probing. So in order to answer that question, Jim we might ask ourselves another question. Where is the potential conflict? How can we have three organizations with three very positive compatible missions and yet somehow the result is not either in the patient's best interests or society's best interests? So it could be that one potential conflict is our current system of payment. And I think Sharon talked a little bit about this before with traditional fee for service payments you're actually incentivizing an office visit or a procedure as opposed to a patient's health in general. Now, often an office visit or a procedure will lead to better health. So it's not a crazy incentive system but it's not quite on target either. If you have global payments or capitated payments which pay organizations based on the number of patients they care for, then the organization itself can make treatment-oriented decisions in a sense that puts control in the hands of providers, the doctors and other clinicians who are actually caring for the patients. And in theory anyway, they're the experts and perhaps that would make more sense. That way organizations and providers are not incentivized to kind of drag people in for traditional office visits. Instead, they may be incentivized to do innovative forms of treatments such as telehealth, video visits, telephone visits, using new technologies to treat in a more efficient, perhaps less expensive way. So that's just one idea based upon the current financial incentive model. And I'm sure there's many other ideas out there too. Thank you. Kelsey, you have a question or comment you wanted to bring up in relation to the third question on the screen. So please go ahead and do that. So one question that I've been thinking about is certainly one of, it sounds like one of the hopes of an inter-organizational ethics process is to really improve the ethical quality of care for the population. But in our fragmented health system, there are also organizations themselves which might be caught up in the dilemmas that exist in creating a system of care. So a question I have for you is, in addition to considering how organizations might communicate and learn from another and deliberate together in ways that support the population, is there also an interest in thinking about how organizations themselves bear the burdens of caring for the population under care? So thinking about inter-organizational or trans-organizational ethics, not just for the population, but also maybe developing fair treatment for example, the hospital that is taking on certain aspects of care or ensuring that when a discharge policy is developed that it's not unduly burdening the ambulatory or primary care practice, which also holds some responsibility for care. So is there also an interest in figuring out how organizations themselves might be subjects of fair treatment in addition to the population that they're all caring for? That is a fabulous question and a fabulous construct because you've taken it from the issue of transfer of money to the consequences of the decisions we make when we seek to optimize our own organization on other parts of the system of which we are a part. And if we are heedless of that, we end up sub-optimizing the whole. And an example I've seen within Kaiser Permanente, just where our hospitals operate on budgets, they have no fee for service revenues, they're given a budget. And beginning of the winter, we get a surge of patients and there are closed wards in hospitals all the time. And the nursing supervisor is called and there's an admit from the emergency department and admitting the patient to our hospital, to a Kaiser Permanente hospital requires calling in staff and probably over staffing the unit for a small, one patient or a small number of patients. That makes the saying yes to that may make the nursing budget look problematic, but saying no means the patient is transferred to another hospital and we pay retail for the care of the patient in an external hospital, an overflow bed in an external hospital and it sub-optimizes the whole. And I think we see that in the absence of coordinating not just the finances but the care as people move between our institutions, between the ambulatory services between the hospital and home and how we facilitate those transitions in a way that does not just hand off care and responsibility without support to another part of the system. That's a really good question and requires exquisite coordination and commitment to make sure that patients don't fall through, people don't fall through the holes in the process of the hand-offs. Thank you, Sharon. Someone whose name is MAB or who has MABB as the identifier wants to speak to question three. So if you could introduce yourself and speak. Yes. Can you hear me? Yes, we can. Okay. Can you hear me? My name is Mary Ann Bowman Beale. That is just a shortcut for a long name. So sorry about that. Where are you located, Mary Ann? I'm in Savannah, Georgia. I'm at Memorial Health in Savannah, Georgia. So one might say trying to do ethics in the Garden of Good and Evil is where I'm located. And let me say it's my first opportunity to be involved in one of your calls. So thank you so much. This is absolutely a marvelous conversation and if I can have just a moment of sheer admiration almost all of your people I have followed and read and you have shaped my work. So it gives me a chance just to thank you and be in conversation with you. So that in and of itself is absolutely wonderful. I thought I would share with you the, we, and I might have tripped on what has been an inter-organizational framework for ethics discussion during this time. And it just came out of the need that we saw to open up a conversation in the community based particularly on what was just an increasing risk during this pandemic of our vulnerable and underrepresented population here in Savannah. And it really was a very simple just shout out to other organizations, peer organizations as well as community partnerships to see if we could not using ethics as the common thread and language weave together a better tapestry or perhaps or even safety net as we headed through this. I will let you know how it goes. It has been a conversation every Thursday since early April. So we may have accidentally had this framework emerge in our community because I don't think there's one of us that even after we passed through this will not say that we have identified a very important way of us to be communicating and identifying opportunities to work together. So I think it is perhaps an example of what you are talking about. Well, Marianne, it sounds like a terrific example. Let us as a group thank you for being here. You are realizing our aim of extending beyond local geography, which the platform allows us to do. And you said something quite important that you have used ethics as a thread to join others together. Can you tell us a little bit more about your experience with that of how ethics has acted as a unifying thread? Absolutely, I would love to. Number one, I do think it just preserves. And I noticed in the comments people were writing, I liked somebody wrote about technologies too and what they felt that was doing to the ethical conversation. I do think, and this is of course where my narrative side will come out, I think people are welcoming and longing for in a very significant way. How do we preserve landscapes for conversation around patients? I know the success of our ethics program here or at least it's a high level of engagement here has really been because it has preserved a landscape for complex conversations in a time when so much was conspiring against it. So I think the same thing is probably what's happened in the community that there is an extraordinary level of value of stopping for a moment. And the thread being this common language we can share no matter where in the story you are or organizationally where you are that you have a place in that conversation. And I think it just is this a marvelous way of preserving a place. And if in fact you use that place to identify key opportunities and leverage points for systemic change, then I think you become rather extraordinarily valuable. And so I think if we can excavate from these conversations, that kind of contribution to the organizations we are in or the communities we hope to serve by linking together then I think we have actually really, we continue to bring to the entire field and above all to our patients. I think what pretty much everybody on this call desires to do so. Mary Ann, thank you very much for what you've brought up and what Mary Ann has brought up calls to mind an effort made by an international group more than 20 years ago, a group called the Tavistock Group that developed a code of ethics intended to be for all participants in healthcare including patients. It was a very elegant piece of work but I think it's safe to say it's primarily sat on the academic shelf and that but the effort is to do what our panelists are doing, what Kaiser Permanente has built in and what Mary Ann just described from Savannah, Georgia. And in the limited time we have remaining would anyone else want to speak to question three from any experiences or ideas about inter-organizational ethical deliberation and collaboration. Sue Pauker, let me just... Can you hear me? Yes, we can hear you now, Sue. I think... Can you introduce yourself to the group? I think a good final thought as these excellent ideas have been vocalized today is how we individually balance our personal combat in ethics between personal values and how we practice medicine right now. So when we see a patient so to speak on telehealth, how do we be sure that we're not missing something that we can't see and can't hear? And yet, how do we balance that against showing up in our office and doing a complete physical exam but risking our lives? So I'm raising in the context of organizational ethics the individual battles we're all facing every day between isolation, engagement and risk and how we balance those original concepts of Moses saying, choose life and whose life do we choose? What Dr. Pauker just brought up is an issue. We're all seeing play out in the school system and in a very bumpy way between parents, teachers union, kids and members of the community.  You've raised a very important issue. Do you want to make one suggestion as to how to do what you just pointed to? Well, I think including patients in the ethical discussions is very important. So I can say to a patient, we're gonna start out on telehealth and then we're gonna move to a physical visit briefly in my office with all kinds of preparations to keep you safe. And I can have that discussion with them but I'm not always asking them how they feel about that. And so in this balance, I think it's critical and I'm sure all of your committees bring in patient perspective and therefore some community perspective. How do I deal on telehealth with somebody who doesn't speak English? How do I deal with someone who doesn't have a computer and can't show me the problem they're talking about? So engaging with the patients on these issues has been one way for me to feel a little better about what I'm doing and going to a talk like this has been inspiring. I haven't felt inspired personally since for a very long time until I heard what Sharon had to say and appreciating what thought and experience goes into that that we are individually trying our best to be ethical. Thank you and that is a very good point at which to wind up our discussion. And we have just seen a wonderful example of what we're trying to foster. We had a voice from Savannah, Georgia, talking about using the threat of ethics to join people together there. We had a voice from Massachusetts, Dr. Susan Pauker, speaking of the inspiration she received from California, Dr. Sharon Levine. So that embodies what we are aiming to do and hoping for. So I wanna thank the panel and the participants for helping us with this first session. This is the first of what will be a series of organizational ethics consortium meetings using the Zoom platform. And at this point, I'm gonna ask Charlotte Harrison to tell us about our next exciting session coming up in a month. Thank you, Jim. It's great to have everyone with us and we hope to see you a month from now, October 23rd at noon. We're gonna be taking up the topic of pursuing health equity. Our speaker is Kedar Mait, who is the president and CEO of the Institute for Healthcare Improvement, which many of you will know and nationally recognized organization. They bring together strategies from quality improvement science and from equity building. And they have built a network of organizations, mainly provider organizations that are committed to improving health equity. And this talk, we'll talk about that network, the strategies and look forward to input from anyone who can join us. Thank you, Charlotte. Again, a warm invitation to all participants to join us in a month. And we would also invite because this is a work in progress and health improvement, quality improvement is the signal organizing concept that Charlotte just brought up. Please give us comments that you have on what has worked well for you and what could be improved because this is a work in progress. It's an effort tremendously worth fostering. As Marianne said from Savannah, the thread of ethics unites us. And as Susan Pauker said, the key element in inter-organizational ethics is probably bringing the patient in individually and collectively. So that's a very good point at which to end. Thank you all. Be well, stay safe, take care of yourselves and Godspeed.


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